HEMODIALYSIS PROCEDUREYousaf khanRenal Dialysis lecturerIPMS-KMU

THE FIRST DIALYSIS SESSION IN CHRONIC AND ACUTE RENAL FAILURE Planned dialysis for ESRD is very different to dialysis for

an acute uremic emergency. In ESRD access may have been planned and formed

several months previously, the patient is aware of the procedure and in general the metabolic derangement of CRF will have been progressing slowly.

A first chronic dialysis session may be performed as a outpatient.

However correction of metabolic abnormalities in ESRD can still have similar effect to that seen in HD for acute uremia.

In ARF access will usually be temporary catheter, the patient may be confused, catabolic, sick or just frightened.

Factors to be considered include: Length of session, Blood flow rate Choice of dialyzer, Anticoagulation Dialysate composition, Fluid removal Skill of Technologist and presence of medical staff.

Anticoagualtion: Heparin free dialysis is preferred for a first dialysis session,

to minimize the risk of pericardial bleeding, bleeding from access sites, or intracerebral bleeding in the setting of hypertension.

Anticaogulation can be introduce subsequently.

Dialysis technologist and medical staff: A first dialysis session required skilled staffing for

monitoring both the patient and equipment and for patient reassurance.

Complication may be severe or unexpected.

FIRST DIALYSIS SPECIFICATIONLength of dialysis: A first dialysis should only reduce blood urea by 30 % For most patient an optimum first session is about 60 -90

minutes.

Blood flow: Usually about 150 – 200ml/mint for the first dialysis session.

Dialyzer: High efficiency dialyzer ( koA >400) are not needed for the first

few dialysis session. If they are used, the length of session or blood flow should be reduced.

Ultrafiltration: No more than 2 liter should be removed during a first dialysis

session. For patient with severe fluid overload – isolated uf

FIRST DIALYSIS SESSION DIALYSATEBicarbonate Preferred to acetate to minimize risk of hypotension. Patients at severe risk of alkalemia may need reduced

bicarbonate concentration (<35mmol/l).Sodium: Avoid correction of hyponatremia too rapidly by altering the

dialysate sodium. In general 140-145 mmol/l is satisfactory.Potassium: Serum potassium will be reduce with correction of acidosis. Use 4-4.5 mmol/l dialysate potassium.

Calcium: Avoid low calcium dialysate as it may contribute to hypotension.

Dialysate flow: Rate does not need altering (500 ml/mint)

HEMODIALYSIS PROCEDURE

HEMODIALYSIS PROCEDUREGeneral Reassessment: Acute and chronic dialysis prescription should be

reviewed, evaluated and carried out accurately to obtain the maximal efficiency for dialysis.

The patients physiologic status is assessed to ascertain the necessity of adjusting any dialysis orders.

All machine parameters are assessed to ensure that the prescribed procedure is correctly implemented.

The goal is to initiate and terminate the dialysis procedure safely and comfortably with no or minimal complication.

RINSING AND PRIMING: Through rinsing of the dialyzer is important because

it may reduce the incidence or severity of anaphylactic dialyzer reaction by virtue of removal of leachable allergens.

Micro bubbles are removed when the venous end of the dialyzer pointed upward.

The dialyzer should be used within 5-10 minutes to avoid leaching of residual ethylene oxide or other leachable allergens into the rinsing fluid.

Dialyzer should be rerinsed briefly immediately prior to dialysis if more than 10 minutes ha elapsed.

PRIMING OF BTL

PATIENT MONITORING PREDIALYSIS Weight, pulse rate, B.P laying and standing temperature, fluid status,

blood investigation and vascular access patency and freedom from infection.

Obtaining Vascular access: Poor vascular access is a limiting factor to patient survival on

hemodialysis. Therefore great care must be taken to maintian adequate vascular

access.

Percutaneous venous cannula ( femoral, subclavian and jugular) Residual heparin or clot is first aspirated from both catheter lumen. Check the patency of each lumen by irrigating with a saline filled

syringe. Heparin loading dose is administered in the venous limb and flushed

with saline Initiate dialysis after 3 minutes.

AVF and graft using permanent vascular access

PATIENT MONITORING PREDIALYSIS

INITIATING DIALYSIS Set the blood flow rate at 50-100 ml/min, until the blood

fills the blood circuit. The priming fluid in the lines and dialyzer is disposed of

to drain until the blood reaches the venous air trap. in unstable patient the priming fluid is usually given to

the patient maintain the blood volume. Increase the blood flow rate to the desired level after

the circuit is filled with blood (150-250 in acute cases) Initiate the dialysis solution flow and adjust the TMP.

Alarms: Blood circuit alarm and dialysis solution circuit alarms

Patient monitoring during dialysis Pulse rate, BP every 30 to 60 minutes in chronic dialysis, but

at least every 15 minute in acute dialysis Food and fluid intake, complication during dialysis and

particular observation.

Termination of dialysisSaline rinse: The blood is returned by pumping sterile normal saline into

the arterial side until the blood is displaced. After the bubble trap the fluid should be very pale pink in

color ( to assure that the patient has lost the least of red cell)

Saline air rinse: The blood is forced by pumping a small amount of saline into

the arterial line, then the line is opened to allow air into the circuit to push the saline and blood.

Again the fluid entering the patient should be very pale pink in color.

Patient monitoring post dialysis: Weight, pulse rate, BP laying and standing,

Temperature, blood investigation and vascular access patency.

All patient parameters and any unusual occurrences should be documented on patient file.

Equipment care: The of dialysis machine is the responsibility of the staff

and of the biomedical technicians. Scheduled maintenance recommended by the

manufacturer should followed meticulously for the safe and efficient function of the equipment.

Thank You