DIALYSIS

CRESENCIO C. CAJIGAL, JR. RN, MAN

Kidney

DIALYSIS
is a procedure that
is given to people who have lost a
kidney, have kidney problems due
to birth defects, or who have
kidney failure.
A mechanical means of removing nitrogenous
waste from the blood by imitating the function
of the nephrons.
Strict aseptic care is mandatory for dialysis
clients.

TYPES OF DIALYSIS
hemodialysis



peritoneal dialysis.


hemodialysis

A mechanical means of
removing nitrogenous waste
and excess fluid from the
blood by imitating the
function of the nephrons via
semi permeable membrane.

ACCESS FOR HEMODIALYSIS
Catheters
- jugular vein
- femoral vein

AV Fistula = anastomosis


ACCESS
HEMODIALYSIS
3x/week total of 9 to 12 hours

Dialysis orders based on body size,
renal function, dietary intake,
concurrent illness

Complications

EQUIPMENTS
Dialysis Machine
Dialysis Tubing arterial line-red
venous line-blue
IVF/IV line
Dialyzer
2 needles
2 10cc syringe
Heparin 6cc
Dialysate solution acetate, bicarbonate






Steps in Hemodialysis Process
Priming
Recirculation -15 minutes.
Dialysis process 4 hours
Termination
MOST COMMON HEMODIALYSIS
COMPLICATIONS
1. Hypotension 20 - 30%
2. Cramps 5 - 20%
3. Nausea / Vomiting 5 - 15%
4. Headache 5%
5. Chest pain 2 - 5%
6. Back pain 2 - 5%
7. Chills 1%
Definition: * Sudden drop in systolic BP to < 90 mmHg
* > 30 mmHg drop in MAP
* > 30 mmHg drop in systolic BP + symptoms
INTRADIALYTIC HYPOTENSION [IDH]
SYMPTOMS OF HYPOTENSION
1. Nausea / Vomiting
2. Cramps
3. Light headedness / dizziness
4. For some, none
INTRADIALYTIC HYPOTENSION
A. Early B. Late

1. Dialyzer volume 1. High UFR
2. Medications a. high interdialytic weight gain
3. Sepsis b. too low dry weight
4. Pericardial disease 2. Acetate dialysis
3. Autonomic neuropathy
4. Heart disease


Subgroup analysis of patients with very
frequent IDH
Co morbidities:
1. Old age
2. DM
3. Autonomic neuropathy
4. Florid uremia
5. Pericardial disease
6. Cardiac disease
a) systolic dysfxn
b) diastolic dysfxn
c) arrhythmia
VOLUME BALANCE IN HEMODIALYSIS
A. Factors decreasing intravascular
volume
1. Ultrafiltration
2. Solute removal decreased osmolality
of post dialyzer blood water moves
out into intracellular compartment
decreased plasma volume
B. Factors replenishing intravascular volume
1. Plasma refilling rate
(UF increased albumin conc. in
intravascular compartment increased
colloid oncotic pressure water moves
in from the intracellular compartment)

2. Increased cathecolamines
a. Increased vascular resistance
b. Increased HR and contractility

VOLUME BALANCE IN HEMODIALYSIS
II. Venous capacity
A. Acetate induced venodilatation
B. Dialysate temperature
C. Food ingestion
D. Dialysate sodium
DIALYSIS-RELATED IMPAIRMENT TO
COMPENSATORY RESPONSES
IV. Vascular resistance
A. Anemia
B. Acetate
C. Temperature
D. Food ingestion
E. Sodium
F. Potassium
G. Calcium
H. Dialyzer membrane
I. Drugs
DIALYSIS-RELATED IMPAIRMENT TO
COMPENSATORY RESPONSES
Strategy to help prevent hypotension during dialysis
1. Use a dialysis machine with an ultrafiltration
controller whenever possible.
2. Counsel patient to limit salt intake, which will result
in a lower interdialytic weight gain, ideally <1 kg / d.
3. Do not ultrafilter to below patients dry weight.
4. Keep dialysis solution sodium level at or above the
plasma level or use sodium gradient dialysis
(controversial).
5. Give daily dose of antihypertensive medications after,
not before, dialysis.
COMMENTARY: Dialysate Sodium
1. Low Dialysate Na increased generation of PGE 2
2. Warning: Never use a dialysate Na lower than the
patients Na. Risk of cerebral edema
3. Sodium profiling: linear, exponential, ramped
4. Recommendations: a) High Na (144 150)
b) Sodium profiling
6. Use bicarbonate containing dialysis solution
7. In selected patients, try lowering the dialysis
solution temperature to 34 36C.
8. Ensure the hematocrit is > 33% prior to
dialysis.
9. Do not give food or glucose orally during
dialysis to hypotension prone patients.
10. Consider use of blood volume monitor.
11. Consider use of -adrenergic agonists
(midodrine) prior to dialysis.

Strategy to help prevent hypotension during dialysis
1. Obligatory increase in splanchnic blood
flow
2. Lasts for 2 hours
3. No food intake during dialysis is
recommended only to those prone to
IDH
COMMENTARY: .Food Ingestion
MANAGEMENT OF DIALYSIS HYPOTENSION
A. Improve cardiac filling
1. Expand intravascular volume [ 0.9 NSS /colloid bolus]
2. Increase plasma refilling [ hypertonic saline / glucose ]
B. Supportive
1. Decrease UFR
2. Trendelenburg position
3. Oxygen
4. Decrease BFR *( ? )
TROUBLE SHOOTING DIALYSIS COMPLICATIONS
PROBLEM MECHANISM PREVENTION TREATMENT
1. Cramps









2.Dysequilibrium
syndrome





a. hypotension 1. correct hypotension a. 0.9 NSS
b. px below dry 2. correct dry weight b. hypertonic glucose
weight c. hypertonic saline
c. low sodium 3. sodium profilling*
dialysate 4. higher sodium
5. vitamin E 400 iu hs
6. Carnitine
7. Quinine
8. Oxazepam

a. cerebral edema 1. slow initial BFR a. supportive
b. cellular acidosis 2. limit initial UFR b. hypertonic glucose
3. mannitol c. hypertonic saline
4. sodium profiling


TROUBLE SHOOTING DIALYSIS COMPLICATIONS
PROBLEM MECHANISM PREVENTION TREATMENT

3. Dialysis
associated
hypoxemia


4. Conductivity











a. metabolic alkalosis 1. identify pxs at risk a. terminate HD
b. complement 2. higher O2 b. ventilate px
activation 3. hydrocortisone*


a. high 1. check system a. correct it
- low water

b. low 1. check system a. correct it
- empty dialysate
- defective proportioning
pump

c. wrong dialysate 1. pre HD check a. get a good
combination lawyer
TROUBLE SHOOTING DIALYSIS COMPLICATIONS
PROBLEM MECHANISM PREVENTION TREATMENT
5. Arterial
pressure











a. High 1. Insertion technique a. repositioning/
- needle/catheter 2. periodic AVF Doppler reinsertion
positioning assessment b. tourniquet
- AVF flow
(arterial)
- hypotension

b. Low 1. pre HD check a. eliminate air and
- disconnected 2. WOF air embolism reconnect
lines



TROUBLE SHOOTING DIALYSIS COMPLICATIONS
PROBLEM MECHANISM PREVENTION TREATMENT

6. Venous
pressure

a. High 1. periodic AVF Doppler a. NSS flushing
- AVF pressure assessment b. readjust BFR
- high BFR 2. reassess anticoag. (too fast vs. too slow)
- clotting in system protocols
- kinked tubings 3. target best BFR

b. Low 1. WOF air embolism a. eliminate air and
- disconnected lines reconnect

Peritoneal dialysis

Continuous ambulatory peritoneal
dialysis (CAPD)

2 liters dialysate, replaced every 4-6
hours

Continuous cyclic peritoneal dialysis
(CCPD
Peritoneal dialysis
In evaluating a client's understanding
of administration of peritoneal dialysis
which client action would require an
intervention by the nurse?
The client warms the dialysate before starting the
infusion.
The client uses soap and water to clean ports
before connecting to dialysis tubing.
The client weighs himself before starting process
The client wears sterile gloves when
connecting/disconnecting the tubing

Peritoneal dialysis
A client with chronic renal failure is
undergoing peritoneal dialysis. Which nursing
measure will be most helpful in promoting
outflow drainage of the dialyzing solution?
Turn the client from side to side.
Elevate the height of the dialysate bag.
Apply manual pressure to the clients lower
abdomen.
Push the peritoneal catheter in approximately one
inch further.