• For patients, access problems can lead to access failure, inadequate dialysis, hospital stays, and even early death.
• Access problems also affect the care team. They
disrupt schedules and make treatment more difficult Infection
• Never cannulate an AVF that looks infected.
• The fistula needle can transfer an infection on the skin into the patient's bloodstream.
• This can cause sepsis (blood poisoning) one of the leading cause of death in people on dialysis.
Dialysis-Related Complications of Fistula
Line Separation
• Exsanguination (severe loss of blood) can occur if a needle comes out, the lines come apart, or the fistula ruptures (bursts)
• To keep needles from being pulled out, follow the center's procedure for taping.
• Fasten the bloodlines securely and set the arterial and venous pressure monitor limits so you will know right away if a. problem occurs.
• The air/foam detector and venous and arterial pressure monitors can help prevent exsanguination if they are armed and working.
• But, sometimes a dislodged needle can cause a slow loss of blood over the course of a treatment.
• In this case, the drop in venous pressure may not be enough to set off the alarm - and you may not see the blood if the patient's arm is hidden by a blanket
• If a patient is losing blood through the tubing, turn off the blood pump and clamp the bloodlines.
• Apply pressure to the needle site if the needles were pulled out.
• Oxygen, saline, or blood volume expanders may be needed if a lot of blood was lost.
• If needed, start emergency procedures.
Air Embolism
• Air that enters the patient's bloodstream can stop the flow of blood, much like a blood clot.
• If enough air enters the bloodstream:
• The heart pumps foam instead of fluid blood. This reduces cardiac efficiency and can cause cardiac arrest.
• Bloody foam in the lungs makes it hard to breathe.
• An air embolus in the brain can mimic a stroke.
• Depending on where the air goes:
• the patient may be highly anxious
• have trouble breathing
• become cyanotic (turn blue)
• have vision problems or low blood pressure
• or become confused, paralyzed, or unconscious.
• Newer dialysis machines do not permit alarm overrides.
• If the air/foam detector alarm sounds, look at the venous line to see if any air is present before you override the alarm.
• The air/foam detector should stop the blood pump if there is air in the venous drip chamber.
• If you suspect that a large amount of air entered the venous system, have the patient lie on his side and tell the doctor.
• Lying on the left side decreases the chance that air will travel to the brain and the pulmonary artery.
Tips to Prevent Blood Loss During Dialysis
To prevent blood loss during dialysis:
• Never let patients cover their needles or bloodlines with sheets or blankets. You must always be able to see the access.
• Secure all bloodlines and access connections before you start a treatment, and tape the needles so they can't be pulled loose.
• Don't let blood tubing touch the floor; it could be stepped on and pulled apart.
• Check to be sure that the air/fowl detector and arterial and venous pressure monitors are working before you start a treatment, and that the monitors are armed once dialysis begins.
Infiltration / Hematoma
• An infiltration occurs when the needle tip goes into the vein and out the other side, or nicks the side of the vessel, letting blood escape into the patient's tissue.
• Infiltration is the most common complication of needle insertion.
• It occur less often once staff have more practice placing needles.
• It harms the access, which can lead to access failure.
• For patients, infiltration causes pain, bruising, the need for an extra cannulation, and loss of trust in the staff.
• Blood that leaks into the tissue around the blood vessel (hematoma) makes the area swollen, hard, and sometimes red.
• An infiltrated venous needle will raise the venous pressure, which will set off the venous pressure alarm to stop the blood pump.
• An infiltration of the arterial needle will cause the arterial pressure to become more negative.
• To prevent infiltration, closely follow the needle placement technique and:
• Use a gentle technique
• Do not rush,
• Develop a feel for the least bit of resistance in the vessel.
• Level the needle to the surface of the skin. Advance it slowly up to the hub as soon as you feel a pressure change and can see a flashback of blood in the needle tubing.
• Don't flip the needles.
• Flush the needles with saline after insertion to check for good placement (no pain, swelling, or resistance to the saline flush).
• Use the wet needle cannulation technique.
• Remove a needle that infiltrates before heparin is used.
• If infiltration occurs after a patient receives heparin, the nurse may tell you to leave the needle in place.
• You will then need to insert another one beyond the site of the infiltration (usually above).
• If a hematoma forms, give the patient an ice pack and something to act as a barrier (i.e. washcloth) between the ice and the skin to hold in place during treatment, to help reduce the swelling.
• The patient should keep ice on for 20 minutes, off for 20 minutes, on for 20 minutes, etc.
• Finally, do not subtract the time you spend taking care of a needle infiltration from the patient's total dialysis time.
• Lost minutes lead to inadequate treatment.
• Add the lost time to the end of the treatment to be sure that the patient receives the prescribed dialysis dose.
Bleeding During Dialysis
• May be a minor problem (oozing at needle sites) or a life-threatening emergency (needle falling out with the blood pump running).
• Frequent loss of small amounts of blood during dialysis adds to the risk of anemia, a shortage of red blood cells.
• Do not flip the dialysis needles. This practice causes the hole to stretch until it is larger than the needle size, causing oozing during dialysis.
Bleeding During Dialysis
• Use a back eye needle for the arterial draw to
• eliminate the need to flip the needle.
• Profuse bleeding may suggest a tear in the blood vessel or bleeding from a remote site within the access. Uncontrolled bleeding is a life-threatening situation. Call the doctor right away.
Recirculation
• Occurs when dialyzed blood returning through the venous needle mixes with blood entering the arterial needle.
• The mixing means that already-dialyzed blood goes back through the dialyzer to be cleaned again, while the rest of the patient's blood is not cleared enough.
• Recirculation makes treatment less efficient.
• Recirculation can occur when:
• The blood flow within the AVF is lower than that in the dialyzer (<300-500 mL.min)
• The needles are placed too close together.
• Lines are reversed
• A stenosis is present
• In severe cases, recirculation will re-clean the same blood so much that it turns dark from lack of oxygen (black blood syndrome).
• Recirculation studies may be done if the delivered dialysis dose drops - as noted by a decrease URR or Kt/v - the blood flow rate drops due to higher venous pressures, or the team thinks stenosis is present.
• These steps can help ensure proper needle placement to prevent recirculation:
• Palpate the patient's access to find the direction of the flow
• Assure that the tips of the arterial and venous needles are at least 1.5 inches apart.
0 comments:
Post a Comment