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An Understanding of the Normal Kidneys
There are 3 prime functions :
1. Excretion of the waste products of nitrogen metabolism 2. Regulation of water and electrolyte balance 3. Endocrine and metabolic functions a. Production of ³Renin´, which affects sodium, fluid volume, and blood pressure b. Production of ³Erythropoietin´ ,which controls red cell production in the bone marrow c. Production of ³Prostaglandin´
Parathyroid Hormone Which increases phosphorous and bicarbonate excretion and stimulates conversion of vitamin D to the active 1.25 vitamin D form . promotes sodium retention and enhances secretion of potassium and hydrogen ion.The normal kidney is a receptor site for several hormones produced by other organs Anti-diuretic hormone (ADH) produced by the pituitary glands. reduces the excretion of water Aldosterone Produced by adrenal cortex.
and low molecular weight proteins.amino acids. uric acid. and its rate production is the glomerular filtration rate (GFR) . Such solutes include electrolytes and urea. There are over a million such units in each of the two kidneys. The Glomerulus filters water and solutes of molecular weight less than 68. This fluid is the glomerular filtrate.The Nephron The nephron is the functional unit of the kidney.000 daltons (albumin). creatinine. glucose.
>99% of this filtrate is reabsorbed in tubules >The function of the Tubules are reabsorption and secretion >Of the 180 Liters of glomerular filtrate each day. The tubules conserve water and electrolytes by returning them to the blood . about 2 L remain as the final urine.>A man of average size has about 180 Liters of filtrate per day. or 100-120 ml/min.
Kidney Failure can be divided into : A.Acute Renal Failure (ARF) B.Chronic Renal Failure (CRF) .
antibiotics Intrinsic kidney disease Note : Acute renal failure is a sudden loss of kidney function and is potentially reversible . Common causes of acute renal Failure : Infection. pain killers. septicemia Major Trauma/ Heavy loss of blood Urinary Tract obstruction Drug induced eg.A.
g.B. Renal calculi Note : Chronic renal failure is progressive and irreversible .. Common causes of chronic renal failure Long standing diabetes mellitus (Diabetic nephropathy) Inflammation of the kidney (Glomerulonephritis) Infections of the kidney (Polycystic kidney) Long standing uncontrolled high blood pressure (Hypertensive nephropathy) Chronic analgesic abuse Obstructive uropathy e.
the patient is said to be ESRF. The has to choose one of the following options of renal replacement therapy (RRT) to maintain life. . When The level of function of kidneys is measured by its glomerular filtration rate (GFR).END STAGE RENAL FAILURE (ESRF) The level of function of kidneys is measured by its glomerular filtration rate (GFR). When GFR drops below 5-10% of normal. The incidence of ESRF is about 100-140 new patients/million population/year.
Signs and Sypmtoms of ESRF include : Nausea and vomiting Breathlessness Pallor ± anemia Edema ± facial. ascites. and swelling of ankle Tiredness and lethargy Raised blood pressure Uremic skin ± sallow discoloration .
Renal Transplantation a. Patients have to be on long tem medications after transplantation to suppress immune response to the transplanted kidney. b. Cadaveric transplant ± where the kidneys are removed from a patient who is pronounced ³brain death´ and prior consent from family is obtained. .Treatment Options for ESRF 1. Emotional related renal transplant ± where the spouse donate one of their kidney. and many other routine blood and x-ray investigations are done prior to transplantation. Living related renal transplant ± where one member of the family donate one of their kidneys. Blood grouping. tissue matching. c.
HEMODIALYSIS This is the process of removing waste products and excess fluid from the blood using the artificial ³Kidney´ also called a dialyzer and an artificial kidney machine also called a hemodialysis machine. This treatment is done 3x a week.Treatment Options for ESRF 2. usually 4 hrs. for the ret of the patient¶s life or until a renal transplant is done. per session. .
A ³Fill Phase´ where fresh dialysate is introduced into the peritoneal cavity c. Continuous Ambulatory Peritoneal Dialysis CAPD uses the same principle of diffusion and is continuous and takes place within the patients peritoneal cavity. A ³Drain Phase´ where the used dialysate is drained from peritoneal cavity b. * The drain and fill phases are undertaken in sequence with the dwell phase and the procedure takes about 20-30 minutes. With successful upgrading of CAPD systems. and during which time the majority of the fluid and solute removal (dialysis) occurs. Each exchange or ³cycle´ has three phases: a. many patients are able to be safely put onto this program and there is bound to be increase in number of new patients being treated on CAPD. Patient does four exchanges each day and is more mobile compared to hemodialysis treatment. .Treatment Options for ESRF 3. A ³Dwell´ phase where the fluid remains in the peritoneal cavity.
and after some time fluid moves back into the blood. The more glucose in the dialysate (high osmolarity). .ULTRAFILTRATION Fluid is removed from the blood ultrafiltration To attract water the dialysis fluid contains glucose. the more fluid can be removed During dialysis the dialysate is diluted. and glucose is consumed in the body Therefore ultrafiltration ceases.
Diffusion through a membrane is called ³dialysis´ Waste products in the blood move to the cleaner dialysis fluid because of the difference in concentration. The dialysate must then be exchanged . no more net transport takes place. When the concentration of waste products is of the same in blood and dialysate. DIFFUSION Waste products are removed from the blood by diffusion.
Ultrafiltration 4. This exchange removes toxins and water from the patients blood and corrects electrolyte imbalances to near normal.Osmosis 3.HEMODIALYSIS ³Hemo´ ± means blood.Diffusion 2. Hemodialysis is an exchange that takes place between a patient¶s blood and a solution termed dialysate across a semi-permeable membrane.Convection . ³Dialysis´ indicates some form of filtration. The basic principles involved in hemodialysis include the following: 1.
During hemodialysis. creatinine. there is bound to be a small amount of membrane permeable solute loss together with the ultrafiltrate. solutes such as urea. The rate of spread depends upon the concentration . .size and ionic status of the molecules in motion. phosphates. In other words during fluid removal. DIFFUSION Molecules in solution are in constant motion and spread uniformly throughout the solution. electrolytes etc are removed by both diffusion and convection while water is removed by both osmosis and ultrafiltration. The substance dissolved in water is known as ³ solute ³ ULTRAFILTRATION This is the movement of fluid through a membrane caused by a pressure gradient. OSMOSIS This is defined as the movement of water through a membrane from a higher to a lower water concentration area. Diffusion can be defined as a flow of solutes from an area of higher concentration to lower solute concentration across a semi-permeable membrane. both positive and negative pressures on the blood and dialysate sides contribute to fluid removal. CONVECTION The movement of solutes with a water flow. In dialysis. uric acid. also known as ³solvent drag".
THE HEMODIALYSIS MACHINE The hemodialysis machine is one of the main components needed to carry out hemodialysis treatment.Dialysate Related Functions .Blood Related Functions 2. The main functions of the hemodialysis machine include: 1.
Main Components of the Hemodialysis Machine A. Blood Pump B. Dialysate Delivery System D. Monitoring Devices . Heparin Infusion Pump C.
-to help in calculation of TMP (Transmembrane Pressure) -to detect accidental separation of bloodline from AVF needle.1. Pressure Monitor These are ³T´ tubes attached to both arterial and venous blood lines and they permit monitoring of pressure at various points in the blood circuit. The air bubble detector is attached to a relay switch which automatically clamps the venous bloodline and shuts of the blood pump whenever air is detected. Venous Pressure Monitoring: -to detect any kink or clot on venous line distal to the venous chamber. Blood Circuit a. The purpose of the ABD is to prevent air bubbles which may have inadvertently entered the blood circuit From being return to the patient. b. -to detect if dialyzer is getting clotted when pressure monitoring is after blood Pump segment. They include: Arterial Pressure Monitoring: -to monitor if arterial blood supply is adequate or not. . Air Bubble Detector (ADB) This is located just distal to venous pressure monitor.
use of the dialysate greater than 42 degree C can lead to hemolysis and sweating. Use of cold dialysate causes the patient to experience chills and shivers. . Temperature Monitor Malfunction of the heater element in the dialysis machine can result in the production of excessively cold or hot dialysate.2. High or low conductivity will result in high or low blood pressure and this affect patient severely. Bypass Valve This valve is solely responsible to divert dialysate to the drain whenever either the temperature or conductivity is out of set safety limits. temperature sensors are used for continuous monitoring and the dialysate bypassed whenever out of safety limits. Any dialysate that is not within the normal acceptable range will have to be diverted to the drain. b. Thus. On the other hand. Dialysis Solution Circuit a. an excessively diluted or concentrated dialysis solution will be produced. Conductivity Monitor If the proportioning system that mixes the concentrate with water malfunctions. c.
d. e. The presence of particulates and micro bubbles can trigger a false alarm. . Negative Pressure / TMP Regulators This consist of negative (dialysate) pressure pumps and regulators and continuously monitor the total TMP and achieve the desired goal for fluid removal. stopping the blood pump and activating both visual and audible alarms. A change in translucence and light scatter in dialysate reduces the light received by the photocell. Blood Leak Detector This device is placed in the dialysate out flow line (effluent line) and detects any blood leak from the blood compartment and activates an alarm condition. A beam of light is directed through a column of dialysate onto a photoelectric cell.
dialysis machine also come with various software allowing the user to choose the desired rate and pattern of ultrafiltration (fluid removal). 3. The options are shown in the form of graphs or bar charts over the treatment time. In this era of information technology.Bicarbonate This option allows the use of the ³two concentrate´ approach to prepare a bicarbonate containing dialysis solution. Ultrafiltration controllers (UFC) have made easy the use of high-flux dialyzers with higher KUF. Bicarbonate powder packed in bag or cartridges has an advantage over solution as less storage space is required and there is less risk of contamination in freshly produced bicarbonate dialysate.Controlled Ultrafiltration Two common methods by which ultrafiltration rate can be precisely controlled include the so-called volumetric method and the use of flow sensors.Options available for upgrading of Hemodialysis machines 1. This is very useful to maintain patients blood pressure. . It also enables safe removal of the desired amount of body fluids. 2. This was previously used for acutely ill patients who are severely acidotic and has now become the standard buffer for chronic hemodialysis.Programmable Ultrafiltration Normally ultrafiltration is perform as a constant rate throughout the dialysis therapy and this was further enhanced with the availability of ultrafiltration controllers.
. Here only one vascular access line (needle) is created and arterial and venous lines are kept either close or open at any one time.4.Variable Sodium This options permit rapid alteration of the dialysis solution sodium concentration by simply turning a dial on the machine. 5.On-Line Clearance Monitor This feature allows the nurse to keep tract of the current rate of clearance of urea and the estimated Kt/v to achieved the desired goal. This is achieved by the use of ³time settings´ or ³pressure settings´ incorporated in the machines. 6. Remedial measures like increasing blood flow or increasing treatment time can be made during dialysis to achieve the set targets. The sodium concentration is usually altered by changing the proportioning of concentrate to water. Monitor The vasodilatory effect of temperature has been known to cause varied problems and with this gadget. This is good for patients with cardiac instability to stabilize blood pressure.Single Needle Dialysis This is not commonly used but is useful in patients with poor vascular access.Blood Temp. the problem is better controlled. 7. This is good tool to use in managing patients with acute renal failure and in patients with cardiac instability and low blood pressure. There has been no theories that cooler dialysate might give better treatment outcomes.
Blood Volume Monitor This monitor enables measurement of changes in blood volume during dialysis with high accuracy and is a very useful tool for patients with repeated episodes of hypotension. The use of ultrasonic sensors to measure the total relative blood volume (RBV) is possible as the sound speed across the blood water content (BWC) changes according to the density of the blood which is affected by the presence of hypotension. .8.Blood Pressure Monitor This is a fully automated non-invasive device for measuring the blood pressure. This is already available in a number of a newer models of hemodialysis machines. operating according to the oscillometric method. 9.
. the machine should be rinsed with one of the decalcifying agents such as Hemoclean or Pure sterile which contain hydrogen peroxide.Decalcification/Sterilization of HD machine The dialysis machine should be cleaned with a light disinfectant after each session of treatment. To avoid calcification along the dialysate path. although a very powerful and effective sterilant is on the decline due to its potential carcinogenic effect and environmentally unfriendly. However the use of formaldehyde. Heat sterilization is still widely used to minimized bacterial growth and spread of hepatitis. peracetic acid and sodium hypochlorite.
To check all calibrations which include blood pump flow rate.Planned Preventive Maintenance All machines have a check list for routine planned preventive maintenance and this schedule must be strictly adhered to promptly. . air bubble detector. etc. negative pressure. 4.To cut down unnecessary increase in cost of repairs. blood leak detector. conductivity.To detect early. 3.To make sure that machine is safe 2. temperature. The purpose is : 1. malfunctioning parts and cut down mean breakdown time.
The smaller the substance. Semi permeable membrane separating (1) and (2). 5. UF coefficient-Indicates water permeability and generally molecular permeability. Membrane material-Indicates blood compatibility. Clearance And Biocompatability A dialyzer is compose of dialysis membrane and supporting structure There are four components: 1. ultrafiltration (UF). Three types are available. . Dialysate Compartment 3. Blood Compartment 2. but not sieving coefficient. clearance. 4. low flux. blood volume. ultrafiltration. Blood volume-The amount of blood required to fill (prime) the dialyzer. Membrane support structure The various characteristics of the dialyzer are: 1. Surface Area-Influences clearance. intermediate flux and high flux. and sterilization method. Sterilization. 4. This can be achieved by sterilization with ethylene oxide gas. Clearance-Refers to the amount of blood which is cleared of a certain substance (eg urea) every minute.Types of Dialyzers. 6. 3. 2. steam or gamma radiation. the higher the rate of clearance.Dialyzers must be sterile and pyrogen -free.
g. .Dialyzer Flux Low (standard) flux dialyzer =substances larger than 8000 Daltons do not cross the membrane. Fresenius HF 70 =Mainly Hemofilters. =Pores are small and this is reflected by the low of ultrafiltration coefficient (between 2-9 ml/mmHg/hour). =Ultrafiltration coefficient is generally > 20 ml/mmHg/hour reflecting the larger pore size (20-80 ml/mmHg/hour) e. Intermidiate Flux =UF coefficient 10-19 ml/mmHg/hour.6.. =Synthetic membranes and altered cellulose -Polyacrylonitile (PAN) -Polysulfone -Polymenthylmethacrylate (PMMA) High Flux Dialyzer =Substances larger than 8000 Daltons cross the membrane. =A high performing high-flux dialyzer has a sieving coefficient for Beta 3 micro globulin > 0. =mainly cellulose and some synthetic membrane. =small ³marker´ molecules such as urea and creatinine pass through freely.
=Small solutes pass through without problems. Advantage of using Hollow fiber dialyzer =small priming volume =handy-small and compact =increase clearance of middle molecules =good ultrafiltration rate (UFR) =ease of processing reuse =reduced risk of leakage .000 to 12. =Always express as a percentage. =Permeability decreases with increasing molecular weight size.000 fiber-like structures (capillaries) with an internal diameter of 200 microns.Sieving Coefficient Defined as membrane permeability to solutes during ultrafiltration. Types of dialyzers available currently include the following: =PARALLEL PLATE DIALYZER (PPD) =HOLLOW FIBRE DIALYZER The hollow fiber dialyzer is the most popular of the above two types and is composed of a group of between 8.
g.x Qb ml/min. The formula used to calculate clearance (CL) is: CL=A-V ------------. The clearance values provided by the manufacturer for urea (mol wt 60) or creatinine (mol wt.Clearance (K) of a Substance The volume of blood (or plasma) from which a substance is completely cleared by the dialyzer per unit time (ml/min)... urea) V=venous sample (e. A A=arterial sample (e.112) etc are in vitro values and slightly overestimated. urea .g.
wt. There is an increase in clearance of larger molecules when high-efficiency or high-flux dialyzer are used. This is an indication of how well the membrane allows the passage of larger molecular weight solutes.Most dialyzer specifications include clearance of vitamin B 12 (mol.1355). All dialysis staff must understand that the blood flow rate plays a major role in the effectiveness of dialysis treatment and are encouraged to put the optimum possible flow rate. The average flow rate is between 300-350 ml/min for patients who are stable and have a well functioning vascular access. .
Mascular Weight (DALTONS) 1. SODIUM CALCIUM UREA CREATININE POSPHATE URIC ACID ALUMINIUM PHOSPHORUS VIT B12 INULIN HEPARIN B 2 MICROGLOBULIN ALBUMIN GLOBULIN RBC/WBC 23 40 60 113 120 168 700 838 1355 5000 800-12000 11000 68000 180000 >above . 9. 14. 5. 13. 8. 6. 4. 3. 2. 11. 10. 12. 7. 15.
The function of the dialysate is to correct the chemical composition of the uremic blood to normal physiological level. The dialysate is made up so as to correspond to normal plasma as closely as possible with certain deliberate deviations.Dialysate Used in HEMODIALYSIS Introduction The term ³dialysate´ is borrowed from physical chemistry and refers to the fluid and solutes that have crossed a membrane. acetate based dialysate was the only form available and helped to expand the hemodialysis treatment modality. This means: -to remove waste products -to normalize the electrolytes by removing some salt -to normalize the pH by adding some buffer -to maintain all vital substances In the mid 60¶s. The calcium concentration needs to be carefully balanced in relation to the administration of vitamins D analogs and calcium-containing phosphate binders to avoid hypercalcemia while still preventing secondary hyperparathyroidism. . The concentration of sodium should be close to the patient¶s physiological level to avoid intercompartmental fluid shifts as well as a sodium loading. The ideal dialysate should contain bicarbonate as buffer.
nausea . better phosphate removal . The patients who where dialyzed with acetate buffer experienced problems of hypotension. better biocompatibility . dialysis treament is better tolerated etc. post treatment fatigue µnot feeling well¶.However there are many disadvantages of using acetate based dialysate for being revealed and slowly but steadily began to be replaced with bicarbonate based dialysate in the 70¶s and aggressively in the 80¶s. vomiting . The advantages of using bicarbonate dialysate include less episodes of hypotension. vomiting . nausea . . stable blood gases .
. a ³bicarbonate" component and an ³acid" component. They include sodium chloride. The advantage of acetate concentrate is the it is stable during storage and is not prone to bacterial contamination. Thus bicarbonate concentrate is prepared in the form of two components . The second problem with bicarbonate concentrate is that it is an excellent growth medium for certain bacteria and should always be handled aseptically. The precipitation of calcium carbonate must be avoided. Both from a microbiological and a chemical point of view. This is achieved by separating the calcium ions from the bicarbonate ions during storage.3 and this is achieved by the addition of acetic acid in the A concentrate. 2 practical issues need special attention. During mixing the pH should be below 7. bicarbonate concentrates should not be stored once the canisters are opened as stability will be affected due to liberation of carbon dioxide which acts as a stabilizer.Types of Dialysate Concentrates There are usually 5 compounds used in the preparation of dialysate concentrate. potassium chloride and magnesium chloride. Serum carbonate is depleted and the acetate level may exceed the rate at which the liver can metabolize it. Acetate dialysate is not suited for rapid. high-efficiency dialysis or high-flux dialysis. sodium bicarbonate or sodium acetate. Bicarbonate Concentrate When using bicarbonate in dialysis. calcium chloride. this is gradually being replaced with bicarbonate dialysate. All hemodialysis machines are designed to be able to use acetate concentrate as the proportioning of reverse osmosis water and dialysate concentrate is simple in the ratio of 1 part concentrate to 34 parts of water to produce acetate dialysate. Acetate Concentrate Many patients have been treated with this type of dialysate for many years but because of some of the side effects experienced by patients.
Magnessium-0.00 (mmol/L) .Potassium-1. Sodium-65.25. magnesium.and Bicarbonate-35.Calcium1.80 and Acetate-4.9.70. and a small amount of acetic acid.Solution ³B´ (indicating bicarbonate) concentrate contains the sodium bicarbonate and part of the sodium chloride.Chloride-26. Eg. Sodium-75. chloride.00.00.00 (mmol/L) 2.00. calcium. potassium.Chloride-80.Solution ³A´ (indicating acidified) concentrate contains most of the sodium.1. Eg.
1. 7. 4. 10. 8. . Ensure that only reverse osmosis water that meets AAMI standards is used for the preparation of the dialysate by the hemodialysis machine. 6.Quality control when handling dialysate concentrate. Observe an investigate for any undue intradialytic patient reactions of a serious nature or uncommon event. Quality control and quality assurance procedure should be establish to ensure conformance to policies and procedures regarding dialysate quality. Take extra precautions to check for bacterial growth when central delivery system for bicarbonate is used. 2. Monthly dialysate analysis for both electrolyte content microbiological / endotoxin content should be done. Liquid bicarbonate concentrate should not be used after being opened for more than 24 hour while the acid solution should be used wihtin 72 hours. 5. Ensure that the hemodialysis machine are in good safe working order with all audio and visual alarms functional to detect any abnormality in the content of the concentrate being used. Ensure proper storage condition and away from sun light and poison puck and similar canisters. 9. Staff handling new canisters of dialysate concentrate should verify correct formula and check that the caps are still intact. Dialysate should be verifies for each dialysis and the nurse should check the conductivity reading on the hemodialysis machine and used the manual conductivity meter (myro meter / phoenix meter) whenever in doubt. 3.
WATER TREATMENT FOR HEMODIALYSIS
1. INTRODUCTION Water has a unique property of being an excellent solvent high heat capacity and surface tension and hence it is very susceptible to be contaminated to the point were it becomes a health hazard. Water is used extensively for making the dialysate required for hemodialysis treatment. A normal person drinks between 1.5-2 liter of water per day and this amount to about not more than 15 liter per week. A patient on hemodialysis is exposed indirectly to about 120 liter of water per session (Dialysate flow rate 500 ml x 60 min x 4 hours) of dialysis therapy and this amounts to about 400 liters per week. The quality of water used is therefore critical to the preparation of a dialysis fluid. It should be free of contaminants which have harmful effects on the health of the patient. The contaminant which may be present in water include suspended solids, dissolve organic and inorganic, heavy metals and trace minerals and microorganism.
CONTAMINANTS IN WATER AND ASSOCIATED DIALYSIS COMPLICATIONS.
Main category impurities are: 1. Suspended solids 2. Dissolved inorganic -sand, silica, etc. -calcium, sodium -magnesium -nitrate, sulfate -chloramines -pesticides, etc.
3. Dissolve organic
4.Heavy metals and Trace elements
-iron, copper, lead -aluminium -cadmium, etc -bacteria, pyrogens -algae -endotoxins
Contaminants and potential toxic effects.
Substance 1 Aluminum Toxic effect - Dialysis encephalopatyrin - Bone disease - Microcytic anemia
- Hypercalcaemia - Hypomagnesaemia 3. Chloramines - Hemolysis, anemia 4.Flouride - Osteoporosis, Osteomalacia 5. Sodium - Hypertension - pulmonary edema - tachycardia - vomiting - headache 6. Zinc - Anemia, nausea - vomiting 7. Sulfate - Nausea, metabolic acidosis 8. Ph - Heparin inactivation - itching 9. Microorganism - Febrile reaction
2. Calcium / Magnesium
25 EU / ml (EU Standard) . To prevent premature damage to the hydraulic parts in the machine. 3. To prevent long term side effects of inadequatley treated water. 4. 2. 2. Calcium and magnesium <0. Acceptable Water Content.Importance of water treatment 1. 1.5 ppm (parts per million) Free from chlorine Free from ions Bacteria count <200 cfu / ml (AAMI Standard) <100 cfu / ml (EU Standard) Endotoxin level < 2 EU / ml (AAMI Standards) < 0. 3. 5. To facilitate production of dialysate with accurate electrolyte content.
.Carbon filter upstream RO unit .No oversized pipes or tube . .HYGENIC ASPECTS ON WATER AND DISTRIBUTION LOOP .Low surface area in softeners and lifter columns.No stagnant or slow moving water .Prevent air contamination in indirect feed of RO water.No rough joints or surfaces .Facilities for disinfection .
001 0.10 0.00 4. Substance Aluminum Chloramines Copper Fluoride Nitrate Sulfate Zinc.14 0.50 0.10 0.01 0. barium Calcium Magnesium Sodium Potassium Chlorine Arsenic.005 each 0.00 70.20 2.10 each 2. lead.AAMI Hemodialysis Water Quality Standard.002 <200 cfu / ml <2 EU / ml .9 0.00 8.00 0.00 100. silver Chromium Cadmium Selenium Mercury Bacteria Endotoxin Maximum concentration (mg/l) 0.0 0.
Reveres Osmosis Water Treatment Equipment Requirments. These include materials such as plastic or appropriate stainless steel. 1. Materials compatibility Any material that contract purified water in a water treatment system should be un reactive in nature to prevent contamination of the product water. assuring there is a means for removal of the disinfectant used. 2. and assure that there is a warning system so the water system cannot be used during the disinfection mode. . Disinfection protection The manufacture of the equipment is responsible for recommending disinfectants to be used in the system .
Safety requirements.1 Monitors shall be design so they cannot be disable while a patient is at risk except for brief necessary period under manual control with the operator at constant attention. 3.5 Electrical circuits shall be separate from hydraulic circuit and adequately protected from fluid leaks.3. conductivity or TDC (total dissolve solid) monitor shall be temperature ± compensated.3 Resistively.2 The sound emitted by audible alarms shall be at list 65 decibels (³A´ scale) at three meter and it shall not be possible to silence these alarm for more than 180 seconds. 3. Each water treatment device shall exhibit the following safety requirements: 3.4 Operation control should be position to minimized inadvertent resetting. 3. 3. .
The purity of the water required The quality of the municipal water supply (chemical and microorganism) The amount water required 4. Treatment Devices 4.4. .1 The decision making process requires three key input parameters: a. activated carbon filter and micro filter.2 Water treatment systems can be divided into three section : a. c. The minimum size be1500 liter to 2000 liters and com complete with cover. b. THE DISTRIBUTION LOOP for reverse osmosis devises A. PRIMARY TREATMENT involving one or more reverse osmosis devices . c. The tanks should be regularly inspected for dirt particle etc and clean at least once a year. PRE-TREATMENT consisting of water storage tanks sediment filter. PRE-TREATMENT (1) Raw water storage tanks The material used should be off stainless steel (grade 304) or high density Polyethylene (HDPE) the tanks should be place in a clean and safe environment with direct feed from the nearest main supply. softener. b.
)Filters Pre filter also sediment filters o sand filters. Back washing at night allows this sediment filter to flush the trapped matter to the drain.(2. remove large particle ranging from 500 micro down to about 5 micro and are generally employed to removed particles and prevent fouling of devices farther downstream layer of coarse-to-fine sand (multimedia filter) remove particle from the feed water. The sand well assume it original layer position and will be ready for duty the following day. . The method is economical and effective.
. Water softener operate on this principle resin head in the tank are coated with Na+. The high concentration of sodium replaces the calcium and magnesium from the beads. There for it is important to check timer on a regular basis to avoid this action during treatment hours. Monitoring of the salt (brine) tank level and product hardness is also important.(3) Softeners Softening of the in coming water is necessary to avoid he hard water syndrome suffer by dialysis patient due to dialysis water contamination with calcium and magnesium and to prevent calcium carbonate scale formation on other water treatment devices downstream. At the time of regeneration the exhausted brine has is sent to the drain. An adjoining salt tanks (brine tank) replenishes and regenerates the softener at night by means of a timer.
the carbon media should be discarded and replace with new carbon. The second tank should be move to the first position. (5) Micro filter Micro filter remove intermediate sized particle of 5-1 micron in diameter and are situated in the pre treatment and primary treatment section of the system in order of decreasing particle size cut off. A formula is used to determine empty bed contact time (EBCT) and the goals is 6-12 minutes(3-6 minutes per working and polishing tank (S).(4) Activated Carbon Filters Carbon adsorption tanks should be size for the maximum of two tanks in a series configuration (one tank feeding the next) A simple port for testing the water after the first tank and before the next tank should be in place. Upon exhaustion (chlorine/chloramines breakthrough) of the first tank. . and the new tank place in the last position.
B. The RO should provide AAMI quality water and minimum rejection level should be set. The audible alarm should be audible in the patient care area when reveres osmosis is the last chemical purification process in the water treatment system. They also prevent bacteria and endotoxin passage. All RO membrane are design for cross flow filtration so the feed water is separated into two streams a permeate (product water) of purified water which has pass through the membrane and a concentrate which has a high concentration of contaminant (reject water). Dissolve solid are un able to pass through the membranes enclosed and pure water the hydraulic pressure overtakes the osmotic pressure. This should constantly be monitored electronically or manual but manual verification should be periodic. Taken from the feed and product flows the percentage of rejected dissolve solids remove is calculated by the formula. . The RO members should be regularly flushed to prevent layering of contaminant effectiveness of the membrane. Common membrane used is the thin film composite. The product water conductivity monitor should activate audible and visual alarm when the product water conductivity exceeds the present alarm limit. From this we derive the term ³reverse osmosis´. Primary treatment (1) Reverse osmosis Unit RO units are the most effective of treating water. Conductivity is the vital measurement in any reverse osmosis system.
DISTRIBUTION LOOP The product water distribution system should not contribute chemical such as aluminum copper zinc and lead or bacterial contamination to the final product water.C. . No need ends or multiple branches should exist in the piping system. and used of simple wall outlets with the shortest possible fluid path and minimum pipe fitting are recommended. It is advisable to use either stainless steel or cross link polyethylene (PEX) material for the piping system. Both direct (no storage tank) and indirect (with storage tank) water distribution system should be configured as a continuous recirculating loop designed with the proper flow and velocity to minimize bacterial proliferation and biofilm formation.
pipes.TREATMENT SYSTEM MAINTENANCE AND QUALITY CONTROL The complete treatment system must be regularly disinfected filters and resin must be periodically clean regenerated and change and precaution should be taken again the formation of biofilms. 2. Biofilm represent one of the most persistent problems in dialysis unit biofilm is a term used to describe the bacteria attached to a surface surrounded by a matrix of their own making. Make it easy for staff to utilized and educate them on the need to recognized and report abnormal findings. 5. . The manufactured of the equipment is responsible for recommending disinfectant to be used in the system assuring there is a means for removal of the disinfectant to safe level recommending testing method for the disinfectant used and assure that there is a warning system so the water system cannot be used during the disinfection mode. They form easily in any crevices or corner of container. It should be numbered sequentially with corresponding number on a system itself. #10% increase in pressure #10% loss in product water quality. Steps in prevention include the avoidance of a water stagnation. uneven surfaces and sharp bend in the water treatment system and storage tanks. low share (turbulent) rates dead end pipes. #10% loss in product water flow. 3. The simple and easy-to-follow water system log is crucial. It also attracts nutrients for bacterial growth. Normal operating parameter should be include on the log adjacent to the information being recorded. 1. 4. treatment devices storage tanks and dialysis machine and are extremely difficult to remove. The 10% rule can be used to determine when to clean the RO membrane. This matrix protects them from this infecting agents and from being swept away by flowing fluid.
To minimize bacterial growth and also save on storage space. In the closed system. Many of the manufacturers of dialysate concentrates have different formulations with different levels of calcium ions to meet the needs of different patients. Many of the hemodialysis machines come with retrofit kits to facilitate the use of powder bicarbonate. .CO2 cannot bubble off. the reaction between sodium bicarbonate and acetic acid cannot proceed to completion. the ³B´ concentrate is usually diluted partially with water the ³A´ concentrate is then proportioned into the mixture just before it goes to the dialyzer. manufacturers now produce the bicarbonate in both solution and powder form (bags or cartridges). and the hydrogen ion content keeps the calcium in solution. Please note that whenever bicarbonate cartridges are used.In the proportioning system. a different concentrate ³A´ solution is used unlike the one used with liquid carbonate concentrate.
Acute benefits Benefits from using bicarbonate in dialysis + no vasodilatation + better fluid management + normal blood gases and breathing + no physiological accumulation of metabolites + better phosphate control + less cytokine induction + better control of acidosis Long term benefits: + normalize acid ±base balance + normalize protein metabolism + optimized body weight + fever long-term complication .
Patients with respiratory problem. 10. 8. Dialysis of pregnant patients. 3. 2. vomiting or hypotension requiring frequent fluid replacement therapy while on acetate dialysis. In cachexic patients who continue to loose weight of adequate acetate hemodialysis.PRIORITY FOR BICARBONATE DIALYSIS IN HEMODIALYSIS UNIT 1. 7. Patients have angina occurring during acetate dialysis with/without arrythmia. those with already deforemed chest wall. 9. 6.g. 4. During high flux dialysis. . Patients with hyperphospatemia. e. 5. Dialysis of geriatic patients. Patients who have severe nausea. Dialysis of acutely ill patients. Patients who have severe cramps or generalized lethargy with or without cramps during dialysis and during the interdialytic period.
Intradialytic lipid infusion 6.High ultrafiltration rate resulting in blood concentration 4.Inadequately reprocessed dialyzer 7.High hematocrit 3.Biocompatible membrane .Blood transfusion during dialysis 5. Poor blood flow 2.ANTICOAGULATION AND HEPARIN ADMINISTRATION ± Factors that aid clotting of the extracorporeal blood : 1.
5. Pre ± Surgery 10. Post ± Surgery 11. 3. 8. 6. 4. . 2. Pericarditis 1. 7.Factors to be considered before deciding heparin dose : Body weight of patient Total volume of extracorporeal blood Blood flow rate Reuse of dialyzer Hematocrit Intradialytic blood transfusion Any underlying bleeding state or disorder Any abnormality in bleeding time and clotting time readings 9.
A minimum of blood flow rate of between 175 ± 200 mls/min is maintained throughout the dialysis . . . etc. a saline rinse is done to the extracorporeal circuit and physical observation made to see any early signs of clotting. Continuous heparinization .An intravenous priming dose is given at the beginning of dialysis and smaller doses are repeated intermittently throughout the treatment.safe and reliable one .The initial dose is usually between 2000-4000 iu and 500-1000 iu given every hour thereof. .Common Methods of Heparinization 1. Tight Heparinazation . before the next hour and so on. Heparin ± free dialysis .prior to end of dialysis 2. followed by continuous infusion of about 1000 iu per hour.³A dose of heparin adequate to keep ACT at 40%´ above baseline is the rule in this technique 4. of dialysis and reduced to 40% during last hour 3. .It is also preferable to use less thrombogenic dialyzer (e.The heparinsed saline used for priming the extracorporeal blood circuit is flushed out completely to ensure no heparin infusion into patient.1000 iu of heparin is given and clotting times are done 15 min.This method is gradually phasing off the ³Tight Heparin´ method and is commonly used in cases of active bleeding. .Every 20 ± 30 minutes.A bolus dose of between 750.percarditis. intracranial bleed.Average bolus varies between 3000-5000 iu .Initial heparin dose /³Bolus´ dose is given at start of dialysis & followed by constant heparin infusion pump available in the machine.Heparin infusion is terminated 30 min. .The activated clotting timer machine (ACT) is commonly used NOTE: In general the ACT reading should be 80% above baseline during first 3 hrs. polysulphone dialyzer.) . Intermittent heparinization . recent surgery.g.Indicated in patients who are slight to moderate risk for bleeding . .Monitoring of actual clotting time should be closely monitored . The additional saline used for periodic flushing should be included in the goal set for fluid removal .most common method .
size artery such as radial and brachial artery. A breakthrough came in the year 1966 when the arteriovenous fistula was introduced by Cimino and Brescia. In order to avoid side effects which might be detrimental to the heart. vascular access is usually created on medium.VASCULAR ACCESS FOR HEMODIALYSIS B. The Vascular access is the main lifeline for the patient on hemodialysis The need for vascular access in patients with renal failure can be either temporay of permanent . It was the first permanent means of easy access to the blood for the treatment of chronic renal failure. Scribner was the first to create an arteriovenous shunt in 1960.H.
Transplant recipients requiring temporary hemodialysis 5. Patients requiring either plasmapheresis or hemoperfusion 6.Temporary Access Indications : Temporary access is used in the following group of patients who require hemodialysis or extracorporeal blood therapy : 1. Patients awaiting maturity of AVF 7. CAPD patients requiring temporary hemodialysis 4. Patients on Continuous Renal Replacement Therapy (CRRT) . ESRD patients without permanent vascular access 3. Patients with acute renal failure 2.
Single Lumen Catheter 2.Types of temporary access : 1. Femoral vein . Double Lumen Catheter Most common are made of either Teflon. polyurethane (PUR) or silicone material Common sites used for access include : 1. Internal Jugular vein 3. Subclavian vein 2.
Care of temporary vascular access :
1. Aseptic technique 2. Proper administration of anticoagulant including heparin block 3. Constant observation for any signs of inflammation 4. Proper anchoring of catheter to avoid dislodgement 5. Look out for any signs of skin erosion, thrombosis and hemorrhage
1. 2. 3. 4. The available types of permanent access include the following : Arteriovenous shunts ± not commonly used now Arteriovenous fistula (AVF) Arteriovenous grafts Permanent catheters
Arteriovenous Shunts The Quinton ±Scribner shunt consists of two Teflon cannula. placed in the radial artery at the wrist and in vein of the lower arm. . this is rarely used now. However due to its many complications and the need to be on oral anticoagulants. and the two tubes are externally connected by a removable Teflon connector. Each cannula is connected to a piece of silastic tubing. 1.
It is constructed in non dominant hand. Advantages of AVF 1. Patient has better arm comfort during dialysis An Immature fistula 1. Has minimal effect on their physical appearance 4. Difficult to cannulate 2. The AVF is usually allowed to rest and mature over a period of between 6-8 weeks and the patient is advised to do light passive exercises of that hand.Poor flow 2. It is superficial access in the lower arm 2. Has fragile veins resulting in blood leakage 3.Infection . Arteriovenous fistula The Cimino ± Brescia arteriovenous fistula is the type of vascular access that is most commonly used. end to side anastomosis.Ischaemia of the hand 4. or better. Has quicker homeostasis post hemodialysis 5. Easy to cannulate 3. Has inadequate blood flows for effective hemodialysis Complications of AVF 1.Edema of the hand 5.Aneurysm 6.2.Thrombosis 3. The fistula is usually created between the radial artery at the wrist and the superficial cephalic vein by side to side .
Avoid prolong period of hypotension 8. Do not take blood pressure on fistula arm 4. Care of AVF : 1. Do not use tight fitting clothing across fistula arm 5. Report to HDU if any sluggish flow detected . Allow adequate time for maturation of AVF 3. No blood sampling or any venipuncture other than hemodialysis 6. Protect future access arm from damage to the vasculature 2. Feel for bruit or thrill at least 2-3 times a day 7.
Occlusion 9.The Vectra Vascular Access Graft (VAG) 3.Pseudoaneurysms 5.Swelling 12.PTFE grafts (Polytetrafluoroethylene) 2.Skin erosion .3.Bleeding 8.Thrombosis 2.Stenosis 10.Graft Infection 3.Embolic events 7.Steal Syndrome 4. Arteriovenous Grafts >The graft is inserted between artery and nearby vein >Both straight and semi curved graft configurations are commonly used Types of synthetic grafts : 1.Dacron or Teflon grafts ( Not commonly used) Complications of Grafts : 1.Kinking/compression 11.Anastomatic disruption 6.
After implant. The needle is then rotated until the face of the bevel is directed downward and advanced parallel to the graft. If the needle is inserted 90 degree angle. If the blood access needle is inserted such that the angle between the needle axis and the graft is too small. provided no contraindications are present.Cannulation These type of grafts may be punctured for vascular access within 24hrs. tears in the wall of the graft can occur. Insert the blood access (dialysis) needle at a 45 degree angle with the bevel up until the graft is penetrated. which may lead to hematoma formation . it increases the possibilty of puncturing the far wall of the graft.
As with all dialysis. These graft generally seal within 1-5 minutes depending on the anticoagulation regime used. bleeding. edema. Strict adherence to aseptic technique 4. For best results follow the established practices listed below : 1.or in absence of strong ³thrill´ 5. of proximal or distal anastomosis 3. Prolong compression or use of clamps may lead to clot formation. do not cannulate if there are signs of infection. Rotate cannulation sites 2. swelling. hematoma. restricting flow through the graft . Do not cannulate within 2 cm.
ascites) Blood pressure under control with minimum drugs or none No cardiomegaly (CXR) Active d well rehabilitated 3 Importance of DRY WT. To confirm if patient has put on body mass and not fluid accumulation . To help in setting total fluid to be removed (GOAL) 2. To assess if patient is compliant to diet and fluid control 3.DRY WEIGHT This is the weight to be maintained by any patient on chronic hemodialysis. facial. at this weight the following signs and symptoms can be noted : Effort tolerance is good No shortness of breath (SOB) No signs of edema (Ankle. : 1.
1.vomiting. 5. 6. HOW TO ASSESS DRY WEIGHT Do chest X ray prior to initiating hemodialysis Adequate counseling and monitoring on diet Carry out gentle hemodialysis for 2-3 weeks Review by doctor to reduce antihypertensive drugs as necessary Observe for presence of edema Record all signs and symptoms of during hemodialysis like hypotension. 3. 7. . 2.etc. has to be reviewed at least three monthly to accommodate for any increase in body mass due to good rehabilitation and adequate dialysis. 4.cramps. Repeat CXR when desired weight is achieved Review by doctor to confirm dry weight Note : Dry wt. 8.
and then followed by 4 hrs. or last hr. The patient should be advised that this is not ideal way to relieve fluid overload and better fluid and dietary compliance is needed . TMP = Venous pressure (VP). of conventional dialysis.Patient in pulmonary edema > Procedure : At the 1st hr. Transmembrane Pressure (TMP) > The difference between pressure of the blood side and the fluid side on the membrane. This is also called isolated ultrafiltration and can be performed by most of the hemodialysis machines > Indications : 1. of dialysis depending on the clinical practice guidelines of the dialysis unit. Above dry weight) 2.Dialysate pressure (DP) TMP is expressed as mmHg Ultrafiltration Rate (UFR) > The amount of water removed per hour per millimeter of mercury transmembrane pressure (ml/hr/mmHg/) Osmotic Pressure > The pressure which develops when two solutions of different concentrations are separated by a semi permiable membrane Ultrafiltration Controller (UFC) > UFC is incorporated in most of the hemodialysis machines and this gadget automatically manages total fluid removal during hemodialysis treatment as per set goal Sequential Ultrafiltration > Aims to get rid of excess water from the patient by doing hemodialysis without using any dialysate.ULTRAFILTRATION > The filtration of water by pressure gradient between two sides of a semi permeable membrane. In most centre this is done 1st hr. Fluid Overload ( 3-4kg.
Muscle Cramps 2. Hypertension 13. in descending order of frequency include the following : 1. Headache 4. Hemolysis 12. Fever and Chills 8. Hypotension 5. Nausea and Vomiting 3. Bleeding / Clotting 10. Convulsions 11. Itching 7. Hematoma 15. First use syndrome 16. Hypoxia . Disequilibrium syndrome 14. Air embolism 9. INTRADIALYTIC COMPLICATIONS AND MANAGEMENT The intradialytic complications that can occur. Chest pain and back pain 6.
Better wellbeing .Dialysis adequacy Pts. Are dialyzed 3x /week .Less hospitalization 5. 4hrs.Better quality of life 3.Improved survival rate w/ minimum complications 2.Better rehabilitation 4./ session w/ the objective of achieving near normal chemical content in blood Importance of providing adequate dialysis to hemodialysis patients : 1.
Ineffective urea clearance 2. Persistent hyperkalemia and metabolic acidosis 2. itchiness. loss of appetite. Blood sampling and timing errors . Poor protein intake due to anorexia 3.etc.) Factors interfering with adequate dialysis 1. Reduction in treatment time 3.Signs of inadequate dialysis : 1. Marked uremia and its symptoms (e. Resistance to moderate doses of Erythropoietin in achieving acceptable levels of hemoglobin or hematocrit 4.g. hiccup.
Used of contaminated water to prepare bicarbonate 4. Nosocomial transmission of blood borne diseases (HBV.Infection Control in Hemodialysis ³ INFECTION constitute the second commonest cause of death in chronic dialysis patients after cardiovascular events´. Vascular access (Temporary vascular access catheters and grafts) 2. Common sources of infection : 1.MRSA) 6.HIV. Use of contaminated bicarbonate concentrate 3.HCV. Multiple blood transfusions to correct anemia 7. Poor adherence to standard precautions protocol . Poor quality control during reprocessing of dialyzers 5.
9. 7. 6. 5. Anemia Renal Osteodystrophy Hepatitis Malnutrition Dialysis Encelopathy Neoplasm Dialysis related Amyloidosis Cardiovascular disease Uremic Neuropathy . 2. 3. 4.Long term complications of hemodialysis 1. 8.
Calcium channel blockers (e.labetol.Medications for hemodialysis patients 1.metoprolol. ACE Inhibitors (e. Calcium carbonate b. 3. Alpha blockers b. captopril.atenol) c.g.g. Antihypertensive drugs >Common types are: a. .enalapril) Phosphate Binders > Common types are : a. Calcium acetate Hematinics Vitamin D Erythropoietin 2. Beta Blockers (e. 5.g. . 4.amlodipine) d. nifedipine.
3. 2. 4.Common psychological problems encountered by patients on hemodialysis 1. Depressions (Including suicide) Uncooperative behavior Sexual dysfunction Rehabilitation .
e. Psychotherapy 4. . CRF to ESRD ) 2. suddenly begin to behave differently 10. Referral to psychologist for counseling 7.Treatment for psychological problems Patient should be informed about deteriorating illness and impending outcome (i. Simple exercises 6. Pre hemodialysis orientation 3. Use of drugs for more difficult patients 8. Staff should take initiative to organize family day outing with patients and encourage them to write articles in dialysis bulletins 1. Staff must be vigilant when someone who has been active and well. Introduction of mentor system 9. Patients who are rehabilitated on the hemodialysis program can be a role models 5.
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