Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Focus on Dialysis (Relates to Chapter 47, “Nursing Management: Acute Kidney Injury and Chronic Kidney Disease,” in the textbook) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Dialysis Movement of fluid/molecules across a semipermeable membrane from one compartment to another Used to correct fluid/electrolyte imbalances and to remove waste products in renal failure Treat drug overdoses Clinically, dialysis is a technique by which substances move from the blood through a semipermeable membrane and into a dialysis solution (dialysate). Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Dialysis Two methods of dialysis available Peritoneal dialysis (PD) Hemodialysis (HD) In PD, the peritoneal membrane acts as the semipermeable membrane. In HD, an artificial membrane (usually made of cellulose-based or synthetic materials) is used as the semipermeable membrane and is in contact with the patient’s blood. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Dialysis Begun when patient’s uremia can no longer be adequately managed conservatively Initiated when GFR (or creatinine clearance) <15 mL/min This criterion can vary widely in different clinical situations, and the physician will determine when to start dialysis on the basis of the patient’s clinical status. Certain uremic complications, including encephalopathy, neuropathies, uncontrolled hyperkalemia, pericarditis, and accelerated hypertension, indicate a need for immediate dialysis. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

General Principles of Dialysis Diffusion Movement of solutes from an area of greater concentration to an area of lesser {See next slide for figure.} Hemodialysis patients are exposed to 120 to 130 L of water during each dialysis treatment. Small-molecular-weight substances can pass from the dialysate into a patient’s blood, so the purity of the water used for dialysis is monitored and controlled. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Osmosis and Diffusion Across Semipermeable Membrane Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

General Principles of Dialysis Osmosis Movement of fluid from an area of lesser to an area of greater concentration of solutes Glucose is added to the dialysate and creates an osmotic gradient across the membrane, pulling excess fluid from the blood. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

General Principles of Dialysis Ultrafiltration Water and fluid removal Results when an osmotic gradient occurs across the membrane Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Peritoneal Dialysis Peritoneal access is obtained by inserting a catheter through the anterior wall. Technique for catheter placement varies. Usually done via surgery In the United States, approximately 12% of patients receiving dialysis treatments are on PD. Preparation of the patient for catheter insertion includes emptying the bladder and bowel, weighing the patient, and obtaining a signed consent form. {See next slide for figure.} Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Tenckhoff Catheter Fig. 47-5. Peritoneal dialysis showing peritoneal catheter inserted into peritoneal cavity. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Peritoneal Dialysis After catheter is inserted, skin is cleaned with antiseptic solution and sterile dressing applied. Connected to sterile tubing system Secured to abdomen with tape Catheter irrigated immediately Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Peritoneal Dialysis Waiting period of 7 to 14 days preferable 2 to 4 weeks after implantation, exit site should be clean, dry, and free of redness/tenderness. Once site has healed, patient may shower and pat dry. Some patients just wash with soap and water and go without a dressing; others require daily dressing changes. However, teach all patients to examine their catheter site for signs of infection. Showering is preferred, as the exit site should not be submerged in bath water. {See next slide for figure.} Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Peritoneal Catheter Exit Site Fig. 47-6. Peritoneal catheter exit site. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Peritoneal Dialysis Dialysis Solutions and Cycles Available in 1- or 2-L plastic bags with glucose concentrations of 1.5%, 2.5%, and 4.25% Electrolyte composition similar to plasma Solution warmed to body temperature Dialysis solutions vary, and the choice of exchange volume is primarily determined by the size of the peritoneal cavity. A larger person may tolerate a 3-liter exchange volume without any difficulty, whereas an average-size person usually tolerates a 2-liter exchange. Ultrafiltration (fluid removal) during PD depends on osmotic forces, with glucose being the most effective osmotic agent currently available. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Peritoneal Dialysis Dialysis Solutions and Cycles Three phases of PD cycle Inflow (fill) Dwell (equilibration) Drain Called an exchange Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Peritoneal Dialysis Dialysis Solutions and Cycles Inflow Prescribed amount of solution infused through established catheter over about 10 minutes After solution infused, inflow clamp closed to prevent air from entering tubing The flow rate may be decreased if the patient has pain. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Peritoneal Dialysis Dialysis Solutions and Cycles Dwell Diffusion and osmosis occur between patient’s blood and peritoneal cavity. Duration of time varies, depending on the method. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Peritoneal Dialysis Dialysis Solutions and Cycles Drain 15 to 30 minutes May be facilitated by gently massaging abdomen or changing position The cycle starts again with the infusion of another 2 L of solution. For manual PD, a period of about 30 to 50 minutes is required to complete an exchange. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Peritoneal Dialysis Systems Automated peritoneal dialysis (APD) Cycler delivers the dialysate. Times and controls fill, dwell, and drain. Continuous ambulatory peritoneal dialysis (CAPD) Manual exchange APD is the most popular form of PD, as it allows patients to accomplish dialysis while they sleep. The machine cycles four or more exchanges per night with 1 to 2 hours per exchange. {See next slide for APD figure.} CAPD: Exchanges are carried out manually by exchanging 1.5 to 3 L of peritoneal dialysate at least 4 times daily, with dwell times averaging 4 hours. For example, one schedule starts exchanges at 7 AM, 12 noon, 5 PM, and 10 PM. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Automated Peritoneal Dialysis Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Peritoneal Dialysis Complications Exit site infection Peritonitis Hernias Infection of the peritoneal catheter exit site is most commonly caused by Staphylococcus aureus or S. epidermidis (from skin flora). Most frequently, peritonitis occurs because of improper technique in making or breaking connections for exchanges. Because of increased intraabdominal pressure secondary to dialysate infusion, hernias can develop in predisposed individuals such as multiparous women and older men. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Peritoneal Dialysis Complications Lower back problems Bleeding Pulmonary complications Protein loss Increased intraabdominal pressure can cause or aggravate lower back pain. Bloody effluent over several days or the new appearance of blood in the effluent can indicate active intraperitoneal bleeding. Atelectasis, pneumonia, and bronchitis may occur from repeated upward displacement of the diaphragm, resulting in decreased lung expansion. The amount of protein loss is usually about 0.5 g/L of dialysate drainage, but it can be as high as 10 to 20 grams per day. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Peritoneal Dialysis Effectiveness and Adaptation Short training program Independence Ease of traveling Fewer dietary restrictions Greater mobility than with HD Learning the self-management skills required to do peritoneal dialysis is usually accomplished in a 3- to 7-day training program. Mortality rates are about equal between in-center hemodialysis patients and peritoneal dialysis patients for the first few years. However, after about 2 years, mortality rates for patients receiving PD are higher, especially for the elderly with diabetes and patients with a prior history of cardiovascular disease. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Hemodialysis Vascular Access Sites Obtaining vascular access is one of the most difficult problems. Types of access include Arteriovenous fistulae and grafts Temporary vascular access AVF have the best overall patency rates and the least number of complications (e.g., thrombosis, infection) of all vascular accesses. In some situations when immediate vascular access is required, percutaneous cannulation of the internal jugular or femoral vein is performed. {See next 4 slides for figures.} Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Vascular Access for Hemodialysis A, Arteriovenous fistula. B, Arteriovenous graft. Fig. 47-8. Vascular access for hemodialysis. A, Arteriovenous fistula. B, Arteriovenous graft. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 25

Arteriovenous Fistula Arteriovenous fistula created by anastomosing an artery and vein. A subcutaneous arteriovenous fistula (AVF) is most commonly created in the forearm with an anastomosis between an artery and a vein (usually cephalic). Fig. 47-9. Arteriovenous fistula created by anastomosing an artery and vein. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Vascular Access Catheter Temporary double-lumen vascular access catheter for acute hemodialysis. A, Soft, flexible dual-lumen tube is attached to a Y hub. B, The distance between arterial intake and venous return lumina typically provides recirculation rates of 5% or less. Fig. 47-10. Temporary double-lumen vascular access catheter for acute hemodialysis. A, Soft, flexible double-lumen tube is attached to a Y hub. B, The distance between the arterial intake and the venous return lumina typically provides recirculation rates of 5% or less. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Vascular Access Catheter A, Right internal jugular placement for a tunneled, cuffed semipermanent catheter. B, Temporary hemodialysis catheter in place. C, Long-term cuffed hemodialysis catheter. Fig. 47-11. A, Right internal jugular placement for a tunneled, cuffed semipermanent catheter. B, Temporary hemodialysis catheter in place. C, Long-term cuffed hemodialysis catheter. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Hemodialysis Dialyzers Long plastic cartridge that contains thousands of parallel hollow tubes or fibers Fibers are the semipermeable membrane. The blood is pumped into the top of the cartridge and is dispersed into all of the fibers. Dialysis fluid (dialysate) is pumped into the bottom of the cartridge and bathes the outside of the fibers with dialysis fluid. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Hemodialysis Procedure Two needles placed in fistula or graft Needle closer to fistula or red catheter lumen pulls blood from patient and sends to dialyzer. Blood is returned from dialyzer to patient through second needle or blue catheter. Heparin is added to the blood as it flows into the dialyzer because any time blood contacts a foreign substance, it has a tendency to clot. {See next slide for figure.} Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Components of Hemodialysis Blood is removed via a needle inserted into a fistula or via catheter lumen. It is propelled to the dialyzer by a blood pump. Heparin may be infused as a bolus predialysis or through a heparin pump continuously to prevent clotting. Dialysate is pumped in and flows in the opposite direction of the blood. The dialyzed blood is returned to the patient through a second needle or catheter lumen. Old dialysate and ultrafiltrate are drained and discarded. Fig. 47-12. Components of a hemodialysis system. Blood is removed via a needle inserted in a fistula or via catheter lumen. It is propelled to the dialyzer by a blood pump. Heparin is infused either as a bolus predialysis or through a heparin pump continuously to prevent clotting. Dialysate is pumped in and Flows in the opposite direction of the blood. The dialyzed blood is returned to the patient through a Second needle or catheter lumen. Old dialysate and ultrafiltrate are drained and discarded. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Hemodialysis Procedure Dialyzer/blood lines primed with saline solution to eliminate air Terminated by flushing dialyzer with saline to remove all blood Needles removed and firm pressure applied Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Hemodialysis Procedure Before treatment, nurse should Complete assessment of fluid status, condition of access, temperature, and skin condition During treatment, nurse should Be alert to changes in condition Perform vital signs every 30 to 60 minutes The difference between the last postdialysis weight and the present predialysis weight determines the ultrafiltration, or the amount of weight to be removed. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Hemodialysis Complications Hypotension Muscle cramps Loss of blood Hepatitis Hypotension that occurs during HD primarily results from rapid removal of vascular volume (hypovolemia), decreased cardiac output, and decreased systemic intravascular resistance. Factors associated with the development of muscle cramps include hypotension, hypovolemia, high ultrafiltration rate (large interdialytic weight gain), and use of low-sodium dialysis solution. Blood loss may result from blood not being completely rinsed from the dialyzer, accidental separation of blood tubing, dialysis membrane rupture, or bleeding after the removal of needles at the end of dialysis. At one time, hepatitis B had an unusually high prevalence in dialysis patients, but the incidence today is quite low. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Hemodialysis Effectiveness and Adaptation Cannot fully replace metabolic and hormonal functions of kidneys Can ease many of the symptoms Can prevent certain complications HD does not alter the accelerated rate of development of cardiovascular disease and the related high mortality. The yearly death rate of patients receiving maintenance dialysis remains high and is estimated to be between 19% and 24%. Individual adaptation to maintenance HD varies considerably. Initially, many patients feel positive about the dialysis because it makes them feel better and keeps them alive, but often great ambivalence is expressed about whether it is worthwhile. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Continual Renal Replacement Therapy (CRRT) Alternative or adjunctive method for treating AKI Means by which uremic toxins and fluids are removed Acid-base status/electrolytes adjusted slowly and continuously Patients selected are usually those who do not respond to dietary interventions and drug therapy. The principle of CRRT is to dialyze patients in a more physiologic way over 24 hours, just as the kidneys do. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Continual Renal Replacement Therapy (CRRT) Can be used in conjunction with HD Contraindication Presence of manifestations of uremia requiring rapid resolution Continued for 30 to 40 days Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Continual Renal Replacement Therapy (CRRT) Hemofilter change every 24 to 48 hours Ultrafiltrate should be clear yellow. Specimens may be obtained for evaluation. {Discuss ultrafiltration therapies.} Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Continual Renal Replacement Therapy (CRRT) Two types of CRRT Venous access Arterial access See Table 47-14 for more information. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Continual Renal Replacement Therapy (CRRT) Most common: Venovenous approaches Continuous venovenous hemofiltration (CVVH) Continuous venovenous hemodialysis (CVVHD) See Table 47-14 for more information. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Continuous Vevovenous Therapies Basic schematic of continuous venovenous therapies. Blood pump is required to pump blood through the circuit. Replacement ports are used for CVVH and CVVHD only and can be given prefilter or postfilter. Dialysate port is used for CVVHD only. Regardless of modality, ultrafiltrate is drained via the ultrafiltration drain port. Fig. 47-14. Basic schematic of continuous venovenous therapies. Blood pump is required to pump blood through the circuit. Replacement ports are used for instilling replacement fluids and can be given prefilter or postfilter. Dialysate port is used for infusing distillate. Regardless of modality, ultrafiltrate is drained via the ultrafiltration drain port. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Continual Renal Replacement Therapy (CRRT) Continuous venovenous hemofiltration (CVVH) Large volumes of fluid removed hourly, then replaced Fluid replacement dependent on stability/individualized needs of patient Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Continual Renal Replacement Therapy (CRRT) Continuous venovenous hemodialysis (CVVHD) Uses dialysate Dialysate bags attached to distal end of hemofilter Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Continual Renal Replacement Therapy (CRRT) Continuous venovenous hemodialysis (CVVHD) Fluid pumped countercurrent to blood flow Ideal treatment for patient who needs fluid/solute control but cannot tolerate rapid fluid shifts with HD Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Continual Renal Replacement Therapy (CRRT) Highly permeable, hollow fiber hemofilter Uses double-lumen catheter placed in femoral, jugular, or subclavian vein. Removes plasma water and nonprotein solutes Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Continual Renal Replacement Therapy (CRRT) CRRT versus HD Continuous rather than intermittent Solute removal by convection (no dialysate required), in addition to osmosis and diffusion Less hemodynamic instability Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Continual Renal Replacement Therapy (CRRT) CRRT versus HD (cont’d) Does not require constant monitoring by HD nurse Does not require complicated HD equipment Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Audience Response Question When implementing care for the patient on peritoneal dialysis, the nurse recognizes that dietary needs include an increased quantity of: 1. Fat. 2. Protein. 3. Calories. 4. Carbohydrates. Answer: 2 Rationale: Dietary protein guidelines for peritoneal dialysis (PD) differ from those for hemodialysis because of protein loss in the dialysate. During PD, protein intake must be high enough to compensate for the losses, so the nitrogen balance is maintained. The recommended protein intake is at least 1.2 g/kg of ideal body weight per day and is increased on the basis of individual needs of the patient. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 48

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Case Study Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 49

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Case Study 65-year-old woman with history of progressive renal failure for 5 years Diagnosed with type 1 diabetes mellitus when 15 years old Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Case Study She has diabetic retinopathy with macular degeneration. Gives herself insulin using an insulin pen Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Case Study Lab values BUN 72 mg/dL Serum creatinine 7.5 mg/dL GFR 12 mL/min Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Discussion Questions What are her options for renal replacement therapy? Which one would be the best choice for her? HD, PD, kidney transplant Kidney transplant restores renal function, but resources for obtaining kidneys for transplant are limited. PD is probably a better choice than HD. The person with diabetes does better on PD than on HD. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.