Education For Emergency Staff Responders For Home Dialysis Programs

Dialysis is a treatment for patients who have limited kidney function. We all know that kidney failure means they don’t urinate like the rest of people do, but probably never gave too much thought to the other ways this affects the lives of the patient and family.

Sure, there are dialysis units and patients go there and have dialysis treatments 3 days a week. We hear about this on television and may even know someone who goes there. If the patient is able to drive him or herself to the unit it really isn’t too difficult other than the cost of gasoline, we would think. If they are elderly or can’t drive the family may rotate who is going to take this person to the treatment and either shop while they are there, sit with them, or go home and come back a few hours later. If no one is available from the family they look to the social worker to help provide some type of assistance which can be anything from a taxi to a wheelchair van, to ambulance transportation and again quite costly. This is of course both directions 3 days a week back and forth to the unit for the treatment. Consider that the patient doesn’t feel well on the days of the treatment. They remove anywhere from 1 pound to an ideal of 2-3 pounds or maybe as much as 10-12 pounds at that 4 hour dialysis treatment. There are also chemical shifts due to the removal of sodium, potassium, chloride, balancing of calcium, phosphorus, magnesium, glucose along with the fluid removal. The patients may experience nausea, cramping, dizziness, hypotension, or bleeding during treatments. Heparin is used to prevent clotting of the blood in the dialyzer and dosages need to be carefully adjusted for each patient to find the amount required for that patient. Imbalance of phosphorus/calcium contributes to bone density loss and osteoporosis is also a frequent problem for dialysis patients.

The dietitian and the dialysis staff reinforce that their new diet is limited in potassium, sodium and phosphorus. If you take a look at the foods in the grocery store you suddenly find every prepared food you can buy from soup to sauces or cereal are loaded with salt and phosphorus and potassium. This problem with the kidney usually is associated with high blood pressure so the patients are usually on 1-3 blood pressure medications, probably not the cheapest drugs ,if they work. Phosphorus isn’t cleared well by any dialysis treatment so most patients are taking phosphate binders such as renagel, $1.45 each, 3-15 daily dosage; fosrenal $2.14 each, 6-12 daily dosage, or sensipar $.98 each, 1-4 daily dosage.

1 The phosphate binders must be taken with or near meal time as they act like a sponge to absorb the phosphorus and bind this in the intestines which prevents it being absorbed in the blood stream. Try to eat a meal if you are a little nauseated and then asked to take 2-6 tablets of a big pill that tastes like chalk and also you are told you can only have 500cc of fluid to drink for that day. Not very appealing. One soda is half of your fluid for the day, don’t forget the liquid in the bowl of cereal or in that fruit is liquid too.. Many of these patients were providing the income to support the family, maybe even carrying the insurance policy for the family. The insurance may have a co payment required for each dialysis treatment. It is difficult to maintain many types of employment on a part time basis, especially when you suddenly can’t work on someone else’s idea of a schedule. Add the cost of the gasoline and the co payment and then take away all or part of the earned income and then add several new, expensive medications and this is a financial disaster for the patient and family.

Hemodialysis requires some type of “access”, a way to take blood out of your body to clean it, and return it back to the body. Our machines run on a 500cc/min blood flow with the ideal access but often times we have to work with 250-400cc blood flows and do the best we can.

The ideal “access” is a fistula and this is usually in the lower or upper arm, preferable on the non dominant arm. Occasionally a fistula is on a leg although I’ve only seen this a couple of times. A fistula is the patients own artery and vein connected by a surgeon. It takes 6 weeks to 6 months for the arterial blood to cause the vein to increase in size enough to insert a needle that is large enough to run the hemodialysis treatment. We use 17 guage as the smallest needle and preferable 15 guage needles for a developed fistula. The new fistulas are cannulated by the more experienced staff members as they tend to be fragile and if bruising occurs there can be pressure enough to clot the fistula or make it difficult to cannulate the next time a patient comes for treatment.

A graft is a synthetic loop of material (dacron) which again connects a patients arterial blood supply to a vein in another spot on either the arm or the leg making a loop or sometimes a straight area with an enlarged spot that can be felt (thrill) and needles can be inserted for blood flows. It is more likely for a graft to become infected or clot since this is a synthetic material rather than the patients own vein. As a patient, particularly a young working person, the body image is altered when you look at this new graft or fistula in your arm or leg. Never take blood pressures on an arm or leg that has a graft or a fistula placed as this may cause bleeding, clot the graft, or harm the graft or the patient. No one other than dialysis staff should draw bloods from these grafts and fistulas

2 either. The access is an arterial/venous blood mixture and you may cause damage or bleeding unless you know how to handle these needles.

In recent years many types of hemodialysis catheters have been used successfully and for longer times than we were able to use in the past. A catheter is usually inserted in the jugular vein and inside the body it leads into the superior vena cava directly above the heart. The outside portion that you see is in the upper chest wall or occasionally in the neck area. A temporary catheter may be only sutured in but the more common catheters today are tunneled catheters with one or two cuffs under the skin that allows the skin to eventually adhere to the cuff to help prevent accidentally pulling the catheter out of the chest. A catheter can also be in the groin area but this is usually when the surgeon has been unable to use the upper body area for some reason. A catheter has clamps on the lines that are kept closed except when in use, and a cap is kept over the end. A catheter is prone to infection so it is handled only with gloves/mask and good hand washing. The exit site is kept covered and dressings are usually changed only at the dialysis units. Most patients tend to remain on in center dialysis for those 3 day a week treatment but today we have a short supply of chairs in the units and some patients want to continue to have the lifestyle they were use to and spend time with their family and not have this disease interrupt their life in this way.

Home dialysis treatments have been offered for many years. In the late 1970's peritoneal dialysis was initiated in the United States, I know home hemodialysis was offered at that time also.

In the 1990's Robert Udall from Ontario, Canada started a home dialysis program with computer monitoring of the patients so one observer could monitor several patients at one time. This was started in the Saratoga Rubin Dialysis Center in Saratoga Springs, NY in 1997. The patients complete a 6 week training course at the center and then dialyze 6 nights weekly in their home, while sleeping. Due to the observer monitoring the computer data there is no need for a partner to be trained or present although many patients do have another person in the home.

The overnight dialysis leaves daytime hours free for normal activities. The dialysis process is done slowly over 7-8 hours so there are less chemical shifts and less weight removal on any one treatment. There are less episodes of cramping or hypotension related to the slower treatments. Patients have less dietary restrictions and require less blood pressure medication and fewer phosphate binders. Many patients are able to eliminate both of these and about 1/3 require the addition of phosphate to the dialysis bath to prevent depletion of

3 the same phosphorus that required binders with in center hemodialysis treatments. Patients spend approximately 45 minutes preparing the machine for this overnight treatment with equipment similar to what is used in the hemodialysis center. They notify the observer when they start treatment and review what the weight and fluid goal is for the treatment. The observer verifies the computer connection and monitors the pressure readings that are significant to the safety of the treatment.

If there is a problem with the treatment an alarm sounds to wake the patient. The patient can usually resolve this alone within a minute. If the alarm is not resolved within 2 minutes the observer will contact the patient to see if they need assistance. There is a nurse and a technician on call if further assistance is needed but most alarms are dealt with by the patient alone. IF the power is lost in the home the patient is trained to return the blood by hand pumps and they don’t complete that treatment. Since treatments are done on 6 nights a week it is not a problem to miss one treatment. If there are prolonged power losses in the area we arrange backup treatments at the Rubin Dialysis Center.

Emergency rescue squad numbers are kept for each home dialysis patient and if the observer is unable to reach the patient by phone on a second attempt for unsolved alarms the rescue squad will receive a request to go to the patients home for assistance. There have not been a lot of calls in the past 9 years but there have been episodes of hypoglycemia, hypotension, myocardial infarction, which could have been totally unrelated to the dialysis procedure. Bleeding is another common dialysis problem that could require assistance if unable to stop this by normal procedures. The catheters we currently use are unlikely to come out during treatment due to the patients skin growing into the cuff, but there have been known incidents of a catheter coming out of the patient, usually related to an infection at the exit site.. If this were to occur direct pressure should be applied to the area and they should be checked by the emergency room physician.

An air embolism is unlikely to occur due to the safety devices used by the dialysis patients. During training patients are taught to lie on the left side with the head lowered and feet elevated and call 911 if they suspect they may have given themselves air. The machine has an air detector on the line returning blood to the patient. Most of the patients using catheters use a special cap with a needleless system that leaves an intact cap on the end of the catheter. This cap is left in place during treatment. At this time many patients have proved to be safely using the catheters and are allowed to remove this catheter cap and connect directly to the blood line to increase dialysis efficiency by increasing the rate of the blood

4 pump speed during treatment. A special locking box is used over a catheter connections to prevent separation during treatment, whether the capping device is used or the patient connects directly to the catheter line without a cap. A blue locking box is kept in place over catheter connections to prevent blood line from separating during treatment. This can be removed by pressing on the sides of the locking box in opposite directions to release the connection.

If you do rescue a patient with a catheter please remember to do this while wearing a mask and gloves to prevent infection of the patient . With universal precautions gloves should be worn with contact with any access to any type of treatment. Rescue of a patient using a catheter would require clamping of both catheter lines and the blood lines (4 clamps) and separating the blood lines from the catheter lines by turning the connection at the red or blue portion in a counterclockwise direction. If no cap is present on the end of the catheter a syringe should be placed on the connection for transport to the hospital. This will prevent accidental air embolism or contamination of the catheter.

Initially all the patients were using a catheter for hemodialysis access. Due to the problem with infection and blockage of the subclavian vessels related to the catheter usage we have progressed to using blunt needles on overnight treatments. In more recent years we have also used a single needle which may be a sharp or a blunt tip on the needle. We have special taping devices used for safety which will be shown to you at this time. The most commonly used tape at this time is made with toupee glue and sticks securely. The wings of the needle are butterfly taped, wrapped again with another tape usually with lines placed in a loop to prevent accidental removal of the needle lines.

In a rescue in a patient’s home the procedure is going to be the same as used with a catheter patient. There are clamps on the blood lines and clamps on the fistula needle lines. These should all be clamped to prevent blood loss. (4 clamps). You are not responsible for the equipment although our staff could tell you how to turn the machine off if the patient is alone in the home. The 4 clamps are closed and the lines are separated. The connections will be taped on fistula needle connections. You separate this by turning the connection counter clockwise at the red or blue connection between the needle and the blood line. You will have an access for medications if they are needed and trained staff are available to give the medications. A syringe should be kept on any open end of any fistula needle to prevent contamination or blood loss.

5 During the last year we have embarked on a newer form of home dialysis called the Nxstage home dialysis program. The machine is easier for the patient to prepare. The preparation time is reduced to about 30 minutes. It only weighs 70 lbs, it is more portable making it easier for the patient to travel. There isn’t an overnight program at this time. The patients doing this program have a partner in the home with them. Most patients are dialyzing during the evening hours but that does vary from one patient to another. The access for this dialysis may be a fistula with needles or a catheter connection to the machine. The fistula patients may have sharp needles or blunt needles. The wings are green on a blunt needle and blue on a sharp needle, otherwise they look exactly the same. The patients are running 6 treatments weekly and the length varies from one patient to another by their medical needs usually between 2-4 hours in length. Due to the shorter length of treatment the fluid goals are removed more quickly so they are somewhat more likely to have cramping or hypotension than on the overnight program, but less likely than when the patient dialyzed 3 days weekly in the dialysis unit. The emergency procedure would be the same, close 4 clamps and disconnect the patient by turning the red or blue connections counter clockwise to separate blood line from the needle lines.

Another form of home dialysis is peritoneal dialysis. The peritoneal dialysis access is a tunneled catheter with 2 cuffs under the skin which allow skin to grow into the cuff to seal the area. Peritoneal dialysis is done by infusing a specially prepared fluid into the abdomen rather than drawing blood from the patient. The abdominal wall has a membrane called the peritoneal membrane that allows exchanges of chemicals (sodium, bun, creatinine, potassium, ca, mg, cl, glucose) and this accomplishes dialysis in a different way than what is done in the unit. This catheter is also handled only with a mask, careful hand washing and staff wears sterile gloves to prevent an infection.

These treatments are performed daily and causes less episodes of hypotension or cramping. The catheter is surgically placed in the lower abdomen which heals for 1 month before being used. This healing time helps prevent accidental movement of the catheter cuffs or leaking around the catheter in the exit site area. Patients are trained for 1-2 weeks to maintain a sterile treatment and prevent infections. In this modality the patient could do 4 separate exchanges of fluid manually during daytime hours, usually divided to 4-5 hours between the exchanges. (continuous ambulatory peritoneal dialysis). They also could be trained to an overnight machine which does the treatment exchanges automatically during the night time hours (continuous cycler peritoneal dialysis).

6 If you were called to a home with a peritoneal dialysis patient in an emergency there is a slide clamp on the line which should be showing a red dot for closed position to disconnect from the machine. Some connections may have a roller clamp that resembles an iv roller clamp and closed is in the tightened position. There is a snap disconnection which is a hard ridge of plastic on the tubing line near the patient connection. There should always be a clamp on the patient side before disconnection from the tubing. The lines usually have a blue clamp that presses closed for safety.

In any type of rescue where a patient is connected to any dialysis treatment remember to close the clamps on the tubing before disconnection occurs. Adhere to universal precautions and wear mask and gloves for both your protection and the protection of the patient from infection. Separate the access tubing from the machine tubing. In the case of no machine attached (ambulatory peritoneal dialysis) you could just bring the bags you find with you to the emergency room for staff to disconnect (optional). If our staff has called you to this home we will be able to give you directions on rescue procedures and please feel free to ask for assistance. There are usually blue emergency clamps kept around any home dialysis patient setting and these can always be applied over the line on either side of a disconnection spot for any type of modality for dialysis. In closing for any patient rescue be sure to close the clamps on both sides of any connection. Wear a mask and gloves while separating the connection. Attach a syringe to any open needle or catheter lines to prevent bleeding, infection or air embolism. Be careful of pressure to a needle site while moving the patient. Do not attempt to remove the needles for transportation as this patient is heparinized and will take some time for the site to clot when the needle is removed. Transport the patient to the hospital for follow-up care.

7