Hemodialysis is a lifesaving procedure that is used to provide temporary support for patients with acute or chronic kidney injury. In dialysis blood is removed from the patient’s body, circulates through an artificial kidney known as a dialyzer while filtering the blood, and then the blood is returned to the body. The dialyzer composition resembles the normal extracellular fluid that are in our bodies, and the dialysate contains electrolytes that can be modified to raise or either lower electrolyte levels depending on the patient’s needs. Hemodialysis requires an access with there being various access sites that can be used, and the access can be either temporary or long term.
The site and type of access depends on the patient’s conditions and the duration of dialysis. Specially trained personnel usually perform the procedure in a hemodialysis unit. It is very important to pay attention to blood pressure and the patient’s hemodynamic status while receiving this treatment. The purpose of this paper is to review the literature for the most current evidenced based practices on performing hemodialysis and preventing complications that may occur while receiving the treatment. This review will also discuss findings of current evidence-based practices that will be compared to the policy and how to prevent common complications of hemodialysis, such as infections, hemolysis and more.
The hemodialysis policy for Cornerstone states that strict sterile technique should be used during preparation of the machine and all equipment to prevent introducing pathogens into the patient’s blood stream. Any equipment that has been disconnected and exposed to air should be discarded immediately. The dialyzer should be tested for residual disinfectant after rinsing and may require a double check by another nurse. All alarms should be turned on and functioning properly and audible to the staff. Before initiating hemodialysis, there should be a pre-assessment done. Apply a topical anesthetic to the puncture site as ordered, preferably 45-60 min before the cannulation. Apply gloves and cleanse the site with an antiseptic used in your facility with these following manufacturer instructions. Chlorhexidine-based solution should be applied for at least 30 seconds using a back and forth friction scrub and allow to dry. When alcohol is used is should be applied in a circular motion for at least 1 minute and allowed to dry. If povidone- iodine is used, apply for 2-3 minutes and allow to dry. Remove gloves and apply new ones.
An appropriate size syringe should be chosen to cannulate the fistula, usually a 17G needle for the first cannulation and about a 15 G for the mature fistula. Ten milliliters of normal saline should be drawn into two syringes, apply tourniquet to upper arm, and stabilize the vessel and insert the needle. The needle should be primed with normal saline until all air is purged and then clamp the needle off. Next, the protective cap will me removed and cannulate the fistula. The arterial need can be inserted at a twenty-five-degree angle in the same direction of blood flow or against the direction of blood flow. The clamp should then be opened, and the tourniquet should be removed. One to five milliliters of blood should be aspirated with a ten-milliliter syringe, flush needle with normal saline and clamp. Secure the needle with some tape and remove the syringe from the end of the arterial needle and connect the two lines.
Dialysate is a high alert med and it is required that before beginning hemodialysis, should be checked by a second nurse to ensure correct patient identity and dialysate is hanging in the prescribed concentration, dosage calculations are correct, machine settings are correct and infusion line is connected to the right port. The results should be compared and if no variation exist the treatment may begin. During the treatment, monitor hemodialysis equipment every thirty minutes and make sure all lines are open and intact. Observing the color of the blood in the dialyzer is important, cherry red may indicate hemolysis and dark red blood may precede filter clotting. Make sure to check pressure readings, they should not exceed 250mm Hg.
During dialysis, the anticoagulant pump should be observed to make sure it is being administered as prescribed. The patient’s vital signs, pain level, intake and output, and lab results, complaints should be monitored to promptly recognize any changes in the condition of the patient, so any problems can be resolved quickly.
Each step-in hemodialysis should be performed correctly, missing any step or performing it incorrectly can cause unnecessary blood loss and inadequate removal of fluid. In the postoperative period of dialysis, the patient should be taught how to care for their access site. The incision must always be kept dry and clean and must also be taught how to palpate or auscultate a thrill (bruit). If there are any signs of infection such as redness, pain or swelling, they should report this immediately. Also, if there is a decrease in the thrill or bruit, that should be reported as well. No blood pressures, blood draws or any excess pressure should be put on the arm with the access site.
There are many complications of dialysis which may include, bacterial infection, hypovolemia, hypotension, cardiac dysrhythmias, air embolus, and hemolysis of the blood cells. There are certain procedures and steps that must be taken to prevent or reduce the risk of these complications. Hemolysis can occur if there is an obstruction of flow. Some signs of obstruction or hemolysis include cherry red blood, hyperkalemia, dyspnea and chest pain.
Review of the literature
Upon the research of hemodialysis, all articles agreed that hemodialysis is complex procedure in which patient safety is an essential priority, and it is essential that training and infection control protocols are established in dialysis units. (Kallen , Patel , & Sinkowitz-Cochran , 2014) (Rylance , 2014) (Yanai, Uehara, & Takahashi, 2006). Intensive education and training are necessary for the establishment of the infection control procedures recommended by the CDC. (Yanai, Uehara, & Takahashi, 2006). In this article they also discussed how Hepatitis B virus outbreaks have occurred in a variety of dialysis units because of lapses in infection control. When procedures are not followed with respect to the preparation and delivery of medications, these failures lead to complications with infections.
All units should ensure that training and continuing professional development (CPD) is available for all renal health professionals, together with all being actively involved in audit and clinical governance. (Rylance , 2014). Following Infection control measures plays a key role in preventing transmission of infections and prolonging survival of the dialysis population.
All studies were in agreement that with strict adherence to infection control precautions, bacterial infections can be avoided. The study entitled “Improving patient safety and avoiding incidents in renal units” identified that dialysis catheter infections can be reduced by improving arteriovenous fistula rates, emphasis on training, catheter care bundles, bacterial surveillance and policies of line removal. (Rylance , 2014).
All articles agreed that vascular access care, hand hygiene, using sterile equipment, recognizing the signs of infection and access management while away from the dialysis unit reduce the risk of infection. (Rylance , 2014) (Yanai, Uehara, & Takahashi, 2006) (Kallen , Patel , & Sinkowitz-Cochran , 2014) (Kallen , Patel , & Sinkowitz-Cochran , 2014). The opinion found in the article entitled “Infection Control and Bloodstream Infection Prevention: The Perspective of Patients Receiving Hemodialysis” states that patients should advocate for their own safety and speak up when they notice problems. Infection control should begin early in the dialysis process at each visit with regular reinforcement.
Hemolysis is another major complication of hemodialysis which is caused by some type of obstruction. Red blood cell damage result from manufacturing errors, kinks in blood tubing, increased pump pressures and improper catheter dimensions. Better quality control and design of the equipment can reduce the risk of hemolysis.
The focus on machines play a major factor in hemolysis. Both articles agreed that a shear is generated when fluid is pumped through the machine, resulting in a flow speed difference between the blood in the tube. One side of the blood cell is exposed to a higher pressure than one side which causes a shear. Red blood cells are being destroyed once the shear rate exceeds a certain limit higher than normal. Both articles agreed that kinked blood lines are one of the most common reported cause of hemolysis. Machines usually have tube organizers built into them to avoid kinking. In conclusion both articles state a pressure as low as -350 mmHg and high as +350 mmHg are considered as safe. (Polaschegg , 2009). (Harman & Dutka , 2007).
Analysis of Findings
Con way Policy follows current evidence- based practice with all the following articles that were reviewed. The methods used, and procedures taken are similar in mostly all articles on how they reduce the risk of infection and hemolysis in dialysis patients. One difference that was noted within the Conway policy was that pressure readings should not exceed 250 mmHg, which may indicate clotting, and should not exceed -250mmHg which may indicate excess suction or hypotension. Another study also found that the best intervention to prevent infection was when patient’s advocate for their own safety and speak up when problems are noticed, this study was the only one that stood out that included the patient in a part of reducing the risk of infection. Overall the procedure for hemodialysis is a multi-dimensional process that involves the staff and the patient to play a role in preventing complications of hemodialysis.
Based on the research from this literature review, Conway policy does follow the most current evidenced based practice, but one exception was the fact they didn’t include patient input about reducing the risk of complications. It is proposed that patient safety is a priority in health care and health care workers should implement and share information regarding solutions to prevent harm.