Dialysis

dialysis

1. Prepared by, Gayathri R 2 nd yr MSc (N) UCON

2. INTRODUCTION Dialysis attempt to reproduce kidney function by allowing wastes and abnormally concentrated substances to pass from a person’s blood by allowing wastes and abnormally concentrated substances to pass from a person’s blood across a semipermeable membrane for excretion from the body. Specifically dialysis is used to remove excessive amounts of drugs and toxins in poisonings of intentional and accidental nature, to correct fluid imbalance, and acid base imbalances and to remove metabolic waste when renal shutdown occurs either suddenly or in patients with chronic end stage kidney disease.

3. DEFINITION Dialysis is procedure for cleaning and filtering the blood. It substitute for kidney function when the kidneys cannot remove the nitrogenous waste products and maintain adequate fluid, electrolyte and acid base balance . [ Barbara K Timby ]

4. It’s defined as exchange of fluid across a semipermeable membrane. Dialysis is not limited to filtration of kidneys and removal of nitrogenous waste from the blood but implies addition or removal of excess water, electrolytes and dialyzable poison from the blood. [ S N Chung]

5. INDICATIONS Acute renal failure Chronic renal failure Poisoning Severe metabolic acidosis Hyperkalemia irrespective of its causes Fluid overload or acute pulmonary edema

6. TYPES Hemodialysis (through the artificial kidney) Peritoneal dialysis (through the peritoneal cavity)

7. HEMODIALYSIS Hemodialysis is an efficient modality for correction of fluid and electrolyte abnormalities due to acute kidney injury or chronic renal failure. However, it is expensive to institute, requires expertise and skilled nursing is not available at most centers. It is not suited for patients with hemodynamic instability, bleeding tendency and in very young children where vascular access might be difficult.

8. Indications

9. Indications of dialysis in acute renal failure (ARF) Severe fluid overload Refractory hypertension Uncontrollable hyperkalaemia Nausea, vomiting, poor appetite, gastritis with haemorrhage Lethargy, malaise, somnolence, stupor, coma, delirium, asterixis, tremor, seizures, Pericarditis (risk of haemorrhage or tamponade) Bleeding diathesis (epistaxis, gastrointestinal (GI) bleeding and etc.) Severe metabolic acidosis Blood urea nitrogen (BUN) > 70–100 mg/dl

10. Indications of dialysis in chronic renal failure (CRF) Pericarditis Fluid overload or pulmonary edema refractory to diuretics Accelerated hypertension poorly responsive to antihypertensive Progressive uremic encephalopathy or neuropathy such as confusion, asterixis, myoclonus, wrist or foot drop, seizures Bleeding diathesis attributable to uremia

11. Equipments & other requirements Vascular access using central venous catheter Temporary access : It is established by percutaneous insertion of catheter into a large vein such as the internal jugular or femoral, subclavian vein is less preferred. Permanent access : Construction of Arteriovenous fistula permits repeated access for months to years.

12. Arteriovenous (AV) fistula

13. AV graft

14. Central venous catheter

15. Dialysate circuit in hemodialysis machine

16. Pediatric dialyzer with tubings Dialysate fluid

17. Procedure of Hemodialysis

18. Risks Hypotension Muscle cramps Itching Sleep problems Anemia Bone diseases Hypertension Fluid overload

19. Risks Pericarditis Hyperkalemia Access site complications Amyloidosis Depression

20. Complications during dialysis Hypotension Muscle cramps Nausea, Vomiting Chest pain and Back pain Fever and Chills Disequilibrium syndrome Dialyzer reaction Arrhythmia Cardiac tamponade Intracranial bleeding Seizures Hemolysis Neutropenia; compliment activation

21. Other Complications Catheter lumen thrombosis Infections Pneumothorax Hemothorax Air embolism Arrhythmia Thrombosis Nerve injury

22. Nursing management Patient care Patient monitoring Physical examination Fistula checking Proper administration Management of catheter infection Client teaching

23. Common medications used DRUG USE ADMINISTRATION TIME Oral calcium phosphate binder To counter high phosphate levels in blood when the kidney are no longer able to control serum levels. Taken with or immediately after meals. Can be taken with a meal before hemodialysis. Erythropoietin (EPO) For chronic anemia to stimulate red blood cell production in the bone marrow. Given IV or SQ during or at the end of hemodialysis treatment. Monitor predialysis hematocrit to determine the amount of erythropoietin. Iron To produce red blood cells. The parenteral form can be taken with a meal before hemodialysis. Antihypertensive agent To regulate hypertension. Morning dose is held and given after hemodialysis. Sodium heparin To prevent clotting in the extracorporeal circuit. Given during hemodialysis by dialysis nurse.

24. PERITONEAL DIALYSIS Peritoneal dialysis (PD) is a treatment for kidney failure. A special sterile fluid is introduced into the abdomen through a permanent tube that is placed in the peritoneal cavity. The fluid circulates through abdomen to draw impurities from surrounding blood vessels in the peritoneum, which is then drained from the body.

25. Indications Patient with acute kidney injury with severe or persistent hyperkalaemia (>7meq/l) Fluid overload (Pulmonary oedema, Severe hypertension) Uremic encephalopathy Severe metabolic acidosis (total CO 2 10-12mEq/L) Hyponatremia and Hypernatremia

26. Materials required Peritoneal dialysis catheter

27. Peritoneal dialysis solution

28. Other materials required Sterile set Surgical blade number 15 Normal saline Suture Povidone iodine; Chlorhexidine

29. Procedure

30. Types Continuous ambulatory PD Automated peritoneal dialysis

31. Types Intermittent peritoneal dialysis Continuous cycling peritoneal dialysis Nightly peritoneal dialysis

32. Benefits of PD Painless and no bleeding Home based therapy Gentler and works more like the natural kidney

33. Signs and symptoms monitoring during dialysis FLUID OVERLOAD FLUID UNDERLOAD PERITONITIS Hypertension Pitting edema of feet, ankles and hands Crackles in lung field Shortness of breath Jugular vein distention Pulmonary edema Fatigue Ascites Periorbital edema Hypotension Tachycardia Muscle cramps (Legs) Abdominal pain during exchange Nausea Vomiting Cloudy outflow fluid (effluent) Systemic infection symptoms

34. Risks Nausea Trouble sleeping Poor appetite Loss of energy Hiccups Dry, itchy skin Weight loss irregular menstrual periods Muscle cramping, especially at night Swelling anemia (low blood count) Trouble breathing

35. Nursing management Predialysis care Intra dialysis care Post dialysis care Client and family teaching

36. Complications Bleeding after catheter insertion Perforation of gut Abdominal pain Leakage around catheter Difficult drainage Pulmonary complications Peritonitis Metabolic problems

37. Disadvantages Infections Weight gain Hernia Inadequate dialysis

38. DIFFERENCE B/W HEMO & PERITONEAL DIALYSIS HEMODIALYSIS PERITONEAL DIALYSIS Advantages   Effective removal of waste product. Care given by trained professional. Regular contact with other patients. Rapid correction of electrolyte imbalance. No equipment to store at home. Treatment usually occurs only three times a week. Schedule flexibility, easier to travel. Few risks of dialysis associated cramps. Clinic visits limited to 1-2 times a month. Patient or family involved in care. No need for needles or vascular access. Steady state therapy, gentler ultrafiltration. Disadvantages   Vascular access surgery required. Use of large needles. Schedule inflexibility. Must travel to center three times a week. Cramping with ultrafiltration. Risk of bacteremia. Permanent external catheter; problems. No off days. Risk of peritonitis. Risk of weight gain from glucose in dialysate. Must store dialysis equipment and supplies at home. Need for self-monitoring care.

39. CONCLUSION In medicine, dialysis is the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally. This is referred to as therapy. Dialysis is used in patients with rapidly developing loss of kidney function, called acute kidney injury (previously called acute renal failure), or slowly worsening kidney function, called Stage 5 chronic kidney disease, (previously called chronic kidney failure and end-stage renal disease and end-stage kidney disease).

40. REFERENCE Ignativicius ,Work man. Text book of medical surgical nursing, Elsevier publishers, 5 th edn. Barbara K Timby, Nancy E Smith. Introductory medical surgical nursing, Lippincott publishers, 9 th edn. Beverly George Gay, Cynthia. Clinical medical surgical nursing, Saunders publishers, 1 st edn. Rakesh Lodha, SK Kabra. Pediatric procedures, CBS publishers, 1 st edn. OP Ghai. Essentials of pediatric nursing, CBS publishers, 7 th edn. Medline plus.com www.mayoclinic.com  

41. Keeping your kidneys always healthy… Thank you…