Dialysis Complications Chemicals in Dialysis

Dialysis Complications

Air in Blood
Cause S&S Prevention Treatment
ID Access A Problems Check connections Correct cause of C f air entering system Remove air from system, by recirculation if necessary

Too high hi h Q QB f for Foam in i Blood l d access, Loose connection, Low Air/Foam level in Arterial detector alarm Drip Bulb, Inadequate priming p gp procedure NS bag empty

Air Embolism
Cause
Disarmed or defective air bubble detector, with air in the blood line lines s

S&S

Prevention Treatment
Clamp Venous line, put patient Left Side Down (LSD), O2, Call 911, CPR may be needed

Air past the Use air detector, detector! SOB, Coughing, Cyanosis, Confusion, Seizure, Death

Blood Loss
Cause
Blood line separation, Dislodged Needle, Cracked di l dialyzer, Major blood leak

S&S
Observation of blood, Blood leak detector alarm, A/V Pressure alarm, Hypotension yp

Prevention Treatment
Ensure tight blood line connections, access visibility, i inspect t dialyzer Clamp lines, control bleeding, NS, blood transfusion

Clotting
Cause
Inadequate antigulation, coag low blood flow rates, air in system

S&S
Blood darker than normal, VP or TMP alarm, poor rinseback

Prevention Treatment
Adequate heparinization maitntain prescribed blood flow, avoid air in blood Change out blood line or yzer as dialy needed, reassess anticoagulation needs

Hypotension
Cause
Excessive UF, Antihypertensives, Poor Cardio vascular status

S&S
Gradual or sudden drop in BP, N/V, Yawning, flush or warm feeling

Prevention Treatment
Correct EDW, Correct pre dialysis wt., with-hold BP med ds, use NA
profiling Turn off ff UF, put patient in trendelenburg, give NS of other volume expander, e pa de ,

Hypertension
Cause
Fluid Overload, Inadequate BP Meds, Renin response

S&S
Dizziness, H/A, N/V, Edema, High measured BP

Prevention Treatment
Control fluid and NA, Accurate EDW, Adjust BP Meds Remove fluid, review EDW, review BP Meds, N h tomy Nephrect (last resort)

Muscle Cramps
Cause
Excessive fluid removal, Osmotic gradient

S&S
Sever pain in muscles, calf muscles most often

Prevention Treatment
Diet and fluid restrictions, NA modeling Hypertonic Saline, NS, Return blood, massage muscl le

Nausea & Vomiting

Cause S&S Prevention Treatment
Close l assessment of vital signs, dont eat on the run, avoid S DDS i i i UF, Minimize trendelenburg, NS, medications

Hypotension, i l i Pt complaint, DDS, vomiting Microbiologic contamination

Headache
Cause
DSS, Fluid shifts, Hypertension Caffeine, withdrawal, anxiety i t

S&S

Prevention Treatment
Acetaminophen

Pt Depends on Complaint cause of head pain

Angina
Cause S&S Prevention Treatment
Asses EDW, D/C Dialysis, accurate UF, O2, nitro, maintain Hct. minimize UF, treat hypotension

Hypotension, Chest pain Anemia, Cardio Cardiovascular disease, anxiety i t

Fever and Chills

Cause
Microbiological, psis either sep or endotoxin. Exposure from Reused Dialyzer, water, or cannulation

S&S
Fever, rigors, feels cold, yp hypotension. Probably pyrogenic if temp increases by 2 deg, with absolute > 100

Prevention Treatment
Proper H2O treatment maintenance and reuse procedures. Aseptic technique when initiating dialysis D/C dialysis, assess source of infection, administer antibiotics

Dialy ysis Diseq quilibrium Sy yndrome (DDS)

Cause
Too rapid removal of BUN. Brain cells swell from osmosis i

S&S
HA, N/V, hypertension, restlesness, convulsions, coma, death

Prevention Treatment
Short, frequent dialysis, concurrent dialysate flow fl Termination of treatment

First Use Syndrome

Cause
Complement activation by dialyzer membrane or ETO

S&S
CP, Back Pain, Hypotension, Hypotension SOB, N/V

Prevention Treatment
Reuse dry dialyzer, use dialyzer sterilized with Gamma Radiation D/C dialysis, change dialyzer order

Anaphylaxis
Cause
ETO sensitivity, medication reaction

S&S
Bronchio restriction, Anxiety, SOB, facial edema, respiratory i t difficulty, cardiac arrest, death

Prevention Treatment
Rinse dialyzer well, test dose of high risk medication (IV I Iron) ) Manage S&S, teminate dialysisi, DO NOT RETURN BLOOD

Seizures
Cause
DDS, Electrolyte imbalance, Hypotension, Medication reaction ti

S&S
Jerking of arms and legs, can easily swallow tongue, eyes roll back

Prevention Treatment
Avoid rapid AntiBP drop, convulsive Minimize meds BUN drop (new patients), ti t ) proper dialy ysate composition

Cardiac Arrest
Cause
Electrolyte imbalance (K), (K) arrhythmia, MI, Air embolism, b li exanguination

S&S

Prevention Treatment
CPR, Return Blood, analysis of blood line and machine

No pulse, no Prevent breath, causes unresponsive to EKG

Hemolysis
Cause
Hypotonic Dialysate, Overheated Dialysate, Pressure in bl dli bloodlines, Disinfectants, Copper, nitrates

S&S
Tightness in Chest, SOB, Back Pain, Pain Hypotension, Cherry Pop lored d blood bl d, col decrease Hct/Hgb, Seizures, cardiac arrest

Prevention Treatment
Proper water treatment, maintain dialysis machines, test b f before treatments, verify absence of sterilant Clamp Venous line, D/C Dialysis, Dialysis DO NOT RETURN BLOOD!, BLOOD! Draw K+ & Hct, Give O2, replace volume, Dialy ysis

Access Recirculation
Cause
Low flow in access, too high Blood Flow Rate, Needles too cl lose together, Lines hooked up backwards

S&S
Dark red blood, Arterial blood lightens after NS bolus, b l increased g clotting

Prevention Treatment
Ensure proper cannulation and hook up of lines, M it Monitor access function Resolve cannulation or hook up issues, surgically rest tore or replace access

Infiltration
Cause
Improper Cannulation, Movement during dialysis

S&S
Pain, swelling, bruising, change in V or A Pressure reading di

Prevention Treatment
Proper Cannulation, Minimize movement during dial di lysi is Remove needle, put ice on site, restick away from i filt ti infiltration

Access Infection Internal

Cause
Break in Aseptic Technique, Poor Hygiene, S di Seeding from another infection

S&S
Redness, Swelling, drainage from site, Fever, Chills

Prevention Treatment
Good technique, dont don t stick inflamed area, Pt education d ti Draw blood cultures, Antibiotics, Surgical revision

Access Infection Central Catheters

Cause
Poor Hook up technique, Colonization of fibrin sheath, t tunnel, l or exit site

S&S
redness, swelling, tenderness, and drainage, fever, exit site it warmth. th

Prevention Treatment
Aseptic Technique, frequent catheter care, antibiotic ointment i t t Culture site, Antibiotics, catheter replacement

Hazardous Chemicals

Most hazardous chemicals in dialysis are disinf fectants

A disinfectant is a chemical that has the ability to kill most, most but not all of the microorganisms present.

Why are disinfectants so important in d l dialysis?

Disinfectants.. Minimize dialysis patients exposure to yproducts in water or toxins or bacterial by dialysis equipment Improve the standard of patient care

However when used improperly,

the disinfection process will be ineffective and the disinfectants themselves can cause great harm!!

Commonly Used Dial lysis Disinf fectants

Peracetic Acid (PAA) Formaldehyde Glutaraldehyde Chlorine and/or Chloramine Ozone Citric acid

Peracetic Acid (PAA) Disinfectants

Stabilized mixture of hydrogen peroxide and peracetic acid CH3C(O)OOH

Uses for PAA Disi Di infect f tant ts

Use Peracetic Acid Concentration Time (minimum) Temp

Dialyzer reuse Dialysis Machine Disinfection Water Distribution Lines Bicarb Mixing & Delivery System RO machines

3.25% 0.5% 0 5% 0.5% 2% 0.75% - 1%

11 hours 30 minutes 30 minutes i 2 hours 30 minutes

< 21C

25C 25C < 25C

*Always refer to the manufacturer's instructions for disinfectant concentration, temperature and dwell times as these parameters may change from one manufacturer to another

Composition of PAA Disinfectants

Chemical Actril Renalin Minncare Peracidin
% Hydrogen Peroxide and PAA 0.8% Hydrogen Peroxide 0.06% Peracetic Acid 20% Hydrogen Peroxide 4% Peracetic Acid 22% Hydrogen Peroxide 4.5% Peracetic Acid 27% Hydrogen Peroxide 4.5% Peracetic Acid Ratio of Hydrogen Peroxide to PAA

13.3:1 5:1 4.8:1 6:1

Formaldehyde
Formaldehyde is available as a solution of ~37% by weight formaldehyde gas in water with ~10% 10% methanol added to prevent polymerization CH2O

Uses for Formaldehyde Disinfectants

Use Dialyzer reuse Dialysis Machine Water Distribution Lines Bicarb Mixer & Delivery System RO machines Formaldehyde Concentration 4% 1% to 2% 1.5% - 2.0% 2% 2% 4% Time
(minimum)

Temp 20C 40C 37C 25C 25C 25C

24 hours 24 hours overnight 1 hour 2 hours 2 hours

*Always refer to the manufacturer's instructions for disinfectant concentration, temperature and dwell times as these parameters may change from one manufacturer to another

Glutaraldehyde Disinfectants
Glutaraldehyde is a colorless liquid used for cold sterilization C5H8O2 Brand name Diacide and Diacide HD Water soluble less rebound

Uses for Glutaraldehyde Disinfectants

Glutaraldehyde Concentration 0.8% 0 75% 0.75% Time
( i i (minimum) )

Use Dialyzer y Dialysis y Machines

Temp p 20C 20C

15 min 15 min

*Always refer to the manufacturer manufacturer's s instructions for disinfectant concentration, concentration temperature and dwell times as these parameters may change from one manufacturer to another.

Chlorine Disinfectants
Clorox or other bleach solutions containing 5.25% sodium hypochlorite
Do not use bleach containing sodium hydroxide

Amuchina
Al Alcavi is 100 for f di dialysi l is machi hines & equi ipment ARM Clean for dialyzer reuse

500 ppm usedilution

Uses for Chlorine Disinfectants

Use Water Treatment System Water Distribution Lines Dialysate Mixing & Delivery System Dialysis Machine Disinfection Chlorine Chl i Concentration 500 ppm 500 ppm 500 ppm 500-750 ppm Time 2 hours 2 hours 2 hours 30-40 mins Temp 25C 25C 25C 25C

*Always Always refer to the manufacturer manufacturer's s instructions for disinfectant concentration, temperature and dwell times as these parameters may change from one manufacturer to another

Ozone
For adequate disinfection of water treatment systems the NANT Dialysis Technology manual recommends 1 ppm ozone for 10 minutes 0.5ppm ozone for 20 minutes

Citric Acid & Heat

In the presence of biofilm biofilm, heat & citric acid is effective for reducing both bacteria and endotoxin concentrations.

Citric Acid & Heat

Use Dialyzer reuse Concentration 1.5% Time 21 hrs Temp 95C

Dialysis y Machine

10% - 50%

95C

*Always refer to the manufacturer's instructions for disinfectant concentration, temperature and dwell times as these parameters may change from one manufacturer to another

Disinfectant Standards for Hemodialysis

What is a Standard?
A practice or a product widely recognized or empl loyed d, especially i ll because of f its it excellence. A level of requirement. In hemodialy ysis, many y of the standards are voluntary

Who sets the Standards?

1. AAMI Association for the Advancement of Medical Instrumentation

Alliance of healthcare professionals, industry representatives and government officials dedicated to the understanding and beneficial use of medical device technology.

Who sets the Standards?

2. Dialysis Industry

The collective Th ll i expertise i of f healthcare h lh professionals, industry representatives, medical device manufacturers and government officials g

AAMI Standards & Guidelines

Standards information supplied by the medical device manufacturer to ensure safe & effective use in the clinical environment Guidelines procedures & practices to help ensure the device is used safely and effectively & its performance is maintained

Standards for Disinfectants

Disinfectant Peracetic Acid Formaldehyde Glutaraldehyde Bleach (NaOH) Free Chlorine Chloramine Ozone Citric Acid & Heat Potency 1% 3.5% 4% 0.8% - 1.0% 0.8% 0.25% - 0.50% Not Applicable Not Applicable PMI* 1.5% - ?? % Residual <3 ppm <5 ppm <2 ppm <0.5 ppm <0.5 ppm <0.1 ppm PMI*

Disinfectant Tests Used in Hemodialysis

Format of Disinfectant Tests

Liquid colorimetric tests Powdered colorimetric tests Dryreagent test strips or papers

Format of Disinfectant Tests

Tests can be read visually by
observing for the development of color comparing the reacted test to a color standard
Some liquid tests can also be read electronically using a meter

Proper Storage & Handling

Deviation from the storage conditions can result in deterioration of the tests performance. performance Poor treatment = Poor performance

Proper Storage & Handling

Protect all ll tests from heat Protect dryreagent test strips from h idit humidity Keep strips in original container Recap bottles immediately

Proper Storage & Handling

Only use product within the Expiration Date
Shelf Life the time limitation within which a device is fit for its intended use when stored per its labeling Use Life the period of time the test strips will still perform to specifications after opening and closing the bottle during typical usage

Test abuse
1. Leaving cap off the bottle of strips 2. Not storing product in refrigerator

Selecting the Right Disinfectant Test

You have to know: the disinfectant are you testing for what is the target concentration of the disinfectant for a particular use what sensitivity and specificity do you require is the test specifically developed, labeled and tested for use in dialysis

Performance Characteristics
Sensitivity Specificity Potency or Residual id l Quantitative, Semiquantitative, Qualitative

Technique

Disinfectant tests are quick & easy to use, compared to the alternative. However Simple to use don't follow instructions

Technique
Follow the Directions for Use closely

Interpretation of Results
Variations in the read time can affect the accuracy Variation in lighting conditions is another factor that may affect test results. Your col lor percepti ion can al lso aff ffect interpretation of test results.

Test Strip Technical Tips

Proper use & testing of disinfectants Read insert Instructi ions for use

Inappropriate Tests

Starch paper HemaStix Urine Strips CliniTest Urine Tablets