EMERGENCY PROCEDURESEMERGENCY PROCEDURES

BY: BY:

LLOYD SMITH RNLLOYD SMITH RN

EMERGENCY TRAININGEMERGENCY TRAINING

• Why is this important ?Why is this important ?• Who needs to be trained ?Who needs to be trained ?• Who will it affect ?Who will it affect ?

Emergency ProceduresEmergency Procedures

• Guidelines for Guidelines for Emergency TransferEmergency Transfer

• Cardiopulmonary Cardiopulmonary ArrestArrest

• Air EmbolismAir Embolism• Anaphylactic ReactionAnaphylactic Reaction• SeizureSeizure• Shortness of BreathShortness of Breath• Cardiac ArrhythmiasCardiac Arrhythmias• Chest PainChest Pain• CrenationCrenation• HemolysisHemolysis• Disequilibrium Disequilibrium

SyndromeSyndrome

• First-use SyndromeFirst-use Syndrome• Blood Blood

Loss/Exsanguinations Loss/Exsanguinations • Dialyzer Blood LeakDialyzer Blood Leak• Clotted DialyzerClotted Dialyzer• Pyrogenic ReactionPyrogenic Reaction• Equipment Problems Equipment Problems

and Alarmsand Alarms• HypertensionHypertension• HypotensionHypotension• HypoglycemiaHypoglycemia• Muscle CrampsMuscle Cramps• Using Patient RestraintsUsing Patient Restraints

Guidelines for Emergency Guidelines for Emergency TransferTransfer

• For patient emergencies involving cardiac arrest, For patient emergencies involving cardiac arrest, impending cardiac arrests, or other potentially live impending cardiac arrests, or other potentially live threatening events, call 911 first, to request an ambulance threatening events, call 911 first, to request an ambulance for patient transport. Inform the dispatcher of the urgency for patient transport. Inform the dispatcher of the urgency involved. Notify the physician on call as soon as possible.involved. Notify the physician on call as soon as possible.

• For patient emergencies of a less urgent nature, call the For patient emergencies of a less urgent nature, call the patient’s primary physician (or physician on call if the patient’s primary physician (or physician on call if the primary physician is unavailable) for an order to transport. primary physician is unavailable) for an order to transport. Then notify a local ambulance service of the need to Then notify a local ambulance service of the need to transport.transport.

• The Charge Nurse should remain with the patient until The Charge Nurse should remain with the patient until he/she has left the building.he/she has left the building.

• The unit secretary or other ancillary staff should prepare The unit secretary or other ancillary staff should prepare the transfer information packet to accompany the patient the transfer information packet to accompany the patient to the hospital. The packet should include: to the hospital. The packet should include:

• The last 3 hemodialysis records.The last 3 hemodialysis records.• Medication ListMedication List• Care PlansCare Plans• Code Summary (if applicable)Code Summary (if applicable)

• If time does not permit, the information may be faxed to If time does not permit, the information may be faxed to the hospital as soon as possible after the transfer. This the hospital as soon as possible after the transfer. This person should also gather the patient’s belongings and person should also gather the patient’s belongings and send them with the patient.send them with the patient.

Guidelines for Emergency Guidelines for Emergency TransferTransfer (cont) (cont)• Only those emergency response personnel needed should Only those emergency response personnel needed should

enter the unit. First responders such as firemen often enter the unit. First responders such as firemen often arrive before paramedics, EMT’s and ambulance arrive before paramedics, EMT’s and ambulance personnel. Their usefulness in the given situation should personnel. Their usefulness in the given situation should be evaluated by the charge nurse.be evaluated by the charge nurse.

• The patient care staff should assist the EMS staff in The patient care staff should assist the EMS staff in preparing the patient for transfer. If additional staff is preparing the patient for transfer. If additional staff is needed during the transport process, a nurse may be sent needed during the transport process, a nurse may be sent with the EMS team at the discretion of the EMS team and with the EMS team at the discretion of the EMS team and KCC Charge Nurse or Clinical Manager.KCC Charge Nurse or Clinical Manager.

• The charge nurse should give a full report to the The charge nurse should give a full report to the ambulance personnel of the events leading up to the ambulance personnel of the events leading up to the transfer.transfer.

• Once the patient has left the building the Charge Nurse Once the patient has left the building the Charge Nurse should call the emergency room triage nurse to notify should call the emergency room triage nurse to notify him/her of the transfer. The Charge nurse should give a him/her of the transfer. The Charge nurse should give a full report of the events leading up to the transfer.full report of the events leading up to the transfer.

• The Clinical Manager, Social Worker, or Charge Nurse The Clinical Manager, Social Worker, or Charge Nurse should notify the patient’s emergency contact of the should notify the patient’s emergency contact of the transfer. Every effort should be made to offer support and transfer. Every effort should be made to offer support and sensitivity to the family member receiving the informationsensitivity to the family member receiving the information

Cardiopulmonary ArrestCardiopulmonary Arrest

• A A cardiac arrestcardiac arrest, also known as , also known as cardiopulmonary arrestcardiopulmonary arrest or circulatory arrest, is or circulatory arrest, is the abrupt cessation of normal circulation of the the abrupt cessation of normal circulation of the blood due to failure of the heart to contract blood due to failure of the heart to contract effectively during systole.effectively during systole.

• Cardiac arrest is a Cardiac arrest is a medical emergencymedical emergency that, in that, in certain groups of patients, is potentially reversible certain groups of patients, is potentially reversible if treated early enough if treated early enough

• The staff member discovering the patient in The staff member discovering the patient in cardiac arrest should call for help without leaving cardiac arrest should call for help without leaving the patient. The staff person responding should the patient. The staff person responding should page “all staff to the patient care area stat” over page “all staff to the patient care area stat” over the intercom.the intercom.

• The patient’s blood should be returned The patient’s blood should be returned immediately. As soon as 3 staff persons are at the immediately. As soon as 3 staff persons are at the chair-side, the patient should be placed in the chair-side, the patient should be placed in the floor, and CPR Started.floor, and CPR Started.

• The charge nurse will make assignments to the code The charge nurse will make assignments to the code team. team. • Code Leader (Charge Nurse):Code Leader (Charge Nurse): Conveys a sense of order Conveys a sense of order

in an emergency environment. Responsible for all in an emergency environment. Responsible for all decisions in the absence of a physician or advanced decisions in the absence of a physician or advanced practitioner. Assigns other responsibilities. Performs practitioner. Assigns other responsibilities. Performs all aspects of electrical therapy. Identifies cardiac all aspects of electrical therapy. Identifies cardiac arrhythmias and chooses appropriate algorithm and arrhythmias and chooses appropriate algorithm and medications based on facility policy. Communicates medications based on facility policy. Communicates activities to the person performing documentation.activities to the person performing documentation.

• Medication Nurse (RN or LPN):Medication Nurse (RN or LPN): Responsible for Responsible for accurate preparation and administration of all accurate preparation and administration of all medications. Communicates medications given to the medications. Communicates medications given to the person performing documentation. Responsible for person performing documentation. Responsible for achieving and maintaining IV access.achieving and maintaining IV access.

• Documentation (LPN or PCT):Documentation (LPN or PCT): Responsible for accurate Responsible for accurate documentation of al events and interventions during documentation of al events and interventions during the code.the code.

• Compressions (CPR certified person):Compressions (CPR certified person): Responsible for Responsible for pulse checks and delivery of compressions during pulse checks and delivery of compressions during cardiac arrest.cardiac arrest.

• Airway ManagementAirway Management (CPR certified person): (CPR certified person): Responsible for achieving and maintaining the Responsible for achieving and maintaining the airway. Responsible for monitoring the delivery of airway. Responsible for monitoring the delivery of O2 and the fill level of the O2 tank.O2 and the fill level of the O2 tank.

• CommunicationsCommunications (Unit Clerk or Ancillary Staff): (Unit Clerk or Ancillary Staff): Responsible for paging physicians, calling 911, Responsible for paging physicians, calling 911, calling the ER triage nurse and copying medical calling the ER triage nurse and copying medical records in anticipation of transport.records in anticipation of transport.

• Only those staff directly involved in the Only those staff directly involved in the resuscitative efforts should be in the immediate resuscitative efforts should be in the immediate vicinity, all other staff should monitor and vicinity, all other staff should monitor and reassure the other patients.reassure the other patients.

• EMS should be notified by dialing 911. Report to EMS should be notified by dialing 911. Report to the EMS dispatcher that CPR is in progress. Page the EMS dispatcher that CPR is in progress. Page the patient’s physician, or physician on call.the patient’s physician, or physician on call.

• The patient should be placed on the cardiac The patient should be placed on the cardiac defibrillator monitor and any lethal arrhythmias defibrillator monitor and any lethal arrhythmias identified. identified.

• If defibrillation is appropriate, this should be If defibrillation is appropriate, this should be performed immediately.performed immediately.

• O2 delivery should be via ambu bag at O2 delivery should be via ambu bag at

100 % at rate of 10 breaths per minute. 100 % at rate of 10 breaths per minute. • IV access should be maintained via the patient’s IV access should be maintained via the patient’s

vascular access, and appropriate medications vascular access, and appropriate medications given per ACLS Guidelines.given per ACLS Guidelines.

• Follow guidelines for emergency patient transport.Follow guidelines for emergency patient transport.

Ethical IssuesEthical Issues• Cardiopulmonary resuscitation and advanced cardiac Cardiopulmonary resuscitation and advanced cardiac

life support are not always in a person's best interest. life support are not always in a person's best interest. This is particularly true in the case of terminal illnesses This is particularly true in the case of terminal illnesses when resuscitation will not alter the outcome of the when resuscitation will not alter the outcome of the disease. Properly performed CPR often fractures the disease. Properly performed CPR often fractures the rib cage, especially in older patients or those suffering rib cage, especially in older patients or those suffering from osteoporosis. Defibrillation, especially repeated from osteoporosis. Defibrillation, especially repeated several times as called for by ACLS protocols, may also several times as called for by ACLS protocols, may also cause electrical burns.cause electrical burns.

• Some people with a terminal illness choose to avoid Some people with a terminal illness choose to avoid such measures and die peacefully. People with views such measures and die peacefully. People with views on the treatment they wish to receive in the event of a on the treatment they wish to receive in the event of a cardiac arrest should discuss these views with both cardiac arrest should discuss these views with both their doctor and with their family. A patient may ask their doctor and with their family. A patient may ask their doctor to place a do not resuscitate (DNR) order their doctor to place a do not resuscitate (DNR) order in the medical record. Alternatively, in many in the medical record. Alternatively, in many jurisdictions, a person may formally state their wishes jurisdictions, a person may formally state their wishes in an advance directive or advance health directive in an advance directive or advance health directive (see POST form at KCC).(see POST form at KCC).

Air EmbolismAir Embolism

• An An air embolismair embolism, or more generally , or more generally gas gas embolismembolism, is a medical condition caused by , is a medical condition caused by gas bubbles in the bloodstream (gas bubbles in the bloodstream (embolismembolism in a in a medical context refers to any large moving medical context refers to any large moving mass or defect in the blood stream). Small mass or defect in the blood stream). Small amounts of air often get into the blood amounts of air often get into the blood circulation accidentally during surgery and other circulation accidentally during surgery and other medical procedures (for example a bubble medical procedures (for example a bubble entering an intravenous fluid line), but most of entering an intravenous fluid line), but most of these air emboli enter the veins and are stopped these air emboli enter the veins and are stopped at the lungs, and thus a venous air embolism at the lungs, and thus a venous air embolism that shows any symptoms, is very rare.that shows any symptoms, is very rare.

Air EmbolismAir Embolism

• The first step in treating Air Embolus The first step in treating Air Embolus is is

prevention.prevention.• Assure alarms test are performed pre-dialysis.Assure alarms test are performed pre-dialysis.• Always change out the NS bag if < 300cc of NS Always change out the NS bag if < 300cc of NS

remains. remains. • Never leave the patient when administering NS Never leave the patient when administering NS

or returning the blood. or returning the blood. • When administering medications or NS by gravity, When administering medications or NS by gravity,

monitor the infusion closely. monitor the infusion closely. • Always assure central catheter ports are clamped Always assure central catheter ports are clamped

when removing caps, syringes or lines.when removing caps, syringes or lines.

• Identify signs and symptoms of air embolus Identify signs and symptoms of air embolus which may include: air or foam observed in which may include: air or foam observed in the venous line below the air detector, chest the venous line below the air detector, chest pain, SOB, cough, seizure, visual pain, SOB, cough, seizure, visual disturbances, hemiparesis, confusion and disturbances, hemiparesis, confusion and changes in mental status, or the patient may changes in mental status, or the patient may describe a sense of impending doom.describe a sense of impending doom.

• Immediately clamp the venous line and turn Immediately clamp the venous line and turn off the blood pump.off the blood pump.

• Place the patient in Trendelenburg position Place the patient in Trendelenburg position on their left side.on their left side.

• Note: This position will aid in trapping Note: This position will aid in trapping the air in the right atrium, which may the air in the right atrium, which may prevent it from traveling to the lungs.prevent it from traveling to the lungs.

• Call for help and request the Charge Nurse.Call for help and request the Charge Nurse.

• Assess patient. If marked changes in the patient’s Assess patient. If marked changes in the patient’s cardiopulmonary and/or mental status are noted, cardiopulmonary and/or mental status are noted, call for the crash cart. Place patient on cardiac call for the crash cart. Place patient on cardiac monitor and assess O2 sat. monitor and assess O2 sat.

• Initiate emergency procedures as indicated by Initiate emergency procedures as indicated by patient’s condition.patient’s condition.

• Recirculate the extracorporeal circuit. Flush the Recirculate the extracorporeal circuit. Flush the fistula needles or catheter ports with NS.fistula needles or catheter ports with NS.

• Notify the patient’s physician or physician on call.Notify the patient’s physician or physician on call.• Return the patient’s blood if indicated/ordered.Return the patient’s blood if indicated/ordered.• Once the patient is stabilized or transported, Once the patient is stabilized or transported,

investigate and identify the source of air. If no investigate and identify the source of air. If no source is identified, or if the dialysis machine may source is identified, or if the dialysis machine may be implicated, pull the equipment, place a service be implicated, pull the equipment, place a service report on the machine and label it “Not for Use”. report on the machine and label it “Not for Use”. Notify the Chief Tech.Notify the Chief Tech.

Anaphylactic ReactionAnaphylactic Reaction

• Anaphylaxis Anaphylaxis is a serious allergic reaction is a serious allergic reaction that is rapid in onset and may cause death.that is rapid in onset and may cause death.

• What are the common causes of What are the common causes of anaphylaxis?anaphylaxis?

• Common causes of anaphylaxis Common causes of anaphylaxis include:include:• Food Food • Medication Medication • Insect stings Insect stings • Latex Latex

• Identify the SIGNS AND SYMPTOMS’s of Identify the SIGNS AND SYMPTOMS’s of anaphylactic reaction that may include: SOB, acute anaphylactic reaction that may include: SOB, acute bronchospasms or bronchoconstriction, chest pain, bronchospasms or bronchoconstriction, chest pain, back pain, hypotension, hypertension, anxiety, back pain, hypotension, hypertension, anxiety, thready-rapid pulse, diaphoresis, nausea, profound thready-rapid pulse, diaphoresis, nausea, profound shock, and/or cardiopulmonary arrest.shock, and/or cardiopulmonary arrest.

• Stop the infusion of medication or blood Stop the infusion of medication or blood immediately. If the product is being infused via the immediately. If the product is being infused via the extracorporeal circuit, stop the blood pump and extracorporeal circuit, stop the blood pump and clamp the venous bloodline. clamp the venous bloodline.

• Place the patient in Trendelenburg position if Place the patient in Trendelenburg position if SIGNS AND SYMPTOMS of shock are present.SIGNS AND SYMPTOMS of shock are present.

• Call for help and request the Charge Nurse Call for help and request the Charge Nurse • Assess the patient. If marked changes in the Assess the patient. If marked changes in the

patient’s cardiopulmonary status are noted, call for patient’s cardiopulmonary status are noted, call for the crash cart. Place the patient on the cardiac the crash cart. Place the patient on the cardiac monitor and assess O2 status. monitor and assess O2 status.

• Attach the NS line directly to the patient’s vascular Attach the NS line directly to the patient’s vascular access. Be prepared to provide NS for volume access. Be prepared to provide NS for volume support if B/P indicates.support if B/P indicates.

• Initiate emergency procedures as indicated by Initiate emergency procedures as indicated by patient’s condition.patient’s condition.

• Administer medications according to Physicians Administer medications according to Physicians Standing Emergency Orders.Standing Emergency Orders.

• Note:Note: Patients taking beta-blockers routinely may Patients taking beta-blockers routinely may not respond adequately tonot respond adequately to epinephrineepinephrine..

• Recirculate the extracorporeal circuit and flush the Recirculate the extracorporeal circuit and flush the unused catheter ports or fistula needles.unused catheter ports or fistula needles.

• Notify the patient’s physician or physician on call.Notify the patient’s physician or physician on call.• Once the patient is stabilized or transferred, Once the patient is stabilized or transferred,

identify the causative agent and label the patient’s identify the causative agent and label the patient’s medical record accordingly. Consider: medications, medical record accordingly. Consider: medications, blood products, dialyzer membranes, and/or blood products, dialyzer membranes, and/or dialyzer germicides.dialyzer germicides.

SeizureSeizure

• A seizure is a sudden change in behavior A seizure is a sudden change in behavior due to abnormal electrical activity in the due to abnormal electrical activity in the brain brain

• Note:Note: Seizure activity during dialysis is Seizure activity during dialysis is usually the result of hypotension or a pre-usually the result of hypotension or a pre-existing seizure disorder. Other possible existing seizure disorder. Other possible causes are drug toxicity, disequilibrium causes are drug toxicity, disequilibrium syndrome, air embolism or hemolysis. syndrome, air embolism or hemolysis. Exact treatment will depend on the causeExact treatment will depend on the cause

• Identify seizure activity.Identify seizure activity.• Quickly assess the venous bloodline for the Quickly assess the venous bloodline for the

presence of air or hemolized blood. If present, stop presence of air or hemolized blood. If present, stop the blood pump, clamp the bloodlines and refer to the blood pump, clamp the bloodlines and refer to the appropriate procedure.the appropriate procedure.

• Call for help and request the Charge Nurse. Call for help and request the Charge Nurse. • Place the patient in Trendelenburg position with the Place the patient in Trendelenburg position with the

head supported to one side.head supported to one side.• Begin an infusion of NS into the extracorporeal Begin an infusion of NS into the extracorporeal

circuit at a rate of about 200 ml/min.circuit at a rate of about 200 ml/min.• Attempt to assess the patient’s blood pressure as Attempt to assess the patient’s blood pressure as

soon as seizure activity will allow. If patient is soon as seizure activity will allow. If patient is hypotensive, refer to the appropriate procedure.hypotensive, refer to the appropriate procedure.

• If possible, insert an oral airway between the If possible, insert an oral airway between the patient’s teeth. Do not attempt to force the airway patient’s teeth. Do not attempt to force the airway between clinched teeth.between clinched teeth.

• Prevent dislodgement of fistula needles or vascular Prevent dislodgement of fistula needles or vascular access catheters with hands on support if necessary.access catheters with hands on support if necessary.

• Notify the patient’s physician or the physician on call Notify the patient’s physician or the physician on call of the event.of the event.

• Follow any medication or laboratory orders given by Follow any medication or laboratory orders given by the physician.the physician.

• As seizure activity subsides, maintain on open airway, As seizure activity subsides, maintain on open airway, and continue to support the head to one side. Be and continue to support the head to one side. Be prepared to suction the patient if needed. Be prepared to suction the patient if needed. Be prepared to provide respiratory assistance if needed.prepared to provide respiratory assistance if needed.

• Note:Note: Hypotensive seizure activity is often followed by an Hypotensive seizure activity is often followed by an episode of nausea and vomiting.episode of nausea and vomiting.

• If the patient’s condition returns to baseline, reinitiate If the patient’s condition returns to baseline, reinitiate dialysis as ordered.dialysis as ordered.

• Note:Note: Patient’s with a seizure disorder may appear Patient’s with a seizure disorder may appear profoundly lethargic after a seizure.profoundly lethargic after a seizure.

• If the patient’s fails to return to baseline, follow If the patient’s fails to return to baseline, follow physician orders. See Guidelines for emergency physician orders. See Guidelines for emergency transport if indicated.transport if indicated.

Shortness of Breath Shortness of Breath

• Difficulty BreathingDifficulty Breathing

• Note:Note: SOB in dialysis patients is SOB in dialysis patients is usually the result of fluid overload, usually the result of fluid overload, anxiety and/or hypotension. Less anxiety and/or hypotension. Less often it may be related to angina, often it may be related to angina, MI, blood, medication orMI, blood, medication or dialyzer dialyzer reactions. Rarely is it the result of air reactions. Rarely is it the result of air embolus, hemolysis or crenation.embolus, hemolysis or crenation.

• Notify the Charge Nurse.Notify the Charge Nurse.• Rule out the possibility of a dialyzer, Rule out the possibility of a dialyzer,

medication, or blood reaction. If SIGNS AND medication, or blood reaction. If SIGNS AND SYMPTOMS’s begin immediately after beginning SYMPTOMS’s begin immediately after beginning the administration of a medication or blood, or the administration of a medication or blood, or starting the dialysis procedure, stop the blood starting the dialysis procedure, stop the blood pump, and treat the patient according to the pump, and treat the patient according to the appropriate anaphylactic or dialyzer reaction appropriate anaphylactic or dialyzer reaction procedure.procedure.

• Rule out the possibility of air embolus crenation Rule out the possibility of air embolus crenation or hemolysis. Evaluate the venous bloodline for or hemolysis. Evaluate the venous bloodline for the presence of bright cherry-colored, blood, the presence of bright cherry-colored, blood, dark blood or air below the air detect, stop the dark blood or air below the air detect, stop the blood pump and refer to the appropriate blood pump and refer to the appropriate procedure.procedure.

• Assess the patient’s blood pressure, and treat Assess the patient’s blood pressure, and treat hypotension if indicated. Reassess the patient hypotension if indicated. Reassess the patient after NS administration.after NS administration.

• Measure Measure O2 O2 saturation. If saturation. If O2 O2 saturation is less saturation is less than 90%, notify the patient’s physician or the than 90%, notify the patient’s physician or the physician on call.physician on call.

• StartStart O2 O2 at:at:• 2 liters/min per nasal cannula for patients with 2 liters/min per nasal cannula for patients with

O2 O2 saturation 95-100% on room air.saturation 95-100% on room air.• 4 liters/min per nasal cannula for patients with 4 liters/min per nasal cannula for patients with

O2 O2 saturation 90-95%saturation 90-95%• 10 liters/min per partial non-rebreather mask 10 liters/min per partial non-rebreather mask

for patients with for patients with O2 O2 saturation < 90%.saturation < 90%.• Assess the patient’s heart rate and rhythm. Assess the patient’s heart rate and rhythm.

Place patient on cardiac monitor if indicated. If Place patient on cardiac monitor if indicated. If the symptoms appear cardiac in origin, return the symptoms appear cardiac in origin, return the patient’s blood and notify the physician.the patient’s blood and notify the physician.

• Evaluate the patient’s fluid volume status. Evaluate the patient’s fluid volume status. Check for pitting edema in the extremities, Check for pitting edema in the extremities, NVD, auscultatate the patient’s lungs.NVD, auscultatate the patient’s lungs.

• If FVO is suspected, review the treatment plan If FVO is suspected, review the treatment plan for appropriate fluid removal.for appropriate fluid removal.

• If unable to resolve the patient’s SIGNS AND If unable to resolve the patient’s SIGNS AND SYMPTOMS, notify the physician.SYMPTOMS, notify the physician.

Cardiac Cardiac Arrhythmias Arrhythmias

• Cardiac arrhythmia is a term that denotes a Cardiac arrhythmia is a term that denotes a disturbance of the heart rhythm. Cardiac disturbance of the heart rhythm. Cardiac arrhythmias can range in severity from entirely arrhythmias can range in severity from entirely benign to immediately life-threatening benign to immediately life-threatening

• Note: Cardiac arrhythmias in dialysis Note: Cardiac arrhythmias in dialysis patients are usually caused by patients are usually caused by electrolyte disturbances, altered electrolyte disturbances, altered medication levels, hypovolemia, anemia, medication levels, hypovolemia, anemia, hypotension or underlying heart disease; hypotension or underlying heart disease; rarely arrhythmias may be related to rarely arrhythmias may be related to irritation of the heart’s conduction irritation of the heart’s conduction system by vascular access catheters.system by vascular access catheters.

• Immediately notify the Charge Nurse of Immediately notify the Charge Nurse of irregularities noted in the patient’s heart irregularities noted in the patient’s heart rhythm.rhythm.

• Place the patient on the cardiac monitor and Place the patient on the cardiac monitor and assess the patient for the presence of lethal assess the patient for the presence of lethal arrhythmias and/or chest pain. arrhythmias and/or chest pain.

• Note:Note: Do not initiate the dialysis treatment if Do not initiate the dialysis treatment if the patient is unstable when he presents to the the patient is unstable when he presents to the dialysis unit. Notify the patient’s physician or dialysis unit. Notify the patient’s physician or the physician on call. In the presence of lethal the physician on call. In the presence of lethal arrhythmias, or if the patient becomes arrhythmias, or if the patient becomes hemodynamically unstable while on dialysis, hemodynamically unstable while on dialysis, discontinue the dialysis treatment and notify discontinue the dialysis treatment and notify the patient’s physician or the physician on call.the patient’s physician or the physician on call.

• Measure the patient’s O2 saturation, and start Measure the patient’s O2 saturation, and start O2 as indicated. Initiate emergency O2 as indicated. Initiate emergency procedures when indicated.procedures when indicated.

• Assess the patient’s blood pressure, and treat Assess the patient’s blood pressure, and treat hypotension if present.hypotension if present.

• Evaluate the appropriateness of the patient’s dry Evaluate the appropriateness of the patient’s dry weight and ultrafiltration plan.weight and ultrafiltration plan.

• Evaluate the patient’s past history of cardiac Evaluate the patient’s past history of cardiac disease.disease.

• Assess the patient for the SIGNS AND SYMPTOMS of Assess the patient for the SIGNS AND SYMPTOMS of potassium imbalance.potassium imbalance.

• Evaluate the patient’s recent serum potassium Evaluate the patient’s recent serum potassium levels.levels.

• Note the potassium content of their current dialysate Note the potassium content of their current dialysate prescription.prescription.

• Assess the patient’s food intake over the last 48 Assess the patient’s food intake over the last 48 hours for high potassium foods. hours for high potassium foods.

• Evaluate the patient’s cardiac monitor strip for Evaluate the patient’s cardiac monitor strip for peaked T waves and/or a widened QRS complex.peaked T waves and/or a widened QRS complex.

• Evaluate the patient for other SIGNS AND SYMPTOMS Evaluate the patient for other SIGNS AND SYMPTOMS of hyperkalemia such as generalized muscle pain and of hyperkalemia such as generalized muscle pain and weakness.weakness.

• Evaluate the patient’s compliance with prescribed Evaluate the patient’s compliance with prescribed cardiac medications.cardiac medications.

• Administer medications and/or draw labs as ordered Administer medications and/or draw labs as ordered by the physician.by the physician.

Transfusion Transfusion ReactionReaction

• Note:Note: Transfusion reactions may occur Transfusion reactions may occur immediately after the start of the transfusion, immediately after the start of the transfusion, any time during the transfusion, or for up to any time during the transfusion, or for up to 48 hours after the transfusion. Types of 48 hours after the transfusion. Types of transfusion reactions include:transfusion reactions include:

• Pyrogenic:Pyrogenic: Usually results from bacterial Usually results from bacterial contamination of the blood. SIGNS AND contamination of the blood. SIGNS AND SYMPTOMS’s include chills, very high fever, SYMPTOMS’s include chills, very high fever, hypotension and eventually shock. Less hypotension and eventually shock. Less severe febrile reactions caused by leukocyte severe febrile reactions caused by leukocyte antibodies or other causes may be identified antibodies or other causes may be identified by chills and fever, muscle aches, nausea and by chills and fever, muscle aches, nausea and vomiting, headaches and flushing. Pyrogenic vomiting, headaches and flushing. Pyrogenic reactions are usually gradual and may not be reactions are usually gradual and may not be seen until well into the transfusion.seen until well into the transfusion.

• Hemolytic:Hemolytic: Results from incompatibility of the donor’s blood to Results from incompatibility of the donor’s blood to the patient’s blood. The onset is sudden and includes SOB, low back the patient’s blood. The onset is sudden and includes SOB, low back pain, chest pain, nausea and vomiting, headache and or fever with pain, chest pain, nausea and vomiting, headache and or fever with chills.chills.

• Allergic:Allergic: Probably due to the patient’s response to allergens in the Probably due to the patient’s response to allergens in the donor’s blood. They are characterized by itching that may be donor’s blood. They are characterized by itching that may be accompanied by a rash or hives. Generally medicating the patient with accompanied by a rash or hives. Generally medicating the patient with antihistamines relieves the symptoms.antihistamines relieves the symptoms.

• Fluid Overload:Fluid Overload: May result when the blood is administered too May result when the blood is administered too quickly, or when the patient is significantly above their dry weight quickly, or when the patient is significantly above their dry weight already. SIGNS AND SYMPTOMS’s include SOB, rapid HR and/or already. SIGNS AND SYMPTOMS’s include SOB, rapid HR and/or drop in blood pressure. SIGNS AND SYMPTOMS’s usually improve drop in blood pressure. SIGNS AND SYMPTOMS’s usually improve with a decrease in the rate of infusion, or by withholding the with a decrease in the rate of infusion, or by withholding the transfusion until a significant amount of ultrafiltration is achieved.transfusion until a significant amount of ultrafiltration is achieved.

•

Identify the SIGNS AND SYMPTOMS’s of a possible transfusion Identify the SIGNS AND SYMPTOMS’s of a possible transfusion reaction. Any unusual symptom experienced by the patient should reaction. Any unusual symptom experienced by the patient should be considered a possible reaction.be considered a possible reaction.

• Stop the blood transfusion. If SIGNS AND SYMPTOMS’s are Stop the blood transfusion. If SIGNS AND SYMPTOMS’s are severe, stop the blood pump and recirculate the extracorporeal severe, stop the blood pump and recirculate the extracorporeal circuit. circuit. DO NOT RETURN THE BLOODDO NOT RETURN THE BLOOD. Flush the patient’s . Flush the patient’s fistula needles or catheter ports with NS.fistula needles or catheter ports with NS.

• Call for assistance, if needed, and alert the Charge Nurse.Call for assistance, if needed, and alert the Charge Nurse.• Assess the patient. If marked changes in the cardiopulmonary status Assess the patient. If marked changes in the cardiopulmonary status

are noted, call for the crash cart. Place the patient on the cardiac are noted, call for the crash cart. Place the patient on the cardiac monitor and assess the 02 status.monitor and assess the 02 status.

• Initiate emergency procedures as indicated Initiate emergency procedures as indicated • Notify the patient’s physician or the physician on call.Notify the patient’s physician or the physician on call.• Administer medications per physician order.Administer medications per physician order.• Notify Blood Assurance. Request a copy of the transfusion reaction Notify Blood Assurance. Request a copy of the transfusion reaction

form via fax.form via fax.• Draw any labs ordered by the physician and/or Blood Assurance.Draw any labs ordered by the physician and/or Blood Assurance.• Complete the reaction section of the blood tag, and complete the Complete the reaction section of the blood tag, and complete the

transfusion reaction form.transfusion reaction form.

CrenationCrenation

• Identify the SIGNS AND SYMPTOMS of crenation. Identify the SIGNS AND SYMPTOMS of crenation. These include flushed face, SOB, sudden rise in blood These include flushed face, SOB, sudden rise in blood pressure, chest pain, abdominal cramps, restlessness, pressure, chest pain, abdominal cramps, restlessness, agitation, convulsions in the presence of dark colored agitation, convulsions in the presence of dark colored blood post dialyzer.blood post dialyzer.

• Immediately clamp the venous line and turn off the Immediately clamp the venous line and turn off the blood pump.blood pump.

• Notify the Charge Nurse.Notify the Charge Nurse.• Assess the patient. Place on cardiac monitor. Be alert Assess the patient. Place on cardiac monitor. Be alert

for SIGNS AND SYMPTOMS of hyperkalemia.for SIGNS AND SYMPTOMS of hyperkalemia.• Start O2 at 2 l/min per nasal cannula. Treat other Start O2 at 2 l/min per nasal cannula. Treat other

symptoms and implement emergency procedures as symptoms and implement emergency procedures as indicated. indicated.

• Check the conductivity of the machine. If crenation Check the conductivity of the machine. If crenation has occurred as a result of the dialysate, the has occurred as a result of the dialysate, the conductivity will be low.conductivity will be low.

• Notify the patient’s physician, or the physician on Notify the patient’s physician, or the physician on call.call.

• Check a stat potassium level on the patient. Check a stat potassium level on the patient. Preserve a sample of dialysate for laboratory Preserve a sample of dialysate for laboratory analysis. analysis.

• The extracorporeal circuit should be tossed.The extracorporeal circuit should be tossed.

• The machine should be pulled and labeled not for The machine should be pulled and labeled not for use. use.

• Notify the Chief Technician, and complete a service Notify the Chief Technician, and complete a service report on the machine.report on the machine.

• Restart dialysis on a fresh machine and dialyzer as Restart dialysis on a fresh machine and dialyzer as ordered by the physician.ordered by the physician.

• Note:Note: The patient’s potassium will probably be The patient’s potassium will probably be elevated. Dialysis should be restarted for a elevated. Dialysis should be restarted for a minimum of 2 hours.minimum of 2 hours.

HemolysisHemolysis

• Identify the SIGNS AND SYMPTOMS of hemolysis. Identify the SIGNS AND SYMPTOMS of hemolysis. These include patient complaints of a burning These include patient complaints of a burning sensation in the access extremity, SOB, hypotension, sensation in the access extremity, SOB, hypotension, hyperkalemia, chest and back pain, nausea and hyperkalemia, chest and back pain, nausea and vomiting, convulsions and/or cardiac arrhythmias or vomiting, convulsions and/or cardiac arrhythmias or arrest in the presence of cranberry-colored almost arrest in the presence of cranberry-colored almost translucent blood post dialyzer.translucent blood post dialyzer.

• Immediately clamp the venous line and turn off the Immediately clamp the venous line and turn off the blood pump.blood pump.

• Notify the Charge Nurse.Notify the Charge Nurse.• Assess the patient. Place on cardiac monitor. Be alert Assess the patient. Place on cardiac monitor. Be alert

for SIGNS AND SYMPTOMS of hyperkalemia.for SIGNS AND SYMPTOMS of hyperkalemia.• Start O2 at 2 l/min per nasal cannula. Treat other Start O2 at 2 l/min per nasal cannula. Treat other

symptoms and implement emergency procedures as symptoms and implement emergency procedures as indicated. indicated.

• Draw a sample of blood from the extracorporeal Draw a sample of blood from the extracorporeal circuit and place in a SST tube. Spin for 5-15 minutes circuit and place in a SST tube. Spin for 5-15 minutes and check for the presence of pink serum indicating and check for the presence of pink serum indicating hemolysis.hemolysis.

• Consider the following causes of hemolysis:Consider the following causes of hemolysis:• Inappropriate dialysate composition resulting in Inappropriate dialysate composition resulting in

hypotonic dialysate.hypotonic dialysate.• Overheated dialysate, usually above 105º F or 40º C.Overheated dialysate, usually above 105º F or 40º C.• Notify the patient’s physician, or the physician on Notify the patient’s physician, or the physician on

call.call.• Check a stat potassium level and H&H on the Check a stat potassium level and H&H on the

patient. Preserve a sample of dialysate for laboratory patient. Preserve a sample of dialysate for laboratory analysis. analysis.

• The extracorporeal circuit should be tossed.The extracorporeal circuit should be tossed.• The machine should be pulled and labeled not for The machine should be pulled and labeled not for

use. use. • Notify the Chief Technician, and complete a service Notify the Chief Technician, and complete a service

report on the machine.report on the machine.• Restart dialysis on a fresh machine and dialyzer as Restart dialysis on a fresh machine and dialyzer as

ordered by the physician.ordered by the physician.• Note:Note: The patient’s potassium will probably be The patient’s potassium will probably be

elevated. Dialysis should be restarted for a minimum elevated. Dialysis should be restarted for a minimum of 2 hours. Consider transport to acute facility.of 2 hours. Consider transport to acute facility.

Disequilibrium Disequilibrium Syndrome Syndrome

• Identify the SIGNS AND SYMPTOMS of disequilibrium Identify the SIGNS AND SYMPTOMS of disequilibrium syndrome. These include patient complaints of a syndrome. These include patient complaints of a headache, hypertension, increased pulse pressure, headache, hypertension, increased pulse pressure, decreased level of consciousness, nausea and decreased level of consciousness, nausea and vomiting, convulsions and/or coma. Disequilibrium vomiting, convulsions and/or coma. Disequilibrium syndrome occurs most often when the patient is very syndrome occurs most often when the patient is very uremic with BUN above 150 mg/dl. Generally signs uremic with BUN above 150 mg/dl. Generally signs and symptoms present early in the dialysis and symptoms present early in the dialysis treatment. Signs and symptoms should be treatment. Signs and symptoms should be differentiated from first use syndrome.differentiated from first use syndrome.

• Note:Note: Disequilibrium syndrome occurs when the Disequilibrium syndrome occurs when the blood osmolarity falls faster than the osmolarity of blood osmolarity falls faster than the osmolarity of the cerebrospinal fluid. (This results from rapidly the cerebrospinal fluid. (This results from rapidly lowering the BUN.) Fluid shifts from the vascular lowering the BUN.) Fluid shifts from the vascular compartment to the cerebral spinal fluid compartment to the cerebral spinal fluid compartment and cerebral edema occurs. Patients compartment and cerebral edema occurs. Patients known or suspected of extremely elevated BUN known or suspected of extremely elevated BUN levels should be dialyzed cautiously in the outpatient levels should be dialyzed cautiously in the outpatient setting. Prophylactic Mannitol, sodium modeling, low setting. Prophylactic Mannitol, sodium modeling, low initial blood flow rates and a low clearance dialyzer initial blood flow rates and a low clearance dialyzer are key.are key.

• Immediately reduce the blood pump speed to Immediately reduce the blood pump speed to 100 ml/min.100 ml/min.

• Notify the Charge Nurse.Notify the Charge Nurse.• Begin administration of Mannitol 25% 50ml IVP, Begin administration of Mannitol 25% 50ml IVP,

slowly via the venous drip chamber.slowly via the venous drip chamber.• Implement emergency procedures as indicated, Implement emergency procedures as indicated,

and be alert for signs of seizure activity.and be alert for signs of seizure activity.• Notify physician if SIGNS AND SYMPTOMS are Notify physician if SIGNS AND SYMPTOMS are

severe or do not resolve with treatment.severe or do not resolve with treatment.• Note:Note: Consider transport to an acute facility if Consider transport to an acute facility if

SIGNS AND SYMPTOMS’s are severe or if there SIGNS AND SYMPTOMS’s are severe or if there is a change in the patient’s mental status.is a change in the patient’s mental status.

• Resume dialysis cautiously once symptoms Resume dialysis cautiously once symptoms subside. Blood flow rates should not exceed subside. Blood flow rates should not exceed 150-200 ml/min initially150-200 ml/min initially

First Use Syndrome First Use Syndrome

• Recognize the symptoms of first-use syndrome and Recognize the symptoms of first-use syndrome and differentiated those symptoms from the symptoms of differentiated those symptoms from the symptoms of hemolysis, crenation, disequilibrium syndrome and hemolysis, crenation, disequilibrium syndrome and dialyzer reaction. The SIGNS AND SYMPTOMS of first-dialyzer reaction. The SIGNS AND SYMPTOMS of first-use syndrome include itching, back pain and use syndrome include itching, back pain and moderate hypotension.moderate hypotension.

• Note:Note: With hemolysis and crenation you will see With hemolysis and crenation you will see changes in the appearance of the blood in the venous changes in the appearance of the blood in the venous bloodline. With disequilibrium Syndrome the patient bloodline. With disequilibrium Syndrome the patient should have some history to indicate the presence of should have some history to indicate the presence of an elevated BUN, and the symptoms tend to be more an elevated BUN, and the symptoms tend to be more severe. With a dialyzer or sterilent reaction, the severe. With a dialyzer or sterilent reaction, the symptoms tend to be more severe and SOB is a symptoms tend to be more severe and SOB is a common feature. First- use syndrome only occurs with common feature. First- use syndrome only occurs with a new, unprocessed dialyzer. First-use syndrome a new, unprocessed dialyzer. First-use syndrome results from complement activation by the new results from complement activation by the new dialyzer membrane, and it occurs more often with dialyzer membrane, and it occurs more often with cellulosic membranescellulosic membranes..

• Immediately reduce the blood pump speed to 100 Immediately reduce the blood pump speed to 100 ml/min.ml/min.

• Notify the Charge Nurse.Notify the Charge Nurse.

• Evaluate the patient’s blood pressure and treat Evaluate the patient’s blood pressure and treat hypotension with NS.hypotension with NS.

• If SIGNS AND SYMPTOMS do not resolve, return the If SIGNS AND SYMPTOMS do not resolve, return the patient’s blood and purge the dialyzer and patient’s blood and purge the dialyzer and extracorporeal circuit with 1000cc of NS.extracorporeal circuit with 1000cc of NS.

• Restart dialysis cautiously with low blood pump Restart dialysis cautiously with low blood pump speeds of 150-200 ml/min.speeds of 150-200 ml/min.

• Consider change in the patient’s dialyzer type or Consider change in the patient’s dialyzer type or individual pre-dialysis individual pre-dialysis preparation procedures as ordered by physician.preparation procedures as ordered by physician.

Blood Loss / Blood Loss / Exsanguination Exsanguination

• Note:Note: Blood loss during dialysis can occur on post blood Blood loss during dialysis can occur on post blood pump along the extracorporeal circuit. Manufacture’s pump along the extracorporeal circuit. Manufacture’s defects have occurred in the actual tubing and blood pump defects have occurred in the actual tubing and blood pump segments. Cuts have been made in the tubing sets when segments. Cuts have been made in the tubing sets when opening packing boxes. Blood loss can occur at the opening packing boxes. Blood loss can occur at the connection between the dialyzer and the bloodline due to connection between the dialyzer and the bloodline due to product defect or improper connection. Blood loss can also product defect or improper connection. Blood loss can also occur from needle dislodgement or dialysis catheter occur from needle dislodgement or dialysis catheter dislodgement. Every effort should be made by the dialysis dislodgement. Every effort should be made by the dialysis staff to secure against needle or catheter dislodgement.staff to secure against needle or catheter dislodgement.

• The staff member discovering the patient should The staff member discovering the patient should immediately clamp the venous bloodline and turn off the immediately clamp the venous bloodline and turn off the blood pump.blood pump.

• Call for assistance and notify the Charge Nurse.Call for assistance and notify the Charge Nurse.• Assess the patient for SIGNS AND SYMPTOMS of blood loss. Assess the patient for SIGNS AND SYMPTOMS of blood loss.

Administer NS, Albumin and oxygen in case of shock. Administer NS, Albumin and oxygen in case of shock. Implement emergency procedures if indicated.Implement emergency procedures if indicated.

• Establish the location of the break in the extracorporeal Establish the location of the break in the extracorporeal circuit.circuit.

• If exsanguination is the result of fistula needle If exsanguination is the result of fistula needle dislodgement: dislodgement:

• Apply sterile gauze and clamp to the needle Apply sterile gauze and clamp to the needle site.site.

• Clamp fistula needles and bloodlines.Clamp fistula needles and bloodlines.• Remove the fistula needle from the bloodline Remove the fistula needle from the bloodline

and dispose of it in a biohazard sharps and dispose of it in a biohazard sharps container.container.

• Recirculate the extracorporeal circuit assessing Recirculate the extracorporeal circuit assessing for the presence of air.for the presence of air.

• Recannulate the vascular access.Recannulate the vascular access.• Restart dialysis.Restart dialysis.• Assess probable cause of needle dislodgement Assess probable cause of needle dislodgement

and take steps to avoid a recurrence. and take steps to avoid a recurrence.

• If exsanguination is the result of dialysis catheter If exsanguination is the result of dialysis catheter dislodgement: dislodgement:

• Apply pressure to catheter site with sterile gauze for Apply pressure to catheter site with sterile gauze for at least 20 minutes.at least 20 minutes.

• Observe the patient for possible SIGNS AND Observe the patient for possible SIGNS AND SYMPTOMS of air embolus.SYMPTOMS of air embolus.

• Clamp catheter ports and bloodlines.Clamp catheter ports and bloodlines.• Remove the dialysis catheter from the bloodlines Remove the dialysis catheter from the bloodlines

and dispose of it in a biohazard sharps container.and dispose of it in a biohazard sharps container.• Recirculate the extracorporeal circuit.Recirculate the extracorporeal circuit.• Assess the patient for possible IV site for blood Assess the patient for possible IV site for blood

return and return blood if possible.return and return blood if possible.• Notify physician of occurrence and follow arrange for Notify physician of occurrence and follow arrange for

access replacement as ordered.access replacement as ordered.• Assess possible causes of catheter dislodgement Assess possible causes of catheter dislodgement

and take steps to prevent recurrence.and take steps to prevent recurrence.

• If exsanguination is the result of a defect in the If exsanguination is the result of a defect in the bloodlines or dialyzer ports: bloodlines or dialyzer ports:

• Return patient’s blood if air in the circuit is not Return patient’s blood if air in the circuit is not identified.identified.

• Change bloodlines out, or change dialyzer out Change bloodlines out, or change dialyzer out depending on the nature of the break.depending on the nature of the break.

• Perform set-up per procedures.Perform set-up per procedures.• Restart dialysis.Restart dialysis.

Note product name and lot # in the medical record.Note product name and lot # in the medical record.• Make all patient care staff aware of occurrence, and Make all patient care staff aware of occurrence, and

trend any additional occurrences. trend any additional occurrences. • Assess possible causes and take steps to prevent Assess possible causes and take steps to prevent

recurrence.recurrence.• If Clinical Manager is not present, and the cause of the If Clinical Manager is not present, and the cause of the

exsanguinations is unclear, preserve extracorporeal exsanguinations is unclear, preserve extracorporeal circuit for evaluation. circuit for evaluation.

• If a product failure is identified, notify Clinical and If a product failure is identified, notify Clinical and Technical Manager.Technical Manager.

Dialyzer Blood Leak Dialyzer Blood Leak

• If you have a blood leak warning, check a dialysate If you have a blood leak warning, check a dialysate sample from the drain line with a Hemastix test sample from the drain line with a Hemastix test strip, by placing the strip in the stream.strip, by placing the strip in the stream.

• Compare the strip to the results-key on the side of Compare the strip to the results-key on the side of the bottle.the bottle.

• For Hemastix results that are For Hemastix results that are NegativeNegative::• You may continue the dialysis treatment if the You may continue the dialysis treatment if the

Phoenix Machine alarm continues Change settings Phoenix Machine alarm continues Change settings on blood leak detector to minimalon blood leak detector to minimal

• If you continue to have a blood leak warning the If you continue to have a blood leak warning the machine will need to be pulled and Complete a machine will need to be pulled and Complete a service report on the machine and label it not for service report on the machine and label it not for use.use.

• The machine should be cleaned and rinsed prior to The machine should be cleaned and rinsed prior to use, for either situation described above.use, for either situation described above.

•For Hemastix results that are For Hemastix results that are moderately moderately positive, or positive, or hemolyzedhemolyzed, do , do not attempt to return the blood.not attempt to return the blood.•Turn off the blood pump.Turn off the blood pump.•Clamp fistula needles or catheter ports and bloodlines.Clamp fistula needles or catheter ports and bloodlines.•Disconnect the extracorporeal circuit, and place the bloodline Disconnect the extracorporeal circuit, and place the bloodline connector between the arterial and venous bloodlines.connector between the arterial and venous bloodlines.•Flush the fistula needles or catheter ports with NS.Flush the fistula needles or catheter ports with NS.•Remove the extracorporeal circuit and dialyzer from the Remove the extracorporeal circuit and dialyzer from the machine.machine.•Complete a service report on the machine and label it not for Complete a service report on the machine and label it not for use.use.•The machine should be cleaned and rinsed prior to its next The machine should be cleaned and rinsed prior to its next use. use. •Set patient up on a different machine, dialyzer and bloodline Set patient up on a different machine, dialyzer and bloodline set per set per procedure.Restart dialysis per procedure.procedure.Restart dialysis per procedure.•For any actual dialyzer blood leak resulting in a positive For any actual dialyzer blood leak resulting in a positive Hemastix on Hemastix on a re or pre-processed dialyzer, a Reprocessing Complaint a re or pre-processed dialyzer, a Reprocessing Complaint must be must be initiated.initiated.

Clotted DializerClotted Dializer• Note:Note: Clotting in the extracorporeal circuit is more likely when Clotting in the extracorporeal circuit is more likely when

very low blood flows are used, there are problems with adequate very low blood flows are used, there are problems with adequate flow to or from the vascular access, very high ultrafiltration rates flow to or from the vascular access, very high ultrafiltration rates are used, the patient’s hemoglobin is high, or very low doses of are used, the patient’s hemoglobin is high, or very low doses of heparin are used.heparin are used.

• Recognize the signs of clotting within the extracorporeal circuit, Recognize the signs of clotting within the extracorporeal circuit, which include: a darkening of the blood, clot formation within the which include: a darkening of the blood, clot formation within the drip chambers, elevated venous pressure, and/or a rise in TMP.drip chambers, elevated venous pressure, and/or a rise in TMP.

• As soon as clotting is suspected, attempt to return the patients As soon as clotting is suspected, attempt to return the patients blood using the NS line method.blood using the NS line method.

• If the venous pressure continues to clime and returning the blood If the venous pressure continues to clime and returning the blood is not possible, turn off the blood pump, clamp the bloodlines and is not possible, turn off the blood pump, clamp the bloodlines and catheter ports or fistula needles.catheter ports or fistula needles.

• Disconnect the patient from the extracorporeal circuit.Disconnect the patient from the extracorporeal circuit.• Flush the fistula needles or catheter ports with NS flushes.Flush the fistula needles or catheter ports with NS flushes.• Set up a new dialyzer and bloodline set per procedure.Set up a new dialyzer and bloodline set per procedure.• Restart dialysis.Restart dialysis.• Assess possible causes of the clotted circuit and take steps to Assess possible causes of the clotted circuit and take steps to

prevent recurrence.prevent recurrence.

Pyrogenic Reaction Pyrogenic Reaction • All patients will have their pre and post dialysis All patients will have their pre and post dialysis

temperature measured. In addition, any patient temperature measured. In addition, any patient complaining of chills or exhibiting signs of chills will complaining of chills or exhibiting signs of chills will immediately have their temperature measured.immediately have their temperature measured.

• Report any patient reporting chills, exhibiting signs of Report any patient reporting chills, exhibiting signs of chills or having a temperature of 100º F or greater to chills or having a temperature of 100º F or greater to the Charge Nurse immediately.the Charge Nurse immediately.

• Assess the patient for SIGNS AND SYMPTOMS of Assess the patient for SIGNS AND SYMPTOMS of possible febrile illness, including access infection, possible febrile illness, including access infection, pulmonary infections, urinary infections, flu SIGNS pulmonary infections, urinary infections, flu SIGNS AND SYMPTOMS’s or other indications of infection. AND SYMPTOMS’s or other indications of infection. Interview the patient for a recent history of fever at Interview the patient for a recent history of fever at home.home.

• Notify the patient’s physician or the physician on call.Notify the patient’s physician or the physician on call.

• Collect 2 sets of blood cultures from the patient. Collect 2 sets of blood cultures from the patient. • Collect cultures of sputum, urine or the vascular access Collect cultures of sputum, urine or the vascular access

site if SIGNS AND SYMPTOMS are present. Administer site if SIGNS AND SYMPTOMS are present. Administer medications or draw other lab tests as ordered by the medications or draw other lab tests as ordered by the physician.physician.

• Consider transfer to acute care facility for patients with Consider transfer to acute care facility for patients with high fevers or if the patient is unstable.high fevers or if the patient is unstable.

• Trend multiple episodes by patient and/or by date. Trend multiple episodes by patient and/or by date. Notify the Medical Director immediately if multiple Notify the Medical Director immediately if multiple episodes or trends develop.episodes or trends develop.

• For any patient developing a fever during or post For any patient developing a fever during or post dialysis that was asymptomatic pre-dialysis Collect a dialysis that was asymptomatic pre-dialysis Collect a specimen of the dialysate from the effluent end of the specimen of the dialysate from the effluent end of the dialyzer in a urine cup. Prepare the dialysate for culture dialyzer in a urine cup. Prepare the dialysate for culture and/or endotoxin evaluation per procedure.and/or endotoxin evaluation per procedure.

HypertensionHypertension

• Note:Note: Hypertension in dialysis patients is most often associated with Hypertension in dialysis patients is most often associated with fluid volume overload and medication non-compliance. It may also be fluid volume overload and medication non-compliance. It may also be aggravated by underlying cardiac and/or renal disease, anxiety, aggravated by underlying cardiac and/or renal disease, anxiety, substance abuse, and occasionally volume contracture due to substance abuse, and occasionally volume contracture due to dehydration.dehydration.

• Notify the Charge Nurse when a blood pressure exceeds 180/90 or Notify the Charge Nurse when a blood pressure exceeds 180/90 or anytime the blood pressure is significantly different for a particular anytime the blood pressure is significantly different for a particular patient.patient.

• Evaluate the patient’s usual trend in blood pressures.Evaluate the patient’s usual trend in blood pressures.• Evaluate the patient’s compliance with prescribed antihypertensive Evaluate the patient’s compliance with prescribed antihypertensive

medications. Reinforce compliance with prescribed medications if medications. Reinforce compliance with prescribed medications if indicated.indicated.

• Evaluate the appropriateness of the patient’s dry weight, fluid Evaluate the appropriateness of the patient’s dry weight, fluid volume status and ultrafiltration plan. Reinforce fluid restriction if volume status and ultrafiltration plan. Reinforce fluid restriction if indicated.indicated.

• Notify the physician when the pre or intradialytic dialysis blood Notify the physician when the pre or intradialytic dialysis blood pressure exceeds 210/110 and is unusual for that patient.pressure exceeds 210/110 and is unusual for that patient.

• Notify the physician when the post-dialysis blood pressure exceeds Notify the physician when the post-dialysis blood pressure exceeds 180/100 and is unusual for that patient.180/100 and is unusual for that patient.

• Note:Note: Patients whom are chronically hypertensive should have Patients whom are chronically hypertensive should have routine orders established for medication administration and routine orders established for medication administration and discharge criteria.discharge criteria.

• Administer medications and instruct the patient on medication Administer medications and instruct the patient on medication changes as ordered by the physician.changes as ordered by the physician.

Hypotension Hypotension • Note:Note: Hypotension in dialysis patients is most often associated Hypotension in dialysis patients is most often associated

with fluid removal from the patient’s vascular system at a rate, with fluid removal from the patient’s vascular system at a rate, which exceeds the vascular refill rate. It may also be aggravated which exceeds the vascular refill rate. It may also be aggravated by, underlying cardiac disease, inaccurate dry weight assessment by, underlying cardiac disease, inaccurate dry weight assessment and occasionally dehydration.and occasionally dehydration.

• Notify the Charge Nurse when a blood pressure is less than Notify the Charge Nurse when a blood pressure is less than 100/50, anytime the blood pressure is significantly different for a 100/50, anytime the blood pressure is significantly different for a particular patient, or when the patient is symptomatic. particular patient, or when the patient is symptomatic.

• Evaluate the patient’s usual trend in blood pressures and usual Evaluate the patient’s usual trend in blood pressures and usual tolerance to ultrafiltration.tolerance to ultrafiltration.

• Evaluate the patient’s prescribed antihypertensive medications. Evaluate the patient’s prescribed antihypertensive medications. • Evaluate the accuracy of the patient’s pre-dialysis weight.Evaluate the accuracy of the patient’s pre-dialysis weight.• Evaluate the appropriateness of the patient’s dry weight, fluid Evaluate the appropriateness of the patient’s dry weight, fluid

volume status and ultrafiltration plan. Reinforce fluid restriction if volume status and ultrafiltration plan. Reinforce fluid restriction if indicated.indicated.

• Utilize sodium modeling and other hyperosmolar agents to Utilize sodium modeling and other hyperosmolar agents to increase the vascular refill rate. Such agents should be used increase the vascular refill rate. Such agents should be used prophylacticly in patients chronically hypotensive during prophylacticly in patients chronically hypotensive during ultrafiltration.ultrafiltration.

• Notify the physician when profound hypotension does not Notify the physician when profound hypotension does not respond to appropriate therapy, or when changes in the respond to appropriate therapy, or when changes in the treatment plan are indicated.treatment plan are indicated.

• When the patient exhibits SIGNS AND SYMPTOMS of severe When the patient exhibits SIGNS AND SYMPTOMS of severe hypotension (diaphoresis, nausea and vomiting, or seizure:hypotension (diaphoresis, nausea and vomiting, or seizure:

• Open the NS line and NS port and administer 150-250cc of Open the NS line and NS port and administer 150-250cc of NS.NS.

• Lower the patient’s UFR to 0.3 l/minLower the patient’s UFR to 0.3 l/min• Reassess the blood pressure every 2-3 minutes until the Reassess the blood pressure every 2-3 minutes until the

patient is stabilized.patient is stabilized.• Be alert for respiratory and/or cardiac arrest and Be alert for respiratory and/or cardiac arrest and

implement emergency procedures as indicated. implement emergency procedures as indicated. • Notify the physician when the post-dialysis blood pressure Notify the physician when the post-dialysis blood pressure

is less than 100/50 unless the patient has a specific order is less than 100/50 unless the patient has a specific order to be discharged with a lower blood pressure.to be discharged with a lower blood pressure.

Hypoglycemia Hypoglycemia • Recognize the SIGNS AND SYMPTOMS of hypoglycemia in Recognize the SIGNS AND SYMPTOMS of hypoglycemia in

diabetic patients. These include diaphoresis, decreased mental diabetic patients. These include diaphoresis, decreased mental status, feeling faint, irritability and or tremors.status, feeling faint, irritability and or tremors.

• Evaluate the patient’s blood pressure to rule out hypotension.Evaluate the patient’s blood pressure to rule out hypotension.• Check the patient’s blood glucose level using the glucometer.Check the patient’s blood glucose level using the glucometer.• Notify the Charge Nurse when a blood sugar is less than 80, Notify the Charge Nurse when a blood sugar is less than 80,

and/or the patient is symptomatic.and/or the patient is symptomatic.• 50% dextrose may be administered at the discretion of the 50% dextrose may be administered at the discretion of the

Charge Nurse after evaluating the patient’s food intake and Charge Nurse after evaluating the patient’s food intake and insulin usage.insulin usage.

• Patients who do not take insulin or oral hypoglycemic agents Patients who do not take insulin or oral hypoglycemic agents should be encouraged to eat a small snack rather than receive should be encouraged to eat a small snack rather than receive 50% dextrose.50% dextrose.

• Patients who have not eaten and taken their insulin should try Patients who have not eaten and taken their insulin should try to eat a small snack in addition to receiving 50% dextrose.to eat a small snack in addition to receiving 50% dextrose.

• Patients who have eaten an appropriate amount of food and Patients who have eaten an appropriate amount of food and taken insulin as prescribed should be evaluated individually taken insulin as prescribed should be evaluated individually when considering 50% dextrose administration.when considering 50% dextrose administration.

• Evaluate the patient’s prescribed hypoglycemic medications Evaluate the patient’s prescribed hypoglycemic medications and recent blood glucose levels. and recent blood glucose levels.

• Notify the physician when profound hypoglycemia does not Notify the physician when profound hypoglycemia does not respond to appropriate therapy, or when changes in the respond to appropriate therapy, or when changes in the treatment plan are indicated.treatment plan are indicated.

Muscle CrampsMuscle Cramps• Note:Note: Muscle Cramps in dialysis patients is most often Muscle Cramps in dialysis patients is most often

associated with fluid removal from the patient’s vascular associated with fluid removal from the patient’s vascular system at a rate, which exceeds the vascular refill rate. It system at a rate, which exceeds the vascular refill rate. It may also be aggravated by, underlying vascular disease, may also be aggravated by, underlying vascular disease, inaccurate dry weight assessment, electrolyte inaccurate dry weight assessment, electrolyte imbalances and occasionally dehydration.imbalances and occasionally dehydration.

• Administer 150cc of NS to the extracorporeal circuit via Administer 150cc of NS to the extracorporeal circuit via the NS line.the NS line.

• Temporarily decrease the ultrafiltration rate to 0.3 l/hr.Temporarily decrease the ultrafiltration rate to 0.3 l/hr.• Notify the Charge Nurse when muscle cramps are Notify the Charge Nurse when muscle cramps are

unrelieved by steps #1 and #2.unrelieved by steps #1 and #2.• Evaluate the patient’s usual trend in fluid volume weight Evaluate the patient’s usual trend in fluid volume weight

gains and their usual tolerance to ultrafiltration.gains and their usual tolerance to ultrafiltration.• Evaluate the accuracy of the patient’s pre-dialysis Evaluate the accuracy of the patient’s pre-dialysis

weight.weight.• Evaluate the appropriateness of the patient’s dry weight, Evaluate the appropriateness of the patient’s dry weight,

fluid volume status and ultrafiltration plan. Reinforce fluid volume status and ultrafiltration plan. Reinforce fluid restriction if indicated. fluid restriction if indicated.

• Note:Note: Patients gaining more than 3 Kg’s between dialysis Patients gaining more than 3 Kg’s between dialysis treatments are more prone to experience side effects associated treatments are more prone to experience side effects associated with ultrafiltration.with ultrafiltration.

If the patient does not usually cramp and no unusual If the patient does not usually cramp and no unusual circumstances are identified, consider recirculating the circumstances are identified, consider recirculating the extracorporeal circuit and weighing the patient in the dialysis extracorporeal circuit and weighing the patient in the dialysis chair.chair.

• Note:Note: The weight of all dialysis chairs is recorded on a sticker The weight of all dialysis chairs is recorded on a sticker located on the back of each chair. While rare, failure of the located on the back of each chair. While rare, failure of the machines ultrafiltration system is possible resulting in excessive machines ultrafiltration system is possible resulting in excessive ultrafiltration and dehydration of the patient. Weighing the patient ultrafiltration and dehydration of the patient. Weighing the patient during the dialysis treatment should provide an indication of the during the dialysis treatment should provide an indication of the accuracy of the ultrafiltration.accuracy of the ultrafiltration.

• Utilize sodium modeling and other hyperosmolar agents to Utilize sodium modeling and other hyperosmolar agents to increase the vascular refill rate. Such agents should be used increase the vascular refill rate. Such agents should be used prophylacticly in patients who chronically have muscle cramps prophylacticly in patients who chronically have muscle cramps during ultrafiltration.during ultrafiltration.

• Note:Note: Mannitol or dialysate sodium adjustments may not be used Mannitol or dialysate sodium adjustments may not be used during the last hour of dialysis.during the last hour of dialysis.

• Dextrose 50% 10-15cc IVP via the venous drip chamber may be Dextrose 50% 10-15cc IVP via the venous drip chamber may be used to relieve cramps in non-diabetic patients during the last used to relieve cramps in non-diabetic patients during the last hour or post dialysis.hour or post dialysis.

• Notify the physician when profound muscle cramps do not Notify the physician when profound muscle cramps do not respond to appropriate therapy, or when changes in the treatment respond to appropriate therapy, or when changes in the treatment plan are indicated.plan are indicated.

Using Patient Using Patient RestraintsRestraints

• Note: Note: Physical restraints may be used only when less Physical restraints may be used only when less restrictive measures prove inadequate to prevent the restrictive measures prove inadequate to prevent the agitated or disoriented patient from injuring himself or agitated or disoriented patient from injuring himself or others and to prevent the patient from deleteriously others and to prevent the patient from deleteriously interfering with medical treatment. The least restrictive interfering with medical treatment. The least restrictive device appropriate for the patient should be used.device appropriate for the patient should be used.

• Identify alternative means to avoid the need for restraints. Identify alternative means to avoid the need for restraints. Consistently reinforce to the patient the importance of his Consistently reinforce to the patient the importance of his medical care. Enlist the assistance of ancillary personnel to medical care. Enlist the assistance of ancillary personnel to sit with the patient. Provide the patient with distractions sit with the patient. Provide the patient with distractions such as coloring books or magazines. Tape bloodlines out such as coloring books or magazines. Tape bloodlines out of the patient’s direct line of vision. Place patients in the of the patient’s direct line of vision. Place patients in the dialysis unit to await transportation when additional dialysis unit to await transportation when additional supervision is needed.supervision is needed.

• If the above measures fail, identify the least restrictive If the above measures fail, identify the least restrictive restraint device appropriate for the patient and the restraint device appropriate for the patient and the situation.situation.

• Contact the physician and obtain an order for the restraint.Contact the physician and obtain an order for the restraint.

• Complete the restraint order form.Complete the restraint order form.• Contact the patient’s emergency contact and Contact the patient’s emergency contact and

request permission to use the restraint device. request permission to use the restraint device. (The patient must consent if competent.) (The patient must consent if competent.) Document their permission to use the device on Document their permission to use the device on the Restraint Form.the Restraint Form.

• Apply the device and assure the patient’s Apply the device and assure the patient’s safety and comfort.safety and comfort.

• Perform routine checks of the patient at least Perform routine checks of the patient at least every 30 minutes to include the condition of the every 30 minutes to include the condition of the restrained limb.restrained limb.

• Remove the restraint device as soon as the Remove the restraint device as soon as the condition justifying its use no longer exists.condition justifying its use no longer exists.

• Document the condition of the extremity at the Document the condition of the extremity at the time the restraint device is removed.time the restraint device is removed.

Questions & AnswersQuestions & Answers

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