HEMODIALYSIS

INTRODUCTION:
Hemodialysis is a treatment to filter wastes and water from blood, as kidneys did when they were
healthy. Hemodialysis helps control blood pressure and balance important minerals, such as potassium,
sodium, and calcium, in blood. Hemodialysis can help to feel better and live longer, but it’s not a cure for
kidney failure. During hemodialysis, blood goes through a filter, called a dialyzer, outside the body. The
dialysis machine pumps blood through the filter and returns the blood to patient’s body.
DEFINITION:
Hemodialysis is the most common renal replacement therapy used with ESKD and kidney failure.
Dialysis removes excess fluids and waste products & chemical and electrolyte balance.
(Iganativicous)
Hemodialysis is a medical procedure to remove fluid and waste products from the blood and to
correct electrolyte imbalances. This is accomplished using a machine and a dialyzer, also referred to as
an "artificial kidney”.
(Medicinenet)
FATHER OF HEMODIALYSIS
William Kolf invented the first “artificial kidney”
PRINCIPLES:
 Diffusion
 Osmosis
 Ultra filtration & solvent drag
Diffusion: Movement of molecules from an area of higher concentration to an area of lower
concentration.
Osmosis: Movement of solvent molecules from lower concentration to higher concentration.
Ultra filtration & Solvent drag: Water moves from an area of high pressure to an area of lower pressure.
More efficient in fluid removal than osmosis. Molecules which are dissolved in the solvent also get
removed- solvent drag.
INDICATIONS:
 Acute poisoning
 Acute renal failure
 Severe edema
 Chronic renal failure
 Hepatic coma
 Metabolic acidosis
 Hyperkalemia
 Transfusion reaction
 Post-partum renal insufficiency
  Cardiac tamponade
 Fluid overload not responding to diuretics & fluid restriction
CONTRAINDICATIONS:
Other chronic disease
No vascular access
Hemorrhage
Hypertension
Very old people
Inability to cope with treatment regimen
Coagulopathy
Inability to survive procedure
HAEMODIALYSIS APPARATUS:
 Dialyzer
 Dialysate
 Blood delivery system
Dialyzer (Artificial Kidney):
 Plastic chamber – contains bundles of capillary tube through which blood circulates while dialysis
solution travels outside the bundle in opposite counter current direction.
 Diffusion & ultrafiltration happens here.
Membranes using in dialyzer-
Flux Property: the efficiency with which a membrane clears water and solutes
Cellulose membrane: low flux
Modified cellulose membrane : low/high flux
Synthetic membrane: low/high
Dialysate Solution:
Bicarbonate solution
1. Sodium Bicarbonate : 600 gm.
2. Sodium chloride : 335 gm.
Concentrated Acidic solution
1. Sodium chloride i.p : 183 gm.
2. Potassium chloride i.p : 5.50 gm.
3. Calcium chloride i.p : 8.00gm
4. Magnesium chloride i.p : 2.75gm
5. Acetic Acid : 9.00gm
6. Dextrose Monohydrate i.p : 38.00gm
7. Purified water : 1 L
Blood Delivery system:
 Blood Pump – moves blood from access site through the dialyzer & back to the patient
Blood flow Rate – 250-500 ml/min
Heparin syringe pump
2 air traps
Air detector
Venous line clamp
VASCULAR ACESS:
PERMENTANT TYPE
 Av Fistula
 Av Graft
TEMPORARY TYPE
 Haemodialysis catheter mainly
o Subclavian,
o Jugular and
o Femoral catheter.
 Sub cutaneous device.
PERMENTANT VASCULAR ACCESS
 Av Fistula
 An arteriovenous fistula (AV) Fistula is an internal access surgically created by a vascular
surgeon using the patient’s own blood vessel.
 AV fistula is created by adjoining artery and vein
 2 blood vessels are joined in a side to side or end to end connection.
 The diversion of arterial blood into the vein causes the vein to become enlarged, distended
and prominent, allowing placement of large gauge needles for the dialysis treatment.
 Access will be able to deliver a blood flow of 300 to 500ml /mt.
 Maturation occur when there is dilation and thickening of the venous segment occurred.
 The Av Fistula can be placed in either the upper or lower arm .The radial artery and cephalic
vein (lower arm) and brachial and cephalic vein (upper arm).
 Venography allows for identification of appropriate vein and help to rule outsites that are not
suitable for use. Doppler flow studies may also be used if venography is not available.
 AV Fistula may take up to 4 months or longer to mature, enough for cannulation.
 Av Graft : Generally called as arteriovenous graft
 When a patient is not a candidate for native AV-Fistula, a vascular graft is substituted. It
can be biological or synthetic material.
 Graft material is implanted subcutaneously into either forearm or upper arm.
 The Graft bridges an artery on one end and a vein on the other end.
 The blood flow is from artery to vein with the AV Graft.
  The graft may be placed in several configuration.eg straight, looped or curved.
 Duration taken for maturation is 2 to 6 weeks after graft placement.
TEMPORARY VASCULAR ACCESS:
Hemodialysis Catheter:
 Subclavian vein, jugular vein and femoral vein are the vessels accessed for using double lumen
catheter.
 Haemodialysis catheter has replaced, the use of AV Shunt for patients receiving immediate
haemodialysis.
 A catheter designed for H.D may be inserted into subclavian, internal jugular or femoral vein
 The lumen of these catheters are much smaller than the permentant access and more time is
required for complete each dialysis (4 to8 hours).
Subcutaneous Device
 Subcutaneous device the implanted beneath the skin.
 These devices are composed of 2 small metallic ports with attached catheters that are inserted
into large central vein.
 The ports of subcutaneous devices have internal mechanism that opens when needles are
removed.
 The blood from one port flows from the body to the H.D machine and return via the other port.
ADVANTAGES:
o Large surface area for cannulation
o Easy to cannulate
o Little time required for maturation.
o Variety of shapes and configuration
o Easy for surgical implantation.
DISADVANTAGES:
o Higher rate of infection
o May reject graft materials
o Higher rate of infection.
o Stenosis at the venous anastomosis, from intimal hyperplasia.
o No development of collateral circulation.
PROCEDURE:
 Blood flow rate: 300-500 ml/min
 Dialysate : 500-800 ml/min
 Usually done 3 times a week and each dialysis lasts for 4 hours.
COMPLICATIONS OF HEMODIALYSIS:
 Hypotension (22-55%)
 Muscle cramps (5-20%)
 Nausea and vomiting (5-15%): due to hypotension
 Headache (5%)- common
 Chest pain (2-5%)
 Back pain (2-5%)
 Itching (5%)- precipitated by dialysis may be due to hypersensitivity to dialyzer membrane
 Fever & chills (<1%)
NURSING MANAGEMENT OF HEMODIALYSIS:
Pre-Dialysis Care:
 Assess vital signs including orthostatic blood pressure (lying, sitting and standing), apical pulse ,
respiration ,and lung sounds
 Record weight (weight changes are effective indicators of fluid volume).
 Assess vascular access site for a palpable pulsation or vibration and audible bruit and for
inflammation, infection and thrombus formation.
 Alert all personnel to avoid using the extremity with the vascular access site for blood pressure or
venipuncture.
 This procedure may damage vessels and lead to failure of the AV Fistula.
Post-Dialysis Care
 Assess and document vital-signs, weight and vascular access site condition. Rapid fluid and
solute removal may leads to orthostatic hypotension ,cardiopulmonary changes and weight loss.
 Monitor BUN ,Serum Creatinine, serum electrolyte and haematocrit levels between dialysis
treatment.
 Assess for dialysis disequilibrium syndrome with headache, nausea and vomiting, altered level of
consciousness and hypertension.
 Assess for nausea, vomiting, muscle cramp and seizure activity.
 Assess for bleeding at the access site. Use standard precautions at all times.
 If transfusion is given during dialysis monitor for possible transfusion reaction.
 Provide psychological support and listen actively.
 Refer to social service and counselling as indicated, clients with renal failure may need additional
support services to help them to adopt to and live with their disease.
CONCLUSION:
Haemodialysis is used for clients with acute or chronic renal failure, fluid and electrolyte and
imbalances etc. It is usually the treatment of choice, when toxic agents such as barbiturates, after an
overdose needed to be removed from the body quickly, in this process the clients toxin-laden blood is
diverted into dialyzer, cleaned and returned to the client.
BIBLIOGRAPHY:
1. Joyce M Black , “Textbook of Medical –Surgical Nursing”, Elsevier Publications,8th Edition,2010, pg no
823 -824.
2. Lippincott Williams & Wikins Hand book of Dialysis ,Wolters Kluwers Publications ,Fifth Edition,
2015 ,Pg no:392 -400.
3. Iganativicious “Text book of Medical Surgical Nursing”, Elsevier Publications, 7th Edition,2009, pg no
612 -614.