SUMMARY: TROUBLESHOOTING POOR BLOOD FLOW IN VASCATHS: Please see the flow chart at the end of the protocol describing possible causes to be considered and how to deal with these in a systematic fashion. A reduced blood flow rate can affect the volume of blood being processed during a set time frame (Dutka & Brickel, 2010). For this reason blood flow is directly related to the efficiency of haemodialysis and a poor blood flow will result in poor dialysis adequacy as measured by Kt/v (Ellis, 2012). The minimum blood flow accepted for treatment to continue is 200mL/minute (Dinwiddie & Bhola, 2010). There are multiple causes effecting blood flow rate, including the patient s blood pressure and heart condition, patient positioning, mechanical kinking, mal-positioning of the catheter tip against the vein wall, drug precipitation, thrombus accumulation, leakage and growth of a fibrin sheath around the catheter s external surface (Chan, 2008). Troubleshooting the causes of poor blood flow through a vascath in a systematic manner will allow the underlying cause/s to be corrected in a timely fashion and an acceptable blood flow rate to be achieved in order to obtain an efficient haemodialysis session. WHAT DO OTHER GUIDELINES SAY? KDOQI (2006): Defines poor blood follow as lower than 300mls/min with an arterial pressure > than - 250 mmhg (NKF, 2006). Equipment: Dressing pack 2 x 10ml syringes 0.9% normal saline for flushing Sterile gloves Betadine 18g drawing up needle A. Procedure for flushing vascath prior to commencing haemodialysis: 1. Don gown and face shield or mask. 2. Attend a procedural hand wash for 60 seconds. 3. Clean trolley with detergent 4. Gather equipment 5. Attend a procedural hand wash for 60 seconds 6. Prepare equipment on a critical aseptic field.
7. Place blue sheet under patient s vascath lumens. 8. Don unsterile gloves. 9. Using the yellow forceps, soak 2-4 pieces of gauze in the Betadine solution. 10. Wrap and rub in the Betadine gauze around the arterial and venous ends of the vascath and around each clamp. Leave to soak for a minimum of 3 minutes. 11. Position trolley in close proximity to the patient. 12. Perform a 3 minute hand wash with antimicrobial hand wash and don sterile gloves. 13. Prepare saline flushes using the 2 x 10ml syringes 14. Unfold the sterile towel on the dressing field and leave it within reach. 15. Using a non touch technique, lift the vascath lumens with one blue forcep and then use the 2 nd forcep to remove the betadine soaked gauze from the lumens. Discard the 2 nd forcep. Place the sterile towel on the patient s chest, then place vascath lumens onto the sterile towel and discard the remaining forcep. 16. Hold the arterial lumen with sterile gauze and with the other hand using another piece of sterile gauze, remove and discard the cap from the lumen. Attach a 3mL syringe. 17. Using a sterile non-touch technique and sterile gauze, unclamp the arterial lumen and withdraw the heparin lock (the volume within the lock is written on each lumen of the catheter). 18. Using a sterile non-touch technique and sterile gauze, reclamp the arterial lumen and disconnect and discard the 3mL syringe. 19. Attach the 10ml syringe containing saline to the arterial lumen, unclamp the lumen using sterile gauze, hold the 10mLsyringe plunger side up (allows air to rise to back of syringe and prevents it being given), draw back slightly to remove air and then flush using turbulent flow. 20. Repeat this motion several times until the flow from each lumen is smooth 21. A supply of extra saline for flushing can be drained into the sterile tray from the wash back bag with the assistance of a second nurse 22. Once the flow from both lumens has improved, connect the patient to the haemodialysis machine as per protocol 23. Aim for a BFR of 200mls/min initially, then gradually increase the pump speed to 300 mls/min, making sure the pressures stay within an acceptable range, aiming for the highest BFR possible 24. As the flow chart stipulates, it may be necessary to reverse lines if the flow from the arterial lumen remains problematic, however, this is not optimal due to the increased risk of recirculation taking place B. Procedure if patient has already been connected to the haemodialysis machine: 1. Follow steps 1 to 19 above 2. It is now necessary for a second nurse to provide assistance with stopping the blood pump and placing the lines into recirculation mode and again for reconnection post flushing 3. Both nurses should use sterile gloves at this point 4. Using a sterile non-touch technique and sterile gauze the lines are disconnected from the vascath and joined together for recirculation using the sterile recirculator 5. Proceed with step 19 above 6. Using a sterile non-touch technique and sterile gauze the lines are reconnected to the vascath and haemodialysis is recommenced
7. The second nurse will assist with stopping and restarting the blood pump as required and clamping the normal saline wash back bag on and off as required REFERENCES: Chan, M. (2008). Hemodialysis central venous catheter dysfunction. Seminars in Dialysis, 21, 6, 516-521 Dinwiddie, L.C. & Bhola, C. (2010). Hemodialysis catheter care: Current recommendations for nursing practice in North America. Nephrology Nursing Journal, 3, 5, 507-528 Dutka,P. & Brickel, H. (2010). A practical review of the kidney dialysis outcomes quality initiative (KDOQI) quidelines for hemodialysis catheters and their potential impact on patient care. Nephrology Nursing Journal, 37, 5, 531-535 Ellis, P. (2012). Meeting the challenge of providing adequate haemodialysis. Journal of Renal Nursing 4, 2, 86-88 National Kidney Foundation (NKF). (2006). Kidney Disease Outcomes Quality Initiative (KDOQI): Clinical Practice Guidelines and Clinical Practice Recommendations: 2006 Updates: Vascular access. American Journal of Kidney Diseases, 48, S176-S307. Retrieved October 12, 2012 from http://www.kidney.org/professionals/ KDOQI/guideline_upHD_ PD_VA/va_rec7.htm
TROUBLESHOOTING POOR FLOW IN VASCATHS CHECK for POOR FLOW < 200 mls/min Kinked lines, Clamps on catheter or lines Drop in BP Obvious clotting Reposition patient o Sit up/lie down/lay on side o Place onto bed Ask patient to cough Try elevating arm above head Flush the catheter vigorously with 0.9% NaCl (as per instructions below) Reversing the lines may be required An experienced nurse may be able to remove the dressing and manipulate a non-tunneled catheter by gentle rotation Start / Obtain order for Actilyse see separate protocol NB: this option should not be used too many times in a row - the catheter may need rewiring if problems persist after actilyse Recommence Dialysis Inform Renal Registrar and Vascular Access CNC (p. 310) Decision will need to be made whether the patient should return to Radiology for rewiring or manipulation of catheter
St George Hospital Renal Department Internal Policy