DEFINITION
Disconnecting patient with arterio-venous fistula from the haemodialysis machine.
PURPOSE
1. To disconnect the patient with AVF from Hemodialysis machine on completion of treatment
2. To investigate malfunction in the system, or patient tolerance
Alert
An air wash back should not be performed under any circumstances. Any reported occurrence results in disciplinary action.
CONDITIONS
1. Applies to all Registered Nursing Personnel working in dialysis centers in Oman.
2. This procedure can be performed by a dialysis nurse undertaking nephrology / Hemodialysis training program, provided he / she is closely supervised by an experienced dialysis nurse at all times
3. A strict aseptic technique should be maintained throughout the procedure in accordance with the policy and procedure on aseptic technique.
4. Hand washing should be performed according to policy and procedure on hand washing.
5. Closed method should be carried out by an experienced dialysis nurses
6. Open method should be carried out by two (2) experienced dialysis nurses
7. Contraindications to carrying out the closed method:
* If the needle is facing fistula
* If there is high residual pressure within the fistula e. g. brachial fistula, graft
* If there is any evidence of clotting in the dialysis lines
8. This policy does not apply in the following circumstances
* Severe blood leak
* Air embolism
* Clotting of blood lines
* Haemolysis of blood in extracorporeal circuit
* Excessive re-circulation time
9. This procedure should be performed by two registered nurses.
Please refer to appropriate policy for discontinuation of Hemodialysis in these emergencies.
EQUIPMENT
1. Trolley cleaned according to policy and procedures on infection control
2. On / off Heamodialysis pack.
3. Fistula clamps x 2 (optional)
4. 0.9% saline 500 ml.
5. Intravenous infusion set
6. One (1) pair of sterile gloves
7. One (1) pair of unsterile gloves
8. Micropore tape.
9. 5 ml sterile syringe (open method only)
10. Specimen containers (if required)
11. Post dialysis medications
12. BP apparatus and stethoscope
PROCEDURE
I – CLOSED PROCEDURE
| SN | Nursing Action | Rationale |
| 01 | Check time of treatment elapsed and keep post dialysis medication ready . | To establish treatment time completed. |
| 02 | Collect all equipment and bring the trolley to patient bedside. | To prevent cross infection. To promote efficient use of resources. |
| 03 | Explain the procedure to be undertaken to the patient. Make a preliminary evaluation of the patient’s condition before disconnecting haemodialysis. Reports any abnormalities. | To ensure that the patient is fit to complete the treatment. |
| 04 | Wash and dry hands as per policy and procedure on hand washing and don gloves. | To prevent cross-infection. |
| 05 | Collect any required blood samples from “A“ port in “A“ bloodline after reducing blood pump speed to 50 ml for 5 mints . | To provide accurate laboratory data. To enable continuity of procedure. |
| 06 | Switch off TMP (Trans-Membrane Pressure) or UF mode.Adjust all alarm limits to minimum (select reinfusion mode for fresenius machine ). | To prevent further fluid loss. To improve wash back. To minimize disruption during discontinuation procedure. |
| SN | Nursing Action | Rationale |
| 07 | Make sure 0.9 % saline to the infusion port on “A“ line. | To maintain continuity of extracorporeal circuit. |
| 08 | Stop blood pump, clamp arterial needle and line. Give intravenous erythropoeitin. Open saline to infusion port. | To maintain safety. |
| 09 | Start blood-pump speed and increase to 100-150 ml/minute, give injection EPO or any other medication in the venous injection port. | To use saline efficiently during wash back. |
| 10 | Apply a light pressure ONLY on the “V“line with fingers in order to facilitate the wash back. Release blood stuck to lines. | To facilitate an efficient wash back. Observe VP and venous site for signs of “blown“ fistula. |
| 11 | As the venous line clears, stop the blood pump taking in consideration the condition of the patient, e. g. Blood Pressure. | To ensure that the wash back reflects the needs of the patient’s condition. |
| 12 | Stop blood pump and clamp saline. | |
| 13 | Clamp the “V“line and fistula needle. | |
| 14 | Unclamp arterial line and fistula needle. Unclamp saline. Apply gentle pressure by clamping the line. Observe if there is any clot in the venous chamber. | Air detector is not utilized, so additional caution is required during this part of the procedure. |
| 15 | Wash and dry hands as per policy and procedure on hand washing. | To prevent cross infection. To maintain aseptic technique. |
| 16 | Prepare medication if required. Open on / off haemodialysis pack. | |
| 17 | Wash and dry hands as per policy and procedure on hand washing. Don sterile gloves. | To prevent cross infection. To maintain aseptic technique |
| 18 | Disconnect the bloodlines from the fistula needles. Connect both lines to the dual connector and close fistula needls with caps. | To prevent blood spillage. To prevent cross infection. |
| 19 | Give any intravenous injections and flush with saline. | As per prescription requirements. |
| SN | Nursing Action | Rationale |
| 20 | Prepare gauze into a pad, hold over “V“needle site, withdraw the needle slowly, and apply pressure immediately (avoid applying too much pressure while withdrawing needle). | To minimize pain. To ensure effective pressure applied to actual needle site. To minimize trauma to fistula. |
| 21 | Remove “A“needle with the same manner. | To minimize pain. To ensure effective pressure applied to actual needle site. To minimize trauma to fistula. |
| 22 | Once haemostasis is achieved, apply small dressing to each site and observe for oozing. | To ensure that the patient is safe to leave the dialysis unit. |
| 23 | Discard fistula needles as per policy and procedures on infection control. | To maintain safety and minimize cross infection. |
| 24 | Discard gloves. | |
| 25 | Wash and dry hands as per policy and procedure on hand washing. | To prevent cross-infection. |
| 26 | Refer to post-dialysis evaluation of patient procedure for further management of the patient. | |
| 27 | Using un-sterile gloves, prepare machine for sterilization, remove dialysis lines, and dispose as per policy and procedures on infection control. Clean machine and clamps as per policy and procedures on infection control. | To maintain standards of infection control and prevent cross infection. |
II – OPEN PROCEDURE
| SN | Nursing Action | Rationale |
| 01 | Check time of treatment elapsed and keep post dialysis medication ready . | To establish treatment time completed. |
| 02 | Collect all equipment and bring the trolley to patient bedside. | To prevent cross infection. To promote efficient use of resources. |
| 03 | Explain the procedure to be undertaken to the patient. Make a preliminary evaluation of the patient’s condition before disconnecting haemodialysis. Reports any abnormalities. | To ensure that the patient is fit to complete the treatment. |
| SN | Nursing Action | Rationale |
| 04 | Both nurses wash and dry hands as per policy and procedure on hand washing. | To prevent cross infection. |
| 05 | First Nurse (with machine) Don un-sterile gloves. Second Nurse (Assisting Nurse) Don sterile gloves. | To maintain aseptic technique. |
| 06 | First Nurse Prepare any medication required and open on / off pack and required equipment. | |
| 07 | Second Nurse (Assisting Nurse) Withdraw 5 mls saline for flushing arterial needle. | |
| 08 | First Nurse Switch off TMP / UF mode, and adjust alarm limits. | To prevent further fluid loss. To improve wash back. To minimize disruption during discontinuation procedure. |
| 09 | First Nurse Disconnect saline from intravenous line and re-cap it. Connect the intravenous set to dual connector. Turn off blood pump. | |
| 10 | First Nurse Clamp “A“line and “A“fistula needle. | |
| 11 | Second Nurse (Assisting Nurse) Disconnect “A“ line from fistula needle. Take samples and flush arterial needle. | To determine accurate post dialysis results. To minimize red cell loss. |
| 12 | First Nurse Connect “A“ line to dual connector, turn on blood pump to 100-150 ml/minute. Apply intermittent light pressure to facilitate a good wash back. | To determine accurate post dialysis results. To minimize red cell loss. |
| 13 | As venous line clears, First Nurse Stop the blood pump taking in consideration the condition of the patient. Clump “V“ line and “V“ fistula needle. | The quantity of saline given in the wash back should reflect the clinical status of the patient. |
| SN | Nursing Action | Rationale |
| 14 | Second Nurse (Assisting Nurse) Disconnect “V“ line from “V“ needle and hand over to first nurse for disposal. | |
| 15 | First Nurse Check and record vital signs. Report abnormalities. | |
| 16 | Prepare gauze into a pad, hold over first needle site, withdraw the needle slowly, and apply pressure immediately (avoid applying too much pressure while withdrawing needle). | To minimize pain. To ensure effective pressure is applied to actual needle site. To minimize trauma to fistula. |
| 17 | Remove second needle in the same manner. | |
| 18 | Once haemostasis is achieved, apply small dressing to each site and observe for oozing. | To ensure that the patient is safe to leave the dialysis unit. |
| 19 | Discard fistula needles as per policy and procedures on infection control. | To maintain safety and prevent cross infection. |
| 20 | Discard gloves. | |
| 21 | Wash and dry hands as per policy and procedure on hand washing. | To prevent cross infection. |
| 22 | Refer to post-dialysis evaluation of patient procedure for further management of the patient. | |
| 23 | Using un-sterile gloves, prepare machine for sterilization, remove dialysis lines, and dispose as per policy and procedures on infection control. Clean machine and clamps as per policy and procedures on infection control. | To maintain standards of infection control and prevent cross infection. |
III- GENERAL REMARKS
| SN | Remarks | Rationale |
| 01 | Heparin should be switched off one hour before disconnection on all fistula patients except otherwise indicated. | To minimize bleeding post haemodialysis. |
| SN | Remarks | Rationale |
| 02 | If haemodialysis is performed on a patient who has temporary vascular access e. g. SVC, JVS, and P. Cath, then heparin infusion should be maintained until the end of dialysis. | To prevent clotting of the catheter. |
| 03 | When applying pressure to the needle site, do not use fistula clamps if the AV fistula is new. | To prevent trauma. |
| 04 | While performing wash back, do not apply forced pressure on the bloodlines if there is already clot present in V chamber or dialyser. | To prevent clot dislodging and entering the circulation. |
| 05 | Remove fistula dressing 4-6 hours post haemodialysis. | To prevent infection and bleeding. |
| 06 | Educate the patient to watch for bleeding or oozing from needle site, if so to re-apply the pressure and reach to nearest clinc / hospital. |