DEFINITION
Disconnecting patient with temporary access from the haemodialysis machine.
PURPOSE
1. To disconnect the patient with temporary access from haemodialysis machine on completion of treatment
2. To investigate malfunction in the system, or patient intolerance
Alert
– An air wash back should not be performed under any circumstances. Any reported occurrence results in disciplinary action.
– Do not use alcohol for cleaning
CONDITIONS
1. Applies to all Registered Nursing Personnel working in dialysis centres in Oman
2. This procedure can be performed by a nurse undertaking nephrology / dialysis training program, provided he / she is closely supervised by an experienced dialysis nurse at all times.
3. Two (2) nurses, of whom one should be an experienced nurse should carry out this procedure.
4. A strict aseptic technique should be maintained throughout the procedure in accordance with the policy and procedure on aseptic technique.
5. Hand washing should be performed according to policy and procedure on aseptic hand washing.
6. 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
Please refer to appropriate policy for discontinuation of haemodialysis in these emergencies.
EQUIPMENT
1. Trolley cleaned according to policy and procedures on infection control policy / bed side table
2. On / off Haemodialysis pack.
3. 0.9% saline ampoules x 2 10mls ( optional )
4. Surgical mask
5. Two (2) pair of sterile gloves
6. Two (2) pair of un-sterile gloves
7. Heparin 5000i.u./ml
8. Syringe 10mls x2 for flushing with normal saline
9. Syringe 2mls x2 for heparin lock (volume to be infused as per manufacturer’s instructions)
10. Luer lock caps x 2
11. Mepore dressing x 2 / transparent dressing
12. Antiseptic solution
13. Antiseptic ointment
14. Specimen containers (if required)
- Post-dialysis medications
16 line clamps
PROCEDURE
I – CLOSED PROCEDURE
| SN | Nursing Action | Rationale |
| 01 | Check time of treatment elapsed. | To establish treatment time completed. |
| 02 | Explain the procedure to be undertaken to the patient. Make a preliminary evaluation of the patient’s condition before disconnecting haemodialysis. Report any abnormalities. | To ensure that the patient is fit to complete the treatment. |
| 03 | Collect all equipment and bring the trolley to patient bedside. | To prevent cross infection. To promote efficient use of resources. |
| 04 | Wash and dry hands as per policy and procedure on hand washing. Don gloves by the Second Nurse | To prevent cross-infection. |
| SN | Nursing Action | Rationale |
| 05 | Collect any required blood samples from “A“ port after reducing blood flow to 50 ml | 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. | To prevent further fluid loss. To improve wash back. To minimize disruption during discontinuation procedure. |
| 07 | Make sure 0.9 % is sufficient for wash back | |
| 08 | Stop blood pump, clamp “A” line. Open saline to infusion port. | To maintain safety. |
| 09 | Start blood-pump and increase the speed to 100-150 ml/minute. Give IV EPO and other IV medication if required through IV port in “V” line. | 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. | To facilitate an efficient wash back. To minimise red cell loss |
| 11 | As the “V“ line become pinkish, 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. | |
| 13 | Clamp the “V“line and “V“ lumen. | |
| 14 | Unclamp “A” line and saline. (when using Althen machine keep “A” chamber up side down ) | Air detector is not utilized, so additional caution is required during this part of the procedure. To prevent air entry to the circuit. |
| 15 | Flush until line is pinkish. Apply gentle pressure by clamping the line. Clamp “A” line and “A” lumen of temp access. Observe patient condition. | To minimise saline infused. To minimise red cell loss. To prevent air embolism. |
| SN | Nursing Action | Rationale |
| 16 | Both nurses should wear mask and Wash hands as per policy and procedure on hand washing. Don sterile gloves by 1st Nurse. | To prevent cross infection. To maintain aseptic technique. |
| 17 | Second Nurse Place the ON & OFF pack on the trolley and opens the pack gently and place all necessary things for disconnection | To ensure aseptic technique can be undertaken. |
| 18 | First Nurse Don sterile gloves and sets things properly including 0.9 % Nacl to flush the catheter and heparin Injection to heparinize the catheter lumens . First Nurse Place sterile field under temp access. | To prevent cross infection. To maintain aseptic technique. To prevent cross infection. |
| 19 | Take gauze soaked with betadine and rub gently the extensions for 2-3 minutes. | To maintain aseptic technique |
| 20 | First Nurse Disconnect the bloodlines from the temp access using sterile gauze. Second Nurse Connect both lines to the dual connector. | To prevent blood spillage. To prevent cross infection. |
| 21 | First Nurse Flush each lumen of the catheter with 10mls 0.9% normal saline using separate syringes | To flush and clear blood cells |
| 22 | First Nurse Push in one-go Heparin 5000 i.u./ml into each lumen (volume as per manufacturer’s instructions). Clamp immediately. Note The clamps should not be opened once the catheter has been heparinized. | To prevent clotting. To prevent back flow. |
| SN | Nursing Action | Rationale |
| 23 | First Nurse Apply sterile lock cap to each lumen. Second Nurse Wrap the lumens with sterile gauze. First Nurse Remove gauze dressing at the exit site and change the gauze. | To maintain aseptic technique |
| 24 | First Nurse Clean the skin at the catheter exit-site with antiseptic solution. Apply antiseptic ointment to the exit site. | To prevent exit site infections |
| 25 | First Nurse Make a sandwich dressing using gauze . and secure the catheter with mepore . | To provide occlusive dressing |
| 26 | First Nurse discard gloves Wash and dry hands (refer to policy and procedure on hand washing). | To prevent cross infection. |
| 27 | Refer to post-dialysis evaluation of patient procedure for further management of the patient ( First Nurse ). | To ensure patients treatment and condition is fully evaluated. |
| 28 | 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 (Second Nurse). | To maintain standards of infection control and prevent cross infection. |
II – OPEN PROCEDURE
| SN | Nursing Action | Rationale |
| 01 | Check time of treatment elapsed. | 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. |
| SN | Nursing Action | Rationale |
| 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 | Both nurses Don mask and wash hands as per policy and procedure on hand washing. | To prevent cross infection. |
| 05 | Second Nurse (with machine) Prepare any medication required. Remove IV line from the port and connect to the dual connector . First Nurse Don sterile gloves , open ON & OFF pack and keep required equipment ready , 0.9% Nacl for flushing and heparin for locking the lumens . | To maintain aseptic technique. |
| 06 | Second Nurse Don un-sterile glove. | To maintain aseptic technique. |
| 07 | First Nurse Place sterile field under the catheter take gauze socked with betadine and rub gently the exlemion and keep for 2 – 3 minutes . Second Nurse Remove un sterile drips. | To maintain aseptic technique. |
| 08 | Second Nurse Switch off TMP / UF mode, and adjust alarm limits. (if Fresenius machine select re-infusion mode . | To prevent further fluid loss. To improve wash back. To minimize disruption during discontinuation procedure. To avoid un necessary alarms |
| 09 | Second Nurse Turn off blood pump. | |
| 10 | Second Nurse Clamp “A“line. First Nurse Clamp “A“ lumen of catheter. |
| SN | Nursing Action | Rationale | ||
| 11 | First Nurse Disconnect “A“ line from temporary access lumen using sterile gauze and flush “A“ lumen. Clamp immediately. | To determine accurate post dialysis results. To minimize red cell loss and maintain patency. To prevent air embolism. | ||
| 12 | Second 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. Give IV medication e.g. Epo if required through “V” port . | To determine accurate post dialysis results. To minimize red cell loss. | ||
| 13 | As venous line clears and becomes pinkish, Second Nurse Stop the blood pump taking in consideration the condition of the patient. First Nurse Clamp “V“ lumen Second Nurse Clamp “V“ line. | The quantity of saline given in the wash back should reflect the clinical status of the patient. | ||
| 14 | First Nurse Disconnect “V“ line from “V“ lumen using sterile gauze and hand over to the assisting nurse. | To prevent air embolism. | ||
| 15 | Second Nurse Connect both lines to the dual connector. | To prevent blood spillage. To prevent cross infection. | ||
| 16 | First Nurse Flush lumen of the catheter with 10 mls Normal Saline 0.9% using separate syringe. | To flush and clear blood cells. | ||
| 17 | First Nurse Push in one-go Heparin 5000 i.u./ml into each lumen (as per manufacturer’s instructions). Clamp immediately. | To prevent clotting. To prevent back flow. | ||
| SN | Nursing Action | Rationale | ||
| 18 | First Nurse Apply sterile lock cap to each lumen, wrap the lumens with sterile gauze. then remove old dressing from the exit site and change gloves . | To maintain aseptic technique | ||
| 19 | First Nurse Clean the skin at the catheter exit-site with antiseptic solution and dry it with sterile gauze. Apply antiseptic ointment to the exit site. Make a sandwich dressing and secure the catheter using me pore or opsite. | To prevent exit site infections. To provide occlusive dressing. | ||
| 20 | Both nurses Discard gloves. Wash and dry hands (refer to policy and procedures on infection control). | To prevent cross infection. | ||
| 21 | First Nurse Refer to post-dialysis evaluation of patient procedure for further management of the patient. | To ensure patients treatment and condition is fully evaluated | ||
| 22 | Second Nurse 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. | ||
| 20 | Discard gloves. | |||
GENERAL REMARKS
| SN | Remarks | Rationale |
| 01 | If haemodialysis is performed on a patient who has temporary vascular access e. g. SVC, JVC, and P. Catheter, then heparin infusion should be maintained until the end of dialysis. | To prevent clotting of the catheter. |
| 02 | 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. |