PURPOSE
1. To remove Antibodies circulating in the plasma
2. RPGN (Rapidly Progressive Glomerular Nephritis)
3. Guillain-Barre Syndrome
4. Mysthenia Gravis
5. Good Pasture Syndrome.
POLICY
1. The procedure is performed as patients requiring Renal Transplant but who have high levels of antibodies on the instructions of the attending physician.
2. 2 nurses of whom are should be our experienced dialysis, should carryout this procedure.
3. Strict aseptic technique should be maintained throughout the procedure in accordance with the policy and procedure of aseptic technique.
4. Hand washing should be performed according to policy & procedure on hand washing.
EQUIPMENT
1. Trolley (washed with soap & water and wiped with spirit 70%)
2. Haemodialysis on & off pack
3. Sterile drape x 2
4. Fenestrated sterile drape x 1
5. FVC set if no access
6. Fistula needle x 2 (if AV Fistula is prevent)
7. 3 way tap
8. Be tadine 10% with 70% spirit
9. Sterile spirit swab
10. Sterile gloves
11. Plaster / Micro pore for dressing
12. Local anaesthesia Injection
13. Sterile syringes (various size)
14. Specimen batter
15. Plasmaflux Kidney (plasma separator) + blood lines (A & V)
16. Filtrate and substitute or Imed lines
17. Imed pump (Gemini pump 2 way). (if using ADM Fresenuis CVVH machine no need for extra pump)
18. Blood warmer
19. Plasma Human or synthetic for replacement
20. Specific Connectors
21. Line clamps x 4
22. Sterile Scissors
23. Haemodialysis machine / CVVH machines
24. Normal Saline 0.9% x 4 (500 mls)
25. Inj. Heparin 5000 iu
26. Dynamap machine (BP monitor)
27. Cliwcal Thermometer
28. Drip stand
29. Emergency Trolley (stand by)
30. Urofix (to collect plasma)
31. Intravenous set.
PROCEDURE
I. Plasma Exchange
| SN | Nursing Action | Rationale |
| 01 | Wash and Dry hands (as per policy and procedure as hand washing). | To prevent cross infection. |
| 02 | Fix plasmaflux kidney as the machine upside down (artery down). | To Expel air from the extra corporial circuit. |
| 03 | Connect blood lines as for regular HD. | To wash and remove air bubbles from the circuit. |
| 04 | Prime the extracorpurial circuit (in the same was as haemodialysis). | To remove (ethline oxide) from the system lines. |
| 05 | Connect 2 Imed Gemini infusion pump and prime the Imed set and set rate. | For plasma infusion. |
| 06 | Fix one of the Imed set to the venous bubble trapper. | To give fresh plasma. |
| 07 | Fix another Imed set (line) to the venous end of the dialysate outlet of the plasmaflux. | To remove plasma from the pt’s blood. |
| 08 | Expel all air with physiological saline running through the lines. | To expel air. |
| SN | Nursing Action | Rationale |
| 09 | Ensure there is no air leak through the connector. | Prevent air entry to the circuit. |
| 10 | Block the arterial end of the filtrate dialysate outlet with special stopper provided in the pack. | |
| 11 | Connect the venous side of the plasma depurator dialysate outlet to the Imed pump set and set rate. | To measure out put (plasma). |
| 12 | Fix physiological saline through the lines run the physiological saline through the line. | |
| 13 | When the fluid come into the plasma sepectur it comes out through the venous lines into the venous bubble trapper and to the lines, clamp the output venous line. | To remove air from the circuit. To remove minute air bubbles and through washy of strilent. |
| 14 | Fluid will come through the line that is fixed to the Imed outlet line. | To expel air bubble from that line. |
| 15 | When the blood paths are flushed throughtly with physiological saline 2 litres (1 litre heparinized saline 5000 iu 500 mls). Ensure that all lines are clamped securely. | To avoid clotting |
II. Plasma Exchange
| 16 | Check the order of the physician and program notes of the patient. | To obtain specific instructions for the management of the patient |
| 17 | Make sure that the procedure have been explain to the patient and consent has bee singed by the patient or next of kin. | To ally fears and gain patients confidence and co-operation. To promote patient education |
| 18 | Ensure privacy. | To avoid unnecessary embarrassment to the patient day procedure. |
| SN | Nursing Action | Rationale |
| 19 | Check the weight of the patient. It is necessary to compare the pre & post procedure Wt. | to assess the patient for Wt loss /Wt gain. |
| 20 | Check and record vital signs. Vital signs should be in removal rang | |
| 21 | Wash and dry hands. | |
| 22 | Open On & Off with all accessories. | |
| 23 | Place Fistula needle on the sterile field. | To prevent infection while doing the procedure. To start Plasmapheresis. |
| 24 | Place sterile syringe on the sterile filed. | |
| 25 | As to the assisting nurses to put Betadine 10% with 70% spirit in the Gallipots. | |
| 26 | Wear sterile gloves. | |
| 27 | Explain the procedure briefly once again to the patient. | To get patient co-operation |
| 28 | Cannulate the patient as for regular dialysis. If the patient has AVP, give loading dose of heparin through the ‘A’ line. Secure both needles securely. | To ensure correct placement of needle. To ensure needle remains patient |
| 29 | Collect blood specimens if any. | For any pre procedure investigations. |
| 30 | Connect Arterial line of the machine to the ‘A’ needle of the patient. | To prevent a rapid reduction in plasma volume and therefore prevent its consequences. |
| 31 | Gently remove both clomps, turn blood pump slowly to 100 ml/mt. | |
| 32 | Note down the time as you begin to bleed the patient. | |
| 33 | While bleeding the patient the saline in the circuit will be collecting in the bottle at the venous end. | To remove normal saline from the line. |
| SN | Nursing Action | Rationale |
| 34 | When the blood came to the venous bubble trappers switch off the blood pump and clamp the venous line Connect the venous line to the venous needle with the patient and gently remove the clamps. | To minimize blood loss |
| 35 | Again switch on the blood pump allow the blood to circulate for 3 – 5 mts before removing the plasma, set the blood pump rate 100 – 150 ml/mt so that body gets a little time to adjest to the blood loss (blood in lines & kidney). | |
| 36 | Connect the hourly heparin to the heparin lines and commence the flow if heparin is contra-indicated dot saline wash every 30 mt. | To prevent clottes of the ectra corporeal circuit. |
| 37 | When the plasma is observed coming through the outlet line, then fix replacement plasma from the blood warmess as the replacement line open the clamp and slowly commence replacement (start Imed pump) Open the clamp or and start Imed pump for both input and put put of plasma. | |
| 38 | Record vital sings. | To access the patient or prevent complications |
| 39 | Take for any sings of anaplylasic. | |
| 40 | Continued the procedure until the amount of plasma prescribed by the physician have been removed and replaced, discontinue the procedure (Do the normal, wash back for regular haemodialysis with N/S). | |
| 41 | Record the amount of plasma exchange. | |
| 42 | If fistula needs are used, remove by applying positive pressure over the site until bleed is stopped and apply. If catheter (JVC, FVC is used, apply dressing and heparinze the catheter. |
| SN | Nursing Action | Rationale |
| 43 | Check and record viral signs. | |
| 44 | Make patient comfortable. |