Procedure Manual
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POLICY: The following people are approved by the Richmond Health Service, Lismore Base Hospital, to determine appropriate monitoring parameters and set appropriate monitor alarm limits:
- All Registered Nurses working in Critical Care departments.
STANDARDS: - Patient assessment to determine monitoring parameters for the particular patient/illness.
- Aim to set alarm limits to alert staff of changes in patient condition.
- Minimise incorrect or inappropriate alarm settings to avoid nurse disruption.
OUTCOMES: - The dual lumen catheter is indicated for use in attaining temporary vascular access for CVVHD and haemodialysis.
- The two lumens are separated by a septum, permitting continuous blood flow out and in with one catheter.
INITIATION OF CVVHD [following priming of lines]
STANDARDS: - To ensure safety and minimise complications associated with the initiation of therapy. To prepare the patient, eliminate anxiety and promote co-operation.
- To provide continuous Haemodialysis treatment for patients with renal failure. CVVHD is an extracorporeal process in which water, electrolytes, small and medium sized molecules are removed from the patient by ultrafiltration and dialysis.
EQUIPMENT: Sterile gown and gloves, face mask
Drape bundle
2 x 5ml syringe
2 x 10ml syringe
Dressing pack
Hibitane tincture
Waterproof sheet
4 x packets of sterile gauze
PROCEDURES: - Explain the procedure to the patient
- Ensure that alarm checks have been performed as per protocol
- Place patient in preferred position
- Drape with waterproof sheet.
- Put on face mask and perform 3 minute surgical hand wash, don gown and gloves
- Prepare equipment
- Drape around vas cath
- Wrap catheter hubs with Hibitane soaked gauze for 3 minutes
- Clean the two catheter lumens and white clamps thoroughly with Hibitane
- Ensure both lumens are clamped
- Remove the injection bungs and discard
- Place a 5ml syringe on each port
- Unclamp lumens
- Withdraw 5ml from each port, reclamp lumens and discard blood. If blood flow is slow, attach 10ml syringe and withdraw plunger several times to check fast blood flow. Repeat the procedure on the venous line if necessary.
- Have your assistant hand you the clamped arterial and venous circuit lines, ensure you receive each line separately with a sterile gauze swab, and connect to appropriate port and secure luer lock.
STARTING THE
PROCEDURE: - Unclamp arterial and venous vascath clamps.
- Unclamp arterial and venous line clamps.
- Ensure air detect bypass button has been reactivated (i.e. turned off and pump will detect air - not illuminated).
- Start blood flow at 50mls/min then to 100-200 mls/min ensuring that there are no red alarms on.
- Commence heparin pump.
- PLEASE NOTE:
* Ensure heparin infusion has been commenced.
* Check blood flow rate is correct.
* Make sure venous alarm limites have been set correctly. Lower one must be slightly above zero, higher one 50mmHg above the venous pressure reading on the pump.
- Set IMED IN pumps to commence dialysate flow at 500mls each (1000/hours in total).
- Set IMED OUT pumps to remove the dialysate 500mls each (1000 total) plus extra fluid to be removed.
- Ensure all connections are tight: lines are secured
Clamps are off
No air in circuit
Fluid draining into ultra filtrate bag
Dialyser is secured
(Dialysate flow of 1500mls/hour total [750ml each pump] will provide better clearance set as directed)
KEEP ACCURATE RECORDS VIA FLOW CHART:
- Check FBC, BSL, VEC's, Ca, Mg, PO4 and coags Q6H or more frequently as directed.
- hourly output is recorded.
- heparin infusion.
- flow rate and venous pressures.
- dialyser flushing (usually Q4H via IV normal saline (100-200mls), include in fluid balance, through side infusion port. There is no need to measure extraction fluid hourly as the amount should be equivalent to that dialed on the extraction pump.
NB: Optimum flow rate is 200ml/min and should be run at this rate if possible.
NB: Venous pressures should never run >200mmHg.
Pre-dilution involves running fluid at a set rate into line prior to pump housing. This dilutes the blood prior to it passing through the dialyser and must be recorded as intake in the appropriate column on the record sheet.
CVVHD - THE SETUP
PRINCIPLES: - Remember that we have a blood side and a dialysate side. The blood side is our first concern.
- We prime the blood side with 2000 mls of heparinized saline to rid the dialyser of air and also glycerine which is still on the membrane. This needs to be rinsed thoroughly to prevent any allergic reactions.
- The dialysate side does not come into contact with the blood and we only need to prime with about 200 mls of fluid so that diffusion can commence immediately.
- In CVVHD we use venovenous access and the blood pump AK10 as the patients 'heart' to provide adequate flow.
EQUIPMENT : 1 large dressing trolley
1 Gambro CVVHD kit
IV Normal Saline - 2 x 1Lt bags with 5000u/s Heparin loaded into each bag
4 x IMED giving sets
4 x IMED pumps
1 plain luer lock giving set
1 syringe driver
1 x 50 ml syringe
Heparin 5000u/s in 50 mls normal saline.
2 x 5 Lt bags of Haemofiltration fluid [HFI fluid]
AK10 blood pump
1 bag of 1000ml Normal Saline [plain, for dialyser flushing]
1 litre sterile jug.
PROCEDURE : - Wash hands
- Clean dressing trolley and open CVVHD pack onto trolley
- Using a 'NO TOUCH' technique -
BLOOD SIDE
* Attach blood lines to the ends of the dialyser, red to red, blue to blue [Blood side of dialyser is denoted by a red dot for 'arterial' line and blue dot for venous line. Although we are venovenous, it is easier to denote blood coming from the patient to the dialyser in the red lines as 'arterial' and blood going from the dialyser to the patient as 'venous' to prevent confusion]
* Clamp arterial line
* Attach spiked end of arterial line [red Vas Cath end] to bag of heparinised saline [5000u/s heparin to one litre]
* Drape venous line [blue Vas Cath end with recirculator hook] into sterile jug
* Following the white lines on the machine, place the blood lines onto the pump as per diagram.
* Place dialyser in the clamp vertically so that the arterial and is on the inferior side (the air will then rise to the top).
* Attach heparin infusion [as ordered] to the blood lines via the syringe driver, and prime line.
* Attach 1 litre plain Normal Saline to the IV inlet port [near arterial pillow] using the plain luer lock giving set. Prime line. This is used to flush dialyser during procedure.
PRIMING THE
DIALYSER: BLOOD SIDE
- Place dialyser in the clamp vertically so that the arterial end is on the bottom (the air will then rise to the top).
- Ensure arterial and venous clamps are off and ultrafiltrate line is not clamped.
- Make sure venous alarms have been set in the extreme positionand that the air detect bypass button is on. Unclamp heparinised saline. Commence pump flow at 50mls/min the increase to 200ml/min.
- Gently tap dialyser to clear air bubbles. Another way is to clamp off venous end for no more than 2 seconds then release (this causes slight back pressure in the dialyser and you will see a small gush of tiny bubbles.
- Continue to prime line with at least 2000mls of the heparinised saline.
- Turn pump off, clamp lines close to the patient ends with extra clamps. This will prevent air entering the lines.
- Connect re-circulating hook (no venous end) to the patient end of the arterial line (after removal of spike) and unclamp lines.
- The pump can now be run at 200mls/min to extract tiny air bubbles.
- Turn air detect bypass button off, perform alarm checks ensuring they remain set correctly at the end of the check (as per alarm test protocol).
DIALYSATE SIDE:
- Attach 2 x IMED lines to 2 bags of 5 Litre Haemofiltration fluid [HFI]
- Attach the ends of the IMED lines to the 'IMED in' Y connection
- Attach the other end of the 'IMED in' Y to the dialysate port nearest the venous end of the dialyser.
- Attach "IMED out Y" to the dialysate port nearest the arterial end of the dialyser.
- Connect 2 x IMED lines to the "IMED out Y".
- Connect the IMED out lines to the drainage bag using the Y connection.
- Insert the dialyser so that the venous end is on the bottom (this means that the dialysate inlet line is also on the bottom making the air rise to the top).
- Prime the IMED lines and eliminate air bubbles. Flush with 200ml HFI fluid.
- Place the ultrafiltrate bag low while priming.
- Place lines into IMED pumps.
- Empty ultrafiltrate bag and turn pump off.
You are now ready to connect to the patient .
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It was originally posted on 6/5/98; 2:28:17 PM.
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