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HEMODIALYSIS ADEQUACY

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HEMODIALYSIS ADEQUACY

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  1. HEMODIALYSIS ADEQUACY Laurie Vinci RN, BSN, CNN September 17, 2011

  2. OBJECTIVES • Identify adequacy of dialysis and it’s components • Discuss K-DOQI Guidelines for hemodialysis adequacy • Discuss nursing interventions to achieve adequate dialysis

  3. Definition: Hemodialysis Adequacy • The delivered dose of hemodialysis that will optimize the survival and well-being of the patient • Numerous studies have demonstrated a correlation between the delivered dose of hemodialysis and patient mortality and morbidity

  4. Components of Hemodialysis Adequacy • Delivered dose of hemodialysis (HD) should be measured at regular intervals no less than monthly • Two components of HD adequacy: 1) Urea Kinetic Modeling (Kt/V) 2) Urea Reduction Ratio (URR) NKF-KDOQI, 2006, CPG 2

  5. Kt/V (Dose of Dialysis) K = Urea clearance through dialysis t = Time of dialysis in minutes V = Volume of urea in proportion to volume of body water

  6. Urea Reduction Ratio (URR) • Difference between pre and post BUN • Statistically significant predictor of mortality URR = PRE BUN- POST BUN X 100 PRE BUN

  7. Methods for Dialysis BUN Blood Sampling • Pre/Post dialysis blood samples must be from same session • Avoid dilution of pre BUN sample (with heparin/saline) NKF-KDOQI, 2006, CPG 3

  8. SLOW FLOW/STOP PUMPMETHOD AT COMPLETION OF DIALYSIS: 1) Turn dialysate flow off, decrease UFR to 50 ml/min, lowest TMP or off 2) Decrease BFR to 100 ml/min for 15 seconds A) Slow Flow: After 15 seconds, leaving blood pump at 100 ml/min, draw BUN sample from port on arterial line. Stop blood pump and terminate treatment per unit protocol. OR B) Stop Pump: After 15 seconds, stop pump, clamp arterial and venous blood lines, draw BUN sample from arterial needle tubing, then terminate treatment per unit protocol

  9. Minimally adequate HD HD treatment 3 x week Kt/V 1.2 or URR 65% Target dose of HD Kt/V 1.3 or URR 70% NKF-KDOQI, 2006, CPG 4

  10. Dose of dialysis should not be based solely on the URR and/or Kt/V. Other factors need to be included: 1) Potassium removal 2) Correction of acidosis 3) Sufficient protein/caloric intake to prevent malnutrition 4) Longer time for fluid removal

  11. Control of Volume and Blood Pressure Blood pressure control improves patient outcomes • UFshould be optimized with a goal to render the patient euvolemic and normotensive • Restrict Na intake to 2 gms/24 hrs • Increasing positive Na+ balance by “Na profiling” or using a high dialysate Na+ concentration should be avoided NKF-KDOQI, 2006, CPG 5

  12. Strategies to Minimize Hypotensive Symptoms • Avoid excessive UF • Slow the UF rate • Perform isolated UF (SUF) • Manipulate Na levels (modeling) • Decrease dialysate temperature from 37C to 34-35C (need MD order) • Administer midodrine pre dialysis (MD order) • Manage Hemoglobin • Optimize patient behavior through education

  13. Interventions: Evaluate elements of HD treatments that may compromise urea clearance • Assessfor access recirculation • Verify flow of blood through the access (especially if loop graft) • Inadequate blood flow from the access resulting in decreased blood flows • Dialyzer blood leak on day Kt/V and/or BUN drawn • Inefficient dialyzer • DFR set too low • Inadequate coagulation • Inadequate dialyzer reprocessing

  14. Review Treatment Documentation on day of Kt/V and URR • Review prescribed treatment vs. actual treatment parameters • Review Blood Flow Rate and Dialysate Flow Rate

  15. Assess for Lab and Blood Sampling Errors • Lab errors • Dilution of pre BUN with N/S or heparin • Drawing pre BUN after HD initiated • Drawing post BUN before HD completed or drawing sample late (>3 mins. after completion) • Blood lines or needles reversed

  16. Assess Reductions in Treatment Times • Treatment Week Month Year • 5 Minutes 15 Minutes 65 Minutes 780 Minutes • (1.08 Hours) (13 Hours/0.54 Days) • 10 Minutes 30 Minutes 130 Minutes 1,560 Minutes • (2.17 Hours) (26 Hours/1.08 Days) • 15 Minutes 45 Minutes 195 Minutes 2,340 Minutes • (3.25 Hours) (39 Hours/1.63 Days) • 20 Minutes 60 Minutes 260 Minutes 3,120 Minutes • (1 Hour) (4.33 Hours) (52 Hours/2.17 Days) • 25 Minutes 75 Minutes 325 Minutes 3,900 Minutes • (1.25 Hours) (5.42 Hours) (65 Hours/2.71 Days) • 30 Minutes 90 Minutes 390 Minutes 4,680 Minutes • (1.5 Hours) (6.5 Hours) (78 Hours/3.25 Days)