Advice: Profile or Not?

[awheat]

I have a question for you experienced HD nurses. I have been working in an HD clinic for 3 months (newbie!) and need some advice.

Here Goes:

New HD patient, did not know he was ESRD until visit to ER = catheter placement and dialysis, w/ graft put in arm. Coming to clinic for last 3 ½ weeks. Last week, SBP dropped from 140's to 70's during 30 minute cycle, symptomatic. UF off, NS given, T-berg positioning and SBP back up (now 160's). Took 45 minutes to get him asymptomatic (T-berg, Semi-fowlers, High Fowlers, drop, back to Semi, High, standing = dizzy, semi, high, OK for 10 minutes, then tried standing = vomiting). The charge at the time said "I have never seen this before" and I kept working with him.

Mind you, I was not re-positioning like a roller coaster - we went from position to position slowly, with several minutes "recovery time" between so that he reported he felt "ok" between each - but talk about orthostatic hypotension!

So, EDW was reset by MD, and next 2 treatments we were conservative w/ the pull (over dry weight, but took only 5000 over 4 ½ hrs), with no complications.

Then yesterday, he comes in 7.4 over. Charge (different from before) sets him to pull max we can (6800) and I jumped in and was adamant about the probs we had in the past 2 weeks so we set him for 5000 again (since he had tolerated that for last 2 treatments). It was first time sticking graft and he tolerated it great, and pressures were excellent. When he had 59 minutes to go he said my "stomach feels funny", re-check of bp: SBP went from 140's to 80's. And we did the dance again. This time he never actually c/o nausea or vomited. But still, symptomatic. And we only got 3900 off by the time this happened.

I asked the charge about next time - should we try a profile for the pull? She said it was the RN's discretion, and since I was an RN "I guess you can if you want to".

So, since I have NO HELP from my charge and I want my client to have safe and effective treatments I am asking you guys out there who know what you are doing (because I surely DO NOT) - do you think I should try a profile? Do we need to call the MD about another EDW adjustment? Guidance please. Any advice appreciated.

[traumaRUs, MSN, APRN]

Absolutely correct Madwife. The latest stats I've seen also show that the older the pt is when they start dialysis, the less likely it is that they will reach the 5 year mark.

I have been seeing more and more pts starting HD when they are 80+ and they usually have poor outcomes.

[anurseadvocate]

I congratulate you on being an advocate for your patient. The behavior of your charge nurse is something I have seen alot -- a lack of respect for the patient, a lack of understanding of the diaysis treatment... This is the problem with incenter care -- taking off large quantities of fluid over a short period of time --- It is obvious, from your statement, that there might be other patients having other problems and if the charge nurse can not give advice, supervision and teaching / education of other RNs perhaps you need to do something more to protect your patients. Perhaps you can ask for an inservice on various aspects of care.. especially considering we don't know all the medical problems/illnesses this patient has which might make a big difference.. the dialysis treatment is not cookie cutter and each patient is an individual with individual needs...

[Fins Up!, ASN, BSN]

traumaRUs

could you post the link to the literature about the profiles.

"latest literature proves that when you use a profile, you are stressing the heart too much".

thanks!

[traumaRUs, MSN, APRN]

I posted the original citation March 30th:Nature Publishing Group : science journals, jobs, and information this helps.

[anurseadvocate]

Many facilities use sodium profiliing, however, recently I have read a few articles where they are advising not to use such -- and they are finding more problems. from recall, related to cardiac --if TraumaRU, or someone can approve, I will look back and post the article --- It is tough removing so much fluid in such a short time -- some units will have the patient come in for an extra treatment, which the physician can order and with supporting rationale, Medicare will cover --

[Tree525]

Why don't you try for a smaller UF goal per tx, say 3500-3800, and have the patient come in for extra treatments?

[traumaRUs, MSN, APRN]

Nowadays, the UF formula our practice uses (as do many others) is no more than 13ml/kg/hour of fluid removal. There have been several articles about sudden cardiac death while on dialysis. If you have ever had this happen (and I have), it is a scary bad deal and you don't get a second chance.

Extra treatments sound good in theory, but dialysis units have to have space and that is not always the case.

[gambutrol]

I agree with fluid restriction education and Na restriction in diet. It's really hard pulling that much fluid in a certain amount of time. Maybe an extra treatment in between his regular treatment schedule so that you're not pulling too much fluid per treatment. Personally, I like UF profiling esp for those who have poor refill.

[Rayden]

Nowadays, the UF formula our practice uses (as do many others) is no more than 13ml/kg/hour of fluid removal. There have been several articles about sudden cardiac death while on dialysis. If you have ever had this happen (and I have), it is a scary bad deal and you don't get a second chance.

Extra treatments sound good in theory, but dialysis units have to have space and that is not always the case.

Based on your contributions and my further reading, we have also implemented this practice in our renal unit. Before our policy was a maximum UF rate of 1000mL/hr, but now we follow the 13mL/kg/hour guideline.

If there's still more fluid that needs to be pulled off, we schedule the patients on extra treatment the next day.