Thirst-Something To Think About

  1. Thirst is a powerful, primitive, primal survival mechanism

    Thirst simply cannot be resisted - no matter how much the patient tries.

    The inevitable result ...?

    Another 4 kg (4 litres) is gained and ... it all starts over again

    The sad facts of a typical dialysis day (for most) ...

    The patient struggles in for HD on a Monday morning after a 'long break', that weekend off for dialysis staff that forces a 68 hour break for without dialysis on each and every facility-based dialysis patient ...

    The arrival scenario ...?

    The patient is short of breath with a 'thumping' heart and a 4 kg weight gain in excess of the weight recorded at the end of the previous Friday's dialysis ... and remember: a 4 kg weight gain equates to a 4 litre retention of ingested fluid

    The dialysis plan ...?

    Remove 4 litres over 4 hours HD ... or about 1 litre/hour for every hour of dialysis

    The dialysis result ...?

    Cramp, nausea and a horrible 'flat' - that awful moment when the blood pressure drops and the eyes roll back in a dead faint

    The treatment response ...?

    A frantic 'revival' effort with intravenous (IV) fluid - when the whole object of the session has been to remove 4 litres of fluid

    The treatment outcome ...?

    The patient goes home, washed out, exhausted and thirsty-as-hell.

    The rest of the day is 'written off' to allow recovery

    Meanwhile ...

    The patient immediately starts to drink fluid (when knowing its wrong) to slake a raging thirst.

    Why ...?

    Because a rapid reduction of blood volume stimulates

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  3. by   anurseadvocate
    Very Powerful - thank you
    There has been alot of research conducted in the area of the prolonged weekend and having all those hours without dialysis -- In fact, from recall, this was mentioned during alot of discussions surrounding every other day dialysis (a petition that was started by a patient a few years ago, or less), as well as this weekend without dialysis (or any two days e..g. for those who do T-Th=SA-....being brought up before legislative avenues, from recall. Alot of literature written on this...
  4. by   anurseadvocate
    Also, as an afterthought, many units allow the technicians to make a judgement call as to whether to use sodium profile, or not -- after speaking with one physician, I was informed that it is the physician's decision as determined by many factors, including BP, etc.,, but there are those units, not all, but some, whereby the aforementioned happens.. then this also causes thirst
  5. by   diabo
    We use critlines in our acute unit. It's the refill that will determine the BP. Many patients don't eat enough protein, and their Albumin levels are very low. That's why the somewhat overweight patients, in many cases, do better. They are getting plenty of protein. (and then some.)

    A person can be overloaded, but if the fluid doesn't transfer into the blood, they will crash. Most doctors are moving away from sodium profiling. It takes more than the last hour for it to clear, and, like has been said, they will just go home and gussle, usually on the dialysis day. The heart is what gets most dialysis patients in the end, and routine playing with the sodium only helps hasten cardiomegaly.
  6. by   Chisca
    The critline monitoring sounds like a much better way of determining how close a patient is to crashing than pulling fluid to an arbitrary dry weight. I really don't see much science in dry weight determinations at least by the physicians I work with. If a patient cramps or crashes then we've reached their dry weight but that seems cruel to me.
  7. by   anurseadvocate
    Chisca, it is cruel, as far as I am concerned -- in fact, at one time, FMC had a device, similar to the critline that they were suppose to put into their units, or, at least some of them -- about six years ago, give or take -- however, there were some type of legal things going on -- I can't remember if it had to do with critline saying they took their idea, or what.. just can't remember -- but FMC never used it to my knowledge --- and they would not use the critline-- probably due to cost -
    tODAY, I talked to a few technicians, as a matter of fact, from a few FMC units --they are all complaining of being told 'in and out, move them'.... hmmmm
  8. by   zero.
    Quote from Chisca
    The critline monitoring sounds like a much better way of determining how close a patient is to crashing than pulling fluid to an arbitrary dry weight. I really don't see much science in dry weight determinations at least by the physicians I work with. If a patient cramps or crashes then we've reached their dry weight but that seems cruel to me.
    I think the physicians you work with needs additional reading. Their practice is indeed cruel.

    Just because the patient had cramps or became suddenly hypotensive doesn't necessarily mean the DW is already achieved. The UF rate is the main culprit for those 2 common complications. The higher it is, the more probability of cramps and hypotension occurring as the treatment progresses. DW is not determined with only one treatment. Say cramps and crashing occurs for 3-4 treatment in a row, then we may consider DW adjustment or determination, but still proper assessment regarding edema, skin turgor, BP trend (consider medications, dialysis prescription machine settings) etc., should be done.

    Speaking of sodium and UF profiling, our new medical director is actually against this practice. He recommended following the 13mL/kg/hour UF rate guideline to determine the maximum UF rate for a particular patient. Does the need arise to pull off more fluid, the patient is then scheduled for an extra treatment the following day.

    Furthermore, we used to have patients with sodium profiling on standing order, and looking at their pre and post weight trends for just 1 month, weight gains during the weekend are indeed significant. We had to talk to the physicians that those standing order needs to be taken out and other measures of stabilizing intra-dialytic vital functions and fluid management had to be done.
  9. by   traumaRUs
    Sodium profiling is really going out from what I see too. And...we too use the 13ml/kg/hr formula for UF.
  10. by   Chisca
    The 13ml/kg/hr formula would seem to argue against the three treatment a week ritual the government has us locked into. If patients were allowed more than 3 treatments a week maybe these higher UF rates would not be ordered so frequently.
  11. by   zero.
    If they have locked you into a three treatment per week system, is it then possible for an extended treatment time, say 5 hours?

    I'm sorry I'm not familiar with how the system is in the US, and I'm surprised that the government is actually dictating as to what the frequency of the patients' treatment should be. I would like to learn more regarding this. Is it the insurance company stating no more than 3 treatments per week?

    Do you also consider sequential UF with the extra hour of treatment, if ever you do sequential?
  12. by   traumaRUs
    In the US, Medicare (our government run healthcare system for seniors and those on dialysis) dictates how many times/week pts run. We can order four times/week and we do so with those pts who have a low ejection fraction. However, we in the US dialyze EVERYONE and I mean EVERYONE!!! I have new pts that start dialysis at age 97!! I have pts that have ejection fractions of 10% that are on multi-organ transplant lists, pts who are so demented and/or mentally ill that they have sitters.
  13. by   Chisca
    Medicare refers to 3x week dialysis as "adequate" and thats what they reimburse for. Insurance companies follow suit and pay for 3 x week. In many cases it is not "adequate".
  14. by   NDXUFan
    Yes, 3 times per week is not enough. Indiana University would argue that the bare minimum should be 5 days per week. Based on seven and half years on dialysis, I would have to agree with that assessment. Diabetic thirst is the worst thing on this earth. I had normal health for years and I can tell you that there is nothing like diabetic thirst. I would not wish it on anyone on this board, it is He!! on earth.

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