[PLTSGT]

I have a patient who cannot use heparin and always has problems with clotting. We are already using citrasate on him but it seems useless. Same thing with q30m saline flushes. He refuses to have his catheter replaced because he said that he is switching to PD (which he drags his feet to consult with a surgeon). He has an AVF which has never been used and he has no intentions of using. He also has plans to sue those doctors who made him this way.

Here's the kicker...He told my boss that he doesn't want me to take care of him because he thinks that everytime I do he always gets this clotting problems which leads to replacing the whole lines/dialyzer.

I believe that he's not intentionally destroying himself and not depressed; he's just arrogant. As of last blood work his kt/v is < 1.1. I honestly want him to get better (obviously) but should I just let him do whatever he wants and let slowly dwindle?

[jnette]

That's always a tough case.. we've had them, too.

He's obviously disgusted with his current circumstances.

The clotting off and extended time due to that is even more frustrating. Have you tried heperanizing the dialyzer itself?

Perhaps allow him to have another staff do his tx. for awhile without making it obvious to the other pts. Maybe after a few weeks he'll see it's not "just you".

Sorry to hear about this, I know how frustrating it can be.. for the patient as well as the staff !

[traumaRUs]

Does he have a documented heparin antibody? The first thing is to determine if this is present. I'm sure you have tPA'd his catheter already but I am all out documenting issues. I go so far as to quote the pt especially if they seem dissatisfied with all care.

[PLTSGT]

No heparin at all.

Somebody told me to rinse his single use dialyzer with 2 bags of saline (Can somebody tell if that REALLY helps as well?).

Yes, we put Activase on both ports.

Well, no one honestly want to keep going back to his station and resetting the alarm and trying to fix the problem especially if we're busy, but we have to.

Yup, I also want to show him that it's not just me that he's having a problem with. I think he's just mad with my candor. He doesn't want to hear what's really up. I wonder what kind of nurse will he be? Yup, he's in nursing school.

[traumaRUs]

I'm an APN in two chronic outpt HDUs. Personally, I can't imagine being an HD pt so I try to give them a break. This has got to be a miserable existence. Many of my pts are difficult to deal with. I try to put myself in their place. We switch techs/nurses on those REALLY difficult pts. Plus, we take a very united approach and plan for things to be done the same way no matter who the caregiver is that particular day.

[CocoaGirl]

At the unit where I work, we have had a few patients that can't have heparin for various reasons. We flush their dialyzer during treatment every 30 mins with 100 NSS to prevent clotting. The additional fluid is added into the target loss. This will usually work, unless it is a poor functioning catheter.

[PLTSGT]

The last time that I was at work, the patient was being flushed q15mins with 100ml NS. It hardly worked and we had more than enough staff to babysit that patient and his machine. Most of the time we don't. The patient also mentioned that everytime his catheter spasms that's when the machine makes the noise.

[AmyLiz]

Not sure if this is possible for you, but in our clinic we have a few pts who have issues with clotting who cannot be on heparin (and some who have clotting issues even with heparin!), so we put them on a saline drip at 200cc/hr per plum pump hooked up to the dialysis tubing.

[LiverpoolJane]

I work on an acute unit and we used to have problems doing heparin free RRT but we have changed our dislysers and the problems have been greatly reduced. We now use an AN69 dialyser and prime the dialyser with heparin then rinse this out with a 500ml bag of saline. We can usually treat 90% + of our patienst heparin free without needing to do the saline flushes etc. There are always going to be the patients that you will have problems with but for the majority we have found this works. It is more expensive for this dialyser but it is cost effective when you consider the cost of replacing the pack when one clots off, not to mention the cost to the patient when they are dropping their HB.