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Advice: Profile or Not?

Posted

Specializes in Med-Surg. Has 2 years experience.

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, CNS

Specializes in Nephrology, Cardiology, ER, ICU. Has 27 years experience.

Since he is normally hypertensive, I would go with an EDW adjustment and fluid restriction education.

Our practice does NOT use profiles as the latest literature proves that when you use a profile, you are stressing the heart too much.

Our practice uses 13ml/kg/hr and that's it. If the pt is still over EDW after that, then we offer a PUF if slot available.

If you've ever had a pt die at the dialysis unit, it makes a big impression on you and our pts die mostly from cardiac disease.

rogue_maverick

Specializes in Nephrology-Dialysis/Surgery/Orthopaedics. Has 4 years experience.

Since he is normally hypertensive, I would go with an EDW adjustment and fluid restriction education.

Our practice does NOT use profiles as the latest literature proves that when you use a profile, you are stressing the heart too much.

Our practice uses 13ml/kg/hr and that's it. If the pt is still over EDW after that, then we offer a PUF if slot available.

If you've ever had a pt die at the dialysis unit, it makes a big impression on you and our pts die mostly from cardiac disease.

Hi TraumaRUs,

Can you give me the link of the latest literature that you mentioned? I also want to read about that.

Thanks!

Does he take any hypertension meds? What time of the day he takes it? Does he take it right before he comes for the treatment?When the hypotension accompanied by leg cramps within the first hour, sodium profiling help with our patients. Some doctors are comfortable with that and some are not. He may gain weight so EDW should be adjusted. Discuss it with his doctor when he comes or calls.

Since he is normally hypertensive, I would go with an EDW adjustment and fluid restriction education.

Our practice does NOT use profiles as the latest literature proves that when you use a profile, you are stressing the heart too much.

Our practice uses 13ml/kg/hr and that's it. If the pt is still over EDW after that, then we offer a PUF if slot available.

If you've ever had a pt die at the dialysis unit, it makes a big impression on you and our pts die mostly from cardiac disease.

Trauma is correct. A lot of folks don't realize that it's the cardiac disease (in all its iterations) that is statistically the biggest "killer" of ESRD patients.

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.

.

Your patient sounds diabetic.

The reason I say this, is because the scenario you've described sounds like diabetic vasculopathy.

Often in cases like this the patient has an impaired ability to regulate orthostats because their peripheral vasculature over time loses the ability to constrict in response to autonomic triggers. Add in heart disease, like cardiomyopathy/ decreased ejection fraction...and the ability to compensate for fluid removal and orthosat pressure is even further impaired.

These are especially challenging patients in the context of "high fluid gainers."

traumaRUs, MSN, APRN, CNS

Specializes in Nephrology, Cardiology, ER, ICU. Has 27 years experience.

Here is a Medscape article about UF rates that says there is increased risk of CV complications for UF's >10ml/kg/hr:

Medscape: Medscape Access

Patients receiving hemodialysis have high rates of cardiovascular morbidity and mortality that may be related to the hemodynamic effects of rapid ultrafiltration. Here we tested whether higher dialytic ultrafiltration rates are associated with greater all-cause and cardiovascular mortality, and hospitalization for cardiovascular disease. We used data from the Hemodialysis Study, an almost-7-year randomized clinical trial of 1846 patients receiving thrice-weekly chronic dialysis. The ultrafiltration rates were divided into three categories: up to 10 ml/h/kg, 10–13 ml/h/kg, and over 13 ml/h/kg. Compared to ultrafiltration rates in the lowest group, rates in the highest were significantly associated with increased all-cause and cardiovascular-related mortality with adjusted hazard ratios of 1.59 and 1.71, respectively. Overall, ultrafiltration rates between 10–13 ml/h/kg were not associated with all-cause or cardiovascular mortality; however, they were significantly associated among participants with congestive heart failure. Cubic spline interpolation suggested that the risk of all-cause and cardiovascular mortality began to increase at ultrafiltration rates over 10 ml/h/kg regardless of the status of congestive heart failure. Hence, higher ultrafiltration rates in hemodialysis patients are associated with a greater risk of all-cause and cardiovascular death.

Here is the citation:

Kidney Int. 2011;79(2):250-257.

I do apologize as the link only takes you to the Medscape sign in screen.

However, if you search

Here is a Medscape article about UF rates that says there is increased risk of CV complications for UF's >10ml/kg/hr:

Medscape: Medscape Access

Patients receiving hemodialysis have high rates of cardiovascular morbidity and mortality that may be related to the hemodynamic effects of rapid ultrafiltration. Here we tested whether higher dialytic ultrafiltration rates are associated with greater all-cause and cardiovascular mortality, and hospitalization for cardiovascular disease. We used data from the Hemodialysis Study, an almost-7-year randomized clinical trial of 1846 patients receiving thrice-weekly chronic dialysis. The ultrafiltration rates were divided into three categories: up to 10 ml/h/kg, 10–13 ml/h/kg, and over 13 ml/h/kg. Compared to ultrafiltration rates in the lowest group, rates in the highest were significantly associated with increased all-cause and cardiovascular-related mortality with adjusted hazard ratios of 1.59 and 1.71, respectively. Overall, ultrafiltration rates between 10–13 ml/h/kg were not associated with all-cause or cardiovascular mortality; however, they were significantly associated among participants with congestive heart failure. Cubic spline interpolation suggested that the risk of all-cause and cardiovascular mortality began to increase at ultrafiltration rates over 10 ml/h/kg regardless of the status of congestive heart failure. Hence, higher ultrafiltration rates in hemodialysis patients are associated with a greater risk of all-cause and cardiovascular death.

Here is the citation:

Kidney Int. 2011;79(2):250-257.

I do apologize as the link only takes you to the Medscape sign in screen.

However, if you search

Hmmmm...

Lots of questions immediately pop into my head.

I'll be interested in reading all the data.

traumaRUs, MSN, APRN, CNS

Specializes in Nephrology, Cardiology, ER, ICU. Has 27 years experience.

They do admit the problem with this is CHF. However, it all comes back to patient safety: I like the X amt of ml/kg/hr. I have had multiple full arrests in dialysis units and several of these were people that continued to not have the personal accountability to restrict fluids.

The other option I have used for people with low EFs and lots of CHF: 4 treatments/week or 4 treatments and a PUF per week. (Now these are pts on the heart transplant list).

They do admit the problem with this is CHF. However, it all comes back to patient safety: I like the X amt of ml/kg/hr. I have had multiple full arrests in dialysis units and several of these were people that continued to not have the personal accountability to restrict fluids.

The other option I have used for people with low EFs and lots of CHF: 4 treatments/week or 4 treatments and a PUF per week. (Now these are pts on the heart transplant list).

Good points, especially in regard to patient safety...no matter what the patient does (or does not do) on their end, the onus is still on us to make appropriate patient-specific treatment decisions.

I'm also a big proponent of nocturnal at-home dialysis. I am not a "fan" of big corporate dialysis chains, but I give companies like DaVita credit for researching and developing these options, no matter what their financial agenda/motive is behind it.

And if you ever find the magic bullet for convincing patients who abuse fluids to stop it, please let me know. Over the years I've tried very hard to educate high fluid gainers as to what will happen in about a year's time if they continue.

I'm not sure I've ever witnessed a chronic fluid abuser who doesn't one day walk into the unit no longer able to achieve a blood pressure above 90 Systolic. That's when the drain-circling begins.

Very frustrating. But let's face it, many of patients that end up on dialysis are there because they were not good, "life managers" to begin with. Rare is the patient with a lifelong history of poor self-management that suddenly sees the light once they're dialysis dependant.

My printer is busticated, so I'm looking forward to printing out the full study you posted at work tomorrow. Thanks for the link.

madwife2002, BSN, RN

Specializes in RN, BSN, CHDN. Has 26 years experience.

Sad truth is only 33% of patients will live to 5 years

traumaRUs, MSN, APRN, CNS

Specializes in Nephrology, Cardiology, ER, ICU. Has 27 years experience.

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.

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!

Specializes in Pulmonary.

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!

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 --

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