Anticougulation during dialysis

deborah mallon · Oct 5, 2005

My new job is going well. We have a few patients who have had their bolus heparin decreased. One to 1K and one to 500U. Both patients continue to have minimal oozing post dialysis, several hours after treatment. I am told by one that it is due to heparin, another tells me it can be other factors. Any ideas? The techs at my unit tell patients it is heparin as cause but in training book stated stenosis? ideas?

HI Student 60,

You are wise to think about other reasons for prolonged post treatment bleeding. The half life of Heparin is relatively shortand with doses as low as you have stated, I would take time to evaluate the access for possible stenosis. Have you done a venous dynamic pressure on these patients? If you need t know how to do this let me know and I can walk you through it. It can be a good indicator of venous stenosis. Keep up the good work and read everything you can about your patient care. There are lots of really good web sites for us. :)

jnette, ASN, EMT-I · Oct 5, 2005

How do you safely do a continuous drip during dialysis? Are you using an infusion pump?

I was wondering the same thing ! :)

If doing acutes, this may well be possible, but I doubt this would be done at an outpatient/chronic unit. At least WE don't have any infusion pumps standing around... even our ONE dinky pump we DO have to infuse the occasional antibiotic is such an antique, it doesn't work so we have to run them by gravity and keep a close eye on them. :rolleyes:

1kittyluvr · Oct 5, 2005

I was wondering the same thing ! :)
If doing acutes, this may well be possible, but I doubt this would be done at an outpatient/chronic unit. At least WE don't have any infusion pumps standing around... even our ONE dinky pump we DO have to infuse the occasional antibiotic is such an antique, it doesn't work so we have to run them by gravity and keep a close eye on them.

I have worked in outpatient dialysis for over 5 yrs. At one time, our company had a device that looked like a blood pressure cuff that allowed for controlled IV infusion (sorry I don't remember the proper name for it). The bag of medication would slide between an opaque cover and the inflation bag. That

way the amount of medication could be easily visualized. We don't currently have one in the unit I work in now. I'll try to find the name of it.

jnette, ASN, EMT-I · Oct 16, 2005

I have worked in outpatient dialysis for over 5 yrs. At one time, our company had a device that looked like a blood pressure cuff that allowed for controlled IV infusion (sorry I don't remember the proper name for it). The bag of medication would slide between an opaque cover and the inflation bag. That
way the amount of medication could be easily visualized. We don't currently have one in the unit I work in now. I'll try to find the name of it.

Know just what you're talking about ! We have one of those as well, and like our old infusion pump, doesn't work worth a doo doo !!!

The multi billion dollar industry that dialysis now is, I would think they could equip their units with a new pump or two ! :stone

RM23 · Oct 17, 2005

The multi billion dollar industry that dialysis now is, I would think they could equip their units with a new pump or two !

__________________

J'nette: The above statement is disturbing. I can only imagine the great frustration you must have when it is so very apparent that you are a dedicated RN who places the patient as 'priority'. The distressing part of this scenario is the profits coming in for the dialysis industries and why areas as you mention are not addressed. It is a safety issue! I have to admit that it certainly sounds like the big guys do not take into account many aspects of delivery of care. If a new piece of equipment would benefit the patient, then why does the clinic manager and/or physician/medical director, not request such equipment? WHen we know, for a fact, that the big guys within the dialysis industry, as well as those educators (training staff) are contributors to many guidelines, recommendations, etc i.e. CDC recommendations, then one has to ask why do some units not adhere to these guidelines, etc. Just throwing this out for feedback. Continue to be the great nurse you are, caring, concerned and being a patient advocate.

1kittyluvr · Oct 20, 2005

I have asked our clinical manager several times for infusion pumps. Her answer to me was that "we don't do enough infusions to warrant the costs." As a charge nurse, I have mentioned this to our NP, and to the docs. But it justs seems to be in one ear and out the other. What do we do? Who else do we turn to?

diabo, RN · Nov 5, 2005

You only need an infusion pump if you infuse post blood pump. Pre pump drip rates can be calculated like we learned in school waaaaay back there.

Steven

nursa · Nov 7, 2005

HI! your post is almost a month old today when I saw it, so a am assuming your problem has been resolved. FYI in the future, when you dialyze a client with coagulation problems, this is what we do in our unit here in Toronto.

We use the Integra machines: we attach a special tubing called the Bioline, or bioflow. This line connects to the venous chamber (the one that usually clots often), and set the machine to deliver 2L of saline per hour. The machine, in this mode, substracts the amount of saline before it reaches the pt. circulation thus allowing for safer fluid removal specially in acute pts.

For ambulatory patients who have no significant coag. issues, we do "flushes" of saline, once qh, and we count those in total wt. loss desired.

Flushing the circuit and filter with 1ml. or 1:10,000.00 hep. and then discarding as pt. is connected works well.

hope this helps.