6% "take off" rule

mmurphy · Nov 16, 2006

I am a Certified Nephrology Nurse with over 20 years experience in dialysis. I have never heard of this 6% "take off" rule. However, too much fluid removal in a free standing facility does present potential for serious complications. Secondly, the extra treatments may be a problem as medicare will not reimburse for extra treatments without a great deal of documentation for necessity.

km5v6r, EdD, RN · Nov 16, 2006

I have never heard of the 6% rule either. In my experience the only rule regarding UF was to not take more then 2 liters/hour off. A 4 hour treatment could result in 8 liters UFed if tolerated. The 6% rule would limit a 70 kg pt to slightly more then 4 liters for the entire treatment. Many pt's will gain that in a weekend. The problem I used to run into was not the pt's wanting to much fluid taken off but those who wouldn't allow their dry wt to be challenged. It only take one good case of cramping to make people shy of becoming to dry. Coming to ER and getting intubated for Pulmonary Edema at 0300 changes the mind about challenging the dry wt, too. Within reason and with teaching I would allow the pt to decide how much fluid to be removed. It is their body and they have to deal with the consequences. Some requested to go into the weekend a little "drier" if they had some big event planned. Others would come in on Monday and wouldn't be down to dry wt until Wednesday. Trying to schedule in extra treatments is a major problem for both the pt and unit. The pt has to rearrange their life, find transportation, adjust medications, etc. The unit has to find a open time spot, try and get reimbursment, rearrange staffing etc. Managable occassionally but not a good long term solution or a viable solutions for large numbers of pts. Just out of curiosity where did you learn the 6% rule?

tired dialysis nurse · Nov 16, 2006

I HAVE NEVER HEARD ABOUT THE 6% RULE EITHER----SOME PTS CAN TOLERATE PULLING 6-8 KILOS, OTHERS COME IN THAT HEAVY AND WE MAY BE ABLE TO PULL ONLY 3, PTS VARY SOOOOO MUCH, THATS WHY PT EDUCATION IS SO VITAL, BUT OF COURSE YOU CAN LEAD A HORSE TO WATER.........WHAT ABOUT THOSE PHOS LEVELS!!!!! I HAD SOME LAB COME BACK AND ONE OF MY PTS HAD A LEVEL ABOVE 13!! OF COURSE HE WAS TAKING HIS BINDERS, OF COURSE HE WAS WATCHING HIS DIET--THE DOC TOLD HIM HE WAS GOING TO WRITE ABOUT HIM IN AN ARTICLE DUE TO THE FACT HE WAS SUCH A MEDICAL MYSTERY, THIS WAS ALL SAID WITH HUMOR--THIS JOB SURE MAKES YOU FEEL LIKE YOU ARE BANGING YOUR HEAD AGAINST A BRICK WALL SOMETIMES:smackingf, KEEP SMILING, TDN

Trauma Columnist · Nov 17, 2006

I am new to dialysis and this is what I was told: to take off more than 6% can result in ischmia to the heart. My population of patients are poor, indigent and extremely noncompliant. Few take their meds correctly and watch their fluid intake, another few occasionally take their meds and watch their fluids but most drink until they puke and don't take their meds AT ALL.

The only source I could find that even addressed fluid gains was: the Review of Hemodialysis for nurses and dialysis personnel by Kallenback, Gutch, Stoner, Corea, 2005, p 198 which states that the ideal fluid gains shouldn't be more than 3% of the EDW. I was told that the max we could take off was 6% because any more and you can have cardiac ischemia.

How much do you guys routinely pull off?

lilypad2424 · Nov 17, 2006

I'm in nursing school, so pardon the DQ. What is dry/wet weight, and what fluid are you pulling off?

DeLana_RN, BSN, RN · Nov 17, 2006

I have to agree with pp, this is news to me but what you say makes sense.

We were told to use our nursing judgement to determine optimal UF (not great advice when you're new to a speciality :rolleyes: - but my "preceptor" was something else - oops, I digress). One of the nephrologists had a limit of 1.5 kg/hr, ours allowed up to 2.0 kg/hr, preferably in bypass (UF only) at such a high rate; you could run in bypass for up to 2 hours. Some patients, however, tolerated 2.0 kg/hr in dialysis mode quite well; needless to say, they were abusing their bodies... we did our best to educate, but usually with little success. But you already know that.

Some of my colleagues were obsessed with "challenging" dry weights until the patients crashed and cramped; my philosophy was to leave them a little wet if in doubt (not much, but with good VS and no c/o). Knowing how my own weight changes daily - and I don't have CKD - this is of course also true for ESRD pts and complicates finding EDW even more.

And some of my RN colleagues never even bothered to estimate dry weight - they would just do whatever the pts wished and let them go out with BPs through the roof (or in the basement) and what not. But of course you can't interfere in their practice...

We were told that "acceptable weight gain" for an average size pt would be 2-3 kg; this was true for many, but I have seen as much as 11 kg (!) successfully pulled off during a tx (using bypass and extending time with a doctor's order). The nephrologist was of course aware of this and no more successful in his pt education. Need I add that the pt has since succumbed to heart disease?!

HTH. Thanks for the info!

DeLana :)

DeLana_RN, BSN, RN · Nov 17, 2006

I'm in nursing school, so pardon the DQ. What is dry/wet weight, and what fluid are you pulling off?

There's no such thing as a DQ! As you know, when kidneys fail the body is no longer able to remove excess fluid (sometimes, some residual function remains and a very few ESRD pts don't have this problem; but most do). So in addition to cleaning the blood, the hemodialysis delivery system (machine) is programmed to remove a certain amount of fluid via UF (ultrafiltration); this is determined by the nurse based on his/her pt assessment.

Estimated dry weight (EDW) is what we determine the pt's "real weight" - i.e., body weight without excess fluids that working kidneys would have removed - to be. It can only be an estimate, and we use VS, edema, lung sounds, and other assessments to help us determine it.

HTH!

DeLana :)

P.S. We don't use the term "wet weight", just pre-tx weight - e.g., EDW is 80 kg, pt presents with 83 kg; we would normally remove 3 kg (3 L), but may try to increase this if we feel that the pt has lost body weight, perhaps due to poor appetite; this is called "challenging EDW".

On the other hand, if the pt seems to have gained wt, we may have to adjust our UF goal (take less fluid off) due to cramping or hypotension during tx.

Trauma Columnist · Nov 17, 2006

As the APN in the facility, they have to get an order from me each time anyone wants to take off more than 6% of the pre-dialytic weight. We have a lot of cocaine users in our facilities and I know they have heart damage.

Thanks DeLana Rn - I have been doing a lot of reading and of course I ask questions too. This is a new area for me as my RN experience was in the ER and ICU only. I had never even seen dialysis done before I accepted this position. Of course, I'm not expected to assist with dialysis, just the medical management part. It made sense to me that if you have hypotension you are having some degree of cardiac ischemia. Also, when you have the fluid shifts that we do in dialysis, you run the risk of increasing the cardiac ischemia.

Many of my patients have ejection fractions of 25% and less so even if they come in waaayy over, taking off a lot leaves them open to sudden death (and I certainly don't want that).

You are a wealth of knowledge - I really appreciate your comments - thank you.

DeLana_RN, BSN, RN · Nov 18, 2006

I've seen pts with EF of

I wish more nephrologists employed ARNPs who usually spend more time with the pts.

DeLana :)

Trauma Columnist · Nov 19, 2006

Delana - How do your doctors bill? I (along with three other NPs) do the Medicare-required three visits per month and then the MD does his one visit. Medicare requires these visits and that they be when pt is on HD.

Don't all nephrologists have APRN's who do this? We are in an 11 MD practice and have 9 units that three of us cover. I have approx 200 pts in two units that I "round" on and care for.

We are pretty accessible for the nurses too.

DeLana_RN, BSN, RN · Nov 20, 2006

I've been away from the clinic for a while and will start in an inpatient/acute hospital unit next week. I'm pretty sure that our local clinics are still only covered by the nephrologists themselves (5 of them) - each is the medical director of one clinic. They do their own visits, and yes, round about once a week.

For some reason, they just haven't (yet?) hired any ARNPs. Too bad, as a nurse I much prefer dealing with a nurse practitioner rather than the often grumpy on-call nephrologist

One can always hope for the future, though.

DeLana :)