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Emergency procedures training

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This document outlines emergency procedures for a dialysis unit. It provides guidelines for responding to various medical emergencies that may occur during dialysis treatment, including cardiac arrest, air embolism, anaphylactic reaction, seizure, shortness of breath, cardiac arrhythmias, and chest pain. For each emergency, it describes signs and symptoms to look for and steps staff should take to assess and stabilize the patient, such as notifying the charge nurse, administering oxygen, treating hypotension, and contacting the patient's physician.

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EMERGENCY PROCEDURES BY: LLOYD SMITH RN
EMERGENCY TRAINING • Why is this important ? • Who needs to be trained ? • Who will it affect ?
Emergency Procedures • Guidelines for Emergency Transfer • Cardiopulmonary Arrest • Air Embolism • Anaphylactic Reaction • Seizure • Shortness of Breath • Cardiac Arrhythmias • Chest Pain • Crenation • Hemolysis • Disequilibrium Syndrome • First-use Syndrome • Blood Loss/Exsanguinations • Dialyzer Blood Leak • Clotted Dialyzer • Pyrogenic Reaction • Equipment Problems and Alarms • Hypertension • Hypotension • Hypoglycemia • Muscle Cramps • Using Patient Restraints
Guidelines for Emergency Transfer • For patient emergencies involving cardiac arrest, impending cardiac arrests, or other potentially live threatening events, call 911 first, to request an ambulance for patient transport. Inform the dispatcher of the urgency involved. Notify the physician on call as soon as possible. • For patient emergencies of a less urgent nature, call the patient’s primary physician (or physician on call if the primary physician is unavailable) for an order to transport. Then notify a local ambulance service of the need to transport. • The Charge Nurse should remain with the patient until he/she has left the building. • The unit secretary or other ancillary staff should prepare the transfer information packet to accompany the patient to the hospital. The packet should include: • The last 3 hemodialysis records. • Medication List • Care Plans • Code Summary (if applicable) • If time does not permit, the information may be faxed to the hospital as soon as possible after the transfer. This person should also gather the patient’s belongings and send them with the patient.
Guidelines for Emergency Transfer (cont) • Only those emergency response personnel needed should enter the unit. First responders such as firemen often arrive before paramedics, EMT’s and ambulance personnel. Their usefulness in the given situation should be evaluated by the charge nurse. • The patient care staff should assist the EMS staff in preparing the patient for transfer. If additional staff is needed during the transport process, a nurse may be sent with the EMS team at the discretion of the EMS team and KCC Charge Nurse or Clinical Manager. • The charge nurse should give a full report to the ambulance personnel of the events leading up to the transfer. • Once the patient has left the building the Charge Nurse should call the emergency room triage nurse to notify him/her of the transfer. The Charge nurse should give a full report of the events leading up to the transfer. • The Clinical Manager, Social Worker, or Charge Nurse should notify the patient’s emergency contact of the transfer. Every effort should be made to offer support and sensitivity to the family member receiving the information
Cardiopulmonary Arrest • A cardiac arrest, also known as cardiopulmonary arrest or circulatory arrest, is the abrupt cessation of normal circulation of the blood due to failure of the heart to contract effectively during systole. • Cardiac arrest is a medical emergency that, in certain groups of patients, is potentially reversible if treated early enough • The staff member discovering the patient in cardiac arrest should call for help without leaving the patient. The staff person responding should page “all staff to the patient care area stat” over the intercom. • The patient’s blood should be returned immediately. As soon as 3 staff persons are at the chair-side, the patient should be placed in the floor, and CPR Started.
• The charge nurse will make assignments to the code team. • Code Leader (Charge Nurse): Conveys a sense of order in an emergency environment. Responsible for all decisions in the absence of a physician or advanced practitioner. Assigns other responsibilities. Performs all aspects of electrical therapy. Identifies cardiac arrhythmias and chooses appropriate algorithm and medications based on facility policy. Communicates activities to the person performing documentation. • Medication Nurse (RN or LPN): Responsible for accurate preparation and administration of all medications. Communicates medications given to the person performing documentation. Responsible for achieving and maintaining IV access. • Documentation (LPN or PCT): Responsible for accurate documentation of al events and interventions during the code. • Compressions (CPR certified person): Responsible for pulse checks and delivery of compressions during cardiac arrest.
• Airway Management (CPR certified person): Responsible for achieving and maintaining the airway. Responsible for monitoring the delivery of O2 and the fill level of the O2 tank. • Communications (Unit Clerk or Ancillary Staff): Responsible for paging physicians, calling 911, calling the ER triage nurse and copying medical records in anticipation of transport. • Only those staff directly involved in the resuscitative efforts should be in the immediate vicinity, all other staff should monitor and reassure the other patients. • EMS should be notified by dialing 911. Report to the EMS dispatcher that CPR is in progress. Page the patient’s physician, or physician on call.
• The patient should be placed on the cardiac defibrillator monitor and any lethal arrhythmias identified. • If defibrillation is appropriate, this should be performed immediately. • O2 delivery should be via ambu bag at 100 % at rate of 10 breaths per minute. • IV access should be maintained via the patient’s vascular access, and appropriate medications given per ACLS Guidelines. • Follow guidelines for emergency patient transport.
Ethical Issues • Cardiopulmonary resuscitation and advanced cardiac life support are not always in a person's best interest. This is particularly true in the case of terminal illnesses when resuscitation will not alter the outcome of the disease. Properly performed CPR often fractures the rib cage, especially in older patients or those suffering from osteoporosis. Defibrillation, especially repeated several times as called for by ACLS protocols, may also cause electrical burns. • Some people with a terminal illness choose to avoid such measures and die peacefully. People with views on the treatment they wish to receive in the event of a cardiac arrest should discuss these views with both their doctor and with their family. A patient may ask their doctor to place a do not resuscitate (DNR) order in the medical record. Alternatively, in many jurisdictions, a person may formally state their wishes in an advance directive or advance health directive (see POST form at KCC).
Air Embolism • An air embolism, or more generally gas embolism, is a medical condition caused by gas bubbles in the bloodstream (embolism in a medical context refers to any large moving mass or defect in the blood stream). Small amounts of air often get into the blood circulation accidentally during surgery and other medical procedures (for example a bubble entering an intravenous fluid line), but most of these air emboli enter the veins and are stopped at the lungs, and thus a venous air embolism that shows any symptoms, is very rare.
Air Embolism • The first step in treating Air Embolus is prevention. • Assure alarms test are performed pre-dialysis. • Always change out the NS bag if < 300cc of NS remains. • Never leave the patient when administering NS or returning the blood. • When administering medications or NS by gravity, monitor the infusion closely. • Always assure central catheter ports are clamped when removing caps, syringes or lines.
• Identify signs and symptoms of air embolus which may include: air or foam observed in the venous line below the air detector, chest pain, SOB, cough, seizure, visual disturbances, hemiparesis, confusion and changes in mental status, or the patient may describe a sense of impending doom. • Immediately clamp the venous line and turn off the blood pump. • Place the patient in Trendelenburg position on their left side. • Note: This position will aid in trapping the air in the right atrium, which may prevent it from traveling to the lungs. • Call for help and request the Charge Nurse.
• Assess patient. If marked changes in the patient’s cardiopulmonary and/or mental status are noted, call for the crash cart. Place patient on cardiac monitor and assess O2 sat. • Initiate emergency procedures as indicated by patient’s condition. • Recirculate the extracorporeal circuit. Flush the fistula needles or catheter ports with NS. • Notify the patient’s physician or physician on call. • Return the patient’s blood if indicated/ordered. • Once the patient is stabilized or transported, investigate and identify the source of air. If no source is identified, or if the dialysis machine may be implicated, pull the equipment, place a service report on the machine and label it “Not for Use”. Notify the Chief Tech.
Anaphylactic Reaction • Anaphylaxis is a serious allergic reaction that is rapid in onset and may cause death. • What are the common causes of anaphylaxis? • Common causes of anaphylaxis include: • Food • Medication • Insect stings • Latex
• Identify the SIGNS AND SYMPTOMS’s of anaphylactic reaction that may include: SOB, acute bronchospasms or bronchoconstriction, chest pain, back pain, hypotension, hypertension, anxiety, thready-rapid pulse, diaphoresis, nausea, profound shock, and/or cardiopulmonary arrest. • Stop the infusion of medication or blood immediately. If the product is being infused via the extracorporeal circuit, stop the blood pump and clamp the venous bloodline. • Place the patient in Trendelenburg position if SIGNS AND SYMPTOMS of shock are present. • Call for help and request the Charge Nurse • Assess the patient. If marked changes in the patient’s cardiopulmonary status are noted, call for the crash cart. Place the patient on the cardiac monitor and assess O2 status.
• Attach the NS line directly to the patient’s vascular access. Be prepared to provide NS for volume support if B/P indicates. • Initiate emergency procedures as indicated by patient’s condition. • Administer medications according to Physicians Standing Emergency Orders. • Note: Patients taking beta-blockers routinely may not respond adequately to epinephrine. • Recirculate the extracorporeal circuit and flush the unused catheter ports or fistula needles. • Notify the patient’s physician or physician on call. • Once the patient is stabilized or transferred, identify the causative agent and label the patient’s medical record accordingly. Consider: medications, blood products, dialyzer membranes, and/or dialyzer germicides.
Seizure • A seizure is a sudden change in behavior due to abnormal electrical activity in the brain • Note: Seizure activity during dialysis is usually the result of hypotension or a pre-existing seizure disorder. Other possible causes are drug toxicity, disequilibrium syndrome, air embolism or hemolysis. Exact treatment will depend on the cause
• Identify seizure activity. • Quickly assess the venous bloodline for the presence of air or hemolized blood. If present, stop the blood pump, clamp the bloodlines and refer to the appropriate procedure. • Call for help and request the Charge Nurse. • Place the patient in Trendelenburg position with the head supported to one side. • Begin an infusion of NS into the extracorporeal circuit at a rate of about 200 ml/min. • Attempt to assess the patient’s blood pressure as soon as seizure activity will allow. If patient is hypotensive, refer to the appropriate procedure. • If possible, insert an oral airway between the patient’s teeth. Do not attempt to force the airway between clinched teeth.
• Prevent dislodgement of fistula needles or vascular access catheters with hands on support if necessary. • Notify the patient’s physician or the physician on call of the event. • Follow any medication or laboratory orders given by the physician. • As seizure activity subsides, maintain on open airway, and continue to support the head to one side. Be prepared to suction the patient if needed. Be prepared to provide respiratory assistance if needed. • Note: Hypotensive seizure activity is often followed by an episode of nausea and vomiting. • If the patient’s condition returns to baseline, reinitiate dialysis as ordered. • Note: Patient’s with a seizure disorder may appear profoundly lethargic after a seizure. • If the patient’s fails to return to baseline, follow physician orders. See Guidelines for emergency transport if indicated.
Shortness of Breath • Difficulty Breathing • Note: SOB in dialysis patients is usually the result of fluid overload, anxiety and/or hypotension. Less often it may be related to angina, MI, blood, medication or dialyzer reactions. Rarely is it the result of air embolus, hemolysis or crenation.
• Notify the Charge Nurse. • Rule out the possibility of a dialyzer, medication, or blood reaction. If SIGNS AND SYMPTOMS’s begin immediately after beginning the administration of a medication or blood, or starting the dialysis procedure, stop the blood pump, and treat the patient according to the appropriate anaphylactic or dialyzer reaction procedure. • Rule out the possibility of air embolus crenation or hemolysis. Evaluate the venous bloodline for the presence of bright cherry-colored, blood, dark blood or air below the air detect, stop the blood pump and refer to the appropriate procedure. • Assess the patient’s blood pressure, and treat hypotension if indicated. Reassess the patient after NS administration. • Measure O2 saturation. If O2 saturation is less than 90%, notify the patient’s physician or the physician on call.
• Start O2 at: • 2 liters/min per nasal cannula for patients with O2 saturation 95-100% on room air. • 4 liters/min per nasal cannula for patients with O2 saturation 90-95% • 10 liters/min per partial non-rebreather mask for patients with O2 saturation < 90%. • Assess the patient’s heart rate and rhythm. Place patient on cardiac monitor if indicated. If the symptoms appear cardiac in origin, return the patient’s blood and notify the physician. • Evaluate the patient’s fluid volume status. Check for pitting edema in the extremities, NVD, auscultatate the patient’s lungs. • If FVO is suspected, review the treatment plan for appropriate fluid removal. • If unable to resolve the patient’s SIGNS AND SYMPTOMS, notify the physician.
Cardiac Arrhythmias • Cardiac arrhythmia is a term that denotes a disturbance of the heart rhythm. Cardiac arrhythmias can range in severity from entirely benign to immediately life-threatening • Note: Cardiac arrhythmias in dialysis patients are usually caused by electrolyte disturbances, altered medication levels, hypovolemia, anemia, hypotension or underlying heart disease; rarely arrhythmias may be related to irritation of the heart’s conduction system by vascular access catheters.
• Immediately notify the Charge Nurse of irregularities noted in the patient’s heart rhythm. • Place the patient on the cardiac monitor and assess the patient for the presence of lethal arrhythmias and/or chest pain. • Note: Do not initiate the dialysis treatment if the patient is unstable when he presents to the dialysis unit. Notify the patient’s physician or the physician on call. In the presence of lethal arrhythmias, or if the patient becomes hemodynamically unstable while on dialysis, discontinue the dialysis treatment and notify the patient’s physician or the physician on call. • Measure the patient’s O2 saturation, and start O2 as indicated. Initiate emergency procedures when indicated. • Assess the patient’s blood pressure, and treat hypotension if present.
• Evaluate the appropriateness of the patient’s dry weight and ultrafiltration plan. • Evaluate the patient’s past history of cardiac disease. • Assess the patient for the SIGNS AND SYMPTOMS of potassium imbalance. • Evaluate the patient’s recent serum potassium levels. • Note the potassium content of their current dialysate prescription. • Assess the patient’s food intake over the last 48 hours for high potassium foods. • Evaluate the patient’s cardiac monitor strip for peaked T waves and/or a widened QRS complex. • Evaluate the patient for other SIGNS AND SYMPTOMS of hyperkalemia such as generalized muscle pain and weakness. • Evaluate the patient’s compliance with prescribed cardiac medications. • Administer medications and/or draw labs as ordered by the physician.
Transfusion Reaction • Note: Transfusion reactions may occur immediately after the start of the transfusion, any time during the transfusion, or for up to 48 hours after the transfusion. Types of transfusion reactions include: • Pyrogenic: Usually results from bacterial contamination of the blood. SIGNS AND SYMPTOMS’s include chills, very high fever, hypotension and eventually shock. Less severe febrile reactions caused by leukocyte antibodies or other causes may be identified by chills and fever, muscle aches, nausea and vomiting, headaches and flushing. Pyrogenic reactions are usually gradual and may not be seen until well into the transfusion.
• Hemolytic: Results from incompatibility of the donor’s blood to the patient’s blood. The onset is sudden and includes SOB, low back pain, chest pain, nausea and vomiting, headache and or fever with chills. • Allergic: Probably due to the patient’s response to allergens in the donor’s blood. They are characterized by itching that may be accompanied by a rash or hives. Generally medicating the patient with antihistamines relieves the symptoms. • Fluid Overload: May result when the blood is administered too quickly, or when the patient is significantly above their dry weight already. SIGNS AND SYMPTOMS’s include SOB, rapid HR and/or drop in blood pressure. SIGNS AND SYMPTOMS’s usually improve with a decrease in the rate of infusion, or by withholding the transfusion until a significant amount of ultrafiltration is achieved.
• Identify the SIGNS AND SYMPTOMS’s of a possible transfusion reaction. Any unusual symptom experienced by the patient should be considered a possible reaction. • Stop the blood transfusion. If SIGNS AND SYMPTOMS’s are severe, stop the blood pump and recirculate the extracorporeal circuit. DO NOT RETURN THE BLOOD. Flush the patient’s fistula needles or catheter ports with NS. • Call for assistance, if needed, and alert the Charge Nurse. • Assess the patient. If marked changes in the cardiopulmonary status are noted, call for the crash cart. Place the patient on the cardiac monitor and assess the 02 status. • Initiate emergency procedures as indicated • Notify the patient’s physician or the physician on call. • Administer medications per physician order. • Notify Blood Assurance. Request a copy of the transfusion reaction form via fax. • Draw any labs ordered by the physician and/or Blood Assurance. • Complete the reaction section of the blood tag, and complete the transfusion reaction form.
Crenation • Identify the SIGNS AND SYMPTOMS of crenation. These include flushed face, SOB, sudden rise in blood pressure, chest pain, abdominal cramps, restlessness, agitation, convulsions in the presence of dark colored blood post dialyzer. • Immediately clamp the venous line and turn off the blood pump. • Notify the Charge Nurse. • Assess the patient. Place on cardiac monitor. Be alert for SIGNS AND SYMPTOMS of hyperkalemia. • Start O2 at 2 l/min per nasal cannula. Treat other symptoms and implement emergency procedures as indicated. • Check the conductivity of the machine. If crenation has occurred as a result of the dialysate, the conductivity will be low.
• Notify the patient’s physician, or the physician on call. • Check a stat potassium level on the patient. Preserve a sample of dialysate for laboratory analysis. • The extracorporeal circuit should be tossed. • The machine should be pulled and labeled not for use. • Notify the Chief Technician, and complete a service report on the machine. • Restart dialysis on a fresh machine and dialyzer as ordered by the physician. • Note: The patient’s potassium will probably be elevated. Dialysis should be restarted for a minimum of 2 hours.
Hemolysis
• Identify the SIGNS AND SYMPTOMS of hemolysis. These include patient complaints of a burning sensation in the access extremity, SOB, hypotension, hyperkalemia, chest and back pain, nausea and vomiting, convulsions and/or cardiac arrhythmias or arrest in the presence of cranberry-colored almost translucent blood post dialyzer. • Immediately clamp the venous line and turn off the blood pump. • Notify the Charge Nurse. • Assess the patient. Place on cardiac monitor. Be alert for SIGNS AND SYMPTOMS of hyperkalemia. • Start O2 at 2 l/min per nasal cannula. Treat other symptoms and implement emergency procedures as indicated. • Draw a sample of blood from the extracorporeal circuit and place in a SST tube. Spin for 5-15 minutes and check for the presence of pink serum indicating hemolysis.
• Consider the following causes of hemolysis: • Inappropriate dialysate composition resulting in hypotonic dialysate. • Overheated dialysate, usually above 105º F or 40º C. • Notify the patient’s physician, or the physician on call. • Check a stat potassium level and H&H on the patient. Preserve a sample of dialysate for laboratory analysis. • The extracorporeal circuit should be tossed. • The machine should be pulled and labeled not for use. • Notify the Chief Technician, and complete a service report on the machine. • Restart dialysis on a fresh machine and dialyzer as ordered by the physician. • Note: The patient’s potassium will probably be elevated. Dialysis should be restarted for a minimum of 2 hours. Consider transport to acute facility.
Disequilibrium Syndrome • Identify the SIGNS AND SYMPTOMS of disequilibrium syndrome. These include patient complaints of a headache, hypertension, increased pulse pressure, decreased level of consciousness, nausea and vomiting, convulsions and/or coma. Disequilibrium syndrome occurs most often when the patient is very uremic with BUN above 150 mg/dl. Generally signs and symptoms present early in the dialysis treatment. Signs and symptoms should be differentiated from first use syndrome. • Note: Disequilibrium syndrome occurs when the blood osmolarity falls faster than the osmolarity of the cerebrospinal fluid. (This results from rapidly lowering the BUN.) Fluid shifts from the vascular compartment to the cerebral spinal fluid compartment and cerebral edema occurs. Patients known or suspected of extremely elevated BUN levels should be dialyzed cautiously in the outpatient setting. Prophylactic Mannitol, sodium modeling, low initial blood flow rates and a low clearance dialyzer are key.
• Immediately reduce the blood pump speed to 100 ml/min. • Notify the Charge Nurse. • Begin administration of Mannitol 25% 50ml IVP, slowly via the venous drip chamber. • Implement emergency procedures as indicated, and be alert for signs of seizure activity. • Notify physician if SIGNS AND SYMPTOMS are severe or do not resolve with treatment. • Note: Consider transport to an acute facility if SIGNS AND SYMPTOMS’s are severe or if there is a change in the patient’s mental status. • Resume dialysis cautiously once symptoms subside. Blood flow rates should not exceed 150-200 ml/min initially
First Use Syndrome • Recognize the symptoms of first-use syndrome and differentiated those symptoms from the symptoms of hemolysis, crenation, disequilibrium syndrome and dialyzer reaction. The SIGNS AND SYMPTOMS of first-use syndrome include itching, back pain and moderate hypotension. • Note: With hemolysis and crenation you will see changes in the appearance of the blood in the venous bloodline. With disequilibrium Syndrome the patient should have some history to indicate the presence of an elevated BUN, and the symptoms tend to be more severe. With a dialyzer or sterilent reaction, the symptoms tend to be more severe and SOB is a common feature. First- use syndrome only occurs with a new, unprocessed dialyzer. First-use syndrome results from complement activation by the new dialyzer membrane, and it occurs more often with cellulosic membranes.
• Immediately reduce the blood pump speed to 100 ml/min. • Notify the Charge Nurse. • Evaluate the patient’s blood pressure and treat hypotension with NS. • If SIGNS AND SYMPTOMS do not resolve, return the patient’s blood and purge the dialyzer and extracorporeal circuit with 1000cc of NS. • Restart dialysis cautiously with low blood pump speeds of 150-200 ml/min. • Consider change in the patient’s dialyzer type or individual pre-dialysis preparation procedures as ordered by physician.
Blood Loss / Exsanguination • Note: Blood loss during dialysis can occur on post blood pump along the extracorporeal circuit. Manufacture’s defects have occurred in the actual tubing and blood pump segments. Cuts have been made in the tubing sets when opening packing boxes. Blood loss can occur at the connection between the dialyzer and the bloodline due to product defect or improper connection. Blood loss can also occur from needle dislodgement or dialysis catheter dislodgement. Every effort should be made by the dialysis staff to secure against needle or catheter dislodgement. • The staff member discovering the patient should immediately clamp the venous bloodline and turn off the blood pump. • Call for assistance and notify the Charge Nurse. • Assess the patient for SIGNS AND SYMPTOMS of blood loss. Administer NS, Albumin and oxygen in case of shock. Implement emergency procedures if indicated. • Establish the location of the break in the extracorporeal circuit.
• If exsanguination is the result of fistula needle dislodgement: • Apply sterile gauze and clamp to the needle site. • Clamp fistula needles and bloodlines. • Remove the fistula needle from the bloodline and dispose of it in a biohazard sharps container. • Recirculate the extracorporeal circuit assessing for the presence of air. • Recannulate the vascular access. • Restart dialysis. • Assess probable cause of needle dislodgement and take steps to avoid a recurrence.
• If exsanguination is the result of dialysis catheter dislodgement: • Apply pressure to catheter site with sterile gauze for at least 20 minutes. • Observe the patient for possible SIGNS AND SYMPTOMS of air embolus. • Clamp catheter ports and bloodlines. • Remove the dialysis catheter from the bloodlines and dispose of it in a biohazard sharps container. • Recirculate the extracorporeal circuit. • Assess the patient for possible IV site for blood return and return blood if possible. • Notify physician of occurrence and follow arrange for access replacement as ordered. • Assess possible causes of catheter dislodgement and take steps to prevent recurrence.
• If exsanguination is the result of a defect in the bloodlines or dialyzer ports: • Return patient’s blood if air in the circuit is not identified. • Change bloodlines out, or change dialyzer out depending on the nature of the break. • Perform set-up per procedures. • Restart dialysis. Note product name and lot # in the medical record. • Make all patient care staff aware of occurrence, and trend any additional occurrences. • Assess possible causes and take steps to prevent recurrence. • If Clinical Manager is not present, and the cause of the exsanguinations is unclear, preserve extracorporeal circuit for evaluation. • If a product failure is identified, notify Clinical and Technical Manager.
Dialyzer Blood Leak • If you have a blood leak warning, check a dialysate sample from the drain line with a Hemastix test strip, by placing the strip in the stream. • Compare the strip to the results-key on the side of the bottle. • For Hemastix results that are Negative: • You may continue the dialysis treatment if the Phoenix Machine alarm continues Change settings on blood leak detector to minimal • If you continue to have a blood leak warning the machine will need to be pulled and Complete a service report on the machine and label it not for use. • The machine should be cleaned and rinsed prior to use, for either situation described above.
•For Hemastix results that are moderately positive, or hemolyzed, do not attempt to return the blood. •Turn off the blood pump. •Clamp fistula needles or catheter ports and bloodlines. •Disconnect the extracorporeal circuit, and place the bloodline connector between the arterial and venous bloodlines. •Flush the fistula needles or catheter ports with NS. •Remove the extracorporeal circuit and dialyzer from the machine. •Complete a service report on the machine and label it not for use. •The machine should be cleaned and rinsed prior to its next use. •Set patient up on a different machine, dialyzer and bloodline set per procedure.Restart dialysis per procedure. •For any actual dialyzer blood leak resulting in a positive Hemastix on a re or pre-processed dialyzer, a Reprocessing Complaint must be initiated.
Clotted Dializer • Note: Clotting in the extracorporeal circuit is more likely when very low blood flows are used, there are problems with adequate flow to or from the vascular access, very high ultrafiltration rates are used, the patient’s hemoglobin is high, or very low doses of heparin are used. • Recognize the signs of clotting within the extracorporeal circuit, which include: a darkening of the blood, clot formation within the drip chambers, elevated venous pressure, and/or a rise in TMP. • As soon as clotting is suspected, attempt to return the patients blood using the NS line method. • If the venous pressure continues to clime and returning the blood is not possible, turn off the blood pump, clamp the bloodlines and catheter ports or fistula needles. • Disconnect the patient from the extracorporeal circuit. • Flush the fistula needles or catheter ports with NS flushes. • Set up a new dialyzer and bloodline set per procedure. • Restart dialysis. • Assess possible causes of the clotted circuit and take steps to prevent recurrence.
Pyrogenic Reaction • All patients will have their pre and post dialysis temperature measured. In addition, any patient complaining of chills or exhibiting signs of chills will immediately have their temperature measured. • Report any patient reporting chills, exhibiting signs of chills or having a temperature of 100º F or greater to the Charge Nurse immediately. • Assess the patient for SIGNS AND SYMPTOMS of possible febrile illness, including access infection, pulmonary infections, urinary infections, flu SIGNS AND SYMPTOMS’s or other indications of infection. Interview the patient for a recent history of fever at home. • Notify the patient’s physician or the physician on call.
• Collect 2 sets of blood cultures from the patient. • Collect cultures of sputum, urine or the vascular access site if SIGNS AND SYMPTOMS are present. Administer medications or draw other lab tests as ordered by the physician. • Consider transfer to acute care facility for patients with high fevers or if the patient is unstable. • Trend multiple episodes by patient and/or by date. Notify the Medical Director immediately if multiple episodes or trends develop. • For any patient developing a fever during or post dialysis that was asymptomatic pre-dialysis Collect a specimen of the dialysate from the effluent end of the dialyzer in a urine cup. Prepare the dialysate for culture and/or endotoxin evaluation per procedure.
Hypertension • Note: Hypertension in dialysis patients is most often associated with fluid volume overload and medication non-compliance. It may also be aggravated by underlying cardiac and/or renal disease, anxiety, substance abuse, and occasionally volume contracture due to dehydration. • Notify the Charge Nurse when a blood pressure exceeds 180/90 or anytime the blood pressure is significantly different for a particular patient. • Evaluate the patient’s usual trend in blood pressures. • Evaluate the patient’s compliance with prescribed antihypertensive medications. Reinforce compliance with prescribed medications if indicated. • Evaluate the appropriateness of the patient’s dry weight, fluid volume status and ultrafiltration plan. Reinforce fluid restriction if indicated. • Notify the physician when the pre or intradialytic dialysis blood pressure exceeds 210/110 and is unusual for that patient. • Notify the physician when the post-dialysis blood pressure exceeds 180/100 and is unusual for that patient. • Note: Patients whom are chronically hypertensive should have routine orders established for medication administration and discharge criteria. • Administer medications and instruct the patient on medication changes as ordered by the physician.
Hypotension • Note: Hypotension in dialysis patients is most often associated with fluid removal from the patient’s vascular system at a rate, which exceeds the vascular refill rate. It may also be aggravated by, underlying cardiac disease, inaccurate dry weight assessment and occasionally dehydration. • Notify the Charge Nurse when a blood pressure is less than 100/50, anytime the blood pressure is significantly different for a particular patient, or when the patient is symptomatic. • Evaluate the patient’s usual trend in blood pressures and usual tolerance to ultrafiltration. • Evaluate the patient’s prescribed antihypertensive medications. • Evaluate the accuracy of the patient’s pre-dialysis weight. • Evaluate the appropriateness of the patient’s dry weight, fluid volume status and ultrafiltration plan. Reinforce fluid restriction if indicated. • Utilize sodium modeling and other hyperosmolar agents to increase the vascular refill rate. Such agents should be used prophylacticly in patients chronically hypotensive during ultrafiltration.
• Notify the physician when profound hypotension does not respond to appropriate therapy, or when changes in the treatment plan are indicated. • When the patient exhibits SIGNS AND SYMPTOMS of severe hypotension (diaphoresis, nausea and vomiting, or seizure: • Open the NS line and NS port and administer 150-250cc of NS. • Lower the patient’s UFR to 0.3 l/min • Reassess the blood pressure every 2-3 minutes until the patient is stabilized. • Be alert for respiratory and/or cardiac arrest and implement emergency procedures as indicated. • Notify the physician when the post-dialysis blood pressure is less than 100/50 unless the patient has a specific order to be discharged with a lower blood pressure.
Hypoglycemia • Recognize the SIGNS AND SYMPTOMS of hypoglycemia in diabetic patients. These include diaphoresis, decreased mental status, feeling faint, irritability and or tremors. • Evaluate the patient’s blood pressure to rule out hypotension. • Check the patient’s blood glucose level using the glucometer. • Notify the Charge Nurse when a blood sugar is less than 80, and/or the patient is symptomatic. • 50% dextrose may be administered at the discretion of the Charge Nurse after evaluating the patient’s food intake and insulin usage. • Patients who do not take insulin or oral hypoglycemic agents should be encouraged to eat a small snack rather than receive 50% dextrose. • Patients who have not eaten and taken their insulin should try to eat a small snack in addition to receiving 50% dextrose. • Patients who have eaten an appropriate amount of food and taken insulin as prescribed should be evaluated individually when considering 50% dextrose administration. • Evaluate the patient’s prescribed hypoglycemic medications and recent blood glucose levels. • Notify the physician when profound hypoglycemia does not respond to appropriate therapy, or when changes in the treatment plan are indicated.
Muscle Cramps • Note: Muscle Cramps in dialysis patients is most often associated with fluid removal from the patient’s vascular system at a rate, which exceeds the vascular refill rate. It may also be aggravated by, underlying vascular disease, inaccurate dry weight assessment, electrolyte imbalances and occasionally dehydration. • Administer 150cc of NS to the extracorporeal circuit via the NS line. • Temporarily decrease the ultrafiltration rate to 0.3 l/hr. • Notify the Charge Nurse when muscle cramps are unrelieved by steps #1 and #2. • Evaluate the patient’s usual trend in fluid volume weight gains and their usual tolerance to ultrafiltration. • Evaluate the accuracy of the patient’s pre-dialysis weight. • Evaluate the appropriateness of the patient’s dry weight, fluid volume status and ultrafiltration plan. Reinforce fluid restriction if indicated.
• Note: Patients gaining more than 3 Kg’s between dialysis treatments are more prone to experience side effects associated with ultrafiltration. If the patient does not usually cramp and no unusual circumstances are identified, consider recirculating the extracorporeal circuit and weighing the patient in the dialysis chair. • Note: The weight of all dialysis chairs is recorded on a sticker located on the back of each chair. While rare, failure of the machines ultrafiltration system is possible resulting in excessive ultrafiltration and dehydration of the patient. Weighing the patient during the dialysis treatment should provide an indication of the accuracy of the ultrafiltration. • Utilize sodium modeling and other hyperosmolar agents to increase the vascular refill rate. Such agents should be used prophylacticly in patients who chronically have muscle cramps during ultrafiltration. • Note: Mannitol or dialysate sodium adjustments may not be used during the last hour of dialysis. • Dextrose 50% 10-15cc IVP via the venous drip chamber may be used to relieve cramps in non-diabetic patients during the last hour or post dialysis. • Notify the physician when profound muscle cramps do not respond to appropriate therapy, or when changes in the treatment plan are indicated.
Using Patient Restraints • Note: Physical restraints may be used only when less restrictive measures prove inadequate to prevent the agitated or disoriented patient from injuring himself or others and to prevent the patient from deleteriously interfering with medical treatment. The least restrictive device appropriate for the patient should be used. • Identify alternative means to avoid the need for restraints. Consistently reinforce to the patient the importance of his medical care. Enlist the assistance of ancillary personnel to sit with the patient. Provide the patient with distractions such as coloring books or magazines. Tape bloodlines out of the patient’s direct line of vision. Place patients in the dialysis unit to await transportation when additional supervision is needed. • If the above measures fail, identify the least restrictive restraint device appropriate for the patient and the situation. • Contact the physician and obtain an order for the restraint.
• Complete the restraint order form. • Contact the patient’s emergency contact and request permission to use the restraint device. (The patient must consent if competent.) Document their permission to use the device on the Restraint Form. • Apply the device and assure the patient’s safety and comfort. • Perform routine checks of the patient at least every 30 minutes to include the condition of the restrained limb. • Remove the restraint device as soon as the condition justifying its use no longer exists. • Document the condition of the extremity at the time the restraint device is removed.
Questions & Answers Thank You!

More Related Content

Emergency procedures training

  • 1. EMERGENCY PROCEDURES BY: LLOYD SMITH RN
  • 2. EMERGENCY TRAINING • Why is this important ? • Who needs to be trained ? • Who will it affect ?
  • 3. Emergency Procedures • Guidelines for Emergency Transfer • Cardiopulmonary Arrest • Air Embolism • Anaphylactic Reaction • Seizure • Shortness of Breath • Cardiac Arrhythmias • Chest Pain • Crenation • Hemolysis • Disequilibrium Syndrome • First-use Syndrome • Blood Loss/Exsanguinations • Dialyzer Blood Leak • Clotted Dialyzer • Pyrogenic Reaction • Equipment Problems and Alarms • Hypertension • Hypotension • Hypoglycemia • Muscle Cramps • Using Patient Restraints
  • 4. Guidelines for Emergency Transfer • For patient emergencies involving cardiac arrest, impending cardiac arrests, or other potentially live threatening events, call 911 first, to request an ambulance for patient transport. Inform the dispatcher of the urgency involved. Notify the physician on call as soon as possible. • For patient emergencies of a less urgent nature, call the patient’s primary physician (or physician on call if the primary physician is unavailable) for an order to transport. Then notify a local ambulance service of the need to transport. • The Charge Nurse should remain with the patient until he/she has left the building. • The unit secretary or other ancillary staff should prepare the transfer information packet to accompany the patient to the hospital. The packet should include: • The last 3 hemodialysis records. • Medication List • Care Plans • Code Summary (if applicable) • If time does not permit, the information may be faxed to the hospital as soon as possible after the transfer. This person should also gather the patient’s belongings and send them with the patient.
  • 5. Guidelines for Emergency Transfer (cont) • Only those emergency response personnel needed should enter the unit. First responders such as firemen often arrive before paramedics, EMT’s and ambulance personnel. Their usefulness in the given situation should be evaluated by the charge nurse. • The patient care staff should assist the EMS staff in preparing the patient for transfer. If additional staff is needed during the transport process, a nurse may be sent with the EMS team at the discretion of the EMS team and KCC Charge Nurse or Clinical Manager. • The charge nurse should give a full report to the ambulance personnel of the events leading up to the transfer. • Once the patient has left the building the Charge Nurse should call the emergency room triage nurse to notify him/her of the transfer. The Charge nurse should give a full report of the events leading up to the transfer. • The Clinical Manager, Social Worker, or Charge Nurse should notify the patient’s emergency contact of the transfer. Every effort should be made to offer support and sensitivity to the family member receiving the information
  • 6. Cardiopulmonary Arrest • A cardiac arrest, also known as cardiopulmonary arrest or circulatory arrest, is the abrupt cessation of normal circulation of the blood due to failure of the heart to contract effectively during systole. • Cardiac arrest is a medical emergency that, in certain groups of patients, is potentially reversible if treated early enough • The staff member discovering the patient in cardiac arrest should call for help without leaving the patient. The staff person responding should page “all staff to the patient care area stat” over the intercom. • The patient’s blood should be returned immediately. As soon as 3 staff persons are at the chair-side, the patient should be placed in the floor, and CPR Started.
  • 7. • The charge nurse will make assignments to the code team. • Code Leader (Charge Nurse): Conveys a sense of order in an emergency environment. Responsible for all decisions in the absence of a physician or advanced practitioner. Assigns other responsibilities. Performs all aspects of electrical therapy. Identifies cardiac arrhythmias and chooses appropriate algorithm and medications based on facility policy. Communicates activities to the person performing documentation. • Medication Nurse (RN or LPN): Responsible for accurate preparation and administration of all medications. Communicates medications given to the person performing documentation. Responsible for achieving and maintaining IV access. • Documentation (LPN or PCT): Responsible for accurate documentation of al events and interventions during the code. • Compressions (CPR certified person): Responsible for pulse checks and delivery of compressions during cardiac arrest.
  • 8. • Airway Management (CPR certified person): Responsible for achieving and maintaining the airway. Responsible for monitoring the delivery of O2 and the fill level of the O2 tank. • Communications (Unit Clerk or Ancillary Staff): Responsible for paging physicians, calling 911, calling the ER triage nurse and copying medical records in anticipation of transport. • Only those staff directly involved in the resuscitative efforts should be in the immediate vicinity, all other staff should monitor and reassure the other patients. • EMS should be notified by dialing 911. Report to the EMS dispatcher that CPR is in progress. Page the patient’s physician, or physician on call.
  • 9. • The patient should be placed on the cardiac defibrillator monitor and any lethal arrhythmias identified. • If defibrillation is appropriate, this should be performed immediately. • O2 delivery should be via ambu bag at 100 % at rate of 10 breaths per minute. • IV access should be maintained via the patient’s vascular access, and appropriate medications given per ACLS Guidelines. • Follow guidelines for emergency patient transport.
  • 10. Ethical Issues • Cardiopulmonary resuscitation and advanced cardiac life support are not always in a person's best interest. This is particularly true in the case of terminal illnesses when resuscitation will not alter the outcome of the disease. Properly performed CPR often fractures the rib cage, especially in older patients or those suffering from osteoporosis. Defibrillation, especially repeated several times as called for by ACLS protocols, may also cause electrical burns. • Some people with a terminal illness choose to avoid such measures and die peacefully. People with views on the treatment they wish to receive in the event of a cardiac arrest should discuss these views with both their doctor and with their family. A patient may ask their doctor to place a do not resuscitate (DNR) order in the medical record. Alternatively, in many jurisdictions, a person may formally state their wishes in an advance directive or advance health directive (see POST form at KCC).
  • 11. Air Embolism • An air embolism, or more generally gas embolism, is a medical condition caused by gas bubbles in the bloodstream (embolism in a medical context refers to any large moving mass or defect in the blood stream). Small amounts of air often get into the blood circulation accidentally during surgery and other medical procedures (for example a bubble entering an intravenous fluid line), but most of these air emboli enter the veins and are stopped at the lungs, and thus a venous air embolism that shows any symptoms, is very rare.
  • 12. Air Embolism • The first step in treating Air Embolus is prevention. • Assure alarms test are performed pre-dialysis. • Always change out the NS bag if < 300cc of NS remains. • Never leave the patient when administering NS or returning the blood. • When administering medications or NS by gravity, monitor the infusion closely. • Always assure central catheter ports are clamped when removing caps, syringes or lines.
  • 13. • Identify signs and symptoms of air embolus which may include: air or foam observed in the venous line below the air detector, chest pain, SOB, cough, seizure, visual disturbances, hemiparesis, confusion and changes in mental status, or the patient may describe a sense of impending doom. • Immediately clamp the venous line and turn off the blood pump. • Place the patient in Trendelenburg position on their left side. • Note: This position will aid in trapping the air in the right atrium, which may prevent it from traveling to the lungs. • Call for help and request the Charge Nurse.
  • 14. • Assess patient. If marked changes in the patient’s cardiopulmonary and/or mental status are noted, call for the crash cart. Place patient on cardiac monitor and assess O2 sat. • Initiate emergency procedures as indicated by patient’s condition. • Recirculate the extracorporeal circuit. Flush the fistula needles or catheter ports with NS. • Notify the patient’s physician or physician on call. • Return the patient’s blood if indicated/ordered. • Once the patient is stabilized or transported, investigate and identify the source of air. If no source is identified, or if the dialysis machine may be implicated, pull the equipment, place a service report on the machine and label it “Not for Use”. Notify the Chief Tech.
  • 15. Anaphylactic Reaction • Anaphylaxis is a serious allergic reaction that is rapid in onset and may cause death. • What are the common causes of anaphylaxis? • Common causes of anaphylaxis include: • Food • Medication • Insect stings • Latex
  • 16. • Identify the SIGNS AND SYMPTOMS’s of anaphylactic reaction that may include: SOB, acute bronchospasms or bronchoconstriction, chest pain, back pain, hypotension, hypertension, anxiety, thready-rapid pulse, diaphoresis, nausea, profound shock, and/or cardiopulmonary arrest. • Stop the infusion of medication or blood immediately. If the product is being infused via the extracorporeal circuit, stop the blood pump and clamp the venous bloodline. • Place the patient in Trendelenburg position if SIGNS AND SYMPTOMS of shock are present. • Call for help and request the Charge Nurse • Assess the patient. If marked changes in the patient’s cardiopulmonary status are noted, call for the crash cart. Place the patient on the cardiac monitor and assess O2 status.
  • 17. • Attach the NS line directly to the patient’s vascular access. Be prepared to provide NS for volume support if B/P indicates. • Initiate emergency procedures as indicated by patient’s condition. • Administer medications according to Physicians Standing Emergency Orders. • Note: Patients taking beta-blockers routinely may not respond adequately to epinephrine. • Recirculate the extracorporeal circuit and flush the unused catheter ports or fistula needles. • Notify the patient’s physician or physician on call. • Once the patient is stabilized or transferred, identify the causative agent and label the patient’s medical record accordingly. Consider: medications, blood products, dialyzer membranes, and/or dialyzer germicides.
  • 18. Seizure • A seizure is a sudden change in behavior due to abnormal electrical activity in the brain • Note: Seizure activity during dialysis is usually the result of hypotension or a pre-existing seizure disorder. Other possible causes are drug toxicity, disequilibrium syndrome, air embolism or hemolysis. Exact treatment will depend on the cause
  • 19. • Identify seizure activity. • Quickly assess the venous bloodline for the presence of air or hemolized blood. If present, stop the blood pump, clamp the bloodlines and refer to the appropriate procedure. • Call for help and request the Charge Nurse. • Place the patient in Trendelenburg position with the head supported to one side. • Begin an infusion of NS into the extracorporeal circuit at a rate of about 200 ml/min. • Attempt to assess the patient’s blood pressure as soon as seizure activity will allow. If patient is hypotensive, refer to the appropriate procedure. • If possible, insert an oral airway between the patient’s teeth. Do not attempt to force the airway between clinched teeth.
  • 20. • Prevent dislodgement of fistula needles or vascular access catheters with hands on support if necessary. • Notify the patient’s physician or the physician on call of the event. • Follow any medication or laboratory orders given by the physician. • As seizure activity subsides, maintain on open airway, and continue to support the head to one side. Be prepared to suction the patient if needed. Be prepared to provide respiratory assistance if needed. • Note: Hypotensive seizure activity is often followed by an episode of nausea and vomiting. • If the patient’s condition returns to baseline, reinitiate dialysis as ordered. • Note: Patient’s with a seizure disorder may appear profoundly lethargic after a seizure. • If the patient’s fails to return to baseline, follow physician orders. See Guidelines for emergency transport if indicated.
  • 21. Shortness of Breath • Difficulty Breathing • Note: SOB in dialysis patients is usually the result of fluid overload, anxiety and/or hypotension. Less often it may be related to angina, MI, blood, medication or dialyzer reactions. Rarely is it the result of air embolus, hemolysis or crenation.
  • 22. • Notify the Charge Nurse. • Rule out the possibility of a dialyzer, medication, or blood reaction. If SIGNS AND SYMPTOMS’s begin immediately after beginning the administration of a medication or blood, or starting the dialysis procedure, stop the blood pump, and treat the patient according to the appropriate anaphylactic or dialyzer reaction procedure. • Rule out the possibility of air embolus crenation or hemolysis. Evaluate the venous bloodline for the presence of bright cherry-colored, blood, dark blood or air below the air detect, stop the blood pump and refer to the appropriate procedure. • Assess the patient’s blood pressure, and treat hypotension if indicated. Reassess the patient after NS administration. • Measure O2 saturation. If O2 saturation is less than 90%, notify the patient’s physician or the physician on call.
  • 23. • Start O2 at: • 2 liters/min per nasal cannula for patients with O2 saturation 95-100% on room air. • 4 liters/min per nasal cannula for patients with O2 saturation 90-95% • 10 liters/min per partial non-rebreather mask for patients with O2 saturation < 90%. • Assess the patient’s heart rate and rhythm. Place patient on cardiac monitor if indicated. If the symptoms appear cardiac in origin, return the patient’s blood and notify the physician. • Evaluate the patient’s fluid volume status. Check for pitting edema in the extremities, NVD, auscultatate the patient’s lungs. • If FVO is suspected, review the treatment plan for appropriate fluid removal. • If unable to resolve the patient’s SIGNS AND SYMPTOMS, notify the physician.
  • 24. Cardiac Arrhythmias • Cardiac arrhythmia is a term that denotes a disturbance of the heart rhythm. Cardiac arrhythmias can range in severity from entirely benign to immediately life-threatening • Note: Cardiac arrhythmias in dialysis patients are usually caused by electrolyte disturbances, altered medication levels, hypovolemia, anemia, hypotension or underlying heart disease; rarely arrhythmias may be related to irritation of the heart’s conduction system by vascular access catheters.
  • 25. • Immediately notify the Charge Nurse of irregularities noted in the patient’s heart rhythm. • Place the patient on the cardiac monitor and assess the patient for the presence of lethal arrhythmias and/or chest pain. • Note: Do not initiate the dialysis treatment if the patient is unstable when he presents to the dialysis unit. Notify the patient’s physician or the physician on call. In the presence of lethal arrhythmias, or if the patient becomes hemodynamically unstable while on dialysis, discontinue the dialysis treatment and notify the patient’s physician or the physician on call. • Measure the patient’s O2 saturation, and start O2 as indicated. Initiate emergency procedures when indicated. • Assess the patient’s blood pressure, and treat hypotension if present.
  • 26. • Evaluate the appropriateness of the patient’s dry weight and ultrafiltration plan. • Evaluate the patient’s past history of cardiac disease. • Assess the patient for the SIGNS AND SYMPTOMS of potassium imbalance. • Evaluate the patient’s recent serum potassium levels. • Note the potassium content of their current dialysate prescription. • Assess the patient’s food intake over the last 48 hours for high potassium foods. • Evaluate the patient’s cardiac monitor strip for peaked T waves and/or a widened QRS complex. • Evaluate the patient for other SIGNS AND SYMPTOMS of hyperkalemia such as generalized muscle pain and weakness. • Evaluate the patient’s compliance with prescribed cardiac medications. • Administer medications and/or draw labs as ordered by the physician.
  • 27. Transfusion Reaction • Note: Transfusion reactions may occur immediately after the start of the transfusion, any time during the transfusion, or for up to 48 hours after the transfusion. Types of transfusion reactions include: • Pyrogenic: Usually results from bacterial contamination of the blood. SIGNS AND SYMPTOMS’s include chills, very high fever, hypotension and eventually shock. Less severe febrile reactions caused by leukocyte antibodies or other causes may be identified by chills and fever, muscle aches, nausea and vomiting, headaches and flushing. Pyrogenic reactions are usually gradual and may not be seen until well into the transfusion.
  • 28. • Hemolytic: Results from incompatibility of the donor’s blood to the patient’s blood. The onset is sudden and includes SOB, low back pain, chest pain, nausea and vomiting, headache and or fever with chills. • Allergic: Probably due to the patient’s response to allergens in the donor’s blood. They are characterized by itching that may be accompanied by a rash or hives. Generally medicating the patient with antihistamines relieves the symptoms. • Fluid Overload: May result when the blood is administered too quickly, or when the patient is significantly above their dry weight already. SIGNS AND SYMPTOMS’s include SOB, rapid HR and/or drop in blood pressure. SIGNS AND SYMPTOMS’s usually improve with a decrease in the rate of infusion, or by withholding the transfusion until a significant amount of ultrafiltration is achieved.
  • 29. • Identify the SIGNS AND SYMPTOMS’s of a possible transfusion reaction. Any unusual symptom experienced by the patient should be considered a possible reaction. • Stop the blood transfusion. If SIGNS AND SYMPTOMS’s are severe, stop the blood pump and recirculate the extracorporeal circuit. DO NOT RETURN THE BLOOD. Flush the patient’s fistula needles or catheter ports with NS. • Call for assistance, if needed, and alert the Charge Nurse. • Assess the patient. If marked changes in the cardiopulmonary status are noted, call for the crash cart. Place the patient on the cardiac monitor and assess the 02 status. • Initiate emergency procedures as indicated • Notify the patient’s physician or the physician on call. • Administer medications per physician order. • Notify Blood Assurance. Request a copy of the transfusion reaction form via fax. • Draw any labs ordered by the physician and/or Blood Assurance. • Complete the reaction section of the blood tag, and complete the transfusion reaction form.
  • 30. Crenation • Identify the SIGNS AND SYMPTOMS of crenation. These include flushed face, SOB, sudden rise in blood pressure, chest pain, abdominal cramps, restlessness, agitation, convulsions in the presence of dark colored blood post dialyzer. • Immediately clamp the venous line and turn off the blood pump. • Notify the Charge Nurse. • Assess the patient. Place on cardiac monitor. Be alert for SIGNS AND SYMPTOMS of hyperkalemia. • Start O2 at 2 l/min per nasal cannula. Treat other symptoms and implement emergency procedures as indicated. • Check the conductivity of the machine. If crenation has occurred as a result of the dialysate, the conductivity will be low.
  • 31. • Notify the patient’s physician, or the physician on call. • Check a stat potassium level on the patient. Preserve a sample of dialysate for laboratory analysis. • The extracorporeal circuit should be tossed. • The machine should be pulled and labeled not for use. • Notify the Chief Technician, and complete a service report on the machine. • Restart dialysis on a fresh machine and dialyzer as ordered by the physician. • Note: The patient’s potassium will probably be elevated. Dialysis should be restarted for a minimum of 2 hours.
  • 33. • Identify the SIGNS AND SYMPTOMS of hemolysis. These include patient complaints of a burning sensation in the access extremity, SOB, hypotension, hyperkalemia, chest and back pain, nausea and vomiting, convulsions and/or cardiac arrhythmias or arrest in the presence of cranberry-colored almost translucent blood post dialyzer. • Immediately clamp the venous line and turn off the blood pump. • Notify the Charge Nurse. • Assess the patient. Place on cardiac monitor. Be alert for SIGNS AND SYMPTOMS of hyperkalemia. • Start O2 at 2 l/min per nasal cannula. Treat other symptoms and implement emergency procedures as indicated. • Draw a sample of blood from the extracorporeal circuit and place in a SST tube. Spin for 5-15 minutes and check for the presence of pink serum indicating hemolysis.
  • 34. • Consider the following causes of hemolysis: • Inappropriate dialysate composition resulting in hypotonic dialysate. • Overheated dialysate, usually above 105º F or 40º C. • Notify the patient’s physician, or the physician on call. • Check a stat potassium level and H&H on the patient. Preserve a sample of dialysate for laboratory analysis. • The extracorporeal circuit should be tossed. • The machine should be pulled and labeled not for use. • Notify the Chief Technician, and complete a service report on the machine. • Restart dialysis on a fresh machine and dialyzer as ordered by the physician. • Note: The patient’s potassium will probably be elevated. Dialysis should be restarted for a minimum of 2 hours. Consider transport to acute facility.
  • 35. Disequilibrium Syndrome • Identify the SIGNS AND SYMPTOMS of disequilibrium syndrome. These include patient complaints of a headache, hypertension, increased pulse pressure, decreased level of consciousness, nausea and vomiting, convulsions and/or coma. Disequilibrium syndrome occurs most often when the patient is very uremic with BUN above 150 mg/dl. Generally signs and symptoms present early in the dialysis treatment. Signs and symptoms should be differentiated from first use syndrome. • Note: Disequilibrium syndrome occurs when the blood osmolarity falls faster than the osmolarity of the cerebrospinal fluid. (This results from rapidly lowering the BUN.) Fluid shifts from the vascular compartment to the cerebral spinal fluid compartment and cerebral edema occurs. Patients known or suspected of extremely elevated BUN levels should be dialyzed cautiously in the outpatient setting. Prophylactic Mannitol, sodium modeling, low initial blood flow rates and a low clearance dialyzer are key.
  • 36. • Immediately reduce the blood pump speed to 100 ml/min. • Notify the Charge Nurse. • Begin administration of Mannitol 25% 50ml IVP, slowly via the venous drip chamber. • Implement emergency procedures as indicated, and be alert for signs of seizure activity. • Notify physician if SIGNS AND SYMPTOMS are severe or do not resolve with treatment. • Note: Consider transport to an acute facility if SIGNS AND SYMPTOMS’s are severe or if there is a change in the patient’s mental status. • Resume dialysis cautiously once symptoms subside. Blood flow rates should not exceed 150-200 ml/min initially
  • 37. First Use Syndrome • Recognize the symptoms of first-use syndrome and differentiated those symptoms from the symptoms of hemolysis, crenation, disequilibrium syndrome and dialyzer reaction. The SIGNS AND SYMPTOMS of first-use syndrome include itching, back pain and moderate hypotension. • Note: With hemolysis and crenation you will see changes in the appearance of the blood in the venous bloodline. With disequilibrium Syndrome the patient should have some history to indicate the presence of an elevated BUN, and the symptoms tend to be more severe. With a dialyzer or sterilent reaction, the symptoms tend to be more severe and SOB is a common feature. First- use syndrome only occurs with a new, unprocessed dialyzer. First-use syndrome results from complement activation by the new dialyzer membrane, and it occurs more often with cellulosic membranes.
  • 38. • Immediately reduce the blood pump speed to 100 ml/min. • Notify the Charge Nurse. • Evaluate the patient’s blood pressure and treat hypotension with NS. • If SIGNS AND SYMPTOMS do not resolve, return the patient’s blood and purge the dialyzer and extracorporeal circuit with 1000cc of NS. • Restart dialysis cautiously with low blood pump speeds of 150-200 ml/min. • Consider change in the patient’s dialyzer type or individual pre-dialysis preparation procedures as ordered by physician.
  • 39. Blood Loss / Exsanguination • Note: Blood loss during dialysis can occur on post blood pump along the extracorporeal circuit. Manufacture’s defects have occurred in the actual tubing and blood pump segments. Cuts have been made in the tubing sets when opening packing boxes. Blood loss can occur at the connection between the dialyzer and the bloodline due to product defect or improper connection. Blood loss can also occur from needle dislodgement or dialysis catheter dislodgement. Every effort should be made by the dialysis staff to secure against needle or catheter dislodgement. • The staff member discovering the patient should immediately clamp the venous bloodline and turn off the blood pump. • Call for assistance and notify the Charge Nurse. • Assess the patient for SIGNS AND SYMPTOMS of blood loss. Administer NS, Albumin and oxygen in case of shock. Implement emergency procedures if indicated. • Establish the location of the break in the extracorporeal circuit.
  • 40. • If exsanguination is the result of fistula needle dislodgement: • Apply sterile gauze and clamp to the needle site. • Clamp fistula needles and bloodlines. • Remove the fistula needle from the bloodline and dispose of it in a biohazard sharps container. • Recirculate the extracorporeal circuit assessing for the presence of air. • Recannulate the vascular access. • Restart dialysis. • Assess probable cause of needle dislodgement and take steps to avoid a recurrence.
  • 41. • If exsanguination is the result of dialysis catheter dislodgement: • Apply pressure to catheter site with sterile gauze for at least 20 minutes. • Observe the patient for possible SIGNS AND SYMPTOMS of air embolus. • Clamp catheter ports and bloodlines. • Remove the dialysis catheter from the bloodlines and dispose of it in a biohazard sharps container. • Recirculate the extracorporeal circuit. • Assess the patient for possible IV site for blood return and return blood if possible. • Notify physician of occurrence and follow arrange for access replacement as ordered. • Assess possible causes of catheter dislodgement and take steps to prevent recurrence.
  • 42. • If exsanguination is the result of a defect in the bloodlines or dialyzer ports: • Return patient’s blood if air in the circuit is not identified. • Change bloodlines out, or change dialyzer out depending on the nature of the break. • Perform set-up per procedures. • Restart dialysis. Note product name and lot # in the medical record. • Make all patient care staff aware of occurrence, and trend any additional occurrences. • Assess possible causes and take steps to prevent recurrence. • If Clinical Manager is not present, and the cause of the exsanguinations is unclear, preserve extracorporeal circuit for evaluation. • If a product failure is identified, notify Clinical and Technical Manager.
  • 43. Dialyzer Blood Leak • If you have a blood leak warning, check a dialysate sample from the drain line with a Hemastix test strip, by placing the strip in the stream. • Compare the strip to the results-key on the side of the bottle. • For Hemastix results that are Negative: • You may continue the dialysis treatment if the Phoenix Machine alarm continues Change settings on blood leak detector to minimal • If you continue to have a blood leak warning the machine will need to be pulled and Complete a service report on the machine and label it not for use. • The machine should be cleaned and rinsed prior to use, for either situation described above.
  • 44. •For Hemastix results that are moderately positive, or hemolyzed, do not attempt to return the blood. •Turn off the blood pump. •Clamp fistula needles or catheter ports and bloodlines. •Disconnect the extracorporeal circuit, and place the bloodline connector between the arterial and venous bloodlines. •Flush the fistula needles or catheter ports with NS. •Remove the extracorporeal circuit and dialyzer from the machine. •Complete a service report on the machine and label it not for use. •The machine should be cleaned and rinsed prior to its next use. •Set patient up on a different machine, dialyzer and bloodline set per procedure.Restart dialysis per procedure. •For any actual dialyzer blood leak resulting in a positive Hemastix on a re or pre-processed dialyzer, a Reprocessing Complaint must be initiated.
  • 45. Clotted Dializer • Note: Clotting in the extracorporeal circuit is more likely when very low blood flows are used, there are problems with adequate flow to or from the vascular access, very high ultrafiltration rates are used, the patient’s hemoglobin is high, or very low doses of heparin are used. • Recognize the signs of clotting within the extracorporeal circuit, which include: a darkening of the blood, clot formation within the drip chambers, elevated venous pressure, and/or a rise in TMP. • As soon as clotting is suspected, attempt to return the patients blood using the NS line method. • If the venous pressure continues to clime and returning the blood is not possible, turn off the blood pump, clamp the bloodlines and catheter ports or fistula needles. • Disconnect the patient from the extracorporeal circuit. • Flush the fistula needles or catheter ports with NS flushes. • Set up a new dialyzer and bloodline set per procedure. • Restart dialysis. • Assess possible causes of the clotted circuit and take steps to prevent recurrence.
  • 46. Pyrogenic Reaction • All patients will have their pre and post dialysis temperature measured. In addition, any patient complaining of chills or exhibiting signs of chills will immediately have their temperature measured. • Report any patient reporting chills, exhibiting signs of chills or having a temperature of 100º F or greater to the Charge Nurse immediately. • Assess the patient for SIGNS AND SYMPTOMS of possible febrile illness, including access infection, pulmonary infections, urinary infections, flu SIGNS AND SYMPTOMS’s or other indications of infection. Interview the patient for a recent history of fever at home. • Notify the patient’s physician or the physician on call.
  • 47. • Collect 2 sets of blood cultures from the patient. • Collect cultures of sputum, urine or the vascular access site if SIGNS AND SYMPTOMS are present. Administer medications or draw other lab tests as ordered by the physician. • Consider transfer to acute care facility for patients with high fevers or if the patient is unstable. • Trend multiple episodes by patient and/or by date. Notify the Medical Director immediately if multiple episodes or trends develop. • For any patient developing a fever during or post dialysis that was asymptomatic pre-dialysis Collect a specimen of the dialysate from the effluent end of the dialyzer in a urine cup. Prepare the dialysate for culture and/or endotoxin evaluation per procedure.
  • 48. Hypertension • Note: Hypertension in dialysis patients is most often associated with fluid volume overload and medication non-compliance. It may also be aggravated by underlying cardiac and/or renal disease, anxiety, substance abuse, and occasionally volume contracture due to dehydration. • Notify the Charge Nurse when a blood pressure exceeds 180/90 or anytime the blood pressure is significantly different for a particular patient. • Evaluate the patient’s usual trend in blood pressures. • Evaluate the patient’s compliance with prescribed antihypertensive medications. Reinforce compliance with prescribed medications if indicated. • Evaluate the appropriateness of the patient’s dry weight, fluid volume status and ultrafiltration plan. Reinforce fluid restriction if indicated. • Notify the physician when the pre or intradialytic dialysis blood pressure exceeds 210/110 and is unusual for that patient. • Notify the physician when the post-dialysis blood pressure exceeds 180/100 and is unusual for that patient. • Note: Patients whom are chronically hypertensive should have routine orders established for medication administration and discharge criteria. • Administer medications and instruct the patient on medication changes as ordered by the physician.
  • 49. Hypotension • Note: Hypotension in dialysis patients is most often associated with fluid removal from the patient’s vascular system at a rate, which exceeds the vascular refill rate. It may also be aggravated by, underlying cardiac disease, inaccurate dry weight assessment and occasionally dehydration. • Notify the Charge Nurse when a blood pressure is less than 100/50, anytime the blood pressure is significantly different for a particular patient, or when the patient is symptomatic. • Evaluate the patient’s usual trend in blood pressures and usual tolerance to ultrafiltration. • Evaluate the patient’s prescribed antihypertensive medications. • Evaluate the accuracy of the patient’s pre-dialysis weight. • Evaluate the appropriateness of the patient’s dry weight, fluid volume status and ultrafiltration plan. Reinforce fluid restriction if indicated. • Utilize sodium modeling and other hyperosmolar agents to increase the vascular refill rate. Such agents should be used prophylacticly in patients chronically hypotensive during ultrafiltration.
  • 50. • Notify the physician when profound hypotension does not respond to appropriate therapy, or when changes in the treatment plan are indicated. • When the patient exhibits SIGNS AND SYMPTOMS of severe hypotension (diaphoresis, nausea and vomiting, or seizure: • Open the NS line and NS port and administer 150-250cc of NS. • Lower the patient’s UFR to 0.3 l/min • Reassess the blood pressure every 2-3 minutes until the patient is stabilized. • Be alert for respiratory and/or cardiac arrest and implement emergency procedures as indicated. • Notify the physician when the post-dialysis blood pressure is less than 100/50 unless the patient has a specific order to be discharged with a lower blood pressure.
  • 51. Hypoglycemia • Recognize the SIGNS AND SYMPTOMS of hypoglycemia in diabetic patients. These include diaphoresis, decreased mental status, feeling faint, irritability and or tremors. • Evaluate the patient’s blood pressure to rule out hypotension. • Check the patient’s blood glucose level using the glucometer. • Notify the Charge Nurse when a blood sugar is less than 80, and/or the patient is symptomatic. • 50% dextrose may be administered at the discretion of the Charge Nurse after evaluating the patient’s food intake and insulin usage. • Patients who do not take insulin or oral hypoglycemic agents should be encouraged to eat a small snack rather than receive 50% dextrose. • Patients who have not eaten and taken their insulin should try to eat a small snack in addition to receiving 50% dextrose. • Patients who have eaten an appropriate amount of food and taken insulin as prescribed should be evaluated individually when considering 50% dextrose administration. • Evaluate the patient’s prescribed hypoglycemic medications and recent blood glucose levels. • Notify the physician when profound hypoglycemia does not respond to appropriate therapy, or when changes in the treatment plan are indicated.
  • 52. Muscle Cramps • Note: Muscle Cramps in dialysis patients is most often associated with fluid removal from the patient’s vascular system at a rate, which exceeds the vascular refill rate. It may also be aggravated by, underlying vascular disease, inaccurate dry weight assessment, electrolyte imbalances and occasionally dehydration. • Administer 150cc of NS to the extracorporeal circuit via the NS line. • Temporarily decrease the ultrafiltration rate to 0.3 l/hr. • Notify the Charge Nurse when muscle cramps are unrelieved by steps #1 and #2. • Evaluate the patient’s usual trend in fluid volume weight gains and their usual tolerance to ultrafiltration. • Evaluate the accuracy of the patient’s pre-dialysis weight. • Evaluate the appropriateness of the patient’s dry weight, fluid volume status and ultrafiltration plan. Reinforce fluid restriction if indicated.
  • 53. • Note: Patients gaining more than 3 Kg’s between dialysis treatments are more prone to experience side effects associated with ultrafiltration. If the patient does not usually cramp and no unusual circumstances are identified, consider recirculating the extracorporeal circuit and weighing the patient in the dialysis chair. • Note: The weight of all dialysis chairs is recorded on a sticker located on the back of each chair. While rare, failure of the machines ultrafiltration system is possible resulting in excessive ultrafiltration and dehydration of the patient. Weighing the patient during the dialysis treatment should provide an indication of the accuracy of the ultrafiltration. • Utilize sodium modeling and other hyperosmolar agents to increase the vascular refill rate. Such agents should be used prophylacticly in patients who chronically have muscle cramps during ultrafiltration. • Note: Mannitol or dialysate sodium adjustments may not be used during the last hour of dialysis. • Dextrose 50% 10-15cc IVP via the venous drip chamber may be used to relieve cramps in non-diabetic patients during the last hour or post dialysis. • Notify the physician when profound muscle cramps do not respond to appropriate therapy, or when changes in the treatment plan are indicated.
  • 54. Using Patient Restraints • Note: Physical restraints may be used only when less restrictive measures prove inadequate to prevent the agitated or disoriented patient from injuring himself or others and to prevent the patient from deleteriously interfering with medical treatment. The least restrictive device appropriate for the patient should be used. • Identify alternative means to avoid the need for restraints. Consistently reinforce to the patient the importance of his medical care. Enlist the assistance of ancillary personnel to sit with the patient. Provide the patient with distractions such as coloring books or magazines. Tape bloodlines out of the patient’s direct line of vision. Place patients in the dialysis unit to await transportation when additional supervision is needed. • If the above measures fail, identify the least restrictive restraint device appropriate for the patient and the situation. • Contact the physician and obtain an order for the restraint.
  • 55. • Complete the restraint order form. • Contact the patient’s emergency contact and request permission to use the restraint device. (The patient must consent if competent.) Document their permission to use the device on the Restraint Form. • Apply the device and assure the patient’s safety and comfort. • Perform routine checks of the patient at least every 30 minutes to include the condition of the restrained limb. • Remove the restraint device as soon as the condition justifying its use no longer exists. • Document the condition of the extremity at the time the restraint device is removed.
  • 56. Questions & Answers Thank You!