The Procedure For Catheter Patients.

                In the last post I explained the procedure of haemodialysis. But when it comes to the starting and closing of the catheter patients, it’s a bit different. It needs more care and patience as there is a higher risk of infection for catheter patients.  The procedure remains the same till priming. After that, remove the protective covering of the catheter with the gloves we primed the dialysis set. Then remove it and don a pair of new sterile gloves. Ask the assistant to open the outer flap of the autoclaved tray. Then open the tray and ask your assistant to open and transfer all the packaged articles to it. Wet a sterile cotton ball with spirit and povidone iodine and wipe the catheter and the portion of the skin to which the catheters come in contact with.  Uncap the catheter and wipe the catheter from the opening towards the other end. Place a sterilized towel under the catheter and withdraw 2-3 ml of blood from each tube using a 5ml syringe. This is to minimize the risk of infection and thromboembolism and to avoid the mixing of old flushed heparin with the blood.  The tubes of the catheter will be of two colours- red, arterial and the blue, venous.  Ensure the free flow of blood in the catheter by repeated aspirations followed by reinfusions.  In some patients, due to careless handling and bending, the catheters may get dislodged or kinked. In such cases, we have to carefully adjust the catheter position manually or try massaging the vicinal part of the catheter insertion.  After a free flow of blood is established, connect the blood lines accordingly and run the pump at a slow rate.

                                                                          After the blood is returned at the end of the dialysis, flush the catheter thoroughly until the transparent tubes become completely clear. Then we have to do hep-locking(1ml of 25000IU heparin diluted with 5ml saline. Some entertain choosing sodium bicarbonate injection instead of normal saline. According to me, it is more preferable. This is to prevent the formation of clots until next dialysis. For some people who frequently get infections, we close the catheter with antibiotics like gentamycin or amikacin. After the flushing is complete, clean the catheter tip with betadine and spirit. No blood or clot should be allowed to remain. Close it tightly with a cap, then repeat  wiping over the entire catheter 2 or 3 times with new swabs. Cover the catheter with a sterile gauze and then by a clean adhesive plaster. Remove the plaster over the catheter insertion site for cleaning. Remove the old gloves and don the new ones. Clean the insertion site thoroughly and most importantly carefully using gauze dipped in betadine and spirit. Repeat twice and move towards periphery. Remember, once you move towards periphery; don’t come back to the insertion site. After drying the site, cover it with sterile gauze then secure with a clean plaster. That’s all….

Dialysis- The Procedure....

Though the basic procedure of the haemodialysis  is same all over the world, the way people perform it may vary according to the conventional system of different countries, fund available and moreover, convenience of the staff performing it. It's up to the staff. But one thing we have to keep in mind is that, there is a standardized procedure that we can modify according to our comfort but never neglect the fundamental things.

Articles needed: A medium sized autoclaved steal tray or a disposable sterile tray containing cotton swabs, a small bowl for the saline, an artery forceps(not necessary if you are confident that you can maintain asepsis) and a sterile towel. Other articles needed included the a dialyzer, blood tubings, fistula needles, transducer protector, adhesive plasters, a 5-10ml syringe, a 10 ml syringe for heparinization, heparin injection and Hydro-cortisone injection(optional).

Transducer Protector

Dialysis Machine

Fistula Needle

Dialyzer connected with blood tubings and dialysate couplings.

Check the weight and vital signs of the patient and set the machine parameters according to it. Hygiene of the patient skin as well as the staff is of a primary concern. Because by sticking the needle, there will be a great risk for the entry of various organisms. Remember, these patients are already weak either by their illness or recurrent hydrocortisone therapies. The nurse should wash hands before and after the procedure to prevent cross infections. Put on clean(no need to put on sterile gloves) gloves. Prime the tubings and dialyzer with at least 2litres of Normal saline. We should ensure that even a small quantity of air is not remaining in the dialyzer to prevent embolism. After priming connect the dialysate couplings to the dialyzer.  Have someone to assist you. Ask your assistant to open the outer flap of the autoclaved tray. Remove your old gloves and put on sterile gloves. Open the tray and fill your bowl with normal saline.Ask your assistant to open all the packets and transfer the equipments to the sterile tray. Wipe the pricking area with a cotton swab applied with spirit and povidone iodine. Then pat dry with another cotton ball. Place the sterile towel under the area. Using a 5ml syringe, prime the fistula needle and stick. Secure the needles with plasters. Always remember to prick at least one inch away from the fistula or graft. Connect the lines and run the pump at a slow rate. Take 1ml of 25000IU heparin in a 10ml syringe and dilute it with rest amount of saline. Set the heparin pump and connect the venous pressure line to a transducer protector. Then change the preparation mode to dialysis mode after all other procedures. It is important because it is the safe mode that detects any air or clot in the bloodstream. Check vital signs every thirty minutes and watch for any complication.

Usually the duration of a maintenance dialysis in clinical setting is 3-5hours. It is determined according to the patient's weight and blood reports. After completing the required time period, its time for ending the procedure. Stop the pump and clamp all the main lines and fistula needles. Connect the arterial line to normal saline and run the pump after releasing the clamps. About 100ml saline is infused to return all the blood to the patient's vein. After returning the blood completely and carefully, remove the needles one by one applying a finger pressure with a rolled gauze piece. Observe for any bleeding. Now the next task is to cleanse the dialysis kit for next use. I'll explain it in the next post....