What Should the Nephrology Nurse Do If The Hemodialysis System Clots Off!

[angieskidney]

This is something that an American Dialysis Nurse typed up on Dialysis & Transplant City that I thought I would share here with his permission:

From: Dialysis Joe  (Original Message) Sent: 04/10/2006 12:09 AM
I have been disturbed to discover that many dialysis staff are attempting to return blood to patients when the hemodialysis blood circuit is clotted.  Their rational for this action is motivated by the concern that a patient will be losing blood cells if they fail to return the blood.
The most important issue to consider when a patient's hemodialysis blood circuit clots is the possibility that, if the blood is returned, the patient may receive a embolism, which can cause a pulmonary emboli, a heart attack, or a stoke.  When you weigh the risk of losing 200ml to 250ml of whole blood, compared to the risks of giving your patient an emboli, losing the blood is the lesser of the two evils.  In fact, they don't even compare.
Anytime that a nurse or technician discovers a significant blood clot in the venous chamber, particularly if it has the ability to interfere with the flow of the patient's blood in the hemodialysis blood circuit, then it's time to worry about the possibilty of causing an embolism.  In this case, it's better to simply throw the blood away and start over.
Another major concern is why the blood clotted to begin with.  Was the heparin loading dose and hourly heparin administered, as prescribed?  Is the physician prescribing enough heparin to anticoagulate the patient significantly enough to get through the treatment?  Has the patient's clotting times changed and why?  All these questions need to be asked and answered.  Otherwise, the situation may only be repeated, putting the patient at risk, again.
Clearly, we don't want to give patients too much heparin.  On the other hand, for better or worse, until a better drug comes along, heparin is the "oil" that makes hemodialysis possible.
In the meantime, I believe that all facilities need to review their policies, making sure that their staff is aware of the dangers of returning clotted blood.  Even micro-emboli can cause tremendous short and long term damage to patients.  We must always keep in mind that the blood returning to the patient is quickly heading directly to their hearts.  Once that blood hits the right ventricle, it then moves directly to the pulmonary tree.  Any blood clots, micro or otherwise, that hit this area can cause a pulmonary emboli, which, if significant in size and number, can cause immediate death.  Please consider that the next time a patients dialysis system clots up and you are making the decision whether, or not, to return the patient's blood.
 
Joe Atkins, Managing Editor
Dialysis & Transplant City

[Epoman]

In the past when my machine has clotted when I was in center, they did not return the blood, nor would I ever let them if they tried. The amount of blood loss is very minimal and is nothing to worry about. It is not worth the risk of getting an pulmonary emboli to save some blood cells. Good post Angie. 

[angieskidney]

In the past when my machine has clotted when I was in center, they did not return the blood, nor would I ever let them if they tried. The amount of blood loss is very minimal and is nothing to worry about. It is not worth the risk of getting an pulmonary emboli to save some blood cells. Good post Angie. 

Thank you

What I want to know ... how do you know if you are clotting? I am still very new so I don't know *blush*

[Black]

... What I want to know ... how do you know if you are clotting? I am still very new so I don't know *blush*

I'm with you, Angie.  How would you know there are clots or micro-emboli?

[Epoman]

... What I want to know ... how do you know if you are clotting? I am still very new so I don't know *blush*

I'm with you, Angie.  How would you know there are clots or micro-emboli?

The dialyzer (filter) will clot and start causing alarms.

[kitkatz]

I never thought about it before.  Hmmm. Have to make some changes, I see at the center, for better treatment when my dialyzer clots.

[DeLana]

I'm an RN who worked in a chronic/outpatient clinic for 5 years.  Everything said so far is correct; all I can add is the following.

When a dialyzer clots, the venous pressure alarm (high) will sound; on the Cobe machines I'm familiar with, this would immediately stop blood flow and clamp the venous return line so that no air or clots in the line could reach the patient.  Another safeguard against clots: there is a filter in the venous chamber. 

It is of course correct NOT to return blood if the dialyzer is clotted; in fact, the machine should not allow the workers to do so if they even tried (due to these alarms which stop the machine and require manual override).  Only in emergencies* can an alternate procedure be used; a clotted dialzyer is NOT an emergency, I assure you (unless it happens several treatments in a row!)  And if anyone attempts to use an old, no longer allowed procedure for returning blood involving "squeezing the bag" (which bypasses the venous chamber/air detector/clot filter) do not let them! But nobody should.  My point is simply: it should not even be possible to return clotted blood, so you should not have to worry about it.

They should then continue dialysis with a dry pack or new dialyzer; the nephrologist may have to be called regarding length of treatment, heparin dose, labs, etc.

Hope this helps (and didn't scare anybody - not my intent!)

DeLana   

*The only time we were ever allowed to take the line out of the safety clamp (and in this case it was necessary and according to policy) was during a power failure for manual blood return; this happened once in 5 years.

[Rerun]

Thank you DeLana! 

[angieskidney]

And if anyone attempts to use an old, no longer allowed procedure for returning blood involving "squeezing the bag" (which bypasses the venous chamber/air detector/clot filter) do not let them! But nobody should.  My point is simply: it should not even be possible to return clotted blood, so you should not have to worry about it.

When I had narrowing in my fistula and wasn't running back (rinseback) very well they would squeeze my saline bag and I remember worrying that that was not very smart but thinking they are dialysis nurses so they should know better (nurses in my unit do everything). They didn't know my fistula had a narrowing...

[DeLana]

Oh, my!     That's one reason why using force by squeezing the bag should never be used; it can destroy a fistula.  Scarier, this outdated procedure (sometimes called "rinsing back the old way") puts the patient at risk for life-threatening embolism by air or clots because the machine's safeguards (air alarm, clot filter) are bypassed.

I'm sorry this happened to you.

DeLana 

[glitter]

I read the last couple of posts last night and I read them to my husband,We have a question-is it also bad to squeeze the saline bag,like when they take your fluid a little low,and your pressure drops and they squeeze some back?

[angieskidney]

I read the last couple of posts last night and I read them to my husband,We have a question-is it also bad to squeeze the saline bag,like when they take your fluid a little low,and your pressure drops and they squeeze some back?

I would think so .. even though they do that to me as well

[DeLana]

I have to tell you one should never say never... I recently started working in a hospital dialysis unit where returning by squeezing the bag is still policy & procedure  (This is NOT the case with the large dialysis companies such as DaVita).  However, we do have an all-nurse staff who monitor the patients very closely.

Still, I don't like it (I was trained by my former employer to NEVER do this), and will only do this if absolutely necessary.  I did get permission to rinse back "my way" (actually, the modern way if you will) and will try to convince my coworkers to do the same.  Change may come slowly, but someone has to start!

DeLana

P.S.  Don't worry if your hospital nurses still do this - but NEVER, EVER let them use a method involving air (yes, in the dinosaur days nurses would return blood with an air flush - I cringe just imagining the risks!  But I'm sure this is never done today as it is very unsafe and completely unnecessary.)

[jedimaster]

At the hospital some nurses still use the squeezing method  , but at home I never do. I rather loose some blood than risking my fistula. I will never force my machine to give me my blood back...I too much of a chicken....

[DeLana]

At the hospital some nurses still use the squeezing method  , but at home I never do. I rather loose some blood than risking my fistula. I will never force my machine to give me my blood back...I too much of a chicken....

Not chicken - just smart!

DeLana