Changing Access with HHD

[Hootie]

After 21 months of HHD  dialysis and 5 fistulagrams, our access is now completely shutdown with stenosis. CVS could not get ballon in to stretch and clean out on Thursday. He is going to map the veins in other side of same arm in the next week to see if he can create a new one.

In the mean time, we  now have a perma  catheter to do dialysis for a minimum of the next 60-90 days. We are familiar with the risks of infection and no showers etc. We get the training for the catheter and NxStage system beginning on Tuesday. We did hospital dialysis Thursday and in center for Friday and planning on Monday.

For the veterans on NXStage with a catheter, what are some critical things you have learned that contributes to you success that may not be obvious in training? I know personal hygiene is at top of list.

We counted up the treatments at home using the fistula and it was somewhere between 340-350 times as we regliously did 5 treatment a week Even with fistula grams over the 21 months the surgeon kept it going. We always ran machine slower than Davita  protocol...300 bps. we are thankful it lasted as long as it did. The good news she gets a break with the needles.

[Xplantdad]

Having a CVC has been just fine for my daughter for over a year with no infection issues at all. Just practice aseptic technique...We use the Chloraprep swab sticks to clean the area...you start at the area closest to the actual point where the tube enters the body and scrub out and away from the entry point. Then flip the swab stick over and repeat.

You can also you tegaderm sheets to cover the area when you need to get into the shower. You just apply one at the bottom of the area that you need to cover, then work your way UP from there...layering (kinda like roofing a house...so the outermost layer is at the top) there is less of a change for water to get in that way.

We run her NXstage at 350 with no issues. Flushing with the heparin and having the exact doses of heparin for the tubes after the run are vital to keeping the caths open. Only once (about a month ago) did we have to go the center and have them put in Activase to unclot the venous side of the cath.

[Hootie]

Thanks for your experiences. Today was our first day training on NXStage center. Previously we had one day in hospital and two days in center. One oddity today was the dark color of the blood from beginning. I understand it should be darker. Nurse kept bolusing small amounts of saline and added some additional heparin. At 2:22 mark we took her off machine with no rinse  back. Nurse was concerned about clotting but no machine alarms. She conferred with nephrologist  who got her to change yellow caps to a heparin lock blue caps to keep clotting down for future sessions We did not notice the dark blood on the big Fresenious machines.

Question, very dark blood is this close to normal for NXStage with CVC? Others with CVC experiences? Two more days and we are back home.

[Xplantdad]

Yes it's normal. When the machine first starts, the blood is like a cherry red but turns dark almost immediately.  One sign of hemolysis is if during the treatment the blood turns cherry red again....something to watch for...among the thousands of other things

Just pay attention to the venous/efffulent and arterial pressures...and the blood pressures...and those will be the indicators that something may be happening

[Hootie]

Thanks, Bruce. You described it to a tee. The HHD nurse was a little rattled as she must have not seen the darker blood. Most who do HHD with her are fistula people. I had not seen the darker blood either. The pressures were fine, maybe a little higher than when the fistula was working fine. V was around 200-215 and A was 145. BP did drop at 2 hour mark. We will watch it again tomorrow.

Appreciate feedback.

[iolaire]

So dark blood comes from the Catheter?  I've noticed some patients have very dark blood and wondered why.

[Xplantdad]

Thanks, Bruce. You described it to a tee. The HHD nurse was a little rattled as she must have not seen the darker blood. Most who do HHD with her are fistula people. I had not seen the darker blood either. The pressures were fine, maybe a little higher than when the fistula was working fine. V was around 200-215 and A was 145. BP did drop at 2 hour mark. We will watch it again tomorrow.

Appreciate feedback.

You are welcome! Holly's pressures run @ 168-175 venous-160-182 Effluent and 175-189 arterial...and blood pressures are pretty consistent and her ending standing blood pressures are high. We are thinking that this is due to the lack of a sympathetic nervous system (from the heart transplant she had when she was 5 1/2 months old)...and her body reacting to trying to equalize the pressures in the body....

As far as the darker blood...when Holly first went on dialysis...that was what I immediately noticed.      Kinda freaked me out to be honest 

I am far from an expert on home hemo on NXStage...but I will help any way I can!

[Hootie]

Well on day 2, we fully understood dark red blood but veinous pressures were 240- 280 and at times slightly above 300 with only 300  bps. Nurse talked to nephrologist and decided to do activase for veinous. Today for day 3 training the veinous was perfect. It worked! However, the arterial was too high when we got well into treatment. At each yawn, cough, or sitting too erect alarms were blaring often. Seems that CVC are very prone to positional status. In supine position things were fine. We got through it but it was a long 3 hour treatment. Glad it happened at training. She is now ready to go back home to her comfortable reclining chair.

We have appointment with cardiovascular surgeon on Monday to get mapping in two places for next fistula. He is going to check CVC placement too, as nurse, patient and caregiver believe arterial should not be that sensitive to positional status.

It's a journey...

[kickingandscreaming]

It's a journey

I wannna go home!  Enough journies!

[Xplantdad]

Wow...We've only run into the positional thing twice...and one time we believe it was the tech's error.  When she first went on dialysis...they had to play with the heparin dose a bit. The second time we were getting slightly high readings on the arterial side-so I asked Holly to lay on her side and flushed a little bit with saline.

I am assuming that your wife's CVC is in the upper right chest area? Holly's CVC is definitely not "touchy" at all...

A few questions for you:

1) You put a specific dose of heparin in the arterial and the venous lines when you are done with treatment, correct? The actual does should be called out on the specific arterial/venous line
2) At the start of the next treatment, you pull that same heparin out with empty syringes, then flush both sides with ~10ml saline, then follow on the venous side with a specific dose of heparin...then immediately followed by a saline flush, before hooking up the lines for dialysis?
3) You have been told to flush with ~50ml saline if you are noticing high pressures....and notating the amount given?

Holly maybe gets two alarms per treatment...most often it's the one  "yellow 5" alarm near the end...but she will occasionally get a low pressure alarm at the start...if I don't speed up the rate fast enough.

Maybe talk to the doc about increasing heparin dose, too?

[Hootie]

CVC is upper left chest.

When nurse did activase for veinous she said protocol called for saline in both sides after Activase yesterday.

After treatment today, we did the 1.8 and 1.9 heparin in lines. We do 5k heparin at beginning in veinous swishing in and out to mix with blood 3-5 times. We did not flush after swishing back and forth.. We do wait 5 minutes before turning machine on to allow heparin to circulate. The heparin dose is up from 3.5k when we used fistula.

A couple times today nurse opened up saline clamps to see if that would work. It did not help.

Moving her back reclining in chair is all that worked. Two treatments over weekend and then CVS meeting Monday and monthly in center meeting with nephrologist and team on Wednesday. We will sort it all out. Thanks for thoughts.

Yes, it's a journey but best news we are back home. We are definitely looking forward to the big call to come on down for a new bean.

[Xplantdad]

Okay, so you do yours slightly differently than we do...but I would guess that the end result is the same.  Since I know that no two people are alike, all I can do is wish you good luck...and positive vibes. Sounds like you have it down really well