Dialysis

Question 2

What is peritoneal dialysis?

Answer 2

-the removal of toxins, electrolytes, and fluid by diffusion through the peritoneal membrane.
-requires placement of catheter into perotneal cavity.
-can be continuous ambulatory peritoneal dialysis, intermittent peritoneal dialysis, or continuous cycling peritoneal dialysis

Question 3

What are some types of infections caused by peritoneal dialysis (hint: there are 3)

Answer 3

1. exit site infection
2. subcutaneous tunnel infections
3. peritonitis

Question 4

what are some risk factors for peritoneal dialysis infections?

Answer 4

-young age
-staph nasal carriage
-lack of compliance with routine procedures (poor exit site care, break in aseptic procedures)
-dialysate leak
-exit site breakdown or poor healing
-trauma to the exit site
-dislodging of the catheter cuff

Question 5

what pathogens most commonly cause exit site infections with peritoneal dialysis?

Answer 5

staphlococci and pseudomonas

Question 6

what pathogens most commonly cause subcuteanoues tunnel infections with peritoneal dialysis?

Answer 6

S. aureus, P. aurginosa, and enterobacteriaceae

Question 7

what pathogens most commonly cause peritonitis with peritoneal dialysis infections?

Answer 7

coagulase-negative staph, s. sureus, and streptococci

Question 8

what are signs and symptoms of an exit site infection?

Answer 8

erythmea, tenderness, exuberant granulation tissue, exit site with purulent and/or bloody drainage

Question 9

what are signs and symptoms of a subcutaneous tunnel infection?

Answer 9

weythmea, edema, or tenderness of the subcutaneous catheter pathway with purulent drainage or cellulitis

Question 10

what are signs and symptoms of peritonitis?

Answer 10

at least two of the following: S & S of peritonitis (abdominal pain or fever), cloudy dialysate with white blood cell counts >100 cells/mm3 and 50 polymorphonuclear leukocytes, positive culture, or gram’s stain of the dialysate

Question 11

what are some steps to reduce peritoneal dialysis related infections?

Answer 11

-proper catheter placement (avoid skin folds, beltline)
-use of a double cuff catheter
-catheter should be placed under sterile conditions in the OR
-proper exit site care of the operative wound and after healing
-being vigilant for early manifestations of infection

Question 12

what does hemodialysis do?

Answer 12

removes toxins, electrolytes, and fluid by circulating the patients blood through a hemodialyzer
-requires a vascular access
-usually a 3-4 hour treatment 3x a week and can be done in center or at home

Question 13

what are 3 types of hemodialysis vascular access (in order of lowest to highest risk of infection)?

Answer 13

1. arterio-venous fistula (AVF)
2. arterio-venous graft (AVG)
3. tunneled, cuffed venous catheter (if catheter is used for more than 3 weeks) or non cuffed catheter for acute hemodialysis less than 3 weeks duration

Question 14

what is AVF?

Answer 14

a surgical creation of anastomosis (connection) between an artry and vein
-causes arterialized blood to flow through the vessel
-results in enforgement and enlargement of the vessel
-lowest risk of infectino

Question 15

what is an arteriovenous graft?

Answer 15

-synthetic material is interposed between an artery and vein
-expanded polytetrafluoroethylene/Teflon
-composite/polyurethane

Question 16

risk of infection from AVF and AVG may result from what?

Answer 16

-break in aseptic technique
-bacterial seeding from another part of the body
-poor hygiene and care of access site
-added risk with AVG is disintegration of graft materials and hemorrhage

Question 17

how do you lower risk of infection with AVF and AVG?

Answer 17

-clean technique with clean barriers and gloves and attention to aseptic technique
-arm should be cleaned with antibactrial soap or scrub with water
-2% chlorhexidine gluconate is the antimicrobial of choice

Question 18

where does a tunnelled, cuffed CVC get placed and what are indications for use?

Answer 18

-placed within right atrium
-indications are long term access (>3 weeks duration)

Question 19

where does a non-cuffed CVC get placed and what are indications for use?

Answer 19

-superior vena cava
-short term or acute dialysis only less than 3 weeks
-use of femoral vein has the highest risk of infection

Question 20

What is the most common bacterial cause of vascular access site infections?

Answer 20

staphlococcus aureus

Question 21

the majority of CVC bloodstream infections in hemodialysis patients are caused by what organisms?

Answer 21

gram positive (coagulase-negative staph and s.aureus)
-usually related to access site care
-can be caused by water associated gram negative organisms (stenotrophamonas, serratia, pseudomonas)

Question 22

what is the preferred antiseptic that should be used to clean the dialysis catheter exit site?

Answer 22

2% chlohexidine gluconate

Question 23

what antiseptic do you use when prepping for insertion?

Answer 23

0.5% chlohexidine with alcohol

Question 24

true or false. when chlorine is removed from water during treatment for hemodialysis, there is little to impede bacterial growth?

Answer 24

True

Question 25

what does treating water for hemodialysis remove?

Answer 25

-chemical, bacterial, or endotoxin contaminants

Question 26

what type of water is used to prepare product water and dialysate for reprocessing of hemodialyszers?

Answer 26

municipal

Question 27

what are some systems used in water treatment for hemodialysis?

Answer 27

-water softener -carbon filter -particualte filters -reverse osmosis -deionizers -filters, ultrafilters, UV light

Question 28

what is the purpose of water softener?

Answer 28

exchanges calcium and magnesium ions for sodium ions

Question 29

what is the purpose of a carbon filter?

Answer 29

removes chlorine, chloramine, and organic material -at least 2 carbon filters recommended

Question 30

what is the purpose of particulate filters?

Answer 30

removes sediment from the water that could damage or clog the system

Question 31

what is the purpose of reverse osmosis?

Answer 31

-removes ions and organics -capable of removing 90-99% of eectrolytes and all bacteria, viruses, and endotoxin

Question 32

what is the purpose of deionizers?

Answer 32

-removes ions but not bacteria or endotoxins -must always be preceded upstream by carbon filters -if DI is the last process in water treatment it must be followed by an ultrafilter -two tanks in series (worker/polisher)

Question 33

what is the purpose of filters, ultrafilters, or UV light

Answer 33

further reduce microbial or endotoxin concentration

Question 34

what are some facts about water distribution and storage systems for hemodialysis?

Answer 34

-plastic pipes are used because metal pipes could contaminate water with chemicals like copper, lead, or Zinc -needs to be a constantly flow of water through all distribution piping (velocity of 1.5 ft/sec) -should be no dead ends or unused branches

Question 35

how often should chemical monitoring of dialysis water be done?

Answer 35

at least yearly if RO and DI are used more often if other treatment methods are used

Question 36

what are some chemicals that are tested during chemical monitoring?

Answer 36

-aluminum -arsenic -antimony -calcium -chlorine -chloramine -copper -cadium -chromium -barium -beryllium -fluoride -sodium -magnesium -nitrate -potassium -thallium -sulphate -zinc -lead -silver -mercury -selenium

Question 37

what adverse event can aluminum in water cause?

Answer 37

anemia, bone disease, dialysis dementia

Question 38

what adverse event can chloramines (combined chlorines) in water cause?

Answer 38

hemolysis, hemolytic anema, methemoglobinemia

Question 39

what adverse event can fluroide in water cause?

Answer 39

bone disease, pruritis, chest pain, N/V, cardiac arrest

Question 40

what adverse event can copper in water cause?

Answer 40

chills, anemia, liver damage, hemolysis

Question 41

what adverse event can zinc in water cause?

Answer 41

fever and anemia

Question 42

what adverse event can calcium or magnesium in water cause?

Answer 42

muscular weakness, hyper/hypotension

Question 43

what adverse event can sodium in water cause/

Answer 43

hypernatremia, increased thirst, excess water intake

Question 44

how is bacteria and endotoxins tested for?

Answer 44

water and dialysate samples

Question 45

what can the presence of endotoxins cause?

Answer 45

-pyrogenic (fever), bacterimic symptoms, flu like symptoms, chills, fever, hypotension, and increase the chance of infection

Question 46

how often should the water distribution or dialysate system be tested?

Answer 46

at least monthly (weekly for 1 month when changes made)

Question 47

total viable bacterial counts and endotixin concentrations must not exceed what?

Answer 47

<100 cfu/mL and <0.25 EU/mL

Question 48

How do you prevent bloodborne pathogens in hemodialysis?

Answer 48

-items taken to the dialysis station should be disposed of, dedicated to a single patient, or cleaned and disinfected -avoid multiple dose med vials -prepare individual patient doses in a designated med prep area -do not use common med carts -do not carry med vials, syringes, alcohol swabs, or supplies in pockets -clean and disinfect the dialysis station between patients (tables, machines, beds)

Question 49

How to you manage HBV in hemodialysis?

Answer 49

-test for HBsAG prior to or on first session. If negative recommend vaccination -susceptible patients (including those with no vaccine response) should be tested monthly for the virus -dialysize positive patients in a separate room with dedicated equipment -do not include positive patients in reuse programs -staff members caring for positive patients should not care for susceptible patients at the same time

Question 50

true or false. Hep B antibody response to vaccine is poorer in hemodialysis patients therefore larger vaccine doses or an increased number of doses is required?

Answer 50

True

Question 51

who is HBV vaccination recommended for?

Answer 51

all susceptible hemodialysis patients and staff

Question 52

booster doses are necessary when?

Answer 52

antibody levels decline below 10 mIU/mL

Question 53

what precautions are required for hemodialysis or Hep C and HIV patients?

Answer 53

-routine -not as easily transmitted

Question 54

how often is HCV testing of hemodialysis patients recommended?

Answer 54

every 6 months along with ALT

Question 55

how often is HIV testing of hemodialysis patients recommended?

Answer 55

not necessary or recommended