I hope one of you guys can help me. We ad an incident last week when the venous needle dislodged from a patient's arm. My question is should we have had an audible alarm and the blood pump stop? Because the the staff never heard the audible or the red traffic light never turned red. thanks in advance for your help.

Had this happen here before, i spent 2 days testing this, it was an H but same thing i am sure. The needle comes out, it can cause a small venous pressure say 10 to even 20, this is above zero and machine will run. But machine will alarm, for sure. What happens is the needle comes out and the venous drops and machine alarms. Tech will hit reset or reset and override, they will not troubleshoot the alarm. Since the venous is above zero the machine will accept that u said its ok, because u hit reset and run all the blood out into the floor. Be SURE that u have techs and nurses troubleshoot and not just hit reset. If the needle comes out and presses against something like chair arm it can even go higher than that. I tell techs here if it says like venous, check the venous, follow the line is it connected and such. Only takes a second to check.

A lot of the times the Tech will go into dialysis menu and open up both sets of alarm windows, thus would cause less alarms. I had to close each alarm limit to smallest range, from there took the options off of main menu. No more problems

At our unit, patients are required to have their accesses visible to staff and not covered by blankets or something else. Of course, this isnt always the case when a patient is cold and is going to cover themselves up. Staff must always be aware of the dangers involved in a venous needle dislodging, and if necessary, pull back a blanket and visually inspect the access. The dangers are very real, and this accident occurs more often then it should. Alarm limits should be set as narrowly, as reasonably possible, also. Hemodialysis has had many risks reduced over the years, but this particular problem is a persistent one, which still requires adherence to basic standards of monitoring in the unit.

Hey Guys,
It's not just the K's or H's. A few years back we had the same thing happen with a C-3, staff said " never alarmed, just blood everywhere, machine must be broke". I had to show my Director, with the aid of a bucket I was mock-dialyzing,that the machine will alarm once the venous pressure drops,but once someone hits reset or override the machine will certainly adjust its' limits and pump every unit of blood the patient has to offer on to the floor. Patient care staff needs to know to actually stop and look to see what the alarm is and not just mute the alarms.

I guess I'm going to go against the grain here but...I don't doubt for a minute that the machine may not have alarmed.

With the high blood flow rates that are commonly used, the "venous pressure" is actually the resistance that the blood is meeting from the needle and not the fistula/graft. With these high blood flows the venous pressure monitor isn't worth much more than to watch for infiltrations.

I have heard of some units that use something similar to a bed wetting monitor under the patients arms that would sense the moisture and alarm. I believe these monitors are also common in nocturnal programs.

Chuck

Here is a link to an article about this.....

http://www.mdsr.ecri.org/summary/detail.aspx?doc_id=8300

Chuck

I thank you for all your help. I checked the dialysis machine and the venous pressure with a NEO meter and the pressure checked out correct. although this incident helped in making the PCTs' to be more alert and monitor their patients'more. Lets just say that the manager for this particular clinic was not happy with the incident.

Do you do your alarm and pressure holding tests before every patient? This will help determine before you start whether all your alarms are working properly as well as your battery at the back of the machine is well charged. I could not empahasize enough the importance of this procedure before each patient's treatment is initiated.

we have this happen with machines other than Fresenius or Braun too. If you can not see the site it is easy to happen...on any machine. When you reset there is still pressure at the tip of the needle from the blood flowing through it. add to that the limits on machines all I believe initially spread than go to the pre set limit. so if you can not see the needle you might be missing the whole picture

I think they figured this out over 3 years ago manny.