Do you give a heparin blous pre treatment via the access- if so how long do you wait until you start the HD treatment? Do you stop heparin before the end of a treatment- if so are the stop times different for a fistula/graft or catheter? Comments?

Our unit policy is to give the initial heparin bolus throught the AVF or catheter and wait 3 to 5 minutes before initiating dialysis. Waiting the 3 to 5 minutes allows the heparin to become systemically distributed. Starting dialysis with anticoagulated blood coming in contact with the dialyzer in those first few minutes of dialysis can go a long way to maximizing the clearance potential of the dialyzer. That is if you continue to keep your patient adequately heparinized throughout the treatment. Our unit uses heparin infusions after the initial bolus. We shut them off one hour prior to the end of the treatment. We found when we switched our heparin administration from a loading bolus followed by a mid-dose to a loadng dose with an infusion our heparin usage was actually less and our Kt/V was better. less heparin can only be better, for our diabetic patients in particular.

Sally- gald to hear you are waiting the few minutes needed to have the most benefit for your patient. How do you get the staff and patients to buy into the need for the wait. What do you do while the few minutes are passing?

We just re-organized the tasks required before initiating the dialysis treatment.
We do our access assessment, cannulate the patient, give the heparin bolus, and then continue our patient assessment. Listening to lungs, checking ankles, talking to the patient about how they have been feeling, etc... Then we make a quick note in the chart documenting all of this. Also we check to see if any new physician orders have been written since the last treatment.That usually takes 3 to 5 minutes. We've found it to be a very efficient use of time and our clearance and reuse numbers have improved.

In other clinics I know of they use the 3 to 5 minutes while the heparin is being distributed systemically to do their residual checks for reused dialyzers.