Do you pull the arterial or venous needle first and why? Do you give Noraml Saline via the venous or arterial needle post treatment if needed? Do you pull different needles first in a graft vs. a fistula? If so why?


[Note: This message has been edited by Deborah Brouwer]

I'm counting on you to be nice.

We stop the blood pump, disconnect the arterial needle from the arterial blood line. Insert the arterial blood line into a saline bag and start the blood pump up again. We usually pull the arterial needle while the rinse back is in progress. The patient holds the site.

Are we doing something wrong? (Now be nice!)

If you are on this site- you care about your patients and your quality or work. That's GREAT! Much in dialysis is not wrong or right, but has the best level of safety for both you and your patients. Hopefully this reply will keep you safe.

The only thing I would suggest is not to pull the needle and insert the needle into the NSS (Normal Saline Solution)bag medication port. You are putting yourself at HIGH RISK for a needle stick. If your push the needle into the medication port, through the side of the port you may stick yourself. You now have an exposure to bloodborne pathogens from a large bore neelde that was in a blood vessel. According to the breakdown of risk from that type of needle stick, you would be at high risk to get the bloodborne pathogen. This type of neeedle stick would require treatment with chemoprophyliactic drugs. Dialysis units are to engineer nursing policy/procedures to redue the exposue to needle sticks as per the bloodborne exposure plans. So if you keep your same procedure and just elimate the needle, you will be doing the best for yourself and your patients. See the posting under blood rinse for more info on the p+p.

I am glad you pull the arterial needle first incase you need to give saline. You can give the saline via the venous needle without risk of infiltartion or injury. If you pull the venous neelde first, postdialysis NSS must be administerated against the blood flow via the arterial neelde.

Let me know what you think about the suggested p+p change. See what your dialysis units thinks about the issue and let me know the comments. One dialysis staff member with a needle stick is one too many! Does your unit offer the drug therapy on site if you do get a blood exposure?


[Note: This message has been edited by Deborah Brouwer]

Deborah!!!!

I'm afraid I didn't make it clear what we do!! We put the end of the arterial blood line into the saline bag - after it has been disconnected from the arterial fistula needle. We would never insert a dirty needle into anything other than the sharps waste container!

At the beginning of the treatment, we prime the dialyzer with a portion of a 1 liter NS bag. We usually have 500 cc left in the 1 liter bag at the end of the treatment. We then disconnect the IV administration set used for priming (and emergency saline boluses) from the saline bag and then insert the end of the arterial blood line into the same port. The needle is still in the patient.

While the blood is being rinsed back, then we pull the arterial needle. The patient holds the arterial needle site while the blood is being returned. When a nearly clear return is achieved in the venous line, we then clamp and pull the venous needle.

I thought from your first post that there was evidence to support pulling the arterial or venous needle first depending on whether the access was a graft or a fistula. Did I read too much into it?

So gald to hear you don't use the needle insetered into the NSS bag. Many dialysis units still use the mediaction port procedure.

Well which needle first was an issue talked about at the ANNA meeting (Spring 1999)in one of the vascular access sessions. Some staff think if you pull the venous needle first on a graft or fistula, the arterial needle will take less time to bleed. Some think if you pull the arterial needle first when you pull and hold the venous needle, the arterial needle might re-bleed from the holding pressure causing a back flow. I just wanted to see what you all think.

I would always pull the arterial first due to the possible need for NSS postdialysis and would not want to give saline via an arterial needle. With the need to increase the AV fistula use, we might see more fragile AVF that might be damaged by pressure from a saline infusing postdialysis via the arterial needle. Your thoughts?


[Note: This message has been edited by Deborah Brouwer]

Deborah,

Your last comment in the previous note made me wonder. I did work a few years ago in a facility where they rinsed back the a portion of the arterial blood line via the saline administration port. We would squeeze the bag of saline to create enough pressure to force saline up through the arterial needle. Then we would clamp the arterial needle and would rinse back the dialyzer and venous blood line through the venous needle as usual.

No one ever mentioned potential damage to the fistula with this method. Can you elaborate?

Sure. When squeezing on the saline bag to return blood or give fluids via the arterial needle, you are forcing in the fluid against the bloodflow within the access(usually the arterial neelde is inserted with the open bevel againt the bloodflow direction or in a wrist fistula facing down towards the hand). The risk is from the lack of a way to control or measure the amount of force used to infuse the fluid and the potential damage to the vessel from excessive force. It would be like running the blood pump at unknown speed with no venous pressure monitoring, something we would never do. The force of the fluids againt the bloodflow direction will back the fluids up into the arterial segement of the fistula and into the arterial anastomosis area. This could traumatize the vessel walls and anastomosis site. With a new fragile fistula the fistula needs to be protected and steps taken to limit vessel damage to the fistula.
Does that make sense?


[Note: This message has been edited by Deborah Brouwer]

When returning blood, we draw up a 10cc syringe of NS, disconnect the arterial blood line from the end of the arterial needle. Needle remains in the patient. Flush the arterial needle with the normal saline and then connect the open end of the blood line to the NS line (that was connected to the arterial line during dialysis.) The entire blood in the circuit can be returned this way. On the Fresenius H,D, Cobe 2, I know squeezing the arterial blood back is not considered safe because you are returning blood without an air detector. There are always good reasons for pulling the arterial or venous first. Leaving the venous needle in until last is a good habit for reasons of NS post dialysis etc.

Hey Deb! Thought that I would respond to this one. At first, at "MY OLD JOB", we was to rinse the arterial needle by squeezing the NSS bag to clear the arterial needle and then clamping the needle and the blood line off and then reurn the blood with the blood pump until the venous line is clear and then clamping this off. This is called - MAINTAINING A CLOSED SYSTEM. I then remove the blood lines and "I" place a 3cc syringe on the venous fistula needle to maintain a sterile needle for NSS infusion if needed. After I have the arterial needle done, I take the patients blood pressure sitting and then standing, if they are OK I then pull the venous needle. It is a lot easier to give NSS with the flow of the blood than trying to force it into the arterial needle! So Deb, how did I do? Have you guessed who I am? One of your long lost Dialysis friends!!!!!

Me again! I now rinse the arterial fistula with a 10cc syringe and then I place the arterial blood line to the port on the NSS line and finish giving the blood back. But I still pull the arterial needle first! I guess every company is different! Gee, many many years ago -- how about rinsing back with air! Gee how dangerous that was!!!!!!!

Patti,
I remember the air rinse days! I prefer the arterial needle first and the venous after sitting and standing blood pressures are obtained. The needle hub must kept sterile with a syringe. You never know when you might need to give NSS postdialysis. I still see units hook up NSS to a fistula needle that was open to the air (no syringe or cap). Patti knows what I pain am I to work with, I expect high standards all the time and I haven't changed. We could be the ones in the dialysis chair! Keep up the good work!
"Debbie does dialysis"


[Note: This message has been edited by Deborah Brouwer]

quote:

Originally posted by Deborah Brouwer:
Patti,
I remember the air rinse days! I like the arterial needle first and the venous after sitting and standing blood pressures are obtained with the needle kept sterile with a syringe. You never know when you might need to give NSS post treatment. I still see units hook up NSS to a fistula needle that was open to the air (no syringe or cap). Patti knows what I pain am I to work with- I expect high standards all the time and I haven't changed. We could be the ones in the dialysis chair! Keep up the good work!
"Debbie does dialysis"

DEBBIE
We use the squeeze method to clear the arterial line I know you stated this could cause damage to the vessel wall due to not knowing the pressures applied. But what is the difference when the venous is also returned with the pump ? I can't believe we can create higher pressures than the pump with squeezing the bags with only enough pressure to clear the lines. Maybe I am thinking wrong but I feel a close system will maintain less infection. Most of the replies stated they attatch the arterial line to the system to clear there is large opportunity for the end of the line to get in contact with something before attaching to the system.

KATERN

Squeezing the bag is done routinely in our center. Could you explain in simple terms why this procedure should not be done and what should be done in it's place so as a patient I can explain it to my workers.

Doing rinse back via a closed system is always a good idea. We use Medisystems High Flow Bloodlines that have a "Y" connector on the priming set. At the end of the treatment we disconnect the arterial line from the patient's fistula needle or catheter (carefully attaching a saline filled syringe to flush the needle or catheter), attach the arterial bloodline to the "Y" on the priming set, turn the blood pump on and rinse back. It's great ! We love it ! No squeezing the bag, no lines falling out of saline bags, just quick, clean and efficient rinsebacks ! These priming sets come in the Medisystems High Flow Bloodlines. I would recommend checking them out.