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posted
Hopefully this is in the right place...Please keep in mind this is on a "Hypothetical" understanding and does not mean it is or has happend..

Recently our clinic has had a massive push for better clearance #s Do any techs have any tips or tricks that they use to get better numbers?

One trick that seems to be getting a push is the One needle up, One needle down Method. where the arterial needle is cannulated against the flow and the venous (of course) is Cannulated with the flow. I have personally done this and it doesn't seem to make much of a difference for anything but Access Flow Testing. KECN and SPKT/V numbers generally are the same with both methods.

Has anyone found placing the needles farther apart or closer together(without being within the 2"-3"s of each other) to have any success or draw back?


I understand "Orders" are set in stone and can't/shouldn't be modified without a Doctors consent. So with that being said does anyone have any tips or tricks they would like to share or comment on?


Jack of ALL Trades...

"I would rather LEARN SOMETHING about EVERYTHING, Then KNOW NOTHING about SOMETHING" Smiler

Anything I say here is Hypothetical and cannot be taken as anything more then my opinion
 
Posts: 3 | Location: Hawaii | Registered: 16 February 2014Report This Post
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Needle placement: Adequate space between needle tips is very important. It reduces the amount of recirculation = better clearance. (Needles in opposite direction is definitely the way to go whenever possible)

Dialysate flow rate: This is not 'always' a prescription here, so sometimes turning it up a bit (aim for 1.5 x to 2 x to pump speed) can make a bit of a difference.

Dr's prescription: Pump speed and dialyser size (surface area) will make the biggest difference, in my opinion (aside from time, of course). So it's always good to discuss this with the Dr when a patient is not reaching adequate clearance.

Oh yes, and needle size. Bigger needles = better flow = higher possible pump speed (and less hemolysis)

Good on you for asking! Hope that helped a bit. Will add more if I think of anything.
 
Posts: 10 | Location: RSA | Registered: 30 January 2014Report This Post
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Awesome! Thanks for the knowledge! I was amazed at how much better the one up one down method worked.. took a patient with low sp kt/v 0.98 to 1.34. Poor guy has to stay 5+hrs hopefully we can dial in him better. I asked the nurse to ask the doc to switch him over to a bigger dialyzer. We will see what happens..


Jack of ALL Trades...

"I would rather LEARN SOMETHING about EVERYTHING, Then KNOW NOTHING about SOMETHING" Smiler

Anything I say here is Hypothetical and cannot be taken as anything more then my opinion
 
Posts: 3 | Location: Hawaii | Registered: 16 February 2014Report This Post
<old school>
posted
The MYTH of bigger needles ,higher flow- better clearances is always talked about as if its etched in stone. I personally have followed 65 patients (fistula) for two years with the following results NO ACCESS BLOOD FLOW PROBLEMS,kt/V >1.2 URR >65%.Simple 16 ga needles,350cc blood flow and 4 hours.
 
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That is all good and well old school. I find that the issue is more with patients who are too afraid of moving from 17g to 16g needles, or staff who think that 17g is sufficient and don't educate their patients.

Also, of the +/- 300 patients who I've personally worked with in the last few years, only 2 have had a pump speed of over 300. With the rest, the Dr's never felt that there was a need to go higher, and if they did, either the access or the patient could not tolerate it.
 
Posts: 10 | Location: RSA | Registered: 30 January 2014Report This Post
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To clear up some myths and mis-information....

Urea is a VERY small molecule that passes through the dialyzer membrane quickly and easily. The determining factors of its clearance is the ability to expose it to the membrane. This is best accomplished by either time or BFR.

To a large degree, switching to a "larger" dialyzer has minimal affect on urea clearance. At a BFR/DFR of 300/500, a F160NR has a urea clearance of 266 while an F200NR is 277. The difference in urea clearance is clinically insignificant yet the larger dialyzer cost (my price) is greater than 50% more.

In 2011, Dr. Richard Ward published a study that proved a DFR greater than 600 was simply a waste of money and resources. If you would like a copy let me know and I will email it to you.

Needle gauge....This is one case where size really does matter. Unless you are running a pre-pump arterial pressure of 0, you are not getting the BFR that the blood pump is set for. The more negative the pressure, the further away from the set value you are. Using a larger gauge needle will help improve actual blood flow but it isn't a magic bullet.

I feel for your situation, it sounds like your MD's need some re-education.

Chuck


DISCLAIMER : My opinions and views are mine and may not be the same as my employer.
 
Posts: 1787 | Location: Baltimore, MD USA | Registered: 24 October 2001Report This Post
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Thank you for all good the great information! Our patients have drastically improved their kt/v numbers within the past few months. Several orders have changed thanks to the diligence of the staff and patients during this push. unfortunately the area we are in is lacking in nephrologist choices. We only have a hand full of nephrologists for our patients to choose from with over 300 patients in our area. This makes it a lot harder to get the attention that the patients deserve. does anyone else have any info or ideas they would like to share?


Jack of ALL Trades...

"I would rather LEARN SOMETHING about EVERYTHING, Then KNOW NOTHING about SOMETHING" Smiler

Anything I say here is Hypothetical and cannot be taken as anything more then my opinion
 
Posts: 3 | Location: Hawaii | Registered: 16 February 2014Report This Post
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Anti coagulation plays an important role on Kt/v calculations as well

pato
 
Posts: 195 | Location: Nashville, TN | Registered: 27 February 2005Report This Post
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