We are at a hospital baced acute center. I hope someone can help me out with my question.
From time to time we get paients with orders for no heparin. During the TX we have clotting of the Lines and Dialyzer.(its a nightmare) anyone got any tricks to help us with clotting.
Thanks

You didn't say if you were speaking of CVVHD or HD so I will assume the latter.

Rinse the dialyzer with 100-200cc of saline while occluding the arterial line. This gives you the opportunity to inspect the dialyzer for evidence of clotting and can interfere with clot formation. Include the flushes in your UF goal. The frequency of the flushes can be increased or decreased as needed. Also, depending on the system you are using, you can flush the venous chamber with saline filled syringe to inspect it also. Careful, because this can be tricky and contaminate the transducer.

Now for the method most acute nurses despise:
Sometimes trisodium citrate is infused into the arterial line. It anticoagulates the blood in the extra-corpeal circuit by lowering its ionized calcium concentration(calcium is required for the coagulation process). The dialysis solution also contains no calcium. The anticoagulation process is reversed by an infusion of calcium chloride in the venous return. Frankly, this method is cumbersome because it requires constant monitoring of the patients blood calcium levels and two infusions going into the extra-corpeal lines.. It can also cause acute alkalemia (citrate metabolism generates bicarbonate)and with over use cause aluminum poisoning (contamination from some glass containers) Some docs love it....grrrr!
Hope this helps...

With acutes, I frequently add 2000-3000 units of heparin to the saline bag that I use to prime. I continue using this for recirculating. The heparin coats the dialyzer fibers and helps prevent clotting. I hang a new bag of saline prior to putting the patient on and dump the prime or run fresh saline through. That way the patient doesn't get the heparin.

At our clinic we have found 50cc saline flushes q 1/2 hr. are the most effective. We also add this to our goal. If the patient is a strict NO heparin I believe the patient would still recieve a small amount if your recirculating the dialyzer and lines with heparin in your saline bag even if you change the bag?

I like what Honey said; that sounds interesting. Ageless, well that is a major P.I.A.

We have had the same situation at our clinic and we will drip NS very slowly approxamately 30-50cc/hour. This worked well for us. Don't worry, we account for that in the UF.

We are having problems with the dialyzer and lines clotting on patient's that run heparin free. Our usual treatment times are 4 hours. I like the idea of the slow constant infusion of NS through the arterial med port of arterial drip chamber (right?). I imagine you run this on a IV pump device. Any other ideas out there? Thanks

Advanced Renal Technologies has a citric acid based concentrate that they claim reduces clotting, you may want to try that.

Chuck

Hello Everyone,

Very good question indeed.

What we teach in our unit, is preplan for the first 30 minutes into the run, to flush with 100cc N/s. If you see clotting around the venous chamber, or dialyzer, the your goal would be to perform 100cc NS flushes q30min.

If you don't, then wait another 30min, that would be every hour, check again, with 100cc. If no clotting, then flush q hourly with 100cc, and please include the flushes in your UF Goal. The last thing you want to do is overload the patient.

As well, we have been using argatroban, it is not dialyzed out like angiomax. And it works well on our critical patients.

We use citrate for our CVVHD patients, but the nurses dislike it due to the regular calcium checks, and with the lab being slow, it takes forever to get your results. Therefore causing more undue stress.

With CVVHD patients, we give predilutional saline prepump, we start with 100cc per hour via pump. If there is clotting within the 1st hour, we increase the rate to 150 and so on..Usually these patients, if they clot off twice in 24 hours, they get consulted with hematology to either start them on anticoagulants IV.

Another new method, that will coming to our unit is BioFlow. It actually drips post pump into the venous chamber and it is removed simultaneously by programming the N/S rinse. For example, we can program the drip rate at 100 cc per hour. This works well, I saw this method up north.

I hope this helps..
Let me know
CarlaRN

I'm not a Nurse and don't know much about the clinical side, however I would like to learn a little more. For what reason is there no heparin? Does it cause a reaction with the patient? Does the Dr. think it not necessary? If the latter is the case, why not pull some ACT tests during treatment and show the Dr. the results in an attempt to persuade him to order heparin? Just looking at it from an outside point of view. Please do explain.

The most common reason for not using heparin in acute situations is because the patient is having some bleeding problems in another area of the body, like the GI tract. Also when a patients platlet count is too low, using heparin could cause the patient to start to bleed internally.

Would it not be best to perhaps put the patient on PD in these cases? Or because of the GI tract problem is that not feasible?