Is it, or is it not, correct to squeeze the bag? Please provide documentation so I can show my doctor.

Concerned:

In what regard are you referencing? Can you please provide some further details to help us with this?

Thanks,
Carol

I'm referring to squeezng the saline bag when the blood is returned at the end of treatment.

I have seen facility specific policies that say when reinfusing blood to apply pressure to the saline bag. I have also seen policies that specifically say never to do that.

I am unaware of any studies that have been done contraindicating the use of doing this. I am sure that there are people out there who are reading this who have had great experiences with both types of reinfusion, and we would love to hear them.

In the meantime, I would ask your nurse manager at the facility what the policy is there for returning blood. If it is against the policy, staff need to quit doing that. If it isn't, than - for now - things are as they should be.

Again, I would love to hear from some folks who have stories one way or the other about reinfusion after hemodialysis. I think hearing those incidents may also help you in forming an opinion on what is best for you during your care.

Let us know what your nurse manager says. In the meantime,
Best wishes,
Carol

I asked my nurse at dialysis about this issue the other day and her response was that the pressure in squeezing the bag is no more than any pressure used when the pump pushes the blood during dialysis at a speed of 200 or greater. So in hers and my mind, it is not doing any more harm than would be to have your pump running at a certain speed for 3- 4 hours. If this is the case then I feel perfectly safe having the bag squeezed to return my blood at the end of the run.

JB

Jaeman:

You raise a very valid point. Oftentimes we perform hemodialysis treatments at blood flow rates of 400 - 500 ml/ minute. At blood flow rates like that, it is very common to see venous pressures between 200 - 300 mm.

I would tend to agree that the pressure exerted is not greater than normal pressure exerted during treatment. It would be interesting to see if there is any documented research out there on this issue. I will try to find some time to do some research over the next week to see if I can find anything of that nature.

Has anyone else out there heard of any research in this area? Are there other thoughts about appropriate ways to reinfuse blood post hemodialysis treatment?

Thanks.
Carol

There are opinions at the Nurses board of Dialysis Online.

Dear Concerned: There is one other issue related to squeezing the saline bag and that is of carpal tunnel syndrome. A number of dialysis staff are suffering from this syndrome--- which MAY be associated with or contributed to this painful syndrome.

Mary Rau-Foster

It is true that pressure created with blood flows of 400 and 500 are well tolerated by the mature access, but this is on the VENOUS end of the access. When squeezing the bag to rinse a patient back the pressure is going into the ARTERIAL end of the access, close to the arterial anastomosis. This is particularly of concern in new, maturing AV fistulas.
I think we all may have developed some procedures that worked with AV Grafts that are not necessarily the best clinical practice now that we are seeing more AV Fistulas in our units.

Hi Pat,
So then what would be the correct procedure in regard to a fistula?

My recommendation would be to do a pro-grade rinseback.
This can be done using a Medisystems Dialysis Priming Set. This priming set has a "Y" at the connection. When you are ready to rinse the patient back, simply clamp the arterial access and blood line, disconnect, attach the patient end of the blood tubing to the "Y" connection, open the clamp on the "Y" and on the blood tubing, turn the blood pump on and "Voila !" you rinse forward through the pump back to the patient. This method gives you a nice closed system during rinseback and you avoid pressure at the arterial end of your access.

[What are the dangers of squeezing the bag?
QUOTE]Originally posted by Carol Isaac MacKusick:
I have seen facility specific policies that say when reinfusing blood to apply pressure to the saline bag. I have also seen policies that specifically say never to do that.

I am unaware of any studies that have been done contraindicating the use of doing this. I am sure that there are people out there who are reading this who have had great experiences with both types of reinfusion, and we would love to hear them.

In the meantime, I would ask your nurse manager at the facility what the policy is there for returning blood. If it is against the policy, staff need to quit doing that. If it isn't, than - for now - things are as they should be.

Again, I would love to hear from some folks who have stories one way or the other about reinfusion after hemodialysis. I think hearing those incidents may also help you in forming an opinion on what is best for you during your care.

Let us know what your nurse manager says. In the meantime,
Best wishes,
Carol[/QUOTE]

As a patient, I am totally against the squeezing the bag procedure. I have a fistula, and in the past when I did not know anything about this procedure, I felt coldness from the saline when the saline was forced into my access through sqeezing the bag, and I also felt an unnatural pressure rright in my access that was very uncomfortable/painful. I long ago requested the techs not squeeze the bag on me and my request was honored. Also, every unit I've ever been in squeezed the bag. I did have several techs argue with me that there was nothing wrong with squeezing, but then twice, units I was in had policy changes and sqeezing the bag was discontinued. Obviously, the units had a reason for discontinuing this procedure and I was glad that I didn't have to correct anymore techs who didn't know my preferance about not squeezing the bag.

I have seen data on squeezing saline bags and not squeezing saline bags. The data shows that squeezing the bag even with two hands can not produce internal access pressures or blood flows in the access greater than that which exsists during the treatment when blood pump flows are 350-500 ml/min. Natural access flow unassisted can range from 400-4000 ml/min. This suggests that accesses would be more effected by treatment parameters then during the return of blood. Perhaps you should have your unit perform a study as to effects on accesses of such a practice.

Our company's policy and procedures does not specifically mention "squeezing the bag" but in the training period for new techs and nurses, this practice is discouraged. In the old days, this was the standard way of clearing the arterial line, but is uneccessary, as the arterial line is connected to the saline bag at the end of treatment, and the entire line can be rinsed clear.

This procedure is used, unofficially, when you want to quickly return the blood to the patient in situations of sudden hypotension or power failure, but again it is discouraged because of the risk, however slight, of damaging the arterial anastomosis or introducing air. If I were a patient I would demand that it not be done, and would quote myself when I say that the loss of <50cc of blood in the tubing section from the bottom of the cartridge to the needle is not enough to risk the loss of my access.