By Peter Laird, MD
Home hemodialysis is undergoing a renaissance in the United Stated with over 5000 patients now utilizing this flexible and convenient therapy in the comfort of their own homes. Safety in the home dialysis environment is a diverse topic with patients having varying skill levels coupled with no standardized training programs. Nevertheless, there are many common safety elements when applied uniformly that will assure the best outcomes and reduction of complications.
Patient safety in the home begins with an attitude towards safety. When a pilot steps into the cockpit of a plane or a surgeon into the operating theatre, there is an expectation of safety as the first and highest priority. Likewise, the home dialysis patient needs to adopt this same reliance on safety first. However, since it is also the place where we live, patients face a difficult compromise between basic living quarters and tending our own dialysis unit. The first step is to have a separate, dedicated space for dialysis and supplies when possible. Supplies should be inspected upon delivery for damage and loss of integrity, discarding any that are compromised. The storage area should minimize exposure to sunlight, moisture, dust and extreme temperature fluctuations. Pets and young children should not enter the supply area.
The daily dialysis session starts with proper setup of the equipment and inspection of all supplies. Crimped bloodlines can lead to hemolysis which can be life threatening. Patients need to examine all prepackaged dialysate for discoloration of the fluid and check for proper prescription. The artificial kidney should not contain any cracks and you should only use supplies that have not expired or had any external damage to the protective coverings. Always check for any leaks of the cartridge or bloodlines prior to starting dialysis while the machine is priming. Review all machine settings to assure that they are correct.
All dialysis machines monitor for internal system failures during the priming session and any alarms should be addressed prior to hooking up. The operators instruction manual must be within easy reach at all times as well as phone numbers for technical support of your specific machine. If there are any unusual sounds or obvious dysfunction of the machine, notify the technical support staff before proceeding with your dialysis session. Inspect all connections to make sure none are loose. Assure that the proper lines are open or closed depending on the system used with all caps in place Lastly, keep emergency supplies for disconnecting the blood lines in the event of an emergency within easy reach including scissors, hemostats, needle nosed pliers as well as a telephone to call for emergency medical attention.
Infection control in the home setting originates with healthful living and general cleanliness. Pathogens abound in un-kept homes especially staphylococcus bacteria that can live on exposed living surfaces for several days. Routine hand washing is the anchor to safe performance of dialysis in the home. Unfortunately, proper hand hygiene is also one of the most ignored tasks leaving home dialysis patients at increased risk. Johns Hopkins revolutionized infection control in the intensive care unit several years ago by developing a “bundled” checklist for central line insertion and after care. This same attention to basic hygiene principles could mitigate many of the common infectious complications associated with hemodialysis.
Shower or wash access site just before the session begins.
Employ diligent hand hygiene from a combination of hand washing and use of alcohol gels during the different steps of home hemodialysis.
Wear gloves and facemasks at all times when inserting needles, hooking up bloodlines and disconnecting at the end of a dialysis session.
Use sterile bandages instead of communal supplies from multi-use dispensers that are easily contaminated.
Disinfect cannulation sites preferentially with chlorhexidine instead of iodine if not allergic to chlorhexidine.
Avoid long-term catheter access and utilize fistulas when possible which significantly reduce all cause complications.
Many patients on home hemodialysis access their fistulas using the constant site cannulation technique also known as buttonhole cannulation. There are several benefits to buttonhole cannulation including reduction in aneurysm formation, reduced pain with needle insertion and significant reduction in infiltration with cannulation. However, recent studies reveal an increased risk of access site infections with buttonhole cannulation versus rope ladder cannulation techniques, especially in the setting of in-center dialysis units. Proper technique may mitigate these infections:
Wash arm and disinfect site with an antimicrobial agent before picking scabs.
Consider single use, sterile disposable tweezers for each buttonhole site instead of reusable metal tweezers that are difficult to disinfect.
Soften scabs prior to removal with alcohol gel or pads covered by warm compresses for several minutes.
Avoid using sterile needles to pick scabs since they can increase tissue damage that then serves as a nidus for infection.
Re-prep buttonhole sites with an antimicrobial agent before cannulation.
Preventing Dialysis Emergencies:
Cafazzo, et al, in 2009(1) noted that the fear of a catastrophic event is one of the most important patient-perceived barriers to home hemodialysis. Air embolism and exsanguination from venous needle dislodgement are the most serious immediate medical emergencies that can occur during hemodialysis, albeit rarely documented. With the popularity of nocturnal home hemodialysis, venous needle dislodgement gains even more importance to prevent since many home nocturnal dialysis patients sleep alone. Unfortunately, venous needle dislodgement remains the most common cause of preventable death in the dialysis unit and is a serious risk for the home hemodialysis patient.
The FDA recently approved the Redsense monitor to detect blood loss during hemodialysis. Many home hemodialysis patients have used bed wetting monitors to protect against undetected venous needle dislodgement in an off label use that is not recommended. Nocturnal hemodialysis patients especially need to utilize an approved moisture alarm device during each session in addition to the usual precautions:
Tape the bloodlines securely before initiating dialysis.
Keep bloodlines and needle insertion sites visible at all times. Never cover with blankets or clothing.
Never tape bloodlines to chairs, tables or other objects that could cause the venous needle to dislodge.
Utilize FDA approved moisture detectors and test frequently to make sure the device is functioning properly.
Never disable pressure alarms designed to detect a sudden change of pressure from venous needle dislodgement.
Never cut the dialysis needle lines during emergencies, you will bleed to death. Clamp and cut above the dialysis needle lines.
Air embolism during hemodialysis occurs when atmospheric gas is introduced into the venous system. As little as 20 ml of air can be fatal when introduced directly into the blood system. Modern home hemodialysis machines all detect small amounts of air and automatically shut down the machine. One of the most common risks for venous air embolism is an empty IV saline bag during rapid infusions for cramps and during the final rinse-back especially if bypassing the machine in a manual rinse-back maneuver. Careful attention observing saline levels will prevent this error. If a saline bag runs dry and introduces air, remove all introduced air in the line before proceeding with any further saline infusion. If the lines cannot be cleared, abort any further infusions since the air can be fatal or cause severe complications. Long-term exposure to even small levels of air bubbles can cause significant clinical effects from micro-bubbles, which can be reduced by up to 75% with careful priming.
Dialysis patients utilizing catheter-based treatments are at the highest risk of venous air embolism since any air is introduced directly into the central blood vessels immediately. Assuring that the catheter is clamped securely before connecting or disconnecting bloodlines limits the risk of venous air embolism. However, a venous catheter crack or disconnection that goes unnoticed can be rapidly fatal. Safely measures to prevent air embolism include:
Use the vascular catheter only for hemodialysis access.
Keep all bloodlines visible during dialysis at all times.
Monitor for cracks, tears or breaks of the catheter hub and Luer lock disconnection during hemodialysis.
Replace saline bags before they become empty.
Suspect air embolism if the patient complains of shortness of breath or has any unusual symptoms during or immediately after a hemodialysis session.
Preparing for Non-medical Emergencies:
All home hemodialysis patients should prepare for local disasters including adverse weather, home fires, earthquakes and epidemics. In addition, during the hot summer months, loss of electricity is a common disruption during dialysis. Patients need to understand manual rinse-back procedures and should have emergency lighting available if dialyzing at night. Emergency preparedness includes keeping supplies available for food, water and shelter in the event of a local disaster as well as having available travel arrangements if they must evacuate the area. There are several basic measures of emergency preparedness that all home dialysis patients need to adapt to their own specific situations.
Keep personal medical information available and consider medical alert bracelets. Keep basic proof of ID and insurance information on hand as well as credit cards and banking information.
Register your home with water and power companies to increase priority restoration in times of emergency.
Have flashlights, batteries, medications, emergency food and water supplies and cell phones charged.
Know the phone number to the backup dialysis unit you are assigned.
Prepare an emergency dialysis supply kit filled with tape, masks, needles, syringes, heparin, saline, gloves, hand sanitizers, betadine and medications.
Trash bags for waste disposal.
Bleach to decontaminate equipment if using the portable NxStage System One and related supplies.
Keep a three-day emergency diet on hand in case you are not able to re-establish your dialysis routine in that time.
All home hemodialysis patients need to spend time developing their own individual emergency preparedness plan and implement that plan upon completion of their dialysis-training program. Fortunately, there are several excellent resources available online. Those that I find helpful include:
Home Dialysis Central: Disaster Planning for PD and Home HD (http://www.homedialysis.org/article/life_at_home/disaster_planning_for_pd_and_home_hd)
KCER: Kidney Community Emergency Response Coalition (http://www.kcercoalition.com/resources.htm)
National Kidney Foundation: Planning for Emergencies (http://www.kidney.org/atoz/pdf/DisasterBrochure.pdf)
Dialysis patients require large amounts of water to perform dialysis making water safety one of the most important elements of a dialysis safety program. There are currently two FDA approved systems for home dialysis that utilize different processes to prepare the cleansing dialysate, the Fresenius 2008K@home dialysis machine and the NxStage System One. The first step for all home hemodialysis patients is to have their tap water analyzed to make sure it adheres to basic water purity for drinking water and does not contain certain heavy metals such as arsenic, other elements or excessive bacteria. Dialysis patients are exposed to higher levels of water each week through their treatments than normal drinking making even small levels of contaminants that are tolerated in drinking water dangerous for the home dialysis patient. Patients should diligently follow the prescribed water testing schedules that your home dialysis trainer sets up.
The Fresenius 2008K@home dialysis machine relies on technology used in conventional in-center dialysis units with a reverse osmosis machine that removes most chemicals and metals from the water. However, it does not remove chlorine and chloramines used by city water systems to purify drinking water or all of the bacteria and their breakdown products called endotoxins. Activated charcoal filters remove the chlorine before the RO system processes the water. Bacteria and endotoxins are removed by specials microfilters.
Patients learn how to test and maintain these systems during the extended training for home dialysis. The key element of water safety is to maintain accurate records and correctly perform all maintenance on schedule. Daily testing for chloramines is a necessary task to prevent serious adverse effects during dialysis. Many patients find daily maintenance of the water systems the most difficult part of home hemodialysis when dialyzing with the standard RO process.
The NxStage System One utilizes ultrapure dialysate that is either pre-packaged in ready to use bags or from the PureFlow SL machine that takes tap water, purifies it with a multi-step process and combines this purified water with sterile dialysate concentrate making 60L of dialysate with each batch. Patients must test daily for chloramines and maintain scheduled testing of the water quality for metals and bacteria levels to ensure safety. Water safety in dialysis is one of the most technically complex aspects of dialysis care in the home requiring close communication with the supporting dialysis unit and continued testing and maintenance of all equipment in conjunction with professional oversight by qualified technicians.
Dialysis Waste Disposal:
Dialysis waste includes used needles, syringes, bandages, bloodlines, artificial kidneys and other biohazards. Proper waste disposal completes the circle started with proper infection control practices in the home hemodialysis setting. One of the greatest safety hazards is proper disposal of used needles that become a biohazard risk to care takers, family members and waste management personnel. Each state has their own guidelines and regulations on proper disposal of all home medical wastes in conjunction with the environmental protection agency (EPA). Patients should enquire from their supporting dialysis unit how to dispose of these wastes safely and in compliance with state, local and federal regulations. Needle safety starts first with a standard sharps disposal container in the home environment that is kept safely away from children and other members of the household.
Many hemodialysis patients have several co-morbid conditions and restricted mobility that places them at higher risk of death or injury from falls in the house. In addition, hemodialysis with high ultrafiltration rates increases the risk of falling from low blood pressure during and immediately after finishing a dialysis session. Adhering to low sodium diets and carefully monitoring for excess intradialytic weight gain is part of home dialysis safety. For patients with congestive heart failure and other cardio-pulmonary diseases that increase fluid retention, physicians and patients should consider daily, nocturnal home hemodialysis that minimizes the amount of fluid removed with each session and in addition removes the fluid slowly over a longer period of time. Many studies reveal less intradialytic hypotension and normalization of blood pressure with this approach making the risk of falling less likely.
Lastly, care partners should be able to perform basic emergency procedures such as placing the hypotensive patient in reverse trendelenberg, give a rapid saline bolus also being able to change the IV bag safely, have emergency numbers available as well as basic medical information to give to the responding paramedics. Hemodialysis in the early pioneering days of dialysis was by necessity a home-based therapy. Today we are rediscovering the benefits of dialyzing in the comfort and safety of the home environment with significantly improved mortality and a lower burden of complications than conventional in-center hemodialysis. As America continues to expand this needed home therapy, home dialysis training programs need to instill basic safety guidelines into the routine practice of dialysis in the home. Patients considering home hemodialysis need to embrace the responsibility of their own treatments and at the same time know that they shall enjoy the benefits of increased freedom to travel and an improved quality of life.
- Patient-Perceived Barriers to the Adoption of Nocturnal Home Hemodialysis - CJASN (April 2009)(4) 784-789, Cafazzo et al