3.4 Post-Dialysis Care, Hemostasis & Discharge

Post-Dialysis Care, Hemostasis & Discharge

The conclusion of a hemodialysis treatment is a critical transition period. The patient has just undergone substantial fluid removal and electrolyte shifts, rendering them vulnerable to cardiovascular instability. The Certified Hemodialysis Technologist (CHT) must execute the termination procedures meticulously, focusing on the safe return of blood, effective hemostasis of the vascular access, and comprehensive post-treatment assessment to ensure the patient is stable for discharge.

Termination of Treatment: The Rinse Back Procedure

When the prescribed treatment time has elapsed or if the treatment must be terminated early due to clinical complications, the blood in the extracorporeal circuit must be returned to the patient. This volume (typically 150-250 mL depending on the circuit) represents a significant portion of the patient's blood volume and must not be wasted unnecessarily.

The Rinse Back Process

1. The ultrafiltration is turned off, and the blood pump is stopped.
2. The arterial needle is clamped, and the arterial bloodline is disconnected from the needle and attached to a sterile saline infusion line.
3. The blood pump is restarted at a slow speed (usually 100-150 mL/min). Normal saline is drawn into the arterial line, pushing the blood through the dialyzer, down the venous line, and back into the patient via the venous needle.
4. The technician must closely monitor the color of the fluid in the venous line. Once the line turns pale pink (indicating the blood has been returned and saline is now flowing), the blood pump is stopped, and the venous needle is clamped.

Critical Safety Note: The technician must maintain visual contact with the venous line and the saline bag throughout the entire rinse back procedure. If the saline bag empties, air will be drawn into the circuit and pumped into the patient, causing a fatal air embolism. Relying solely on the machine's air detector during rinse back is unsafe practice.

Needle Removal and Hemostasis

Once the blood has been returned, the needles must be carefully removed, and bleeding from the arteriovenous (AV) fistula or graft must be stopped (hemostasis). Because patients are heparinized during treatment, they are at an increased risk for prolonged bleeding.

Procedure for Needle Removal

1. Don appropriate Personal Protective Equipment (PPE), including a face shield, as there is a high risk of blood splatter during needle removal.
2. Carefully remove the tape securing the needle while holding the needle hub securely to prevent trauma to the vessel.
3. Withdraw the needle smoothly and quickly at the same angle it was inserted.
4. Do not apply pressure while the needle is being pulled out. Applying pressure over the sharp needle can slice the vessel wall, causing internal bleeding, hematoma formation, and permanent damage to the access.

Achieving Hemostasis

Once the needle is completely removed, apply sterile gauze and immediate, firm pressure.

• Two-Point Pressure: The correct technique involves applying pressure not just at the skin exit site, but also slightly above it to compress the actual hole in the blood vessel wall. The skin hole and the vessel hole are rarely perfectly aligned due to the angle of insertion.
• Pressure Duration: Hold continuous pressure for 10-15 minutes (or as dictated by facility protocol). Do not "peek" by lifting the gauze frequently, as this disrupts the forming clot.
• Avoid Mechanical Clamps: Manual pressure using two gloved fingers is the gold standard. Hemostatic clamps (C-clamps) should be used with extreme caution, only when specifically ordered, and closely monitored. Excessive pressure from clamps can completely occlude blood flow, leading to thrombosis (clotting) of the entire fistula or graft.

Assessing for Complications

After bleeding stops, the technician must inspect the site. The presence of a localized swelling or a hard lump that pulses suggests a hematoma or a pseudoaneurysm caused by blood leaking into the surrounding tissue. The access must also be auscultated for a bruit and palpated for a thrill to ensure it has not clotted during hemostasis.

Post-Dialysis Assessment and Discharge

Before a patient can safely leave the facility, their clinical stability must be verified.

Vital Signs Evaluation

Post-dialysis blood pressure and heart rate must be measured. A patient should never be discharged if their standing blood pressure indicates severe orthostatic hypotension (a significant drop upon standing accompanied by dizziness). If a patient is hypotensive, they should remain seated or supine, and the clinical team may need to administer normal saline boluses to restore intravascular volume.

Post-Dialysis Weight

The patient must be weighed accurately after the treatment. This "post-weight" serves two critical functions:

1. Verification of Therapy: It determines if the target dry weight was achieved. If the post-weight is significantly higher than the target dry weight, the patient was under-dialyzed regarding fluid removal.
2. Baseline for Next Treatment: Today's post-weight is the starting point for calculating the Interdialytic Weight Gain (IDWG) at the patient's next appointment.

Patient Evaluation

Assess the patient's overall well-being. Are they steady on their feet? Are they experiencing any lingering cramps, headaches, or dizziness? Discharge requires the patient to be alert, oriented, hemodynamically stable, and free from active bleeding. Proper execution of post-dialysis care ensures that the benefits of the therapy are secured and the patient transitions safely back to their daily life.