Dialysis Without Anticoagulation(Heparin Free Dialysis)

Mahmoud Eid

KUC Alexandria Egypt

Indications For Dialysis without anticoagulationbull Pericarditisbull Recent surgery with bleeding complications or risk especially Vascular and

cardiac surgery (AVF Catheter Insertion)

bull Eye surgery (retinal and cataract)

bull Renal transplant ()

bull Brain surgery

bull Coagulopathy

bull Thrombocytopenia

bull Intracerebral hemorrhage (Hgic stroke is the most common indication in USA)

bull Ischemic stroke Active bleeding

bull acutely ill patients

bull Patientrsquos at increased risk of bleeding (oral anticoagulation systemic anticoagulation)

bull Tips

bull The clinician must identify the true indications of heparin free dialysis as itrsquos use may be associated with some serious adverse effects

bull Risk vs Benefit

bull Eg in patients with persistent HTN

bull If there is no clear indication please consider (restricted heparin regimens other anticoagulants)

bull Patient Safety Comes first not money

Techniques

bull Regional Citrate anticoagulation (Ca)

bull Regional Heparin Anticoagulation (Protamine)

bull Intermittent Saline Flush (ISF)

bull Continuous Saline flush (CSF) predilution

bull Heparin CoatedGrafted Dialyzer Membranes

bull Citrasate acid concentrate for bicarbonate-based dialysis that uses citric acid

Technical or operator-induced factors (resulting in clotting) bull Dialyzer Priming Retained air in dialyzer (due to inadequate priming or poor priming technique)

bull Rapid blood pump speed while primingbull Not giving enough time (no rush)bull Empty priming bagsbull Air in the infusion or heparin linebull Tip return the dialyzer to the upright position after the ECC is filled with the patient bloodbull Proper wetting of the fibers

bull Vascular Access Inadequate blood flow due to needlecatheter positioning or clotting

bull Excessive access recirculation due to needletourniquet position reversal of catheter blood lines

bull Frequent interruption of blood flow due to inadequate delivery or machine alarm situations

bull High level of Blood in the venous air chamber (must leave 13 empty)

Tip (you must be able to see the stream of the blood in the chamber to avoid stasis)

bull Excessive ultrafiltration (rate gt net)

Signs of clotting in the extracorporeal circuit

bull Extremely dark blood

bull Shadows or black streaks in the dialyzer

bull Foaming with subsequent clot formation in drip chambers and venous trap

bull Rapid filling of transducer monitors with blood

bull Teetering (suction) blood in the postdialyzer venous line segment that is unable to continue into the venous chamber but falls back into the line segment)

bull Presence of clots at the arterial-side header of the dialyzer

bull Rapid rise of TMP

bull Unexplained increase in the venous pressure

Scoring The Circuit(sagedal2013)

Venous Chamber

Normal 1

fibrinous 2

Clot formation 3

Clotted System 4

Dialyzer

Normal 1

few blood stripes (affecting less than 5 of the surface fibres)

2

many blood stripes (more than 5 of the surface fibres)

3

coagulated filter 4

Also in case of AVF Hemostasis lt10 minutes =1 10-30 minutes=2 gt 30 minutes=3

Prescription General) bull Prime the circuit properly

bull Heparin rinse (This step is optional Avoid if heparin-associated thrombocytopenia is present) Rinse extracorporeal circuit with saline containing 3000 units of heparinL

bull allow the heparin-containing priming fluid to drain by filling the extracorporeal circuit with either the patients blood or unheparinizedsaline at the outset of dialysis

bull High blood flow rate Set the blood flow rate to 350-400 mL per minute if tolerated (FROM THE START) If a high blood flow rate is contraindicated due to the risk of disequilibrium consider using a small-surface-area dialyzer andor slowing the dialysate flow rate or shortening the treatment sessions

ISF bull Anticoagulation-free HD utilizing NS flushes was reported by Sanders et al 1985

bull The utility of this step is controversial one recent study suggested that use of a saline rinse may actually promote clotting (perhaps via introduction of microbubbles into the circuit) (Sagedal et al 2006)

bull The purpose of the ISF is to bull allow inspection of a hollow-fiber dialyzer for evidence of clotting bull allow for timely discontinuation of treatment or changing of the dialyzerbull believed by some to reduce the propensity for dialyzer clotting or interfere with clot

formation

bull Procedure Rinse the dialyzer rapidly with 50-250 mL of saline while occluding the blood inlet line every 15-60 minutes until the dialyzer and the venous chamber are clear

bull The extra volume should be calculated and added to the UF

bull Online machines with programmed bolus (5008)

bull SHOULD NOT BE USED ROUTINELY WITH HEPARIN ANTICOAGULATION

Continuous Saline Infusion

bull CSI can also be used as an alternative to coagulation during dialysis Utilizing this technique saline is administered to the ECC continuously throughout the dialysis session at a given rate 200 mLhour (Zimbudzi 2013)

Indications For Dialysis without anticoagulationbull Pericarditisbull Recent surgery with bleeding complications or risk especially Vascular and

cardiac surgery (AVF Catheter Insertion)

bull Eye surgery (retinal and cataract)

bull Renal transplant ()

bull Brain surgery

bull Coagulopathy

bull Thrombocytopenia

bull Intracerebral hemorrhage (Hgic stroke is the most common indication in USA)

bull Ischemic stroke Active bleeding

bull acutely ill patients

bull Patientrsquos at increased risk of bleeding (oral anticoagulation systemic anticoagulation)

bull Tips

bull The clinician must identify the true indications of heparin free dialysis as itrsquos use may be associated with some serious adverse effects

bull Risk vs Benefit

bull Eg in patients with persistent HTN

bull If there is no clear indication please consider (restricted heparin regimens other anticoagulants)

bull Patient Safety Comes first not money

Techniques

bull Regional Citrate anticoagulation (Ca)

bull Regional Heparin Anticoagulation (Protamine)

bull Intermittent Saline Flush (ISF)

bull Continuous Saline flush (CSF) predilution

bull Heparin CoatedGrafted Dialyzer Membranes

bull Citrasate acid concentrate for bicarbonate-based dialysis that uses citric acid

Technical or operator-induced factors (resulting in clotting) bull Dialyzer Priming Retained air in dialyzer (due to inadequate priming or poor priming technique)

bull Rapid blood pump speed while primingbull Not giving enough time (no rush)bull Empty priming bagsbull Air in the infusion or heparin linebull Tip return the dialyzer to the upright position after the ECC is filled with the patient bloodbull Proper wetting of the fibers

bull Vascular Access Inadequate blood flow due to needlecatheter positioning or clotting

bull Excessive access recirculation due to needletourniquet position reversal of catheter blood lines

bull Frequent interruption of blood flow due to inadequate delivery or machine alarm situations

bull High level of Blood in the venous air chamber (must leave 13 empty)

Tip (you must be able to see the stream of the blood in the chamber to avoid stasis)

bull Excessive ultrafiltration (rate gt net)

Signs of clotting in the extracorporeal circuit

bull Extremely dark blood

bull Shadows or black streaks in the dialyzer

bull Foaming with subsequent clot formation in drip chambers and venous trap

bull Rapid filling of transducer monitors with blood

bull Teetering (suction) blood in the postdialyzer venous line segment that is unable to continue into the venous chamber but falls back into the line segment)

bull Presence of clots at the arterial-side header of the dialyzer

bull Rapid rise of TMP

bull Unexplained increase in the venous pressure

Scoring The Circuit(sagedal2013)

Venous Chamber

Normal 1

fibrinous 2

Clot formation 3

Clotted System 4

Dialyzer

Normal 1

few blood stripes (affecting less than 5 of the surface fibres)

2

many blood stripes (more than 5 of the surface fibres)

3

coagulated filter 4

Also in case of AVF Hemostasis lt10 minutes =1 10-30 minutes=2 gt 30 minutes=3

Prescription General) bull Prime the circuit properly

bull Heparin rinse (This step is optional Avoid if heparin-associated thrombocytopenia is present) Rinse extracorporeal circuit with saline containing 3000 units of heparinL

bull allow the heparin-containing priming fluid to drain by filling the extracorporeal circuit with either the patients blood or unheparinizedsaline at the outset of dialysis

bull High blood flow rate Set the blood flow rate to 350-400 mL per minute if tolerated (FROM THE START) If a high blood flow rate is contraindicated due to the risk of disequilibrium consider using a small-surface-area dialyzer andor slowing the dialysate flow rate or shortening the treatment sessions

ISF bull Anticoagulation-free HD utilizing NS flushes was reported by Sanders et al 1985

bull The utility of this step is controversial one recent study suggested that use of a saline rinse may actually promote clotting (perhaps via introduction of microbubbles into the circuit) (Sagedal et al 2006)

bull The purpose of the ISF is to bull allow inspection of a hollow-fiber dialyzer for evidence of clotting bull allow for timely discontinuation of treatment or changing of the dialyzerbull believed by some to reduce the propensity for dialyzer clotting or interfere with clot

formation

bull Procedure Rinse the dialyzer rapidly with 50-250 mL of saline while occluding the blood inlet line every 15-60 minutes until the dialyzer and the venous chamber are clear

bull The extra volume should be calculated and added to the UF

bull Online machines with programmed bolus (5008)

bull SHOULD NOT BE USED ROUTINELY WITH HEPARIN ANTICOAGULATION

Continuous Saline Infusion

bull CSI can also be used as an alternative to coagulation during dialysis Utilizing this technique saline is administered to the ECC continuously throughout the dialysis session at a given rate 200 mLhour (Zimbudzi 2013)

bull Tips

bull The clinician must identify the true indications of heparin free dialysis as itrsquos use may be associated with some serious adverse effects

bull Risk vs Benefit

bull Eg in patients with persistent HTN

bull If there is no clear indication please consider (restricted heparin regimens other anticoagulants)

bull Patient Safety Comes first not money

Techniques

bull Regional Citrate anticoagulation (Ca)

bull Regional Heparin Anticoagulation (Protamine)

bull Intermittent Saline Flush (ISF)

bull Continuous Saline flush (CSF) predilution

bull Heparin CoatedGrafted Dialyzer Membranes

bull Citrasate acid concentrate for bicarbonate-based dialysis that uses citric acid

Technical or operator-induced factors (resulting in clotting) bull Dialyzer Priming Retained air in dialyzer (due to inadequate priming or poor priming technique)

bull Rapid blood pump speed while primingbull Not giving enough time (no rush)bull Empty priming bagsbull Air in the infusion or heparin linebull Tip return the dialyzer to the upright position after the ECC is filled with the patient bloodbull Proper wetting of the fibers

bull Vascular Access Inadequate blood flow due to needlecatheter positioning or clotting

bull Excessive access recirculation due to needletourniquet position reversal of catheter blood lines

bull Frequent interruption of blood flow due to inadequate delivery or machine alarm situations

bull High level of Blood in the venous air chamber (must leave 13 empty)

Tip (you must be able to see the stream of the blood in the chamber to avoid stasis)

bull Excessive ultrafiltration (rate gt net)

Signs of clotting in the extracorporeal circuit

bull Extremely dark blood

bull Shadows or black streaks in the dialyzer

bull Foaming with subsequent clot formation in drip chambers and venous trap

bull Rapid filling of transducer monitors with blood

bull Teetering (suction) blood in the postdialyzer venous line segment that is unable to continue into the venous chamber but falls back into the line segment)

bull Presence of clots at the arterial-side header of the dialyzer

bull Rapid rise of TMP

bull Unexplained increase in the venous pressure

Scoring The Circuit(sagedal2013)

Venous Chamber

Normal 1

fibrinous 2

Clot formation 3

Clotted System 4

Dialyzer

Normal 1

few blood stripes (affecting less than 5 of the surface fibres)

2

many blood stripes (more than 5 of the surface fibres)

3

coagulated filter 4

Also in case of AVF Hemostasis lt10 minutes =1 10-30 minutes=2 gt 30 minutes=3

Prescription General) bull Prime the circuit properly

bull Heparin rinse (This step is optional Avoid if heparin-associated thrombocytopenia is present) Rinse extracorporeal circuit with saline containing 3000 units of heparinL

bull allow the heparin-containing priming fluid to drain by filling the extracorporeal circuit with either the patients blood or unheparinizedsaline at the outset of dialysis

bull High blood flow rate Set the blood flow rate to 350-400 mL per minute if tolerated (FROM THE START) If a high blood flow rate is contraindicated due to the risk of disequilibrium consider using a small-surface-area dialyzer andor slowing the dialysate flow rate or shortening the treatment sessions

ISF bull Anticoagulation-free HD utilizing NS flushes was reported by Sanders et al 1985

bull The utility of this step is controversial one recent study suggested that use of a saline rinse may actually promote clotting (perhaps via introduction of microbubbles into the circuit) (Sagedal et al 2006)

bull The purpose of the ISF is to bull allow inspection of a hollow-fiber dialyzer for evidence of clotting bull allow for timely discontinuation of treatment or changing of the dialyzerbull believed by some to reduce the propensity for dialyzer clotting or interfere with clot

formation

bull Procedure Rinse the dialyzer rapidly with 50-250 mL of saline while occluding the blood inlet line every 15-60 minutes until the dialyzer and the venous chamber are clear

bull The extra volume should be calculated and added to the UF

bull Online machines with programmed bolus (5008)

bull SHOULD NOT BE USED ROUTINELY WITH HEPARIN ANTICOAGULATION

Continuous Saline Infusion

bull CSI can also be used as an alternative to coagulation during dialysis Utilizing this technique saline is administered to the ECC continuously throughout the dialysis session at a given rate 200 mLhour (Zimbudzi 2013)

Techniques

bull Regional Citrate anticoagulation (Ca)

bull Regional Heparin Anticoagulation (Protamine)

bull Intermittent Saline Flush (ISF)

bull Continuous Saline flush (CSF) predilution

bull Heparin CoatedGrafted Dialyzer Membranes

bull Citrasate acid concentrate for bicarbonate-based dialysis that uses citric acid

Technical or operator-induced factors (resulting in clotting) bull Dialyzer Priming Retained air in dialyzer (due to inadequate priming or poor priming technique)

bull Rapid blood pump speed while primingbull Not giving enough time (no rush)bull Empty priming bagsbull Air in the infusion or heparin linebull Tip return the dialyzer to the upright position after the ECC is filled with the patient bloodbull Proper wetting of the fibers

bull Vascular Access Inadequate blood flow due to needlecatheter positioning or clotting

bull Excessive access recirculation due to needletourniquet position reversal of catheter blood lines

bull Frequent interruption of blood flow due to inadequate delivery or machine alarm situations

bull High level of Blood in the venous air chamber (must leave 13 empty)

Tip (you must be able to see the stream of the blood in the chamber to avoid stasis)

bull Excessive ultrafiltration (rate gt net)

Signs of clotting in the extracorporeal circuit

bull Extremely dark blood

bull Shadows or black streaks in the dialyzer

bull Foaming with subsequent clot formation in drip chambers and venous trap

bull Rapid filling of transducer monitors with blood

bull Teetering (suction) blood in the postdialyzer venous line segment that is unable to continue into the venous chamber but falls back into the line segment)

bull Presence of clots at the arterial-side header of the dialyzer

bull Rapid rise of TMP

bull Unexplained increase in the venous pressure

Scoring The Circuit(sagedal2013)

Venous Chamber

Normal 1

fibrinous 2

Clot formation 3

Clotted System 4

Dialyzer

Normal 1

few blood stripes (affecting less than 5 of the surface fibres)

2

many blood stripes (more than 5 of the surface fibres)

3

coagulated filter 4

Also in case of AVF Hemostasis lt10 minutes =1 10-30 minutes=2 gt 30 minutes=3

Prescription General) bull Prime the circuit properly

bull Heparin rinse (This step is optional Avoid if heparin-associated thrombocytopenia is present) Rinse extracorporeal circuit with saline containing 3000 units of heparinL

bull allow the heparin-containing priming fluid to drain by filling the extracorporeal circuit with either the patients blood or unheparinizedsaline at the outset of dialysis

bull High blood flow rate Set the blood flow rate to 350-400 mL per minute if tolerated (FROM THE START) If a high blood flow rate is contraindicated due to the risk of disequilibrium consider using a small-surface-area dialyzer andor slowing the dialysate flow rate or shortening the treatment sessions

ISF bull Anticoagulation-free HD utilizing NS flushes was reported by Sanders et al 1985

bull The utility of this step is controversial one recent study suggested that use of a saline rinse may actually promote clotting (perhaps via introduction of microbubbles into the circuit) (Sagedal et al 2006)

bull The purpose of the ISF is to bull allow inspection of a hollow-fiber dialyzer for evidence of clotting bull allow for timely discontinuation of treatment or changing of the dialyzerbull believed by some to reduce the propensity for dialyzer clotting or interfere with clot

formation

bull Procedure Rinse the dialyzer rapidly with 50-250 mL of saline while occluding the blood inlet line every 15-60 minutes until the dialyzer and the venous chamber are clear

bull The extra volume should be calculated and added to the UF

bull Online machines with programmed bolus (5008)

bull SHOULD NOT BE USED ROUTINELY WITH HEPARIN ANTICOAGULATION

Continuous Saline Infusion

bull CSI can also be used as an alternative to coagulation during dialysis Utilizing this technique saline is administered to the ECC continuously throughout the dialysis session at a given rate 200 mLhour (Zimbudzi 2013)

Technical or operator-induced factors (resulting in clotting) bull Dialyzer Priming Retained air in dialyzer (due to inadequate priming or poor priming technique)

bull Rapid blood pump speed while primingbull Not giving enough time (no rush)bull Empty priming bagsbull Air in the infusion or heparin linebull Tip return the dialyzer to the upright position after the ECC is filled with the patient bloodbull Proper wetting of the fibers

bull Vascular Access Inadequate blood flow due to needlecatheter positioning or clotting

bull Excessive access recirculation due to needletourniquet position reversal of catheter blood lines

bull Frequent interruption of blood flow due to inadequate delivery or machine alarm situations

bull High level of Blood in the venous air chamber (must leave 13 empty)

Tip (you must be able to see the stream of the blood in the chamber to avoid stasis)

bull Excessive ultrafiltration (rate gt net)

Signs of clotting in the extracorporeal circuit

bull Extremely dark blood

bull Shadows or black streaks in the dialyzer

bull Foaming with subsequent clot formation in drip chambers and venous trap

bull Rapid filling of transducer monitors with blood

bull Teetering (suction) blood in the postdialyzer venous line segment that is unable to continue into the venous chamber but falls back into the line segment)

bull Presence of clots at the arterial-side header of the dialyzer

bull Rapid rise of TMP

bull Unexplained increase in the venous pressure

Scoring The Circuit(sagedal2013)

Venous Chamber

Normal 1

fibrinous 2

Clot formation 3

Clotted System 4

Dialyzer

Normal 1

few blood stripes (affecting less than 5 of the surface fibres)

2

many blood stripes (more than 5 of the surface fibres)

3

coagulated filter 4

Also in case of AVF Hemostasis lt10 minutes =1 10-30 minutes=2 gt 30 minutes=3

Prescription General) bull Prime the circuit properly

bull Heparin rinse (This step is optional Avoid if heparin-associated thrombocytopenia is present) Rinse extracorporeal circuit with saline containing 3000 units of heparinL

bull allow the heparin-containing priming fluid to drain by filling the extracorporeal circuit with either the patients blood or unheparinizedsaline at the outset of dialysis

bull High blood flow rate Set the blood flow rate to 350-400 mL per minute if tolerated (FROM THE START) If a high blood flow rate is contraindicated due to the risk of disequilibrium consider using a small-surface-area dialyzer andor slowing the dialysate flow rate or shortening the treatment sessions

ISF bull Anticoagulation-free HD utilizing NS flushes was reported by Sanders et al 1985

bull The utility of this step is controversial one recent study suggested that use of a saline rinse may actually promote clotting (perhaps via introduction of microbubbles into the circuit) (Sagedal et al 2006)

bull The purpose of the ISF is to bull allow inspection of a hollow-fiber dialyzer for evidence of clotting bull allow for timely discontinuation of treatment or changing of the dialyzerbull believed by some to reduce the propensity for dialyzer clotting or interfere with clot

formation

bull Procedure Rinse the dialyzer rapidly with 50-250 mL of saline while occluding the blood inlet line every 15-60 minutes until the dialyzer and the venous chamber are clear

bull The extra volume should be calculated and added to the UF

bull Online machines with programmed bolus (5008)

bull SHOULD NOT BE USED ROUTINELY WITH HEPARIN ANTICOAGULATION

Continuous Saline Infusion

bull CSI can also be used as an alternative to coagulation during dialysis Utilizing this technique saline is administered to the ECC continuously throughout the dialysis session at a given rate 200 mLhour (Zimbudzi 2013)

Signs of clotting in the extracorporeal circuit

bull Extremely dark blood

bull Shadows or black streaks in the dialyzer

bull Foaming with subsequent clot formation in drip chambers and venous trap

bull Rapid filling of transducer monitors with blood

bull Teetering (suction) blood in the postdialyzer venous line segment that is unable to continue into the venous chamber but falls back into the line segment)

bull Presence of clots at the arterial-side header of the dialyzer

bull Rapid rise of TMP

bull Unexplained increase in the venous pressure

Scoring The Circuit(sagedal2013)

Venous Chamber

Normal 1

fibrinous 2

Clot formation 3

Clotted System 4

Dialyzer

Normal 1

few blood stripes (affecting less than 5 of the surface fibres)

2

many blood stripes (more than 5 of the surface fibres)

3

coagulated filter 4

Also in case of AVF Hemostasis lt10 minutes =1 10-30 minutes=2 gt 30 minutes=3

Prescription General) bull Prime the circuit properly

bull Heparin rinse (This step is optional Avoid if heparin-associated thrombocytopenia is present) Rinse extracorporeal circuit with saline containing 3000 units of heparinL

bull allow the heparin-containing priming fluid to drain by filling the extracorporeal circuit with either the patients blood or unheparinizedsaline at the outset of dialysis

bull High blood flow rate Set the blood flow rate to 350-400 mL per minute if tolerated (FROM THE START) If a high blood flow rate is contraindicated due to the risk of disequilibrium consider using a small-surface-area dialyzer andor slowing the dialysate flow rate or shortening the treatment sessions

ISF bull Anticoagulation-free HD utilizing NS flushes was reported by Sanders et al 1985

bull The utility of this step is controversial one recent study suggested that use of a saline rinse may actually promote clotting (perhaps via introduction of microbubbles into the circuit) (Sagedal et al 2006)

bull The purpose of the ISF is to bull allow inspection of a hollow-fiber dialyzer for evidence of clotting bull allow for timely discontinuation of treatment or changing of the dialyzerbull believed by some to reduce the propensity for dialyzer clotting or interfere with clot

formation

bull Procedure Rinse the dialyzer rapidly with 50-250 mL of saline while occluding the blood inlet line every 15-60 minutes until the dialyzer and the venous chamber are clear

bull The extra volume should be calculated and added to the UF

bull Online machines with programmed bolus (5008)

bull SHOULD NOT BE USED ROUTINELY WITH HEPARIN ANTICOAGULATION

Continuous Saline Infusion

bull CSI can also be used as an alternative to coagulation during dialysis Utilizing this technique saline is administered to the ECC continuously throughout the dialysis session at a given rate 200 mLhour (Zimbudzi 2013)

Scoring The Circuit(sagedal2013)

Venous Chamber

Normal 1

fibrinous 2

Clot formation 3

Clotted System 4

Dialyzer

Normal 1

few blood stripes (affecting less than 5 of the surface fibres)

2

many blood stripes (more than 5 of the surface fibres)

3

coagulated filter 4

Also in case of AVF Hemostasis lt10 minutes =1 10-30 minutes=2 gt 30 minutes=3

Prescription General) bull Prime the circuit properly

bull Heparin rinse (This step is optional Avoid if heparin-associated thrombocytopenia is present) Rinse extracorporeal circuit with saline containing 3000 units of heparinL

bull allow the heparin-containing priming fluid to drain by filling the extracorporeal circuit with either the patients blood or unheparinizedsaline at the outset of dialysis

bull High blood flow rate Set the blood flow rate to 350-400 mL per minute if tolerated (FROM THE START) If a high blood flow rate is contraindicated due to the risk of disequilibrium consider using a small-surface-area dialyzer andor slowing the dialysate flow rate or shortening the treatment sessions

ISF bull Anticoagulation-free HD utilizing NS flushes was reported by Sanders et al 1985

bull The utility of this step is controversial one recent study suggested that use of a saline rinse may actually promote clotting (perhaps via introduction of microbubbles into the circuit) (Sagedal et al 2006)

bull The purpose of the ISF is to bull allow inspection of a hollow-fiber dialyzer for evidence of clotting bull allow for timely discontinuation of treatment or changing of the dialyzerbull believed by some to reduce the propensity for dialyzer clotting or interfere with clot

formation

bull Procedure Rinse the dialyzer rapidly with 50-250 mL of saline while occluding the blood inlet line every 15-60 minutes until the dialyzer and the venous chamber are clear

bull The extra volume should be calculated and added to the UF

bull Online machines with programmed bolus (5008)

bull SHOULD NOT BE USED ROUTINELY WITH HEPARIN ANTICOAGULATION

Continuous Saline Infusion

bull CSI can also be used as an alternative to coagulation during dialysis Utilizing this technique saline is administered to the ECC continuously throughout the dialysis session at a given rate 200 mLhour (Zimbudzi 2013)

Prescription General) bull Prime the circuit properly

bull Heparin rinse (This step is optional Avoid if heparin-associated thrombocytopenia is present) Rinse extracorporeal circuit with saline containing 3000 units of heparinL

bull allow the heparin-containing priming fluid to drain by filling the extracorporeal circuit with either the patients blood or unheparinizedsaline at the outset of dialysis

bull High blood flow rate Set the blood flow rate to 350-400 mL per minute if tolerated (FROM THE START) If a high blood flow rate is contraindicated due to the risk of disequilibrium consider using a small-surface-area dialyzer andor slowing the dialysate flow rate or shortening the treatment sessions

ISF bull Anticoagulation-free HD utilizing NS flushes was reported by Sanders et al 1985

bull The utility of this step is controversial one recent study suggested that use of a saline rinse may actually promote clotting (perhaps via introduction of microbubbles into the circuit) (Sagedal et al 2006)

bull The purpose of the ISF is to bull allow inspection of a hollow-fiber dialyzer for evidence of clotting bull allow for timely discontinuation of treatment or changing of the dialyzerbull believed by some to reduce the propensity for dialyzer clotting or interfere with clot

formation

bull Procedure Rinse the dialyzer rapidly with 50-250 mL of saline while occluding the blood inlet line every 15-60 minutes until the dialyzer and the venous chamber are clear

bull The extra volume should be calculated and added to the UF

bull Online machines with programmed bolus (5008)

bull SHOULD NOT BE USED ROUTINELY WITH HEPARIN ANTICOAGULATION

Continuous Saline Infusion

bull CSI can also be used as an alternative to coagulation during dialysis Utilizing this technique saline is administered to the ECC continuously throughout the dialysis session at a given rate 200 mLhour (Zimbudzi 2013)

ISF bull Anticoagulation-free HD utilizing NS flushes was reported by Sanders et al 1985

bull The utility of this step is controversial one recent study suggested that use of a saline rinse may actually promote clotting (perhaps via introduction of microbubbles into the circuit) (Sagedal et al 2006)

bull The purpose of the ISF is to bull allow inspection of a hollow-fiber dialyzer for evidence of clotting bull allow for timely discontinuation of treatment or changing of the dialyzerbull believed by some to reduce the propensity for dialyzer clotting or interfere with clot

formation

bull Procedure Rinse the dialyzer rapidly with 50-250 mL of saline while occluding the blood inlet line every 15-60 minutes until the dialyzer and the venous chamber are clear

bull The extra volume should be calculated and added to the UF

bull Online machines with programmed bolus (5008)

bull SHOULD NOT BE USED ROUTINELY WITH HEPARIN ANTICOAGULATION

Continuous Saline Infusion

bull CSI can also be used as an alternative to coagulation during dialysis Utilizing this technique saline is administered to the ECC continuously throughout the dialysis session at a given rate 200 mLhour (Zimbudzi 2013)

Continuous Saline Infusion

bull CSI can also be used as an alternative to coagulation during dialysis Utilizing this technique saline is administered to the ECC continuously throughout the dialysis session at a given rate 200 mLhour (Zimbudzi 2013)

Heparin coated membranes

bull Hemophan user will prime the dialyzer with 12-20000 units of heparin circulated for 30 minutes before dialysis coated with (Mujais et al 1996)

bull AN69 ST dialyzers the user primes the dialyzer with 10000 units heparin 2L saline

bull Should be avoided in HIT due to mild heparinemia (Gueacutery et al 2014)

bull Plysulphone membrane some authors noted that there was some heparin adsorption (Kodras 2008Sagedal 2011 no difference between polysulphone and AN69 when both coated with heparin)

bull Heparin grafted membrane Evodial (Gambro) better success in Heparin Free Dialysis with (CSI amp ISF) Lavill et al 2014

bull Different membrane materials and circuit design There is no solid evidence to suggest that any one type of membrane material is better for heparin-free dialysis Although heparin coatings and LMWH coatings are being tried

Bicarbonate dialysis solution with low-concentration citrate (Citrasate)

bull A small amount of citric acid is used instead of acetic acid as the acidifying agent citrate by complexing with calcium has been suggested to inhibit blood coagulation and platelet activation locally at the dialyzer membrane surface resulting in improved dialyzer clearance and increased dialyzer reusability (Ahmad et al 2005)

Other technical points

bull elimination of dead spaces in blood tubing and reducing the presence of airblood interfaces in dialysis lines may be the most promising approaches to lower incidence of extracorporeal circuit clotting (Streamline tubing)

bull Blood product transfusion or lipid administration Administration via the inlet blood line has been reported to increase clotting risk during dialysis (can be administered after the dialyzer safely)

bull Heparin free hemodialysis with prophylactic change of system is a safe and practical method of treatment for patients at high bleeding risk but it is less effective more expensive and the patient requires closer care (Preuschof et al 1988 )

bull

bull Different membrane materials and circuit design There is no solid evidence to suggest that any one type of membrane material is better for heparin-free dialysis Although heparin coatings and LMWH coatings are being tried

Bicarbonate dialysis solution with low-concentration citrate (Citrasate)

bull A small amount of citric acid is used instead of acetic acid as the acidifying agent citrate by complexing with calcium has been suggested to inhibit blood coagulation and platelet activation locally at the dialyzer membrane surface resulting in improved dialyzer clearance and increased dialyzer reusability (Ahmad et al 2005)

Other technical points

bull elimination of dead spaces in blood tubing and reducing the presence of airblood interfaces in dialysis lines may be the most promising approaches to lower incidence of extracorporeal circuit clotting (Streamline tubing)

bull Blood product transfusion or lipid administration Administration via the inlet blood line has been reported to increase clotting risk during dialysis (can be administered after the dialyzer safely)

bull Heparin free hemodialysis with prophylactic change of system is a safe and practical method of treatment for patients at high bleeding risk but it is less effective more expensive and the patient requires closer care (Preuschof et al 1988 )

bull

Bicarbonate dialysis solution with low-concentration citrate (Citrasate)

bull A small amount of citric acid is used instead of acetic acid as the acidifying agent citrate by complexing with calcium has been suggested to inhibit blood coagulation and platelet activation locally at the dialyzer membrane surface resulting in improved dialyzer clearance and increased dialyzer reusability (Ahmad et al 2005)

Other technical points

bull elimination of dead spaces in blood tubing and reducing the presence of airblood interfaces in dialysis lines may be the most promising approaches to lower incidence of extracorporeal circuit clotting (Streamline tubing)

bull Blood product transfusion or lipid administration Administration via the inlet blood line has been reported to increase clotting risk during dialysis (can be administered after the dialyzer safely)

bull Heparin free hemodialysis with prophylactic change of system is a safe and practical method of treatment for patients at high bleeding risk but it is less effective more expensive and the patient requires closer care (Preuschof et al 1988 )

bull

Other technical points

bull elimination of dead spaces in blood tubing and reducing the presence of airblood interfaces in dialysis lines may be the most promising approaches to lower incidence of extracorporeal circuit clotting (Streamline tubing)

bull Blood product transfusion or lipid administration Administration via the inlet blood line has been reported to increase clotting risk during dialysis (can be administered after the dialyzer safely)

bull Heparin free hemodialysis with prophylactic change of system is a safe and practical method of treatment for patients at high bleeding risk but it is less effective more expensive and the patient requires closer care (Preuschof et al 1988 )

bull

D5W vs Saline

bull No data Most done with NS a new clinical trial underway ldquoEffect of Sodium Concentration of Priming and Rinsing Fluids on Weight GainrdquohttpclinicaltrialsgovshowNCT01168947

bull According to you experience Stick to NS

Patient on Oral Anticoaguation

bull First assess the need for oral anticoagulation

bull Therapeutic vs Prophylactic

bull INR regular follow up

bull According to assessment of the circuit patient may need extra anticoagulation using heparin or not Read more Krummel et al 2013 Ziai et al 2005

Patient on Oral Anticoaguation

bull First assess the need for oral anticoagulation

bull Therapeutic vs Prophylactic

bull INR regular follow up

bull According to assessment of the circuit patient may need extra anticoagulation using heparin or not Read more Krummel et al 2013 Ziai et al 2005

Aspirin

bull Reduction of plateletfibrin deposition in haemodialysersby aspirin administration Stewart et al 1975

bull Effect of sulphinpyrazone and aspirin on platelet adhesion to activated charcoal and dialysis membranes in vitro Winchester et al 1977

bull small number + in vitro

bull according to risk of bleeding gastric SE vs benefits

SLED

bull SLED

bull Marshall et al 2001 amp Berbec et al 2006 26 amp 29 respectively clotting

bull CRRT

bull Nagarik ET AL 2010

Dialysis Dose Delivery

bull Mcgill et all 2005 no difference in the dialysis dose and increased dialyzer treatment time is not necessary

Water for dialysis

bull Some senior dialysis veterans(patients mostly) claim that excessive ECC clotting could be related to the quality of dialysis water

Clotting in dialyzers due to low pH of dialysis fluid Schwarzbeck et al 1977

Dialysis Dose Delivery

bull Mcgill et all 2005 no difference in the dialysis dose and increased dialyzer treatment time is not necessary

Water for dialysis

bull Some senior dialysis veterans(patients mostly) claim that excessive ECC clotting could be related to the quality of dialysis water

Clotting in dialyzers due to low pH of dialysis fluid Schwarzbeck et al 1977

Water for dialysis

bull Some senior dialysis veterans(patients mostly) claim that excessive ECC clotting could be related to the quality of dialysis water

Clotting in dialyzers due to low pH of dialysis fluid Schwarzbeck et al 1977

Catheter Locking

bull McGill et al 2005 Instillation of heparin solution in dialysis catheters after HF-HD results in prolonged unintentional anticoagulation The duration and intensity of anticoagulation are sufficient to create increased risk of hemorrhagic events Heparin locking after HD should be avoided in cases where adverse hemorrhagic events are likely

bull Avoid Heparin Locking in HIT Heparin-induced thrombocytopenia due to heparin lock in a hemodialysis patient a case report (Chan et al 2014)

ACCP Guidelines (Suggest the use of regional citrate over the use of heparin or LMWH in patients requiring catheter locking 2C)

Alternatives

bull Citrate (low and high concentration)

bull Saline flushes and saline lock

bull Beigi et al 2014 Flushing PermCath with normal saline 09 is as effective as heparin in maintaining patency of the catheter while it may reduce the risks associated with heparinbull in the saline flush group it was locked with saline solution 09

bull Hypertonic saline solution (10 saline catheters retaining time and average blood flow velocities remained the same Chen et al 2014)

bull Low heparin concentration (100 uml-1000 u ml)

Alternatives

bull Citrate (low and high concentration)

bull Saline flushes and saline lock

bull Beigi et al 2014 Flushing PermCath with normal saline 09 is as effective as heparin in maintaining patency of the catheter while it may reduce the risks associated with heparinbull in the saline flush group it was locked with saline solution 09

bull Hypertonic saline solution (10 saline catheters retaining time and average blood flow velocities remained the same Chen et al 2014)

bull Low heparin concentration (100 uml-1000 u ml)

Recommendations

bull Good priming

bull No Rushing

bull Written protocol (indications procedure)

bull Think of the patientrsquos safety

THANK YOU

THANK YOU