A 63-year-old man was admitted with severe renal failure requiring urgent hemodialysis with creatinine levels 16 mg/dl and 297 mg/dl through double lumen (dl, beginning with a positive venous catheter showing urinary urea level > 160 mg/dl).
Subsequently, on a monthly basis, she received the four chemotherapy cycles already indicated with VAD (Vincristine, Adriamycin and Dexamethasone) during hospitalization.
For this purpose, coordination was provided by both services, starting hemodialysis on the first day of the cycle at 8 hours, and once the same period was completed, chemotherapy treatment could be avoided by continuous infusion for 21 hours until the following time.
After the fourth cycle of treatment, a partial response was observed, which led the patient to propose a protective isolation room for MM, causing a medullary aplasia and subsequent autologous transplantation of M
This type of room does not have a water circuit treated for hemodialysis, so the use of CVVHDF intermittently was proposed as a therapeutic form.
Thus appears the need for training of nephrology nursing as it should be involved both in the technique and in the comprehensive treatment of the patient and should collaborate closely in their care or with the unit of medical and nursing staff.
• Apply individualized nursing care to a patient with renal failure in situations of spinal cord aplasia after autologous Bone Marrow Transplantation, admitted to a protective isolation room and performing the procedure
• Learning of the VVHDF monitor management, Fresenius Multifil®
• To know the protective isolation room, its characteristics and way to work in it.
• Learning how to care for immunosuppressed patients with spinal cord aplasia whose duration is expected to be 2-3 weeks.
• To know how to act in the face of complications of bone marrow transplantation.
(a) Discharge of care to immunosuppressed patients
The nursing team of the Pathophysiology Department instructed us about the characteristics of the isolation unit, the way of access, the peculiarities of the immunosuppressed patient, the problems faced, the risks inherent to the transplant, highlighting the following problems:
• Changes in gas exchange related to post-transplant anaemia.
• Feeding disorders related to oral mucosal disorders.
• Changes in nutrition related to vomiting, diarrhoea and poor intake.
• Changes in the pattern of elimination (either diuresis or faeces)
• Changes in sleep pattern.
• Alterations in communication with the family related to their stay in a restricted access isolation room (only one person is allowed to stay)
• Anxiety that provokes the new situation, uncertainty about the evolution of the treatment, recovery and future before the two pathologies.
(b) become familiar with the characteristics of a protective reversed isolation room;
The isolation unit of pathology has restricted access.
After placement of a garment, the placement of a sterile uniform is necessary to access the enclosure that communicates with the protective reversed isolation room.
The hallway is equipped with a positive-pressure air installation with regard to the room for access to clothing and nursing control.
The isolation room is 8 m2 equipped with the minimum necessary furniture for patient care, sealed air, positive air above the upper limit and external ventilation 12 hours, and a completely changing environment through a filter.
(c) Advancement of monitors
The indication of CVVHDF as a technique to use was the acquisition of a new monitor Fresenius Multifilter® that does not require connection to hemodialysis water network, which was already used in our service.
The learning of nurses responsible for patient care had to be harmless, since we had little time to apply this therapy in a new environment for our service (a restricted access room, with a single presence of a nurse).
We proceeded 15 days before the transplant to the extraction of own cells of the patient by the sera conventional hemodialysis technique and then began the treatment with 'burnfalán' (140 mg/iv/m2 body surface protocol adapted to medulla therapy).
On day 4 post-transplantation we performed the first CVVHDF for which we proceeded as follows:
1.
Entry of the nurse into the isolation unit; for this purpose in the clothing, usual clothing and supplements were removed, sterile uniform was placed, garlic and masked.
2.
Transmission of the patient's current condition by the nurse of a mental health unit.
3.
Entry of all necessary material for the session and tubes to obtain blood samples.
Once all the material is inside the room and always with the door closed, the monitor is prepared.
4.
The patient's general condition was assessed by taking the vital signs and weight, corroborating the ultrasound guided.
5.
Hand washing, changing the mask and placing sterile gloves
6.
Assessment of the catheter insertion point, patency check and cure with asepsis.
7.
Blood sample extraction for analysis.
8.
Start of connecting the patient and introducing the medication and administering the anticoagulation medication.
9.
Once implemented, therapy was constantly monitored and parameters were controlled, as well as patient care.
The most frequent incidents were as follows:
• Alarm of blood flow caused by patient movements, postural changes, need for liquid intake, need to cough, evacuate, attend telephone calls, which were numerous when the visits were restricted and counting on business.
• Blood pressure and heart rate remained within acceptable levels
• On day +6, the patient had a febrile episode of 38o, mucositis, general pain requiring administration of antipyretics and analgesia with hemocultive chloride, removing the central line inserted for administration of antibiotic treatment according to protocol.
The fever disappears soon after, with a clear improvement in her general condition.
The hemocultive was positive for staphylococcus epidermis.
There were no circuit coagulation problems adjusting the heparin administration according to the system indication.
Asepsis measures in handling the hemodialysis catheter were adequate, allowing its use both during this process and throughout the treatment until the end of the dialysis program, with negative orifice and content cultures.
The maintenance of some residual function by the patient allowed that despite the serum therapy used the gains were not high, starting to perform CVVHDF every 48 hours although they were previously raised every 24 hours.
