Dialysis Water Treatment


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1 : Water Treatment for Hemodialysis AAMI Standards for Dialysate (2004) Salwa Ibrahim, MD MRCP Assistant Professor, Cairo University, Egypt
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3 : Why water purity is important during HDx
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5 : Philadelphia Incident-1987 A nurse in the facility noticed an unusually large number of hematocrits were lower than normal Patients also complained of headaches, malaise, and were hypotensive Forty-four patients out of 107, required transfusions After 2-3 days of symptoms, it became apparent that chloramine was the culprit causing haemolysis it was discovered that the water requirements for the facility had increased, and more RO membranes were added without increasing the size of the pretreatment carbon to accommodate the higher flow rate Furthermore, no written policy was in place regarding the testing of total chlorine levels and double checks with signatures were not standard procedure This incident illustrates the need for staff education
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11 : Carbon adsorption To remove chlorine and chloramines At least 2 Granulated Activated Carbon (GAC) of minimum iodine number of 900 or greater Mesh size 12x40 Empty bed contact time 5 minutes
12 : Reverse Osmosis Percent rejection and water quality monitors shall be used and continuously displayed with audible and visual alarms that can be heard in patient care area
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14 : AAMI Goal is to Prevent Patient Harm from our water How to do this?
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21 : Chlorine Test Free Chlorine Combined chlorine (chloramine) Hardness Test Measure calcium carbonate Less than 1 grain per gallon <17.5 mg/L Test post softener
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24 : Bacteria Testing System Should be performed at a minimum once a month for established system After a suspected pyrogenic reaction After modification of the water treatment system
25 : Bacteria sample collection Test worst Case scenario Right before disinfecting water system Collect dialysate as it exits from dialyzer at end of day Sample all points of use Allow sample port to flush 30-60 seconds Do not use betadine or bleach to clean port
26 : Bacteriology testing methods Must be assayed within ½ h of drawing or refrigerated at 5 degree C not longer than 24 hours Culture media of choice is trypticase Soy Agar (TSA) Incubate at 35-37 degree C for 48-72 hours Count viable colonies with magnifying device Shall not exceed 200 CFU/ml with an action level of 50 CFU/ml
27 : Bacteriology of the dialysate Collected during the termination of dialysis Every hemodialysis machine Total viable bacterial cont shall not exceed 200 CFU/ml with an action level of 50 CFU/ml The endotoxin level should be less than 2 EU/ml with an action level of 1 EU/ml
28 : Limulus Amebocyte Lysate (LAL) Assay AAMI Standard is < 2 Eu/ml with an action level of 1 EU/ ml Monthly testing Collect samples First point on the loop Last point on the loop After storage tanks After UV light After UF
29 : 50/200 50/200
30 : Summary Perform continuous monitoring of the source water Test for chlorine and chloramine before each shift Monitor conductivity continuously Perform routine bacterial culture and endotoxin Routine cleaning and disinfection of the system to prevent biofilm
31 : Q-1 Mr. X comes to the dialysis unit with no complaints. He initiates dialysis and within 30 minutes he exhibits shaking chills. No other patients are experiencing symptoms. You assess him for a source of infection and find no likely cause. Your next step should be to A. give the patient acetaminophen. B. draw water cultures. C. test dialysate for endotoxins. D. check the patient’s temperature postdialysis.
32 : Q-2 The dialysis technician reports 150 CFU/ml in the dialysis water. You should A. re-test next month. B. disinfect the water treatment system. C. test for endotoxins. D. disinfect the dialysis machines.
33 : Q-3 AMMI states chemical analysis of water for hemodialysis shall be performed at least annually only. at least annually and when RO membranes are replaced only. C. at least annually, when RO membranes are replaced, and when percent rejection falls below 90% only. D. at least annually, when RO membranes are replaced, when percent rejection falls below 90%, and with seasonal change
34 : Q-4 The Association for Advancement of Medical Instrumentation (AAMI) recommends that all water treatment devices are labelled with A. the type of device only. B. the type of device and how it functions only. C. the type of device, how it funtions, and what to monitor. D. the type of device, how it functions, what to monitor and the manufacturer's contact information.
35 : Thanks For Your Attendance

 

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