Covid 19 information for dialysis professionals and dialysis providers habeeb

Information for Dialysis
Professionals and Dialysis
Providers
COVID-19
Habeeb Rahman P.K.
Dialysis technologist
Burjeel Hospital,UAE
habeebpkh03@gmail.com

‘CO’ stands for ‘corona’
‘VI’ stands for ‘virus’
‘D’ stands for ‘disease’
’19’ refers to 2019
Novel coronavirus Coronaviruses are viruses that circulate among animals but some of them
are also known to affect humans. The 2019 novel coronavirus was identified in China at the
end of 2019 and is a new strain that has not previously been seen in humans.
COVID-19

Is it Contagious COVID-19?
Virus Mortality: Comparison with Other Viruses
•COVID-19
•SARS
•MERS
•Recent Influenza Pandemics
•Swine Flu
2-3%
9.6%
34%
0.1%
0.02%
3
6
COVID-19 have been reported worldwide with
210 countries till 11/04/2020

• It takes between 2-14 days for symptoms to start
• Common symptoms: Fever, cough, sore throat, shortness of breath, muscle aches,
fatigue
• Less common symptoms: sputum production, headache, diarrhea
• Initial symptoms might be mild and fever might be absent
• Pneumonia caused by other organisms (including bacteria) and other viruses (such
as influenza)
Signs and Symptoms of COVID-19
Fever Cough
Shortness
of breath
Muscle
aches
DiarrhoeaSore
throat

Do people with COVID-19 lose their sense of
smell or taste?
Several groups of doctors, particularly those who
work in the ears/nose/throat field, have reported
that some people who lost their sense of smell or
taste and tested positive for the disease even
without other symptoms.
It may capable of causing severe illness, and some
infected people have died. It is possible that people
with underlying health conditions are at higher risk for
severe disease.

Clinical Assessment for patients suspect COVID-19

▪ Person-to-person spread is the primary mode
of transmission
•Between people in close contact with one
another (about 6 feet)
•Through respiratory droplets when an
infected person coughs or sneezes
▪ Contact with infected surfaces or objects
It may be possible to get COVID-19 by
touching surfaces and then touching your
mouth, nose, or eyes
COVID-19 is a new disease and we are still learning how it spreads
Transmission COVID-19

Diagnosis and treatment
Because symptoms are similar to
many other illnesses, tests are
needed to make the diagnosis
(throat swab, blood test).
There is no specific treatment.
Mild symptoms can be treated
with medicine to lower the fever,
or relieve pain.
If symptoms are more severe,
treatment in hospital is required.

•Remdesivir: an experimental antiviral medication which has been
used to treat Ebola virus.
•Chloroquine: oral prescription medication used for malaria
prevention or treatment in areas where malaria remains sensitive.
•Hydroxychloroquine: oral prescription medication used for
treatment of rheumatoid arthritis.
•Lopinavir-Ritonavir: antiviral medication used against HIV
The drugs being trailed include:
There are currently no medications that are proven to be consistently
effective in the prevention or treatment of COVID-19. Patients receive
supportive care, aimed at relieving their symptoms and preventing
complications while they recover. This can include the use of mechanical
ventilation if required.

❖People aged 65 years and older
❖People who live in a nursing home or long-term care facility
❖Other high-risk conditions could include:
❖ People with chronic lung disease or moderate to severe asthma
❖People who have serious heart conditions
❖ People who are immunocompromised including cancer
treatment
❖People of any age with severe obesity (body mass index [BMI]
>40) or certain underlying medical conditions, particularly if not
well controlled, such as those with diabetes, renal failure, or liver
disease might also be at risk
❖People who are pregnant should be monitored since they are
known to be at risk with severe viral illness, however, to date
data on COVID19 has not shown increased risk
Definition of High risk

Does kidney disease put me at a higher risk?
People on dialysis can have weaker immune systems,
making it harder to fight infections.
People with kidney
disease and other
severe chronic
medical conditions
are at higher risk for
more severe illness.

Preparing for COVID-19 in the
Outpatient Hemodialysis Setting

Instruct patients to call ahead to report fever or
respiratory symptoms, which allows facility to:
•Plan for their arrival – ER or dialysis isolation
•Direct them to the hospital

▪ I suggest to set a patient preparation area
▪ History of contact or recent travel asked (for both patient and
accompanying person)
▪ Check vital sings
▪ Screen for fever (for both patient and accompanying person)
▪ Assess symptoms of respiratory infection
▪ Provide tissues, alcohol-based hand rub (ABHR), and trash
cans
Receiving /Waiting Area

Waiting Area
• The patients without positive screening or history, can
stay in the waiting room
• The waiting room should be adequately ventilated or
air conditioned
• There should be 1-meter distance between the sitting
chairs
• The accompanying persons should be instructed to go
back and sit in the private vehicle or if they do not have
one, can wait in the reception or lobby
• Instructions to patients and accompanying persons to
be displayed in front of the hemodialysis unit
• At the entry to dialysis, the patient should do the hand
wash or hand rub
• Try to provide Dialysis schedules on time - Avoid waiting

Daily exposure to news about coronavirus may result
in a range of responses. Reactions can be emotional,
somatic, and behavioral, and can impact mental and
physical health. It is important to be aware of your
reactions to the outbreak and know strategies to
cope with distress.

Symptomatic contacts/those with undiagnosed
moderate to severe respiratory infections

• Dialyze in isolation room or in isolation shifts (or in a corner bed)
• Staff to wear full PPE (to wear N95 mask)
• To avoid aerosol generating procedures like nebulization in the dialysis room
• The patients also to wear surgical mask
• To avoid intradialytic meals (candy may be tried)
• Patients and healthcare workers to take Hydroxychloroquine prophylaxis to
be prescribed by the doctor in charge (ICMR recommendation on dosing
need not be modified)
• Before starting HCQS, take a baseline ECG and repeat one 2 days later to
assess QT interval. If the QT interval prolongation is more than 450 ms , take
a Cardiology opinion. If the second ECG shows QT prolongation of more than
25% from the baseline QT, to stop HCQS.
• After the patient goes, fumigation or disinfection may be carried out
• To avail only private vehicles for coming to dialysis unit
Symptomatic contacts/those with undiagnosed moderate to severe
respiratory infections

• Separate toilet attached to the isolation room should be there
• Designated staff should not deal with other patients in the same
shift
• No dialyzer reuse until the incubation period is over
• The patients also to wear surgical mask
• Strict universal precautions with frequent hand hygiene
• Sample to be sent for testing at the earliest
• To notify the Hospital Infection Control Committee
• Fumigation of the room and surface disinfection is mandatory at
the end of the dialysis.
• To come for dialysis either in private vehicles/hospital ambulance
• All other general instructions to be followed.
Continue : Symptomatic contacts/those with undiagnosed moderate
to severe respiratory infections

❑Symptomatic Covid-19 patients should be hospitalized in isolation
room and should be monitored adequately by the medical team.
❑Based on the available evidence, the nephrologist can decide on
the treatment protocol (Available evidence suggest that it is better to start
the drugs early in the course of the illness before it becomes more severe. Dose
is 400/100 mg per orally 12th hourly for Lopinavir/Ritonavir (dose modification
is not required and is not cleared by hemodialysis) and for HCQS, it is 400 mg
12th hourly x 1 day followed by 200 mg 12th hourly x 4 days)
❑Anti-bacterial antibiotics can be initiated to treat secondary
bacterial pneumonia according to the hospital antibiotic policy.
❑Ensure supports : Need for ventilator support, Emergency
Specialty care like Cardiology, Pulmonology, and Intensive Care
and Urgent surgical intervention
Symptomatic COVID-19 Patients

Entering and exit
also, the patient to
be given the hand
rub
If respiratory symptoms or
Asymptomatic contacts 6 feet
Surface
disinfection
between shifts
is mandatory
Try achieve dry
weight and make
adequate HD , to avoid
emergency dialysis or
Extra HD
Try to minimize
travel through
public transport
Frequent disinfection of
the toilet(housekeeping
staff also to wear PPE )
Do not be allowed
to bring in outside
stuffs (Including
food items)

❖ The patient should not be allowed to bring in mobiles, blankets, or any
unnecessary items
❖ Staff again to take history for fever or contact or travel (chart like corona board to
be filled for every patient and kept in the hemodialysis chart)
❖ All staff to adhere to universal precautions
❖ Machine external surface disinfection between shifts is mandatory
❖ The cots, beds, handrails of weighing machines, nursing station, doorknobs, BP
cuffs etc. to be disinfected frequently
❖ Minimize intradialytic snacks as much as possible
❖ Keep the HD record in the unit. Do not send it with the patient
❖ At the exit also, the patient to be given the hand rub
❖ To keep the patient in dry weight so as to avoid emergency presentation. If
possible, try to do extended hours of dialysis like 5 hours to maintain the patients
dry weight and potassium balance especially for those doing twice weekly
hemodialysis
❖ Try to minimize travel through public transport
❖ Since viral shedding can occur through faeces and urine, frequent disinfection of
the toilet to be done and housekeeping staff also to wear PPE and take all
universal precautions

"I attribute my success to this; I never gave nor took any excuse."
—Florence Nightingale
Be Ready
Be aware
Before

Personal Protective Equipment (PPE) –COVID KIT
–Isolation gown/PE apron
–Coverall (Body cover )
–Gloves (Nitrile Glove )-2
–Facemask-1
–Goggle -1
–PP elastic boot cover -2
❑ The isolation gown should be worn over or instead of the cover
gown that is normally worn by hemodialysis personnel
❑ Personal glasses and contact lenses are NOT considered adequate
eye protection

Donning and Doffing PPE

1. Always put on essential required PPE when handling either a suspected, probable
or confirmed case of viral infection
2. The dressing and undressing of PPE should be supervised by another trained
member of the team.
3. Put on rubber boots. If not available, make sure you have closed, puncture and
fluid resistant shoes and put on overshoes
4. Put first pair of nitrile gloves
5. Place the impermeable gown over the scrubs
6. Put on face protection:
a) Put on a medical mask
b) Put on goggles or a face shield
7. Put on face protection: 6a Put on a medical mask. 6b Put on goggles or a face
shield
8. Perform hand hygiene.
9. Put on gloves* (over cuff).
10.If an impermeable gown is not available, place waterproof apron over gown.
11.Verification
Donning PPE (Putting on)

2Hand hygiene1

4
Put first pair of nitrile gloves
Hand hygiene perfumed used
alcohol-based solution

Buttoning up the backside
of the gown :Perform by
assistant
Place the impermeable gown over the scrubs.
5

Fitting the respirator’s metal nose clip
Wearing of goggles with
temples
Put on face protection:
Put on a medical mask.6a Put on goggles or a face shield.6b

Don Surgical Cap/Bouffant
Both ears must be
cover and no hair
must stick out
head cap
7
Hand hygiene8

10
9
Wearing of gloves

Removing (doffing) the PPE
1. Remove waterproof apron and dispose of safely. If the apron is to be
reused, place it in a container with disinfectant.
2. Remove waterproof apron and dispose of safely. If the apron is to be
reused, place it in a container with disinfectant.
3. Remove gown and gloves and roll inside-out and dispose of safely.
4. If wearing rubber boots, remove them (ideally using the boot
remover) without touching them with your hands. Place them in a
container with disinfectant.
5. Perform hand hygiene.
6. If wearing a head cover, remove it now (from behind the head).
7. Remove face protection: Remove face shield or goggles (from
behind the head). Place eye protection in a separate container for
reprocessing.
8. Remove mask from behind the head. When removing mask, untie
the bottom string first and the top string next.
9. Perform hand hygiene

Remove gown and gloves and roll inside-out and dispose of safely.
3

Remove face protection:
Gasp ear or head piece with
ungloved hand
7a

MASK OR RESPIRATOR
WASH HANDS OR USE AN ALCOHOL-BASED
HAND SANITIZER IMMEDIATELY AFTER
REMOVING ALL PPE
7b
8

Limited Reuse and Extended Use of N95 Respirators and Face Shields
LIMITED REUSE
– Limited reuse refers to the practice of using the same N95
respirators for multiple encounters with patients, but doffing after
each encounter.
– The respirator is stored in between encounters and is donned prior
to the next encounter with a patient.
EXTENDED USE
– Extended use refers to the practice of wearing the same N95
respirators for repeated close contact encounters with several
different patients, without removing between patient encounters.
– Extended use is well suited to situations wherein multiple patients
with the same infectious disease diagnosis, whose care requires use of
a respirator, are cohorted (e.g., housed on the same hospital unit or
same room).
– Instructions: The Limited Reuse instructions on the next slide applies
when patient care is complete or at the end of shift.

Maintain good personal hygiene
• Wash your hands frequently with soap and
water.
• Use alcohol-based hand sanitiser when
soap and water are not readily available.
• Cover your coughs and sneezes. Use a
tissue or change your face mask
• Immediately throw the tissue in a bin and
wash your hands.

Avoid exposure
Avoid touching your face (eyes, nose and mouth) – especially
if you have touched objects handled by many people (such
as handrails, door handles).
Do not share food, drinks and personal items.
Avoid shaking hands, kissing or hugging; instead wave,
bow, nod or use any other culturally appropriate
gesture to greet visitors maintaining a distance of at
least one metre.
When in public areas, as much as possible, keep 1-2
metres distance from other people.
Get the flu shot – this will reduce the risk of seasonal flu
and possible confusion with COVID-19 symptoms.

• Try to avoid coming in public transport. Hospital administration can arrange
for accommodation in the hospital itself if needed
• Staff with contact history should not come for work until the quarantine
period is over
• It is better to convert the to two pools, each half taking 12-hour duty for one
week, while the second half on home quarantine and then rotate every week.
• Staff should know the correct steps in putting and removing PPE.
• Staff should teach the patients about the proper disposal of the mask.
• Staff attending to positive patients or suspects should be given HCQS
prophylaxis
• Staff more than 50 years of age, pregnancy, or with any comorbidities, should
not be attending positive patients or suspects
• Try to minimize group rounds and case discussions in the unit
• Staff members should have meals at different times

Incidence of AKI in all ICU admissions may be around 15-40%, but this rate may be
increased in the setting of COVID-19 with ARDS. RRT if required should be delivered to
such patients in a safe and timely manner and at the same time minimizing the exposure
to the Nephrologist and Dialysis staff
COVID 19 patients with acute kidney injury
❖ Indications to start RRT are similar patients with AKI
❖ The decision to initiate RRT is as per nephrologist’s discretion.
❖ Vascular access to be placed under ultrasound guidance with universal
precautions.
❖ All HD/CRRT for Covid 19 related AKI to be done only in isolation ICUs.
❖ After each dialysis sessions, HD equipments to be cleaned with the
disinfectant before removing from that room and additional cleaning
before the machine is used for another patient.

CRRT Modalities
• SCUF- Slow Continuous Ultrafiltration
Ultrafiltration
• CVVH- Continuous Veno-Venous Hemofiltration
Convection
• CVVHD- Continuous Veno-Venous Hemodialysis
Diffusion
• CVVHDF- Continuous Veno-Venous Hemodiafiltration
Diffusion and Convection

CRRT Machines

SCUF
Syringe pump
Return Pressure Air Detector
Blood Pump
Access PressureFilter Pressure
BLD
Hemofilter
Patient
Effluent Pump
Return Clamp
Pre Blood Pump
Effluent Pressure

306100135
CVVH
Return Clamp
Patient
Access Pressure
Effluent Pump
Syringe Pump
Filter Pressure
Hemofilter
Pre
Post
Post
Replacement PumpReplacement Pump Pre Blood Pump
Effluent Pressure

306100135
CVVHD
Return Clamp
Access Pressure
Blood PumpSyringe Pump
Filter Pressure
Hemofilter
Patient
Effluent PumpDialysate Pump Pre Blood Pump
BLD
Effluent Pressure

CRRT : Prescription
AKI
Dose : ml/kg/BW/hr

Please mail your feed backs and Questions
habeebpara@outlook.com
Share your ideas and innovation did on dialysis

• https://www.kidney.org/coronavirus/kidney-disease-covid-19#does-kidney-disease-put-me-higher-risk
• CRRT work shop –Dr.Osama El-Sahath
• Bellomo R, Ronco C. Continuous renal replacement therapy in the intensive care unit. Intensive Care Med 1999;25:781-789.
• 2. Abdeen O, Mehta R.L. Dialysis modality in the intensive care unit. Crit Care Clin 2002;18:2;223-247.
• 3. Bellomo R,Ronco C. Indications and criteria for initiating renal replacement therapy in the intensive care unit. Kidney Int
1998,Vol.53,Suppl.66:S-106-109.
• 4. Burchardi H. History and development of continuous renal replacement techniques.Kidney Int1998, Vol.53, Suppl.66:S120-124.
❑ CDC Web Resources
▪ InfectionPreventionand Control Guidance for HealthcareSettings:
– https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-
recommendations.html
▪ Steps Healthcare FacilitiesCan TakeNow to Prepare
– https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/steps-to-prepare.html
▪ People at Risk for Serious Illness
– https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/high-risk-
complications.html
▪ Healthcare Infection Preventionand ControlFAQs
– https://www.cdc.gov/coronavirus/2019-ncov/infection-control/infection-prevention-
control-faq.html
▪ Videos
– https://www.cdc.gov/coronavirus/2019-ncov/communication/videos.html
References
• NAK:Covid -19 guidelines for nephrologists
• ASN: COVID-19 Information for providers of dialysis service
• CDC Guidelines for Infection control
• Clinical Assessment for patients suspect COVID-19 DOH- UAE

Published on 11-04-2020

Covid 19 information for dialysis professionals and dialysis providers habeeb

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