Recollections of dialysis in the 1970s.
Large dialysate tanks, arteriovenous shunts, large Kiil plate
dialysers, glass peritoneal dialysate bottles were the norm in 1970s
history, kidney, renal, nursing, dialysis
|Publication:||Name: Renal Society of Australasia Journal Publisher: Renal Society of Australasia Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 Renal Society of Australasia ISSN: 1832-3804|
|Issue:||Date: July, 2009 Source Volume: 5 Source Issue: 2|
|Product:||Product Code: 8089010 Dialysis Clinics NAICS Code: 621492 Kidney Dialysis Centers SIC Code: 8092 Kidney dialysis centers|
|Geographic:||Geographic Scope: Australia Geographic Code: 8AUST Australia|
One man pulled his shunt out while lifting an engine out of his
car, another caught the protruding loop on a door knob.
Dialysis in the 1970s was very different from today. Ada recalls a time in the early 1970s when the cut off age for accepting people for dialysis was 50 (which was also in line with the age of acceptance for transplantation). With the election of a Labour government in 1972, funding was increased for health services and older people were accepted. However, we remember the 1970s as a time when the patients were generally much younger and many people were still working. Remaining in the workforce was strongly encouraged and was used as an argument for taking people onto dialysis, as their 'economic contribution' helped offset the cost of their treatment. During these years very few patients with diabetes were accepted for dialysis; they were considered 'high risk' with poor survival prospects and many were never referred by their general practitioners.
There were two main dialysis treatments. Both were home based, as in-hospital, or community dialysis units, were not established until 1979-1980. Intermittent peritoneal dialysis, in the days before continuous ambulatory peritoneal dialysis (CAPD), was done overnight three times a week. Multiple glass bottles of peritoneal dialysis fluid were connected and hung onto a stand, with fluid delivered via 'octopus' tubing.
Fluid was pumped into the patient's peritoneal cavity via a Watson Marlow pump. Timers and three clamps allowed for automated inflow, dwell, and outflow cycles while the patient slept.
Haemodialysis patients had only arteriovenous shunts for access until Cimino Brescia fistulas started to be used after 1976. A shunt comprised two pieces of Teflon tipped silastic tubing inserted into an adjoining artery and vein, and joined externally via a straight connector. Due to the high risk of the tubing becoming disconnected, patients had to have two stainless steel 'shunt clips' at hand at all times to clamp the tubing in case of disconnection. Occasionally the tubing not only came apart, but was dislodged completely. One man pulled his shunt out while lifting an engine out of his car, another caught the protruding loop on a door knob. Patients were well equipped to deal with these situations: gauze and pressure!
Shunts would clot frequently, and if the patient or helper couldn't declot the shunt at home, the on call nurse would be called in to declot it. This often involved vigorous syringing, trying to suck the clot out, and often required the assistance of a plastic cannula attached to the end of the syringe to try and 'snare' the clot. Many patients were treated with aspirin and persantin to try to prevent recurrent clotting. Patients using shunts for dialysis did not need blood pumps or arterial pressure monitors, as the blood came out of the artery driven by the patient's heart.
Machines were much bulkier than today's machines. The machines first used at the Austin Hospital were the 'Sue Evans' designed tank systems. Dialysate was mixed by hand in a 150 litre insulated tank. One hundred litres of cold water, and 50 litres of hot water, were added first, and stirred for five minutes before testing the temperature. Once that was correct, four and a half litres of dialysate was added, and the mix stirred again. A manual test was then done to check the electrolyte mix. This was called the 'chloride test' and involved adding reagent to a sample of the solution, until the sample turned purple. The conductivity, an estimate of the electrolyte mix, could then be calculated. The solution in the tank was kept warm via a floating lid, and the tank insulation, and would provide enough dialysate for a long overnight run of 10 hours; the standard treatment time. The machines did not require temperature monitors or conductivity monitors.
Kiil plates were used before disposable dialysers were introduced. These dialysers were 'built' every Friday afternoon.
Three Perspex boards were scrubbed in the bath, and then one board at a time placed onto the supporting frame. Plastic ports were placed between two layers of cellophane, then the central board placed on top, another two layers of cellophane, and then the top Perspex plate. The boards were bolted down, working diagonally across the frame to ensure even tension. A pressure test was performed to ensure there were no air or blood leaks from the cellophane, or around the edge gasket. Air was pumped into the dialyser and the outlet port clamped for 30 minutes, then the pressure drop recorded. Once the 'pressure test' was done the dialyser was sterilised with a formalin solution and left over the weekend. Formalin was rinsed out before use on Monday morning. If the pressure test failed, you started again to rebuild the Kiil.
Venous pressure monitors were used to monitor the blood return to the patient and to check for clotting. Fluid was removed by the venous pressure alone as there was no negative pressure pump to suck fluid out. If the venous pressure was too high and too much fluid was being removed, saline replacement or extra drinks were given. If the venous pressure was too low, additional pressure was created by tightening a stop cock on the venous line below the venous drip chamber to provide enough pressure for fluid removal. This pressure was manually calculated, taking into account the surface area of the dialyser, the porosity of the membrane, the time on dialysis, and amount of fluid removal required. After a few runs, individual charts could be drawn up showing how much transmembrane pressure each patient needed to lose the required amount of fluid. This was all very different from the automated machines of today that do all the calculations and apply the correct pressure with the press of a button.
Prior to going home on dialysis, patients and their helpers would dialyse unsupervised in the hospital overnight, and would phone the on call nurse if assistance was needed. This gave them a period of consolidation without nursing staff present. Routine dialysis times were 10 hours overnight, three times a week.
Infection control procedures were strictly adhered to. There was no eating, drinking, eye scratching or pen chewing in the unit, and if any food or snacks were seen, it would incur the wrath of the Unit Director. In the early 1970s, major outbreaks of Hepatitis B had occurred overseas, and in some dialysis units both staff and patients had died. Hepatitis B vaccines had not yet been developed so we relied on strict infection control measures. Patients known to have Hepatitis B were dialysed at Fairfield Infectious Diseases Hospital. Staff were given gamma globulin injections to try to maintain some measure of protection.
In the pre epoetin era, haemoglobins were low, generally only 6-8 g/dl, particularly with anephric patients. Many patients received blood transfusions of two units every 3-4 weeks to keep them 'relatively asymptomatic' and consequently nearly all had iron overload. Some patients would give their own blood transfusions at home on dialysis. Patients in the 1970s struggled with their low haemoglobins, acetate dialysis machines and feeling unwell. Dialysers frequently ruptured involving large blood loss, and many patients experienced pyrogenic reactions while having treatment. Patients' families struggled to support them especially as many of the patients were young and still working and raising families. Dialysis is not much easier now for patients our machines may be better and we know what we are doing more than we did then, but the patients are older and frailer and it's still no fun being on dialysis. We have a lot of admiration for those people undergoing dialysis.
Submitted January 2009 Accepted May 2009
Margaret Morris at Margaret.MORRIS@svhm.org.au
Lang, D., Wilcox, A. & Morris, M. 2009 Historical Reflections: Recollections of dialysis in the 1970s Renal Soc Aust J 5(2) 66-67
Dorothy Lang (nee Alderson) was Deputy Charge Nurse, Dialysis Training Unit, Austin Hospital in the 1970s. Ada Wilcox is Nurse Unit Manager, Dialysis Training Unit, Austin Health, Victoria. Margaret Morris is the Renal Anaemia Co-ordinator, and Nurse Practitioner, Dialysis, St Vincent's Health, Victoria
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