In June 2011, the heart failure program at Maimonides Medical Center in Brooklyn, N.Y., began using aquapheresis therapy as an option to manage patients with severe fluid overload. With the Aquadex FlexFlow system, the device-based therapy removes extra sodium and water from the blood and the body in 24 to 48 hours or sometimes longer, depending on the amount of fluid that needs to be removed.
Although the patients length of stay in the hospital is dependent on his or her overall medical status and comorbidities, aquapheresis uses a simplified form of ultrafiltration and manages fluid removal more efficiently than standard diuretic therapy.
“The average removal rate is approximately 200 to 250 mL per hour, and since the amount and rate to be removed can be specified exactly, there is a gradual reduction of fluid that has less impact on the patients blood pressure, heart rate and electrolyte levels,” said Sandra Francis, RN, FNP-C, nurse practitioner, department of cardiology, heart failure program and advanced cardiac interventional unit. “As a result, patients experience fewer side effects and remain symptom-free for longer periods of time.”From left, Aleksandra Zagorin, RN, nurse practitioner, home medical care for the elderly; Margaret Sosnowski, RN, instructor for education department; and Jennifer Dorman, RN, clinical nurse specialist, rapid response team, discuss the Vermont Nurses in Partnership preceptor program at Maimonides Medical Center.
In the nurse practitioner-run program, treatment goals are to remove excess fluid, achieve fluid balance, relieve symptoms and improve the overall quality of life for patients. A patient referred for aquapheresis initially is evaluated by a nurse practitioner, and after a thorough exam, the NP and medical director discuss the treatment plan with the patient, staff nurses, bedside physician assistants, residents and primary attending physician. Once the patient gives the NP written consent, and a central or peripheral venous access line is inserted, the patient receives a weight-based heparin bolus.
During aquapheresis therapy, the HF program team closely monitors and records the patients intake and output and daily weights; adjusts fluid removal rates; and monitors electrolyte and coagulation levels. Patients are on continuous heparin infusions during this therapy, and these rates are titrated to maintain coagulation levels based on recommended guidelines.
“Our patients may have multiple disciplines involved in their care,” Francis said. “Since aquapheresis is primarily a fluid removal therapy used in patients who are in a state of fluid overload, we confer with all of these specialists.”
RNs and NPs monitor patients by telephone after discharge to reinforce education and compliance with diet and medication regimens at home. To date, 25 patients have been treated with aquapheresis and each patient has had an average of five to 10 liters of excess fluid removed successfully, Francis said.Eileen Williamson, RN, Nurse.coms senior vice president and CNE, third from left, discusses the latest nursing initiatives at Maimonides with, from left, Lourdes Ortega, RN, staff nurse, medical-oncology; Jennifer Dorman, RN, clinical nurse specialist, rapid response team; and Viktoriya Fridman, RN, NICHE-BOOST program coordinator.
“Aquapheresis therapy can fundamentally change a patients outlook on life, supporting her or him to feel better and also stay home and out of the hospital,” said Thomas Smith, RN, CNO. “We intend to measure and focus on the quality of life of our aquapheresis patients at Maimonides, since they tell us that it improves [their lives] in significant and palpable ways.”