Complications of Hemodialysis: Complications of Hemodialysis Reynel Dan L. Galicinao HD Nurse Trainee Nephrology Center of St. Alexius Common Complications during Dialysis : Common Complications during Dialysis Hypotension 25-60% of treatment sessions Cardiac arrhythmias 5-60% (usually asymptomatic) Cramps 5-25% Nausea & vomiting 5-15% Headache 5-10% Back pain 2-5% Chest pain 2-5% Itching 1-5% Fever 1% Less Common Complications : Less Common Complications Air embolism Seizures Hemolysis Severe dialysis disequilibrium 1st use syndromes Acute urticaria Cardiac tamponade Dialysis Disequilibrium Syndrome: Dialysis Disequilibrium Syndrome Occur in ARF or CRF if blood urea levels are reduced too fast, in those with very marked uremia, or pre-existing alterations in mental state Manifestations: headache , nausea, disorientation, restlessness, blurred vision, asterixis, fits, coma even death, occurring during or after dialysis Milder symptoms : cramps , nausea , dizziness PowerPoint Presentation: Probably caused by cerebral edema due to osmotic influx of water into the brain after removal of urea by dialysis, before equilibration across cell membranes occurs. Cerebral acidosis may play a role Rare in pts initially dialyzed for 2 h at low BFR Slow removal of urea minimizes risk Initial blood urea reduction during a 1 st dialysis should be <30%. PowerPoint Presentation: Prophylactic phenytoin Used in pts at highest risk (severe uremia , abnormal mental state) 1000 mg loading dose, then 300 mg/day Symptoms are self-limiting over a few hrs . Pts with severe fitting can be treated with IV mannitol ( 10-15 g) or hypertonic saline (5 ml of 23%). Hypotension: Hypotension Occurs in 15-50 % of HD sessions Can be episodic or persistent (less common) More frequent in pts with lower body mass, cardiac disease Intradialytic hypotension forms part of a vicious cycle maintaining HPN & fluid overload The response to a drop in BP is frequently to infuse NS or hypertonic saline, leaving the pt hypertensive, necessitating further use of antihypertensive agents, which in turn worsen intradialytic hypotension by inhibiting appropriate reflexes (tachycardia, vasoconstriction ) Other s/sx : N &V , cramps, yawning Common Causes of Hypotension: Common Causes of Hypotension Patient-specific causes Diabetes Autonomic neuropathy Reduced cardiac reserve (especially LVH & diastolic dysfunction) Arrhythmias Poor nutritional state High wt gain Ingestion of food during HD (increased splanchnic venous pooling) Antihypertensive agents impairing cardiac stability & reflexes Septicemia Release of adenosine during organ ischemia (e.g. induced by hypotension; adenosine is a vasodilator & inhibits norepinephrine release) Common Causes of Hypotension: Common Causes of Hypotension Treatment-specific Causes Rapid fluid removal (high UF rate) Antihypertensive agent use Rapid reduction in plasma osmolality (leading to water movement from the vascular into interstitial compartment) Warm dialysate Low sodium dialysate Low dialysate osmolarity Use of acetate as buffer (a vasodilator) Bioincompatibility Less Common Causes of Hypotension: Less Common Causes of Hypotension Pericardial effusion or tamponade Reactions to dialysis membranes Increased dialysate magnesium GI bleeding Disconnection of blood lines MI Hemolysis Air embolism Hypotension from excessive UF: Hypotension from excessive UF During UF, as water is removed from the vascular compartment, blood volume is maintained by movement of water from tissues (refilling). This can only occur until the true dry wt is achieved. Hypotension will be induced if UF is too rapid or excessive, as adequate refilling will not occur Most pts with ESRD also have diastolic dysfunction, which impacts on cardiac output especially under conditions of reduced vascular filling Factors contributing to uncontrolled UF: Factors contributing to uncontrolled UF HD machines without volumetric control of UF can lead to rapid fluctuations in UF rates Pts who drink too much between HD sessions have excessive (unachievable ) UF requirements during the HD This is usually driven by salt consumption (often hidden in foods). Salt intake of 0.5 g/day will lead to a 1.5 kg wt gain on average in a 70 kg anuric pt Wt gain should be 1 kg/day Excess BFR is a rare cause of hypotension Too low EDW will lead to hypotension. This occurs especially during recovery from an acute illness when lost muscle wt is being recovered. Management of Hypotension: Management of Hypotension Episodes of hypotension are uncomfortable & distressing for pts Hypotension lead to morbidity, contribute to cardiovascular mortality. Immediate management requires volume resuscitation: place pt head-down administer 100 ml bolus of NS (some units use 10 ml of 23% saline, 30 ml 7.5% saline, 50 ml 20% mannitol or albumin solutions ) reduce UF rate to zero if BP does not normalize rapidly, further saline may be given PowerPoint Presentation: Hypertonic saline may increase thirst, prevent achievement of dry wt, worsen fluid overload Albumin is very expensive In most cases hypotension is due to excess UF, rapidly corrected Other explanations should be sought if BP does not respond to reasonable saline replenishment, especially cardiac causes, GI bleeding , sepsis PowerPoint Presentation: If hypotension occurs repeatedly, review : Dry wt (too low ?) Use of short-acting antihypertensive agents pre-HD (give drugs post HD; doesn’t apply to most modern long-acting agents ) UF rate Wt gains between sessions (counsel pt about salt, limit wt gain to 1 kg/day, look for hidden fluids (soup, salt intake ) Dialysate sodium (keep above plasma sodium ) Use bicarbonate not acetate dialysate Lower dialysate temperature to 34-36°C (makes some pts feel uncomfortable ) Increase Hb Avoid food intake during HD PowerPoint Presentation: If all else fails the following drug treatments can sometimes help: Carnitine 20 mg/kg/treatment IV Midodrine 2.5-30 mg 30 min before dialysis; increases peripheral vascular resistance, increases venous return & cardiac output; can give second dose in middle of session; Sertraline 50-100 mg/day PO Prevention of hypotension: Prevention of hypotension Hypotension is unpleasant for pts , makes achievement of euvolemia difficult, leads to persistent fluid overload & HPN As cardiovascular disease is the major cause of mortality in ESRD, controlling HPN is of paramount importance. Episodic intradialytic hypotension prevents this happening . PowerPoint Presentation: Time on dialysis Slower, longer HD often cures episodic hypotension but is not favored by pts . Pts need educating . Sodium ramping or profiling Used to minimize symptoms of hypotension & cramping by optimizing vascular refilling-dialysate sodium is set at a high level (e.g. 155 mmol/l) during the 1 st hr (or 2) of dialysis, then either stepped downwards in intervals or reduced gradually over the next 3 h PowerPoint Presentation: Sequential UF & isovolemic dialysis Helps some pts achieve dry wt without hypotension Less effective than sodium profiling UF is performed initially without dialysis during the first hr or 2 of a session, ensuring fluid loss occurs while plasma urea & sodium concentrations may be highest, and allowing most rapid refilling of the vascular compartment Subsequent dialysis is performed with minimal further UF Tends to increase HD session time PowerPoint Presentation: Temperature modelling The pt's temperature is kept 0.5°C below normal by reducing the dialysate temperature This essentially leads to cutaneous vasoconstriction, which helps maintain BP during dialysis Very effective in preventing hypotension Carnitine There is some evidence that carnitine deficiency may contribute to hypotension on dialysis (muscle fatigue, cardiomyopathy , anemia), and may be helped in some pts by regular IV carnitine therapy Cramps: Cramps Occur in up to 90% of HD treatments, mainly towards the end of dialysis A significant cause for early termination & underdialysis Cause not entirely clear Associated with hyponatremia , hypotension, hypovolemia , hypoxia , carnitine deficiency. Cramps are increased in pts using low sodium dialysate & requiring increased UF Management of Cramps: Management of Cramps Minimize interdialytic wt gain & need for excessive UF, prevent dialysis hypotension, higher sodium dialysate, or sodium profiling. IV saline (normal or hypertonic ); IV 50% dextrose are very effective (but saline will contribute to HPN & volume overload) Local massage offers some relief Carnitine supplementation & quinine sulphate may help some pts . Quinine is best used 2 h before dialysis. Vitamin E (400iu ) Some pts respond to diazepam , carbamazepine , amitriptyline , phenytoin , or alcoho l Nausea, Vomiting, Headache: Nausea, Vomiting, Headache Common Usually associated with hypotension May be a minor manifestation of disequilibrium syndrome due to excess urea removal in pts with persistent marked uremia Rarely precipitated by caffeine or alcohol withdrawal during HD Management of N&V, headache: Management of N &V, headache Treat & prevent hypotension Antiemetics & paracetamol may help if not precipitated by hypotension Reduction of BFR (by 25-30 %) during 1 st hr of HD sometimes useful (but overall dialysis time must be lengthened to maintain dose of dialysis ) Use bicarbonate rather than acetate dialysis Chest Pain: Chest Pain Commonly caused by angina, but also by hypotension, DDS, hemolysis , air embolism Recurrent angina during HD should be investigated cardiologically , can be treated with nitrates or Β ²-blockers Both agents may cause hypotension Air embolism: Air embolism Rare, air detectors will clamp venous blood lines if air is detected in the return circuit May occur while manipulating CVCs Introduction of 1 ml/kg air may be fatal In sitting pts air tends to move upwards into cerebral venous circulation and cause fitting & coma. In recumbent pts it causes chest pain, dyspnea , chest tightness, cough; may pass through the pulmonary vascular bed and embolize into arterioles causing acute neurologic signs Foam is usually seen in the venous blood line Churning sound may be heard on cardiac auscultation Management of Air Embolism: Management of Air Embolism Clamp venous line; stop blood pump Place pt in left lateral position, with head & chest down Administer 100% O2 (enhances nitrogen diffusion out of air bubbles ), cardiopulmonary support as necessary Rarely , percutaneous aspiration of air from the ventricle necessary Hemolysis: Hemolysis Severe hemolysis is rare S/sx: chest pain, abdominal or back pain, chest tightness, headache, nausea, malaise Life threatening hyperkalemia can occur if unrecognized Should especially be considered if several pts complain of similar symptoms simultaneously Venous blood may develop a darker appearance, plasma will appear pink in clotted or spun blood samples Hb falls Causes of Hemolysis: Causes of Hemolysis Overheating of dialysate Contamination with bleach, formaldehyde, or peroxide from water purification or reprocessing Chloramine, nitrates, or copper from water supply Hypotonic dialysate Kinks in blood tubing Malfunctioning blood pump Management of Hemolysis: Management of Hemolysis Stop blood pump immediately; clamp lines Risk of severe hyperkalemia Check potassium & Hb Hemolysis may continue for several hrs after removal of precipitant Seek cause urgently, as multiple pts may be affected if it is due to water or a central dialysate problem Dialyzer Reactions: Dialyzer Reactions AKA: first use syndromes Can occur with reused dialyzers S evere anaphylactic reactions (type A) typically occurring within the first few min of HD (but can occur up to 30 min) Milder reactions (type B) occur min to hrs after starting HD PowerPoint Presentation: Type A Anaphylactic Type B Mild Incidence Rare (max 5/100 000 dialyses) Common (3-5/100 dialyses) Onset Usually 1 st 5 min Up to 30 min 30-60 min Symptoms Moderate-severe Mild Anaphylaxis Chest pain, back pain Itching, urticaria, cough, abdominal cramps, dyspnea, burning, collapse, death Causes Ethylene oxide (previously common, now rare; pts often have IgE anti-ethylene oxide antibodies) ACE inhibitors & AN69 membranes (activation of bradykinin system by membrane amplified by ACEI Bacterial contamination of dialysate in high flux dialysis Reused dialyzers (bacterial contamination, endotoxin, unknown causes) Heparin allergy (rare) Acetate dialysate Unknown Complement activation PowerPoint Presentation: Type A Anaphylactic Type B Mild Treatment Stop dialysis immediately Exclude other causes of chest pain Clamp lines & discard Supportive CPR if necessary O2 IV antihistamines, steroids, adrenaline (SC/IM) if severe Continue HD Outcome Can be fatal Seek cause Symptoms usually resolve after 30-60 min Prevention Seek cause Avoid ethylene oxide sterilized dialyzers Rinse all dialyzers well, with increased volumes Stop ACE inhibitors, especially if using AN69 or PAN membrane Change membrane type If occurs with different dialyzers on several occasions, try heparin-free dialysis Change from cellulose to modified cellulose or synthetic membrane Reusing dialyzers may help Blood clotting during HD: Blood clotting during HD Contact between blood & the various plastic surfaces within the extracorporeal circuit initiates platelet adherence, activation of the intrinsic clotting pathway, thrombosis . Clotting is promoted by slow BFR, high Hb, high UF rate, intradialytic BT, or parenteral nutrition containing lipid. Most HD sessions require anticoagulation, usually with heparin. Low MW heparin, prostacyclin, regional anticoagulation with citrate, heparin-protamine Heparin-free dialysis is possible Clotting during dialysis: Clotting during dialysis Can contribute to anemia & necessitate BT (with risk of HLA sensitization). Leads to underdialysis Features : Blood becomes very dark in circuit Streaking in dialyzer Visible clots in bubble trap Visible clots in venous lines Clots in arterial end of dialyzer (not just small strands) Venous pressure will drop if clot forming in dialyzer, or rise if clot distal to monitor Arterial pressure may rise Dialysis Encephalopathy: Dialysis Encephalopathy Aluminum toxicity Occurs as a result of aluminum in the water sources used in the dialysate, ingestion of aluminum-containing antacids (phosphate binders) Assessment : Progressive neurological impairment Mental cloudiness Speech disturbance Dementia Muscle incoordination Bone pain Seizures Management of Dialysis Encephalopathy: Management of Dialysis Encephalopathy Monitor for s/sx Notify the physician if dialysis encephalopathy occur Administer aluminum-chelating agents as prescribed so that the aluminum is freed up & dialyzed from the body LEARNING ACTIVITY: LEARNING ACTIVITY PowerPoint Presentation: 1. A client is diagnosed with CRF and told she must start HD. Client teaching would include which of the following instructions ? 1. Follow a high potassium diet 2. Strictly follow the HD schedule 3. There will be a few changes in your lifestyle. 4. Use alcohol on the skin and clean it due to integumentary changes. PowerPoint Presentation: 2. A client receiving HD treatment arrives at the hospital with a BP of 200/100, a HR of 110 , a RR of 36. O2 saturation on room air is 89%. He complains of SOB, +2 pedal edema is noted. His last HD treatment was yesterday. Which of the following interventions should be done first? 1. Administer oxygen 2. Elevate the foot of the bed 3. Restrict the client’s fluids 4. Prepare the client for HD. PowerPoint Presentation: 3. The client with CRF is at risk of developing dementia related to excessive absorption of aluminum. The nurse teaches that this is the reason that the client is being prescribed which of the following phosphate binding agents? 1. Alu-cap (aluminum hydroxide) 2. Tums (calcium carbonate) 3. Amphojel (aluminum hydroxide) 4. Basaljel (aluminum hydroxide) PowerPoint Presentation: 4. The client newly diagnosed with CRF recently has begun HD. Knowing that the client is at risk for DDS, the nurse assesses the client during dialysis for: 1. Hypertension, tachycardia, fever 2. Hypotension, bradycardia, hypothermia 3. Restlessness , irritability, generalized weakness 4. Headache, deteriorating LOC, twitching PowerPoint Presentation: 5. A client with CRF has completed a HD treatment. The nurse would use which of the following standard indicators to evaluate the client’s status after dialysis? 1. Potassium level, wt 2. BUN, creatinine levels 3. VS, BUN 4. VS, wt. PowerPoint Presentation: 6. The client with CRF returns to the nursing unit following a HD treatment. On assessment the nurse notes that the client’s temp is 100.2. Which of the following is the most appropriate nursing action? 1. Encourage fluids 2. Notify the physician 3. Monitor the site of the shunt for infection 4. Continue to monitor vital signs PowerPoint Presentation: 7. The nurse is performing an assessment on a client who has returned from the dialysis unit following HD. The client is complaining of a headache & nausea and is extremely restless. Which of the following is the most appropriate nursing action? 1. Notify the physician 2. Monitor the client 3. Elevate the head of the bed 4. Medicate the client for nausea PowerPoint Presentation: 8. The client with CRF who is scheduled for HD this morning is due to receive a daily dose of enalapril (Vasotec). The nurse should plan to administer this medication: 1. Just before dialysis 2. During dialysis 3. On return from dialysis 4. The day after dialysis PowerPoint Presentation: 9. The client being hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale , anxious. The nurse suspects air embolism. The nurse should: 1. Continue the dialysis at a slower rate after checking the lines for air 2. Discontinue dialysis and notify the physician 3. Monitor VS every 15 minutes for the next hr 4. Bolus the client with 500 ml of normal saline to break up the air embolism. PowerPoint Presentation: 10. Which of the following nursing interventions should be included in the client’s care plan during dialysis therapy? 1. Limit the client’s visitors 2. Monitor the client’s BP 3. Pad the side rails of the bed 4. Keep the client NPO PowerPoint Presentation: Thank You !