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HEMODIALYSIS EMERGENCIES
The document discusses common complications of hemodialysis including hypotension, muscle cramps, nausea and vomiting, and headache. It notes the percentages of patients experiencing each complication and describes causes such as rapid ultrafiltration, cardiovascular issues, and dialysis disequilibrium syndrome. Prevention strategies are outlined including accurate setting of dry weight and dialysate modifications. Treatment of muscle cramps is also addressed.
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HEMODIALYSIS EMERGENCIES
- 1. By Kareem Nagaty Assistant lecturerof internal medicine & nephrology
- 3. Common complications Lesscommon complications Hypotension Disequilibrium syndrome Muscle Cramps Dialyzer reactions Nausea and vomiting Arrhythmias Headache Cardiac tamponade Chest pain Seizures Back pain Hemolysis Itching Air embolism Fever and chills Hypoxemia
- 4. Hypotension 25 to 55% Cramps 5 to 20 % Nausea & vomiting 5 to 15 % Headache 5 % Chest pain 2 to 5 % Back pain 2 to 5 % Itching 5 % Fever and chills Less than 1 %
- 5. Common complications Lesscommon complications Hypotension Disequilibrium syndrome Muscle Cramps Dialyzer reactions Nausea and vomiting Arrhythmias Headache Cardiac tamponade Chest pain Seizures Back pain Hemolysis Itching Air embolism Fever and chills Hypoxemia
- 7.
- 8. Volume related: Rapid UF(large weight gain) Inacurate dry weight Low dialysate sodium V.C failure: High dialysate temprature Autonomic neuoropathy Acetate buffer Antihypertensive drugs Eating during sessions Cardiovascular related: Arrhythmia Ischemia Decrease cardiac reserve Variable causes: Tamponade Septicemia Dialyzer reaction Air embolism Causes of IDH
- 9.
- 10. Volume overloaddue to suboptimal ultrafiltration, LVH, and interdialytic hypertension. Fistula thrombosis. Increased mortality and morbidity.
- 11. TREATMENT Emergency: _Stop or decreaserate of UF _Trendelenberg position _Decrease blood flow rate _I.V bolus of saline Etiology: e.g. _Cardiac disease _Pericardial disease _Sepsis Frequent & Resistant: _Increase time or frequency of HD _Nocturnal dialysis _Peritoneal dialysis
- 13. Volume related: Rapid UF(large weight gain) Inacurate dry weight Low dialysate sodium V.C failure: High dialysate temprature Autonomic neuoropathy Acetate buffer Antihypertensive drugs Eating during sessions Cardiovascular related: Arrhythmia Ischemia Decrease cardiac reserve Variable causes: Tamponade Septicemia Dialyzer reaction Air embolism Causes of IDH
- 14. Accurate settingof the "dry weight”. Minimize interdialytic weight gain. Steady, constant ultrafiltration. Increased dialysate sodium concentration. Bicarbonate dialysate buffer. Temperature control. Improvement in cardiovascular performance. Midodrine among patients with autonomic neuropathy. Avoidance of food ingestion during dialysis. No antihypertensive medications prior to treatment.
- 15. Accurate settingof the "dry weight”. Minimize interdialytic weight gain. Steady, constant ultrafiltration. Increased dialysate sodium concentration. Bicarbonate dialysate buffer. Temperature control. Improvement in cardiovascular performance. Midodrine among patients with autonomic neuropathy. Avoidance of food ingestion during dialysis. No antihypertensive medications prior to treatment.
- 16. Accurate settingof the "dry weight”. Minimize interdialytic weight gain. Steady, constant ultrafiltration. Increased dialysate sodium concentration. Bicarbonate dialysate buffer. Temperature control. Improvement in cardiovascular performance. Midodrine among patients with autonomic neuropathy. Avoidance of food ingestion during dialysis. No antihypertensive medications prior to treatment.
- 17. Accurate settingof the "dry weight”. Minimize interdialytic weight gain. Steady, constant ultrafiltration. Increased dialysate sodium concentration. Bicarbonate dialysate buffer. Temperature control. Improvement in cardiovascular performance. Midodrine among patients with autonomic neuropathy. Avoidance of food ingestion during dialysis. No antihypertensive medications prior to treatment.
- 18. Accurate settingof the "dry weight”. Minimize interdialytic weight gain. Steady, constant ultrafiltration. Increased dialysate sodium concentration. Bicarbonate dialysate buffer. Temperature control. Improvement in cardiovascular performance. Midodrine among patients with autonomic neuropathy. Avoidance of food ingestion during dialysis. No antihypertensive medications prior to treatment.
- 19. Accurate settingof the "dry weight”. Minimize interdialytic weight gain. Steady, constant ultrafiltration. Increased dialysate sodium concentration. Bicarbonate dialysate buffer. Temperature control. Improvement in cardiovascular performance. Midodrine among patients with autonomic neuropathy. Avoidance of food ingestion during dialysis. No antihypertensive medications prior to treatment.
- 20. Accurate settingof the "dry weight”. Minimize interdialytic weight gain. Steady, constant ultrafiltration. Increased dialysate sodium concentration. Bicarbonate dialysate buffer. Temperature control. Improvement in cardiovascular performance. Midodrine among patients with autonomic neuropathy. Avoidance of food ingestion during dialysis. No antihypertensive medications prior to treatment.
- 21. Accurate settingof the "dry weight”. Minimize interdialytic weight gain. Steady, constant ultrafiltration. Increased dialysate sodium concentration. Bicarbonate dialysate buffer. Temperature control. Improvement in cardiovascular performance. Midodrine among patients with autonomic neuropathy. Avoidance of food ingestion during dialysis. No antihypertensive medications prior to treatment.
- 22. Accurate settingof the "dry weight”. Minimize interdialytic weight gain. Steady, constant ultrafiltration. Increased dialysate sodium concentration. Bicarbonate dialysate buffer. Temperature control. Improvement in cardiovascular performance. Midodrine among patients with autonomic neuropathy. Avoidance of food ingestion during dialysis. No antihypertensive medications prior to treatment.
- 23. Accurate settingof the "dry weight”. Minimize interdialytic weight gain. Steady, constant ultrafiltration. Increased dialysate sodium concentration. Bicarbonate dialysate buffer. Temperature control. Improvement in cardiovascular performance. Midodrine among patients with autonomic neuropathy. Avoidance of food ingestion during dialysis. No antihypertensive medications prior to treatment.
- 24. Accurate settingof the "dry weight”. Minimize interdialytic weight gain. Steady, constant ultrafiltration. Increased dialysate sodium concentration. Bicarbonate dialysate buffer. Temperature control. Improvement in cardiovascular performance. Midodrine among patients with autonomic neuropathy. Avoidance of food ingestion during dialysis. No antihypertensive medications prior to treatment.
- 25. The 2007European best practice guidelines in hemodialysis recommend the following stepped approach to the prevention of IDH: First-line approach — The first-line approach includes dietary counseling (sodium restriction), no food intake during dialysis, clinical dry weight reassessment, bicarbonate as the dialysis buffer, dialysate temperature of 36.5ºC, and/or appropriate dosing and timing of antihypertensive agents.
- 26. Second-line approach— The second-line approach includes objective methods to assess dry weight, cardiac evaluation, gradual reduction of dialysate temperature from 36.5ºC (lowest 35ºC), consideration of blood volume controlled feedback, increase in dialysis time and/or frequency, and/or use of a high dialysate calcium concentration. Third-line approach — If other treatment options have failed, the guidelines recommend the third-line approach which involves consideration of midodrine or L- carnitine supplementation or peritoneal dialysis.
- 27. Common complications Lesscommon complications Hypotension Disequilibrium syndrome Muscle Cramps Dialyzer reactions Nausea and vomiting Arrhythmias Headache Cardiac tamponade Chest pain Seizures Back pain Hemolysis Itching Air embolism Fever and chills Hypoxemia
- 28. A crampis a prolonged involuntary muscle contraction that occurs in a muscle which voluntarily contracts when it is already in its most shortened position. Cramps tend to occur most frequently near the end of hemodialysis treatments. Most commonly involve the muscles of the lower extremity, but the muscles of the hands, arms, and abdomen may also be affected. Cramps occur more often in older, nondiabetic, anxious patients. Low PTH values and high serum creatine phosphokinase concentrations are also more frequent among patients with dialysis-associated cramps
- 29. Plasma volumecontraction. Hyponatremia. Tissue hypoxia. Hypomagnesemia. Carnitine deficiency. Elevated serum leptin levels.
- 30. The reversalof low blood pressure. Hypertonic saline or dextrose: triple saline or 50% dextrose are equally effective. _hypertonic saline may be preferred among those with volume depletion. _hypertonic dextrose may be the better therapeutic option (in nondiabetic patients) because it does not adversely affect salt and water balance. Mannitol infusion: not preferred. Local massage of the affected muscle and the application of moist heat
- 31. Minimize interdialyticweight gains. Prevention of dialysis-associated hypotension. Higher dialysate sodium concentration. Carnitine supplementation. Quinine sulfate. Vitamin E. Others.
- 32. Minimize interdialyticweight gains. Prevention of dialysis-associated hypotension. Higher dialysate sodium concentration. Carnitine supplementation. Quinine sulfate. Vitamin E. Others.
- 33. Minimize interdialyticweight gains. Prevention of dialysis-associated hypotension. Higher dialysate sodium concentration. Carnitine supplementation. Quinine sulfate. Vitamin E. Others.
- 34. Minimize interdialyticweight gains. Prevention of dialysis-associated hypotension. Higher dialysate sodium concentration. Carnitine supplementation. Quinine sulfate. Vitamin E. Others.
- 35. Minimize interdialyticweight gains. Prevention of dialysis-associated hypotension. Higher dialysate sodium concentration. Carnitine supplementation: _ Carnitine may be given intravenously (20 mg/kg) after hemodialysis or orally (330 mg two to three times per day). Quinine sulfate. Vitamin E. Others.
- 36. Minimize interdialyticweight gains. Prevention of dialysis-associated hypotension. Higher dialysate sodium concentration. Carnitine supplementation. Quinine sulfate: _decreased excitability of the motor end-plate to nerve stimulation and increased muscle refractory period, thereby preventing prolonged involuntary muscle contraction. _not used due to side effects. Vitamin E. Others.
- 37. Minimize interdialyticweight gains. Prevention of dialysis-associated hypotension. Higher dialysate sodium concentration. Carnitine supplementation. Quinine sulfate. Vitamin E: _400 I.U alone or in combination with vitamin C. Others.
- 38. Minimize interdialyticweight gains. Prevention of dialysis-associated hypotension. Higher dialysate sodium concentration. Carnitine supplementation. Quinine sulfate. Vitamin E. Others: _short acting benzodiazepines, nifedipine , phenytoin , creatine monohydrate, carbamazepin , amitriptyline , and gabapentin. _they are still under investigations.
- 39. Common complications Lesscommon complications Hypotension Disequilibrium syndrome Muscle Cramps Dialyzer reactions Nausea and vomiting Arrhythmias Headache Cardiac tamponade Chest pain Seizures Back pain Hemolysis Itching Air embolism Fever and chills Hypoxemia
- 40. Hypotension. Earlymanifestations of Disequilibrium syndrome. Gastroparesis (cause nausea and vomiting). High dialysate sodium or calcium (cause nausea and vomiting). Caffeine use (cause headache). Metabolic disturbances: eg. hypoglycemia, hypernatremia, and hyponatremia (cause headache).
- 41. TTT ofhypotension. Detection and management of Disequilibrium syndrome. Antiemetics: eg. Metoclopramide. Acetaminophen.
- 42. Prevention ofhypotension. Decrease dialysate sodium. Metoclopramide: 10 mg prior to dialysis session if persistent vomiting. A cup of coffee in heavy caffeine user suffering from headache. Causious trial of magnesium supplementation in persistent headache.
- 43. Common complications Lesscommon complications Hypotension Disequilibrium syndrome Muscle Cramps Dialyzer reactions Nausea and vomiting Arrhythmias Headache Cardiac tamponade Chest pain Seizures Back pain Hemolysis Itching Air embolism Fever and chills Hypoxemia
- 44. Non-specific backpain sometimes associated with chest pain. Chest pain may be: _mild non-specific _hypotension _ disequilibrium syndrome _angina _acute coronary syndrome _hemolysis _air embolism _pulmoary embolism
- 45. The presenceof cardiovascular disease is an important predictor of mortality in patients with ESRD. Angina is the commonest presentation of CAD in dialysis patient. Frequent episodes of hypotension during hemodialysis may be the presentation of CAD. Exertional dyspnea, (intradialytic or interdialytic), sudden cardiac arrest or death, and arrhythmias are less common presentations.
- 46. There isextremely poor prognosis in dialysis patients with an acute myocardial infarction (AMI), this may be due in part to a relatively increased number of "atypical clinical presentations" resulting in underdiagnosis and undertreatment. As an example, the presence of dyspnea alone due to an acute myocardial infarction in an individual scheduled to undergo a regular chronic dialysis procedure may be mistakenly attributed to volume overload. In addition, baseline abnormalities on the electrocardiogram, such as left ventricular hypertrophy, may mask characteristic changes with ischemia.
- 47. Extremely uncommonin dialysis patients during hemodialysis sessions. May be observed after manipulation of thrombus or occlusion of the dialysis access.
- 48. Common complications Lesscommon complications Hypotension Disequilibrium syndrome Muscle Cramps Dialyzer reactions Nausea and vomiting Arrhythmias Headache Cardiac tamponade Chest pain Seizures Back pain Hemolysis Itching Air embolism Fever and chills Hypoxemia
- 49. May beaccompined by other minor allergic symptoms. May be low-grade hypersensitivity to dialyzer or blood circuit components. Antihistaminics may be given during dialysis session. Chronic pruritis may be due to uremia, elevated phosphorus level or viral hepatitis. Uremic pruritis may be treated by: increase dialysis dose, high flux membranes, EPO, Primrose oil or tacrolimus oint.
- 50. Common complications Lesscommon complications Hypotension Disequilibrium syndrome Muscle Cramps Dialyzer reactions Nausea and vomiting Arrhythmias Headache Cardiac tamponade Chest pain Seizures Back pain Hemolysis Itching Air embolism Fever and chills Hypoxemia
- 51. You shouldseek for the source of infection. Special consideration should be given to vascular access. Infection control practice should be followed in hemodialysis unit.
- 52. Common complications Lesscommon complications Hypotension Disequilibrium syndrome Muscle Cramps Dialyzer reactions Nausea and vomiting Arrhythmias Headache Cardiac tamponade Chest pain Seizures Back pain Hemolysis Itching Air embolism Fever and chills Hypoxemia
- 53. A centralnervous system disorder described in dialysis patients. It is characterized by neurologic symptoms of varying severity that are thought to be due primarily to cerebral edema. New patients just being started on hemodialysis are at greatest risk, particularly if the BUN is markedly elevated. Other predisposing factors include severe metabolic acidosis, older age, pediatric patients, and the presence of other central nervous system disease.
- 55. Acute symptomsdevelop during or immediately after hemodialysis. Early findings include headache, nausea, disorientation, restlessness, blurred vision, and asterixis. More severely affected patients progress to confusion, seizures, coma, and even death. Milder signs and symptoms associated with dialysis — such as muscle cramps, anorexia, and dizziness developing near the end of a dialysis are also part of this syndrome.
- 56. Uremia. Subduralhematoma. Cerebral infarction. Intracerebral hemorrhage. Meningitis. Metabolic disturbances (hyponatremia, hypoglycemia).
- 57. Symptoms areself-limited and usually disappear within several hours. Mild nonspecific symptoms, such as nausea, vomiting, or headache, is symptomatic. Sever life thereatening symptoms: _ABC _Dialysis is stopped in the patient with seizures or coma. _raising the plasma osmolality with either hypertonic saline or 12.5 g of hypertonic mannitol. Some physicians administer 50 % dextrose solution.
- 58. Prevention isthe mainstay of therapy in the DDS. A new dialysis patients with very high BUN concentrations or neurologic symptoms, The initial dialyses should be gentle: _the initial session not more than 2 hours. _low blood flow rate of 150 to 250 mL/min. _small surface area dialyzer. _concurrent rather than countercurrent blood and dialysate flow. _repeated daily for three or four days with gradual increase in time and blood flow rate. _marked fluid overload can be treated with ultrafiltration.