Complications of Hemodialysis p y

Objectives
Understand the problems and complications encountered during hemodialysis g y
The cause/s of each The signs and symptoms of each The management and intervention of each

Special attention to:

Di Disequilibrium syndrome ilib i d Hypotension Air embolism
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Problems and Complications

Monitoring during the dialysis treatment is done to prevent, prevent detect and treat complications Observations should be recorded on the patients hemodialysis treatment sheet, progress notes or sheet electronic medical record Continuous monitoring and early detection can reduce and may even prevent problems and complications
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Common Complications
Patient C P ti t Complications li ti Technical C T h i l Complications li ti Clotting Hypotension (20-30%) Muscle Cramps p Blood leak Disequilibrium Syndrome Power failure Nausea and Vomiting Hemolysis y Headache Chest Pain Air Embolism Itching Air in bloodlines Fever and Chills Exsanguination Pyrogen reaction Dialyzer reactions Hypertension

Patient P ti t complications li ti
Hypotension (20-30%) Muscle Cramps Disequilibrium Syndrome Nausea and Vomiting Headache Chest Pain Itching Fever and Chills Pyrogen reaction Hypertension

Hypotension
Most common complication in hemodialysis
Defined as low blood pressure Decreased systolic blood pressure by >20-30 mmHg from predialysis pressure Systolic blood pressure <100 mmHg

Causes of Hypotension
Common Causes Removing too much weight
Inaccurate target weight Inaccurate pre-weight

Less Common Causes Anemia

Hemorrhage

Taking Antihypertensive pills before dialysis (BP meds) Heart disease

MIs or arrhythmias

Septicemia

Low weight gain or dehydration Anaphylaxis Air embolism Eating/drinking during g g g dialysis Dialyzer reaction

Signs and Symptoms of Hypotension

Gradual or sudden decrease in B/P Increase in pulse C ld clammy skin (diaphoresis) Cold, l ki (di h i) Nausea/Vomiting Cramping p g Chest pain/angina Yawning, feeling dizzy, sleepy or weak Pallor ll Decreasing mental status to loss of consciousness Seizure

Treatment of Hypotension
Treat the symptoms
Pay attention to how the patient feels NS bolus Place patient in trendelenburg position Use Sodium modeling

Prevention - determine the cause

E l Evaluate target and pre-weight for accuracy d i h f Evaluate that fluid goal was correct Review medication list for BP meds

Muscle Cramps
Painful muscle spasms (usually in extremities) Causes:
Associated with removal of large amounts of fluid
Hypotension

Changes in electrolytes (blood chemistry)

Rapid sodium removal Low potassium levels p

Inaccurate fluid removal goal

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Signs and Symptoms of Muscle Cramps

Can occur anytime in dialysis especially dialysis, middle to end of treatment M scle cramping of extremities that can Muscle e tremities often be seen Hypotension i

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Treatment of Muscle Cramps

Treat the symptoms:
Normal saline bolus Reduce UFR Massage o apply oppos g force ss ge or pp y opposing o ce Assess dry weight

Prevention:
Sodium modeling Assess for accurate target weight

Disequilibrium Syndrome
Defined as a set of systemic and neurologic y g symptoms that include
Nausea & vomiting Headache Restlessness Hypertension i Slurred speech Seizure and coma
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Cause of Disequilibrium Syndrome

Causes
Slower transfer of urea from the brain tissue to the blood
Fluid shift into the brain due to removal of wastes from the blood stream causing cerebral edema g

Rapid changes in serum electrolytes, especially in new patients

Elevated El t d BUN > 150 BFR to high Treatment time too long Dialyzer to big for first treatments (too efficient)

Treatment of Disequilibrium Syndrome

Treat the symptoms:
Monitor new patients carefully for hypertension Decrease BFR Treat N/V and headache per protocol Be alert for restlessness, speech/mental changes

Prevention:
A Assess new patients electrolyte levels i l l l l Use a smaller dialyzer, lower BFR and shorter dialysis time for first few treatments

Nausea and Vomiting

Causes:
Hypotension Uremia Disequilibrium Syndrome

Treatment the symptoms:

Hypotension = NS bolus Determine relationship to dialysis
Is the patient sick?

Prevention
Uremic patient or one with Disequilibrium Syndrome require careful pre-assessment and monitoring during the initial treatments
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Headache
Causes:
Hypertension Inaccurate dry weight with too much fluid removed Rapid fluid or electrolyte shift - Disequilibrium Syndrome Anxiety/nervous tension Caffeine withdrawal

Symptoms
P i in the head or facial area Pain i h h d f i l Hypotension Nausea or vomiting
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Headache Treatment
Treat the symptoms
U it policy for analgesics Unit li f l i Hypertension: BP assessment Hypotension NS bolus

Prevention:
Patients require careful pre-assessment and monitoring during t t d i treatments t Goal is to identify the cause and then prevent it in the future
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Chest Pain
Myocardial Infarction Angina: Chest pain p Chest pain p Caused from ischemia Caused from ischemia that results in tissue (lack of oxygen to tissue) death Resolved by Not resolved by Nitroglycerin Nitroglycerin

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Causes of Chest Pain

Ischemia to heart muscle (Coronary Artery Disease) Anemia Hypotension from fluid depletion Hypovolemia Anxiety-stress, physical exertion, illness Blood flow rate increased too rapidly on patient with known kno n cardiac disease

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Angina and MI Symptoms

Angina
Pressure, pain localized or may radiate to neck, jaw, shoulders, arms-may arms may come and go Apprehension Choking/strangling sensation Squeezing/crushing/pressure S i / hi / sensation Duration 1-2 minutes Nausea Pallor, cool clammy skin

MI
Pressure, pain localized or may radiate to neck, jaw, shoulders, arms may arms-may come and go Apprehension Choking/strangling sensation Squeezing/crushing/pressure sensation Nausea Pallor, Pallor cool clammy skin Hypotension

Treatment
Treat the symptoms:
Hypotension Angina pain with Nitroglycerin MI pain requires analgesics Anxiety/stress A i /

Prevention
Accurate fluid removal and weight assessment

Itching
Causes:
Dry skin Secondary hyperparathyroidism Abnormal levels of calcium, magnesium and phosphorus in tissues Allergies Uremia with an elevated BUN

T t Treatment: t
Adequate dialysis to regulate electrolyte levels Lotions or medications for dry skin/allergies

Prevention:
Control of uremia and secondary hyperparathyroidism Adequate dialysis to regulate electrolyte levels

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Chills and Fever

Causes:
Infection or septicemia
Vascular access Respiratory illness

C ld dialysate or malfunctioning thermostat Cold di l t lf ti i th t t

Patient has shaking/shivering without fever

Pyrogenic reaction

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Symptoms
Infection:
Fever during dialysis Feeling cold with a fever Redness, swelling, tenderness, warmth or drainage from access site

Septicemia:
Fever, chills, vomiting and headache Hypotensive shock

Respiratory
Productive coug oduc ve cough

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Pyrogenic Reaction
Fever reaction due to presence of dead bacteria endotoxins
Low molecular weight endotoxin fragments may be able to cross any membrane, irrespective of membrane pore size distribution

C Caused by contamination of: db t i ti f

Bicarbonate containers/system Water system Machine Dialyzer or bloodlines

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Symptoms of Pyrogenic Reaction

Symptoms:
Cold sensation upon treatment initiation (40-70 minutes into treatment) Sudden shaking chills, then temperature elevation (1-2 hours after chills) - resolves after end of treatment Note increased pulse before chills develop Hypotension (drop in B/P >30 mm/Hg) Headache/Muscle aches

Treatment:
R Remove f from di l i immediately dialysis i di t l Gather samples of dialysate/blood per company policy

Prevention
Proper disinfection/sterilization Use of aseptic technique
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Hypertension
Causes:

Fluid overload Non-compliance Non compliance with blood pressure medications Anxiety Renin overproduction
Gradual or sudden rise in BP Headache, blurring vision Nausea/Vomiting Dizziness Di i Seizure

Symptoms: (frequently asymptomatic)

Treatment
Review of BP medications Assessment of target weight and fluid removal goal
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Technical Complications
Clotting Blood l k Bl d leak Power failure Hemolysis H l i Air Embolism
Air in bloodlines

Exsanguination Dialyzer reactions

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Clotting in the Extracorporeal Circuit

Formation of blood clots in the dialyzer and blood lines Causes:
Inadequate anticoagulation Low blood flow rate Air in blood lines
P Poor priming techniques i i t h i Loose connections

Clotting
Signs of Clotting:
Increasing venous pressure readings Dark blood in lines or drip chambers Fibrin in drip chambers (furry appearance) Visible clots or clumping of dark blood in the drip chamber or dialyzer TMP alarm problems

Treatment:
Anticoagulation Vascular access
Needle placement CVC problems

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Blood Leak
Cause:
Membrane rupture allowing RBCs to cross over the membrane into the dialysate

Signs:
Blood leak alarm P iti test for blood in dialysate Positive t t f bl d i di l t

Interventions
Check dialysate outflow with Blood leak strip If positive, stop treatment, do not return blood If negative may need to get different machine

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Power Failure
Cause:
Electricity is disrupted to the machine
Storm/tornado/fire/construction

Signs:
Unable to mute alarms Air detector trips, clamping venous line

Intervention:
K Know h to f venous li and hand crank blood how free line d h d k bl d Company policy

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Hemolysis
Breakdown or destruction of RBCs
Releases potassium from damaged cells into the blood stream Decreasing the oxygen carrying capacity of the RBC

Potentially life threatening

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Causes of Hemolysis
Mechanical M h i l
Poorly functioning or incorrectly calibrated blood pump Excessive negative pressure in the extracorporeal circuit Deformity in lines (kinks, (kinks folds, etc) Over occlusion of blood pump

Chemical and Thermal

Chemical: Delivery of improperly prepared dialysate di l t Dialysate contaminated with chemical agents such as formaldehyde, bleach chlorine formaldehyde bleach, chlorine, copper, nitrates and nitrites Thermal Overheated dialysate (> 42 degrees C)

Signs of Hemolysis
Dialyzer/blood lines: i l /bl d li
Cherry colored blood in venous line

Patient:
Shortness of breath Chest, abdominal and/or back pain C di arrest Cardiac

Intervention
Stop dialysis and DO NOT return blood to the p p y patient By symptom

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Air Embolism
Introduction of enough air into extracorpeal system to stop circulation C Causes:
Empty IV bag Air leak in blood lines Air detector not armed Loose connections Separation of blood lines Patient inhales while central vascular catheter is open to air Pre-safety checks not done or done improperly y p p y
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Signs and Symptoms of Air Embolism

Extracorpeal System:
Ai pocket or foam (pink) in venous line Air k f ( i k) i li

Patient:
Coughing, shortness of breath Chest i Ch pain or pressure Tachycardia Distended neck veins Cyanosis/Gray color Slight paralysis on one side of body (cerebral) Confusion, convulsions, coma Possible cardiac/respiratory arrest
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Treatment of Air Embolism

Clamp blood lines and stop blood pump Place patient in trendelenburg position turning them on their LEFT side Treat symptoms:
Oxygen to address shortness of breath and chest pain Normal saline to support blood pressure

C ll 911 Call

Air in Bloodlines
Causes:
Under filling drip chambers Empty saline bag Loose connections Dialysis Di l i needle removed while blood pump is dl d hil bl d i running Poor priming

Air in Bloodlines
Signs:
Air bubbles/foam in bloodlines Air in blood alarm

Intervention/prevention
Keep level of drip chambers up Replace empty saline bags immediately Tighten connections when priming Tape needles securely Follow correct priming procedure

Exsanguination
Extreme blood loss
Causes:
Blood li Bl d line separation ti Needles dislodging from access Rupture of access (at anastomosis or aneurysm) Crack in dialyzer casing/Rupture of dialyzer Loose dialyzer caps/connections

Symptoms:
Blood on the floor or in the chair Obvious bleeding source Hypotension Machine pressure change alarms Shock Seizures Cardiac arrest
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Treatment of Exsanguination
Identify the source of blood loss S Stop di l i dialysis
Return blood if possible (not contaminated system) Treat the symptoms: y p Normal saline to support blood pressure Oxygen for shortness of breath

Call 911

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Dialyzer Reactions y
Causes
First use syndrome Hypersensitivity to membrane

Dialyzer Reactions
First Use Syndrome Hypersensitivity

Back pain Chest pain Hypotension Pruritis Nausea Vague discomfort

Anxiety Hives, Hives pruritis Dyspnea, wheezing Chest tightness g Possible cardiac arrest

Dialyzer Reactions y
Intervention
Stop treatment if anaphylactic response
Respiratory distress Cardiac distress

Symptom management

Prevention
Use of synthetic membrane Reuse of dialyzers Proper priming of reuse and new dialyzers

QUESTIONS?