INTRADIALYTIC

COMPLICATIONS
By: KATHERINE V. NAVARRO, RN, CNN
INTRADIALYTIC COMPLICATIONS:
Acute Hemolysis
• Rupture of blood cells due to:
1. Hypertonic/Hypotonic Dialysate – incorrect dialysate composition outside
physiologic parameters, conductivity meter failure
2. Hypertonic/Hypotonic IV Solutions – rapid administration of hypertonic saline,
overheated dialysate (> 42°C)
3. High Negative Pressure in the EC Circuit – AP > -250mmHg, blood kinks, occluded
blood pump roller
4. Trauma to the RBC – narrowed tubing, needle trauma, catheter malfunction
5. High Blood Flow Rate through a small gauge needle
6. Chloramine, Nitrates, Copper leak in dialysis water
7. Presence of sterilant in dialysate
Signs and Symptoms
• Back and abdominal pain
• Chest tightness
• Dsyrhythmias
• Headache
• Hyperkalemia
• Hypotension, hypoxemia
• Localized burning and pain in the blood return site
• Venous bloodline becomes translucent, deep burgundy or cherry – red
in color
Treatment
• Discontinue dialysis
• Clamp venous line immediately and do not re-infuse the hemolyzed blood
• Administer oxygen
• Notify POD
• Monitor V/S and cardiac rhythm
• Obtain blood samples and dialysate samples
• If symptoms are severe, replace blood volume
• Save extracorporeal circuit for analysis
• Remove HD machine for analysis of technician
Prevention
• Verify dialysate conductivity and temperature every dialysis
• Clean concentrate containers, lines and filters
• Protect electrical components from corrosive effects of dialysate
• Assure routine maintenance of monitors and alarms
• Use appropriate blood flow rates and needle gauge
• KDQI discourages the increase of sodium balance during dialysis
(Sodium Profiling)
• Assess EC circuit for kinks and defects
• Monitor patient routinely
INTRADIALYTIC COMPLICATION:
Air Embolism
• Introduction of large quantity of air into the venous circulation can be
caused by:
1. Defective or disarmed EC air detector
2. Loose connections or a disconnection at the arterial blood access
site
3. Cracked CVC lumen
4. Micro-emboli created by blood passing over a defective area in the
EC circuit
5. Air dissolved in very cold water exceeding the capacity
Signs and Symptoms
(Dependent on the position)
1. SEATED – infused air will travel to the cerebral system without
entering the heart, can lead of loss of consciousness, convulsions,
death
2. RECUMBENT – infused air will travel into the heart, generating foam
and passing to the lungs, resulting to SOB, cough, chest pain,
churning sound on auscultation
3. TRENDELENDURG – air will travel to lower extremities, leaving patchy
cyanosis
4. Foam or patches of air in the venous bloodline
5. Patient hears rushing air, sound of a freight train
Treatment
• Immediately STOP infusin of air, CLAMP the venous bloodline and
STOP the blood pump
• Place patient on left side in a recumbent position with head and chest
tilted downward to trap air in the apex of the right ventricle
• Provide cardiorespiratory support (100% O2 via mask)
• Might be necessary to aspirate air from atrium via percutaneous
needle
• Monitor V/S
• Notify physician
Prevention
• Accurate use of air foam detector at all times all throughout HD treatment
• Visual Inspection of the venous bloodline before connection to access
• Visual inspection of the catheter
• Secure interlocking connections throughout the EC circuit
• Maintain blood pump speed at rate access can deliver
• Return blood with normal saline vs air rinse back
• Use IV solutions in collapsing bags
• Heparin infusion after blood pump
• Saline administration line and all stagnant lines double clamped
• Monitor patient routinely
INTRADIALYTIC COMPLICATION:
Angina/Chest Pain
• Sensation of chest pain, pressure, or squeezing caused by:
1. Anemia
2. ASCVD (Arteriosclerotic cardiovascular disease)
3. Coronary artery spasm
4. Hemolysis
5. Hypervolemia and hypovolemia
6. Hypoxemia
7. Type B dialyzer reaction
Signs and Symptoms
1. GENERAL:
• Pain/tightness in the arm, jaw, neck

2. DIABETIC/ELDERLY:
• SOB
• Weakness
• Dizziness
• Confusion
Treatment and Prevention
• Prevent hypovolemia
• Decrease UF rate to minimum
• Administer oxygen
• Place in reclining position
• Volume replacement if needed
• Give NTG per order if BP is WNL (within normal limits)
• Maintain Hgb WNL
• Cardiac monitoring to assess EKG changes
• Notify physician
• Discontinue dialysis if chest pain is unresolved or severe
INTRADIALYTIC COMPLICATION:
Bleach Exposure
- Blood or tissue exposure to a cytotoxic chemical, sodium hypochlorite

Signs and Symptoms:

1. brady/tachycardia 6. Hypotension
2. Cardiac arrest 7. Respiratory distress
3. Chest pain 8. Shock
4. Cyanosis 9. Vomiting
5. Hemolysis and resultant 10. Vessel thrombosis (blood
hyperkalemia exposure)
Treatment
1. Discontinue dialysis
2. Clamp venous line immediate and do not reinfuse hemolyzed blood
3. Notify POD
4. Monitor V/S
5. Cardiac massage and respiratory support (O2 sat and O2 therapy)
6. Obtain blood and dialysate samples
Prevention
1. Appropriate testing for presence of bleach
2. Prohibit disinfection of dialysate and water treatment system while
ongoing treatment
3. Monitor patient routinely
4. Patient should be left unattended during treatment
INTRADIALYTIC COMPLICATION:
Cardiac Arrest
- Abrupt loss of cardiac function caused by:

1. Anemia 8. Overheated dialysate

2. Cardiac tamponade 9. Large air embolism
3. Diminished ischemia tolerance 10. Left Ventricular hypertrophy
4. Electrolyte and acid base 11. Shock
imbalance 12. Co-morbidities
5. Exposure to sterilant 13. Rapid infusion of cold blood
6. Exsanguination products
7. Hemolysis 14. Unsafe dialysate composition
Signs and Symptoms
1. Absence of apical or carotid pulse
2. Lack of spontaneous respiratory effort
3. Unresponsive
4. Asystole or ventricular fibrillation on cardiac monitor
Treatment
1. Assess for signs and symptoms
2. Begin CPR and activate emergency resources
3. Return blood to patient, leave access line in place for fluid and
medication administration
Prevention
1. Ensure dialysate composition
2. Adjust UFR to avoid IV depletion
3. ECG monitoring for patients at risk
4. Refer dysrhythmic patients
INTRADIALYTIC COMPLICATION:
Cardiac Stunning
• Prolonged and severe myocardiac ischemia can lead to myocyte cell
death without the potential for recovery of contractile function of the
cells.
• “Hybernating myocardium” – protective mechanism in which the
myocardial oxygen demand is reduced in the presence of decreased
oxygenation
Intervention and Prevention
1. Reduced dialysate temperature to avoid vasodilation
2. Avoid high UFR (<10mL/kg/hr)
3. Use blood volume monitoring
4. More frequent HD sessions
5. Increase length of HD to reduce UFR
6. Reassess dry weight monthly
INTRADIALYTIC COMPLICATION :
Disequilibrium Syndrome
Patient at risk:
1. Children
2. History of head injury
3. Subdural hematoma
4. Stroke
• Rapid removal of urea during HD results in the development of an
osmotic gradient between the brain and plasma due to the relatively
slow transport of urea across the blood-brain barrier in the CSF.
• Seen in patients with very high urea plasma concentration with CKD
and rapid urea removal
Signs and Symptoms
1. Occurs towards the end of 8. Decreased LOC
dialysis till 24 hours 9. Behavior changes
2. Blurred vision 10. Muscle cramps
3. Cardiac arrhythmia 11. Nausea and vomiting
4. Headache 12. Seizures
5. Increase pulse pressure 13. Tremors and restlessness
6. Hypertension 14. Death or coma
7. Restlessness
Treatment and Prevention
1. Early identification of mild symptoms
2. Reduce efficacy of dialysis: use of less efficient dialyzer, decrease
treatment time, decrease blood and dialysate flow rates, use
concurrent dialysate flow
3. Short, more frequent dialysis treatment
4. Increase sodium concentration (>140 mEq/L)
5. Administer osmotic agents
6. Terminate treatment if severe
INTRADIALYTIC COMPLICATION:
Dizziness
4 Types:
1. Vertigo – strong sense of motion or spinning
2. Lightheadedness – woozy or disconnected from environment
3. Disequilibrium – feeling off –balance, unsteady or wobbly
4. Presyncope – a feeling of losing consciousness or about to faint
Causes:

1. Anemia
2. Autonomic neuropathy
3. Carotid sinus syndrome
4. Hypoxemia
5. Medications
6. Postural Hypotension
7. Vasovagal syncope
8. Hypovolemia/ischemia
Treatment
1. Assess blood pressure and cardiac rate and rhythm
2. Volume replacement will be dependent upon severity of symptoms
and blood pressure
3. Normal saline replacement as needed, oral fluids to increase
sympathetic tone
4. Sitting for 10-15 mins for plasma refilling
5. Maintain anemia management goals
6. Educate (sit down, lie down, elevate feet, drink extra cup of fluid)
Prevention
1. Frequent reassessment of dry weight
2. Prevent hypovolemia
3. Adjust UF goal to allow for reduction for the UFR
4. Change position slowly at the end of treatment
5. Have patient move legs and feet prior to standing
6. Reassess anti-hypertensive medications
7. Instruct patient on blood pressure parameters
8. Add proximately 0.2-0.5 kg to eDry weight
INTRADIALYTIC COMPLICATION:
Dysrhythmia
Causes:
1. Electrolyte imbalance, pH changes
2. Hyperkalemia/Hypokalemia
3. Rapid infusion of large bolus of IV solution
4. Removal of antiarrhythmic medications during dialysis
5. Use of incorrect dialysate
6. Hypoxemia/myocardial stunning
7. High UFR
Signs and Symptoms
1. Chest pain
2. Dizziness
3. Fatigue
4. Irregular heart rate
5. Palpitations
6. Anxiety
7. Snycope
8. Mostly asymptomatic
Treatment
1. Administer oxygen
2. Reduce UFR to minimum
3. Reduce dialysate temperature to 34-36°C
4. Administer antiarrhythmic medications as ordered
5. Cardiac monitoring
6. Discontinue for severe cases
Prevention
1. If with Digoxin, use higher dialysate potassium but never less than
2.0 mEq/L
2. Reassess serum electrolytes monthly
3. Monitor heart rate and rhythm
4. Individualize UFR, limit IV solution given as a bolus, reinfuse blood
at lower BFR during termination
5. Use isothermic dialysate temperature
INTRADIALYTIC COMPLICATION:
Dialysis Encephalopathy
1. Neurologic disorder resulting from the accumulation of aluminum in
the body
2. Aluminun Toxicity
•Water not properly treated, ingestion of large quantities
(meds)
Signs and Symptoms
1. Ataxia
2. Dementia
3. EKG changes
4. Emotional alterations
5. Gait changes
6. Myoclonus
7. Seizures
8. Speech Disturbance
9. Trembling
10. Anemia
Treatment Prevention
1. Discontinue oral aluminum- 1. Use of appropriately treated
based medications water for dialysis
2. Chelation of aluminum with 2. Use of non-aluminum based
deferoxamine phosphate binders
3. Renal transplant
INTRADIALYTIC COMPLICATION:
Exsanguination
- Loss of circulating blood volume, enough to cause death, approximately more than half of the total blood volume

Etiology
1. Accidental or traumatic separation of the bloodlines, dislodgement
of the needles
2. Rupture of vascular access aneurysm or anastomosis
3. Open CVC limb or dislodgement
4. Dialyzer membrane rupture with failure of blood leak detector
5. Failure to connect venous bloodline to the patient when discarding
priming volume
6. Undetected internal bleeding
Signs and Symptoms
1. Visualization of bleeding source
2. Hypotension
3. Increased heart rate
4. Decreased in Hgb/Hct level
5. Shock, seizures and cardiovascular collapse
Treatment
1. Immediately stop blood pump and place a clamp on both sides of
the separated bloodlines or catheter
2. Apply pressure to any bleeding site. Apply tourniquet if unable to
control bleeding
3. Evaluate appropriateness to return blood
4. Administer oxygen, volume expander
5. Monitor V/S
6. Blood replacement as indicated
Prevention
1. Ensure all interlocking connections on bloodlines and access are
secure
2. Ensure vascular access visualization
3. Securely tape needles
4. Ensure arterial and venous pressure monitors and blood leak
detectors working properly
5. Secure bloodlines to the patient during treatment, not to any other
object
6. Ensure complete stasis of access site prior to discharge
INTRADIALYTIC COMPLICATION:
Fever and Chills
Etiology
1. Suspect infection with even small increase in temperature (NV:
36°C)
2. Introduction of pyrogens or endotoxins via dialysate, water or
dialyzer
3. Dialysate temperature higher than patient’s temperature
Signs and Symptoms
1. Patient feels cold, with involuntary shaking and fever
2. Increase in body temperature
3. Headache
4. Myalgia
5. Nausea and vomiting
Treatment
1. Assess for signs and sources of infection
2. Obtain V/S
3. Notify physician
4. Obtain cultures
5. Discontinue HD without returning blood if endotoxin reaction is
suspected
6. Administer antimicrobials and antipyretics as ordered
7. Maintain dialysate temperature of 34-36°C
Prevention
1. Appropriate water treatment and reuse program
2. Aseptic treatment initiation
3. Minimize the time supplies are prepared prior to treatment
4. Routine cleaning of dialysis machine, dialysate equipment
5. Isothermic dialysate
6. Protect patient from known and unknown infectious agent
INTRADIALYTIC COMPLICATION:
Headache
- onset during HD, worsens during treatment or resolves 72 hours post HD
- occurs during at least half of prescribed dialysis treatment

Etiology:
1. Mild DDS
2. Caffeine withdrawal
3. Magnesium deficiency
4. Hypovolemia
5. Hypertension
Treatment Prevention

• Administer analgesic medication • Ensure appropriate treatment

as ordered parameters
• Adjust treatment parameters as • Administer IV magnesium as
indicated ordered
INTRADIALYTIC COMPLICATION:
Hypotension
• Occurs in 15-55%, most common intradialytic complication
• Associated with increased mortality and morbidity
• Impairs tissue perfusion and compromise dialysis adequacy
BP = Cardiac Output x Peripheral Vascular resistance
Cardiac Output = Stroke volume x heart rate
Intradialytic Hypotension (IDH)
• Decrease in systolic blood pressure by ≥ 20 mmHg or decrease in
mean arterial pressure by 10 mmHg
• If pre-HD SBP is less than 100 mmHg, then IDH is SBP ≥ 10 mmHg with
associated symptoms
Etiology
1. Posture changes. Autonomic neuropathy due to diabetes and
uremia blunts peripheral vascular resistance response to orthostatic
hypotension
2. Hypoxemia/Tissue Ischemia – triggers release of adenosine
(vasodilator)
3. Medications – antihypertensive, vasodilators (narcotics, analgesia)
4. Inaccuracies in UF rate or amount – hypervolemia or hypovolemia
5. Incorrect end goal or target of dialysis body weight
6. Reduced plasma osmolality
Etiology
7. Core body heating (dialysate greater than 36°C, high UF rate)
8. Eating immediately prior to, during or immediately after HD –
splanchnic vasodilation
9. Electrolyte imbalance
10. Acetate dialysate contributes to hypotension
11. Anemia (Hct <30%, Hgb <10 g/dL) – viscosity, hypoxemia
12. Unstable CV status, Septicemia, dialyzer reaction, carnitine
deficiency
Clinical patterns of Hypotension
1. Episodic hypotension which occurs during the latter stages of
dialysis and associated with vomiting, muscle cramps and other
vagal symptoms (such as yawning)
2. Chronic persistent hypotension which may occur in long – term
patients with whom predialysis systolic BP of less than 100 mmHg,
are frequently observed
Signs and Symptoms
1. Anxiety
2. Complaints of not feeling well
3. Cramps
4. Decreased LOC
5. Diaphoresis
6. Dizziness
7. Headache
8. Pallor
9. Post treatment malaise and fatigue
10. Nausea and vomiting
11. Arrhythmia
12. Yawning
Treatment
1. Position to Modified Trendelenburg position (True Trendelenburg
may impair lung capacity and oxygenation leading to more profound
hypotension)
2. Reduce UFR to minimum
3. Administer oxygen
4. Administer NSS (100-200mL), osmotic agents (use of mannitol is not
supported due to continued fluid shifts after HD)
5. Administer oral fluids if less severe, black coffee (if allowed) will
increase sympathetic tone
Prevention
1. Accurate pre dialysis and post dialysis weights
2. Dry weight evaluated every treatment
3. BP and PR measure before, during and after HD (rapid pulse indicated
compensation)
4. Use of dialysis log to summarize relevant information
5. Start HD with patient’s feet one notch off the floor, instruct to sit up and stand
slowly at end of treatment
6. Assess and treat hypoxemia
7. Withhold antihypertensive medications immediately before and during dialysis
8. Adjust and individualize UFR – UF profiling, Iso UF
Prevention
9. Isothermic dialysate
10. Encourage patient to eat small, high quality protein meal vs. large
carbohydrate meal and hour before and after HD
11. Assess lab values to identify and correct electrolyte imbalances
12. For patients with autonomic neuropathy, administer alpha-adrenergic
agonist (midodrine) 15-30 minutes prior to HD (half life to 2-2 ½ hours)
13. Instruct patient to take BP at home
14. Encourage fluid restrictions to 1L plus urinary output (IFG 1-2 kg
weekdays, 1.5-3 kg weekend)
15. Extend treatment time
INTRADIALYTIC COMPLICATION:
Hypertension
Intradialytic Hypertension
Etiology:
• Genetic predisposition
• Pre-existing hypertension
• Extracellular volume excess
• Increased renin-angiotensin system activity
• Increased sympathetic activity
• Uremic toxins
• Blood hyperviscosity
• Correction of hypoxia-induced vasoconstriction
• Increased dialysate sodium
Treatment and Prevention
Lifestyle Modifications
• Such as weight reduction, dietary modification, sodium restriction,
physical activity and moderation of alcohol consumption can reduce
systolic blood pressure from 2-14 mmHg
Treatment and Prevention
Adjustment of target weight
• On a regular basis. Gradual reduction of interdialytic weight gain over
a few weeks using zero sodium balance, salt restricton, longer dialysis
or extra dialysis sessions may yield a significant benefit
Treatment and Prevention
Reducing ERYTHROPOETIN dose
• In patients with severe hypertension and withholding of anti-
hypertensive medications on the days of dialysis
Treatment and Prevention
• NEPHRECTOMY in resistant cases
• Renal transplantation or
• Conversion to PD
INTRADIALYTIC COMPLICATION:
Hypoxemia
Etiology:
1.