Complications_Dialysis

Complications of Hemodialysis

Objectives

Understand the problems and complications ♦

encountered during hemodialysis

The cause/s of each –

The signs and symptoms of each –

The management and intervention of each –

Understand the problems and complications ♦

Disequilibrium syndrome –

Hypotension –

Air embolism –

Problems and Complications

♦ Monitoring during the dialysis treatment is done to prevent, detect and treat complications

♦ Observations should be recorded on the patients hemodialysis treatment sheet, progress notes or electronic medical record

♦ Continuous monitoring and early detection can reduce and may even prevent problems and complications

Common Complications

Technical Complications

Patient Complications

Hypotension (20-30%) •
Muscle Cramps •
Disequilibrium Syndrome •
Nausea and Vomiting •
Headache •
Chest Pain •
Itching •
Fever and Chills •
Pyrogen reaction •
Hypertension •

Patient complications

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

Less Common Causes

Anemia ♦

– Hemorrhage

Low weight gain or dehydration ♦

♦ Anaphylaxis

Air embolism ♦

Eating/drinking during dialysis ♦

Dialyzer reaction ♦

Common Causes

Removing too much weight ♦

– Inaccurate target weight

– Inaccurate pre-weight

Taking Antihypertensive pills before dialysis (BP meds) ♦

Heart disease ♦

– MI’s or arrhythmias

Septicemia ♦

Signs and Symptoms of Hypotension

Gradual or sudden decrease in B/P ♦

– Increase in pulse

Cold, clammy skin (diaphoresis) ♦

Nausea/Vomiting ♦

Cramping ♦

Chest pain/angina ♦

Yawning, feeling dizzy, sleepy or weak ♦

Pallor ♦

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 ♦

– Evaluate target and pre-weight for accuracy

– 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 •

– Inaccurate fluid removal goal

Signs and Symptoms of Muscle Cramps

♦ Can occur anytime in dialysis, especially middle to end of treatment

♦ Muscle cramping of extremities that can often be seen

♦ Hypotension

Treatment of Muscle Cramps

♦ Treat the symptoms:

– Normal saline bolus

– Reduce UFR

– Massage or apply opposing force

– Assess dry weight

♦ Prevention:

– Sodium modeling

– Assess for accurate target weight

Disequilibrium Syndrome

Defined as a set of systemic and neurologic symptoms that include ♦

– Nausea & vomiting

– Headache

– Restlessness

– Hypertension

– Slurred speech

– Seizure and coma

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 causingg cerebral edema

– Rapid changes in serum electrolytes, especially in new patients

• Elevated 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:

– Use a smaller dialyzer, lower BFR and shorter dialysis time for first few treatments

Nausea and Vomiting

• Causes:

– Hypotension

– Uremia

• 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

Headache

• Causes:

– Hypotension

– Inaccurate dry weight with too much fluid removed

– Rapid fluid or electrolyte shift – Disequilibrium Syndrome

– Anxiety/nervous tension

– Caffeine withdrawal

• Symptoms:

– Pain in the head or facial area

– Hypotension

– Nausea or vomiting

Headache Treatment

• Treat the symptoms:

– Unit policy for analgesics

– Hypertension: BP assessment

– Hypotension – NS bolus

• Prevention:

– Patients require careful pre-assessment and monitoring during treatments

– Goal is to identify the cause and then prevent it in the future

Chest Pain

Myocardial Infarction

: Angina

• Chest pain

• Caused from ischemia that results in tissue death

• Not resolved by Nitroglycerin

• Chest pain

• Caused from ischemia (lack of oxygen to tissue)

• Resolved by Nitroglycerin

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 cardiac disease

Angina and MI Symptoms

MI

Angina

• Pressure, pain localized or may radiate to neck, jaw, shoulders, arms-may come and go

• Apprehension

• Choking/strangling sensation

• Squeezing/crushing/pressure sensation

• Nausea

• Pallor, cool clammy skin

• Hypotension

• Pressure, pain localized or may radiate to neck, jaw, shoulders, arms-may come and go

• Apprehension

• Choking/strangling sensation

• Squeezing/crushing/pressure sensation

• Duration 1-2 minutes

• Nausea

• Pallor, cool clammy skin

Treatment

• Treat the symptoms:

– Hypotension

– Angina pain with Nitroglycerin

– MI pain requires analgesics

–Anxiety/stress

• 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

• Treatment:

– 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

Chills and Fever

• Causes:

– Infection or septicemia

• Vascular access

• Respiratory illness

– Cold dialysate or malfunctioning thermostat

• Patient has shaking/shivering without fever

– Pyrogenic reaction

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 cough

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

Caused by contamination of:

– Bicarbonate containers/system

– Water system

– Machine

– Dialyzer or bloodlines

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:

– Remove from dialysis immediately

– Gather samples of dialysate/blood per company policy

• Prevention

– Proper disinfection/sterilization

– Use of aseptic technique

Hypertension

• Causes:

– Fluid overload

– Non-compliance with blood pressure medications

– Anxiety

– Renin overproduction

Symptoms: (frequently asymptomatic) •

– Gradual or sudden rise in BP

– Headache, blurring vision

– Nausea/Vomiting

– Dizziness

– Seizure

Treatment •

– Review of BP medications

– Assessment of target weight and fluid removal goal

Technical Complications

• Clotting

• Blood leak

• Power failure

• Hemolysis

• Air Embolism

– Air in bloodlines

• Exsanguination

• Dialyzer reactions

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

• Poor priming techniques

• 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

Blood Leak

• Cause:

– Membrane rupture allowing RBC’s to cross over the

membrane into the dialysate

• Signs:

– Blood leak alarm

– Positive test for blood in dialysate

• Interventions

– Check dialysate outflow with Blood leak strip

– If positive, stop treatment, do not return blood

– If negative may need to get different machine

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:

– Know how to free venous line and hand crank blood

– Company policy

Hemolysis

Breakdown or destruction of RBC’s •

– Releases potassium from damaged cells into the blood stream

– Decreasing the oxygen carrying capacity of the RBC

• Potentially life threatening

Causes of Hemolysis

Chemical and Thermal

Mechanical

Chemical:

• Delivery of improperly prepared dialysate

• chemical agents such as Dialysate contaminated with formaldehyde, bleach, chlorine, copper, nitrates and nitrites Thermal

• Overheated dialysate (> 42 degrees C)

• Poorly functioning or incorrectly calibrated blood pump

• Excessive negative pressure in the extracorporeal circuit

• Deformity in lines (kinks,folds, etc)

• Over occlusion of blood pump

Signs of Hemolysis

• Dialyzer/blood lines:

– Cherry colored blood in venous line

• Patient:

– Shortness of breath

– Chest, abdominal and/or back pain

– Cardiac arrest

• Intervention

– Stop dialysis and DO NOT return blood to the patient

– By symptom

Air Embolism

Introduction of enough air into extracorpeal system to stop circulation

• 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

Signs and Symptoms of Air Embolism

• Extracorpeal System:

– Air pocket or foam (pink) in venous line

• Patient:

– Coughing, shortness of breath

– Chest 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

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

• Call 911

Air in Bloodlines

• Causes:

– Under filling drip chambers

– Empty saline bag

– Loose connections

– Dialysis needle removed while blood pump is 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 line separation

– 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

Treatment of Exsanguination

• Identify the source of blood loss

• Stop dialysis

– Return blood if possible (not contaminated system)

• Treat the symptoms:

– Normal saline to support blood pressure

– Oxygen for shortness of breath

• Call 911

Dialyzer Reactions

• Causes

– First use syndrome

– Hypersensitivity to membrane

Dialyzer Reactions

Hypersensitivity

First Use Syndrome

• Anxiety

• Hives, pruritis

• Dyspnea, wheezing

• Chest tightness

• Possible cardiac arrest

• Back pain

• Chest pain

• Hypotension

• Pruritis

• Nausea

• Vague discomfort

Dialyzer Reactions

• 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