Presentation done at Dialysis workshop at Indus Hospital Derabassi

1. ACUTE COMPLICATIONS OF
HAEMODIALYSIS
Dr Narinder Sharma
Indus International
Hospital, Derabassi

2. What we will discuss
 Some common acute complications that can
occur during dialysis
 How to manage them
 When to call the doctor

3. CASE DISCUSSION 1
 A 55 year old male is coming to your dialysis
set up two times a week. He is a diabetic (on
Insulin), suffers from Coronary Artery
Disease (his last ECHO revealed an EF of
25%.). His weight gain before each HD
averages about 4.5 kg. Today, about one
hour into his dialysis, he complains of
sweating, restlessness, dizziness & nausea.

4. What will you do now?

5. What will you do now?
Check the BP and RBS

6. Case Discussion 1
 BP was 80/40
 RBS was 121
What will you do next?

7. Case Discussion 1
What will you do next?
 Give Normal Saline bolus about 200 ml

8. Case Discussion 1
What will you do next?
 Give Normal Saline bolus about 200 ml
 STOP UF

9. Case Discussion 1
What will you do next?
 Give Normal Saline bolus about 200 ml
 STOP UF
 Raise the foot end of the bed

10. Case Discussion 1
What will you do next?
 Give Normal Saline bolus about 200 ml
 STOP UF
 Raise the foot end of the bed
HOW DO THESE MEASURES HELP?

11. Case Discussion 1
What will you do next?
 Give Normal Saline bolus about 200 ml
 STOP UF
 Raise the foot end of the bed
These measures will increase the effective
circulating volume

12. Case Discussion 1
 BP after 10 minutes is 88/54
WHAT WILL YOU DO NOW?

13. Case Discussion 1
CALL THE PHYSICIAN !

14. Case Discussion 1
 The doctor finds the BP to be 90/60, pulse
135/minute, irregular.
 He orders HD to be terminated. Further
advises moist oxygen inhalation and an
immediate ECG.

15. ACUTE COMPLICATIONS OF
HAEMODIALYSIS
HYPOTENSION
The single most common complication
encountered during haemodialysis
Why does hypotension occur during
haemodialysis?

16. ACUTE COMPLICATIONS OF
HAEMODIALYSIS
Why does hypotension occur during
haemodialysis?
The most common cause of hypotension during
dialysis is excess removal of fluid during UF

17. ACUTE COMPLICATIONS OF
HAEMODIALYSIS
How much fluid removal is excessive?

18. ACUTE COMPLICATIONS OF
HAEMODIALYSIS
How much fluid removal is excessive?
UF rate more than 12 ml/kg/hr

19. ACUTE COMPLICATIONS OF
HAEMODIALYSIS
How much fluid removal is excessive?
In a 50 kg patient you should not remove more
than ….. ml/hour

20. ACUTE COMPLICATIONS OF
HAEMODIALYSIS
How much fluid removal is excessive?
In a 50 kg patient you should not remove more
than 600 ml/hour

21. ACUTE COMPLICATIONS OF
HAEMODIALYSIS
What can happen if hypotension is not
immediately dealt with?

22. ACUTE COMPLICATIONS OF
HAEMODIALYSIS
What can happen if hypotension is not
immediately dealt with?
There will be decreased organ perfusion causing
• Myocardial ischaemia
• Cardiac arrhythmias
• Cardiac Arrest
• Seizures
• Death

23. ACUTE COMPLICATIONS OF
HAEMODIALYSIS
What can happen if hypotension is not immediately
dealt with in a patient of AKI during dialysis

24. ACUTE COMPLICATIONS OF
HAEMODIALYSIS
What can happen if hypotension is not immediately
dealt with in a patient of AKI during dialysis
Further Renal Ischaemia > Delayed Renal Recovery

25. ACUTE COMPLICATIONS OF
HAEMODIALYSIS
OTHER CAUSES OF HYPOTENSION
Cardiac
 MI
 Arrhythmias
 Structural heart disease
 Pericardial Tamponade

26. ACUTE COMPLICATIONS OF
HAEMODIALYSIS
OTHER CAUSES OF HYPOTENSION
Patient Related
• Anti Hypertensive medication
• Autonomic Neuropathy (Diabetes, Uremia)
• Food Ingestion
• Tissue Ischaemia
• Bacterial Sepsis
• Anaemia

27. ACUTE COMPLICATIONS OF
HAEMODIALYSIS
OTHER CAUSES OF HYPOTENSION
Dialysis related
• Acetate Dialysate
• Low Dialysate Na and Ca
Haemolysis
Air Embolism – is your air flow detector working
Dialyzer Reaction – First use/ Reuse/ Pyrogen

28. DIALYSIS REACTIONS
 5-20 minutes into HD
– Anaphylaxis (IgE mediated)
 First Use Reaction
 Reuse Reaction (Formaldehyde, Renalin)
– Anaphylactoid (Bradykinin / Histamine mediated)
 20-40 minutes into HD
– Mild Reaction (Complement mediated)
– Use of Cellulose membranes
 Anytime during HD
– Pyrogen Reaction (Bacterial Contamination)

29. ACUTE COMPLICATIONS OF
HAEMODIALYSIS
HOW CAN YOU PREVENT HYPOTENSION?

30. ACUTE COMPLICATIONS OF
HAEMODIALYSIS
HOW CAN YOU PREVENT HYPOTENSION?
– During Dialysis
 Increase Blood flow gradually

31. ACUTE COMPLICATIONS OF
HAEMODIALYSIS
HOW CAN YOU PREVENT HYPOTENSION?
– During Dialysis
 Increase Blood flow gradually
 Check BP every 30 minutes for stable patients and
every 10 minutes for new patients

32. ACUTE COMPLICATIONS OF
HAEMODIALYSIS
HOW CAN YOU PREVENT HYPOTENSION?
– During Dialysis
 Increase Blood flow gradually
 Check BP every 30 minutes for stable patients and
every 10 minutes for new patients
 25 D injection – increase intravascular osmotic pressure

33. ACUTE COMPLICATIONS OF
HAEMODIALYSIS
HOW CAN YOU PREVENT HYPOTENSION?
– During Dialysis
 Increase Blood flow gradually
 Check BP every 30 minutes for stable patients and
every 10 minutes for new patients
 25 D injection – increase intravascular osmotic pressure
 UF Profiling – give time for fluid to move from interstitial
to intravascular space

34. ACUTE COMPLICATIONS OF
HAEMODIALYSIS
HOW CAN YOU PREVENT HYPOTENSION?
– During Dialysis
 Increase Blood flow gradually
 Check BP every 30 minutes for stable patients and
every 10 minutes for new patients
 25 D injection – increase intravascular osmotic pressure
 UF Profiling – give time for fluid to move from interstitial
to intravascular space
 Na Profiling – higher initial Na will help maintain the BP

35. ACUTE COMPLICATIONS OF
HAEMODIALYSIS
HOW CAN YOU PREVENT HYPOTENSION?
– Correct Interdialytic weight gain

36. ACUTE COMPLICATIONS OF
HAEMODIALYSIS
HOW CAN YOU PREVENT HYPOTENSION?
– Correct Interdialytic weight gain
– Patient counselling – salt and fluid intake

37. ACUTE COMPLICATIONS OF
HAEMODIALYSIS
HOW CAN YOU PREVENT HYPOTENSION?
– Correct Interdialytic weight gain
– Patient counselling – salt and fluid intake
– Withdraw antihypertensive drugs before dialysis

38. ACUTE COMPLICATIONS OF
HAEMODIALYSIS
HOW CAN YOU PREVENT HYPOTENSION?
– Correct Interdialytic weight gain
– Patient counselling – salt and fluid intake
– Withdraw antihypertensive drugs before dialysis
– Avoid food before and during dialysis

39. ACUTE COMPLICATIONS OF
HAEMODIALYSIS
HOW CAN YOU PREVENT HYPOTENSION?
– Correct Interdialytic weight gain
– Patient counselling – salt and fluid intake
– Withdraw antihypertensive drugs before dialysis
– Avoid food before and during dialysis
– Correction of anaemia and hypoalbuminaemia

40. ACUTE COMPLICATIONS OF
HAEMODIALYSIS
HOW CAN YOU PREVENT HYPOTENSION?
– Correct Interdialytic weight gain
– Patient counselling – salt and fluid intake
– Withdraw antihypertensive drugs before dialysis
– Avoid food before and during dialysis
– Correction of anaemia and hypoalbuminaemia
– Use Cool Dialysate

41. ACUTE COMPLICATIONS OF
HAEMODIALYSIS
HOW CAN YOU PREVENT HYPOTENSION?
– Correct Interdialytic weight gain
– Patient counselling – salt and fluid intake
– Withdraw antihypertensive drugs before dialysis
– Avoid food before and during dialysis
– Correction of anaemia and hypoalbuminaemia
– Use Cool Dialysate
– Short daily HD

42. CASE DISCUSSION 2
 A 52 year old female on regular dialysis three
times a week complains of sudden pain in
her fistula arm 40 minutes into her dialysis.
 What should you do?

43. Case Discussion 2
 Check position of fistula needle
 Look for swelling, redness, discolouration
 Look for aneurysm
 Is the fistula vein too thin?
 Decrease Blood flow if above measures fail
 Inform Physician

44. Case Discussion 3
 A 58 year old male on HD twice a week, with
5 kg weight gain between each HD session
complains today of severe cramping pain
both legs two hours into his dialysis. His BP
is 110/50. RBS 98
 What should you do?

45. Case Discussion 3
 Give Normal Saline bolus 200 ml
 25D 100 ml
 Can you give Hypertonic Saline?

46. ACUTE COMPLICATIONS OF
HAEMODIALYSIS
How to prevent cramps during dialysis
 Accurate Interdialytic wt gain
 Increase dry wt by 0.5 kg
 Na Profiling
 Carnitine
 Quinine SO4 2 hrs prior to dialysis
 Exercise

47. Case Discussion 4
 A 24 year old moderately built male has come with a
BUN of 165 mg/dl, Creatinine 20 mg/dl. Examination
revealed pedal edema. BP 130/90. ABG showed
severe metabolic acidosis. A femoral catheter was
inserted and HD was started with blood flow of 260
ml/min. After about 2 hours, towards the end of HD,
patient began to complain of headache and had an
episode of vomiting. BP 170/90 RBS 108 His
sensorium deteriorated rapidly and he was shifted to
the ICU.
 What can be the cause?

48. Case Discussion 4
 A 24 year old moderately built male has come with a
BUN of 165 mg/dl, Creatinine 20 mg/dl. Examination
revealed pedal edema. BP 130/90. ABG showed
severe metabolic acidosis. A femoral catheter was
inserted and HD was started with blood flow of 260
ml/min. After about 2 hours, towards the end of HD,
patient began to complain of headache and had an
episode of vomiting. BP 170/90 RBS 108 His
sensorium deteriorated rapidly and he was shifted to
the ICU.
 What can be the cause?
Dialysis Disequilibrium Syndrome (DDS)

49. ACUTE COMPLICATIONS OF
HAEMODIALYSIS
How to prevent DDS

50. ACUTE COMPLICATIONS OF
HAEMODIALYSIS
How to prevent DDS
Less Efficient HD !

51. ACUTE COMPLICATIONS OF
HAEMODIALYSIS
How to prevent DDS
Less Efficient HD !
 Reduce blood flow rates to 150 – 200 ml/min for
initial HD
 Short initial dialysis using small surface area
dialyzers
 Target URR should be 30%

52. Case Discussion 5
 A 64 year old non diabetic, hypertensive dialysis
patient on thrice weekly HD (average blood flow 300-
350 ml/min) with left Brachiocephalic Fistula
complains of a feeling of coldness and tingling
sensation in her fistula arm with mild pain occurring
during her dialysis session.
What has happened to the patient?

53. Case Discussion 5
 A 67 year old non diabetic, hypertensive dialysis
patient on thrice weekly HD (average blood flow 300-
350 ml/min) with left Brachiocephalic Fistula
complains of a feeling of coldness and tingling
sensation in her fistula arm with mild pain during her
dialysis session.
What has happened to the patient?
Dialysis-Associated Steal Syndrome

54. ACUTE COMPLICATIONS OF
HAEMODIALYSIS
Dialysis-Associated Steal Syndrome
AVF > reduced blood flow to hand > ischaemic changes

55. ACUTE COMPLICATIONS OF
HAEMODIALYSIS
Dialysis associated Steal Syndrome –
AVF > reduced blood flow to hand > ischaemic changes
 Examine the arm for
– temperature change
– Loss of sensation
– signs of muscle wasting / gangrene
 Check peripheral pulses
 Inform the doctor

56. Case Discussion 6
 A 37 year old hypertensive patient on dialysis
twice a week complains of throbbing
headache 90 minutes into his dialysis. He
also c/o tightness in his abdomen.
 What will you do?

57. Case Discussion 6
 Check BP and RBS

58. Case Discussion 6
 Check BP and RBS
 Has the patient eaten anything before/during
dialysis

59. Case Discussion 6
 Check BP and RBS
 Has the patient eaten anything before/during
dialysis
 Is the patient a habitual coffee drinker?

60. Case Discussion 6
 Check BP and RBS
 Has the patient eaten anything before/during
dialysis
 Is the patient a habitual coffee drinker?
 Inform the doctor

61. Case Discussion 6
 Check BP and RBS
 Has the patient eaten anything before/during
dialysis
 Is the patient a habitual coffee drinker?
 Inform

62. ACUTE COMPLICATIONS OF
HAEMODIALYSIS
COMMON CAUSES OF HEADACHE DURING
DIALYSIS
• Hypotension
• Hypertension
• Hypoglycaemia
• Acid Reflux
• Caffeine withdrawal
• DDS

63. CASE DISCUSSION 7
 A 74 year old female who has started HD
about 2 months ago c/o chest pain 30
minutes into her dialysis session. She is non
diabetic but suffers from hypertension. Her
last ECHO revealed EF of 20 %
 What will you do?

64. CASE DISCUSSION 7
 A 74 year old female who has started HD
about 2 months ago c/o chest pain 30
minutes into her dialysis session. She is non
diabetic but suffers from hypertension. Her
last ECHO revealed EF of 20 %
• Check BP, Pulse, RBS
• Rule out Acid Reflux

65. CASE DISCUSSION 7
 BP 110/70
 Pulse 58/minute , regular
 RBS 110
Now what will you do?

66. CASE DISCUSSION 7
 Start moist oxygen
 Give Sorbitrate
 Stop UF Give 200 ml Normal Saline bolus
 Call the doctor
 Get an ECG done
 Inj. PAN I/V stat
 If pain persists, stop dialysis

67. ACUTE COMPLICATIONS OF
HAEMODIALYSIS
Common Causes of Chest Pain during HD
• Ischaemic Heart Disease
• Acid Reflux Disease
• Dialyzer Reactions
• Pleural Effusion
• Pericarditis
• muscle pain

68. CHILLS AND FEVER
Infection or septicemia
Vascular access
Respiratory illness
Cold dialysate or malfunctioning thermostat
Patient has shaking/shivering without
fever
Pyrogenic reaction

69. CLOTTING
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

70. 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
Treatment:
Anticoagulation
Vascular access
Needle placement

71. HEMOLYSIS
Rare but potentially life threatening complication of
HD
Presentation may relate to the cause as well as the
hemolysis itself
Manifestations:
Non-specific malaise
Weakness
Nausea
Abdominal pain
Arrhythmia
Cardiac arrest

72. HEMOLYSIS
Mechanical
Poorly functioning or incorrectly calibrated blood pump
Excessive negative pressure in extracoporeal pump
Deformities in lines..kinks
Overocclusion of blood pumps
Chemical
Improper dialysate
Chemical contaminantes
Thermal
Overheated dialysates

73. HEMOLYSIS
Fall in Hb
Pink plasma with elevated free plasma Hb
Elevated LDH, low haptoglobin
Increased bilirubin
Hyperkalemia
Intervention
– Stop dialysis and DO NOT return blood to the patient
– By symptom

74. AIR EMBOLISM
Introduction of enough air into extracorpeal system to
stop circulation
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

75. 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/respirator arrest

76. 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

77. 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

78. Thank You !