Well, even after a few months I still feel out of place and ‘useless’ like a medical student when on the haemodialysis ward. The one with the chronic patients. I stick out like a sore thumb, just observing the nurses do their thing. Patients come and go like clockwork. It’s the first time I’m there after three pm and the patients are different then the ones in the morning shift, which I am more used to. Also, at the clinic, there are new lady MO’s! Finally, so glad to make some new friends. Easier to ask for their phone number also.

Sharing from lecture notes on complications during haemodialysis, I was told by a nephrologist that this is probably the most important part of the whole logbook when it comes to becoming a PIC of HDC (person in charge of haemodialysis center).

Complications During Haemodialysis
Part 1
Dr Rizna Abdul Cader UKMMC

Complications during HD:
Part 1. chest pain hypotension seizure arrhythmia
Part 2. first use reaction hypoxia bleeding from access pyrogenic reaction air embolism

Chest pain
Mild chest pain ±back pain (1-4%) Unknown cause No specific management or prevention strategy May try: switch dialyzer membrane
But must rule out important causes Acute coronary events Angina AMI Gastritis Pneumothorax Haemolysis Air embolism Pericarditis
Acute coronary event

Common in ESRD patients Traditional and non traditional risk factors 50% 1-year mortality Pathogenesis: Pathogenesis: Artherosclerosis Arteriosclerosis LVH Altered coronary perfusion Subendocardial ischemia

Acute coronary event: Management 1 Stop/Decrease UF in mild case Stop HD Attend to patients Nasal oxygen, ECG and frequent monitor : BP etc Nasal oxygen, ECG and frequent monitor : BP etc SL GTN if BP permitted Inform nephrologist in charge Refer for cardiologist

Acute coronary event: Management 2 Revascularization CABG Percutaneous Intervention (PCI)
Medications beta blockers ,oral nitrates beneficial: risk of hypotension. Diltiazem and verapamil could be use in beta blocker intolerance
Other causes of chest pain
Gastritis Pneumothorax Haemolysis Air embolism Air embolism Pericarditis

Hypotension

  • Commonest intradialytic complication
  • Hypovolaemia has been implicated as a major causal factor
  • Manifestations hypotension hypotension nausea vomiting muscle cramps fits cardiac arrhythmias.
  • Hypovolaemia is not consistently reflected by blood pressure changes
  • Hypovolaemia is sometimes asymptomatic
  • Impairment of specific compensatory response will lead to hypotension, e.g. diabetic autonomic neuropathy

Factors causing intradialytic hypotension: Impaired plasma refilling rate due to: high ultrafiltration(UF) rate low predialysishaematocrit low sodium dialysate acetate dialysate Inappropriate increase in venous capacity due to: Inappropriate increase in venous capacity due to: intradialyticingestion of food high body temperature low sodium dialysate acetate dialysate Decreased vascular resistance due to: anaemia high temperature food ingestion acetate dialysate Cardiac dysfunction

Other causes for hypotension:
pericardial tamponade arrhythmia dialyser reaction haemolysis haemolysis air embolism myocardial infarction occult haemorrhage septicemia

Management of hypotension: Lie patient in the Trendelenburg position Reduce or stop ultrafiltration depending on severity Reduce blood flow rate Infuse normal saline 100-250cc at a time to a maximum of 500cc 500cc Oxygen therapy Haemodialysis is terminated if persistent hypotension Refer out for investigating the causes in hospital

Management of hypotension:
If hypotension persists exclude: gastrointestinal bleeding acute myocardial infarction or ischaemia cardiac arrythmias,cardiac Cardiac tamponade Cardiac tamponade pulmonary embolism
Carry out the following investigations : ECG, blood glucose,

Measures to prevent hypotension:
Reassessment of “dry weight” when indicated Avoid rapid and excessive ultrafiltration Avoid excessive IDWG, maintain it <3-4% of dry weight Consider higher sodium concentration or sodium/UF profiling Consider UF profiling Consider UF profiling Consider use of a cooler dialysate temperature (34-36 oC) Avoid heavy meals prior to/during dialysis in hypotension-prone patients Avoid acetate dialysate Omit the predialysis dose of antihypertensive drugs Use sequential ultrafiltration Ensure haematocrit remains stable at 30% or greater prior to dialysis

Seizure: Etiology

  • Generalized seizures –integral feature of advanced uremic encephalopathy
  • Can be manifestation of severe dysequilibrium syndrome
  • Intracranial bleed –focal seizure
  • Intracranial bleed –focal seizure
  • Others: Aluminium encephalopathy
  • Hypertensive encephalopathy
  • Alcohol withdrawal
  • Hypocalcemia
  • Arrhythmias

Seizure: Predisposing factors

  • Incidence of seizure higher in children
  • Pre-dialysis hypocalcaemia
  • Hypoglycemia
  • Hypoglycemia
  • EPO with hypertension 1 seizure per 13 patient-years of therapy
  • Seizure common in epilepsy patients

Seizure: Diagnosis:

  • EEG not useful, never normal in ESRD patient
  • Important to exclude: aluminium toxicity
  • aluminium toxicity
  • underlying metabolic causes
  • structural intracranial lesion

 

Seizure: Prevention:

Identify susceptible patients Prevention of dialysis dysequilibrium syndrome IV calcium for those with low pre-dialysis serum IV calcium for those with low pre-dialysis serum calcium, & use high calcium dialysate Control BP, especially those initiated with EPO, titrate up anti-hypertensive

For some reason the last four pages from the slides, ie pages 18-22 refuse to load so I will continue that part another day….

 

This is the second lecture on complications.

Complications During Haemodialysis
Part 2
Dr Rizna Abdul Cader UKMMC

Complications during HD: Part 2

First use reaction Hypoxia Bleeding from access Bleeding from access Pyogenic reaction Air embolism

Dialyzer Reactions:
Type A (Anaphylactic type) Those with a history of atopy are at risk. Occurs usually during the first few minutes of dialysis. Mild: Itching,urticaria Itching,urticaria Cough, sneezing watery eyes abdominal pain, diarrhoea Severe anaphylactic reaction

Dialyzer Reactions: Type A Management Stop dialysis Clamp blood lines-disconnect extracorporeal circulation Assess severity Drugs-anti-histamine/ steroid Drugs-anti-histamine/ steroid Cardiovascular support

Prevention Proper dialyzer rinsing prior to use Re-use procedures prior to first use

Avoid ETO sterilized dialyzer for those with history of type A dialyzer reaction Pre-dialysis anti-histamine for those with persistent mild reaction
Type B (non-specific dialyzer reaction) Typically manifests with chest pain, may or may not be accompanied by back pain. Less severe and generally dialysis can be continued Onset of symptom later than Type A.
Management Supportive Exclude myocardial ischemia/ sub-clinical Hemolysis
Prevention Reuse procedure on new dialyzer Try different dialyzer membrane

Dialysis associated hypoxemia: Definition: PO2 drop by 5-30mmHg during HD No clinical significant in normal patient Deleterious in pulmonary disease patients Deleterious in pulmonary disease patients
Dialysis associated hypoxemia: Etiology 1. Hypoventilation during HD Mechanism Acetate-containing dialysate Acetate-containing dialysate Blood loses CO2 Patient hypoventilates to maintain PCO2 hypoxemia Bicarbonate-containing dialysis solution: alkalosis When bicarbonate level high ( >35mM) Bicarbonate diffusion from dialysate to blood to raise pH This, suppress ventilation hypoxemia
Dialysis associated hypoxemia: Etiology 2. Intrapulmonary diffusion block Mechanism Dialysis using unsubstituted cellulose membranes causes Dialysis using unsubstituted cellulose membranes causes sequestation of neutrophils in the lung. Alveolar-to-alveolar oxygen gradient increased very early during dialysis, due to neutrophil embolization into pulmonary capillaries
Herrero et al, 2002

Dialysis associated hypoxemia:
Management Intervention are usually not required Nasal oxygen for those with active cardiac ischemia or severe COPD patients Venturi mask oxygen, more appropriate in patients with Venturi mask oxygen, more appropriate in patients with CO2 retention Prevention By oxygen administration Avoid unsubstituted celloluse dialyzer in high risk patients Use a bicarbonate solution, with low bicarbonate concentration.

Bleeding From Vascular Access:
Dialysis patients have a higher incidence of bleeding
The causes include: platelet dysfunction / impaired platelet-endothelium interaction interaction use of anticoagulation during haemodialysis platelet-dialyser membrane interaction leading to thrombocytopenia
Bleeding: Presenting features include: bleeding from venepunctures sites subdural haematoma subarachnoid haemorrhage gastrointestinal bleeding gastrointestinal bleeding haemopericardium

Bleeding from access: Management Compress the access, tight bandage, arrange vascular referral minimal heparinisation-monitor activated clotting time (ACT)hourly; keeping ACT between 150-180 seconds heparin-free haemodialysis-this requires increased blood flow rate and frequent flushing with isotonic saline and frequent flushing with isotonic saline blood transfusion for severe blood loss FFP, cryoprecipitate, DDVAP (0.3-0.4 μg/kg) may be required protamine when haemostasis is poor in heparinised patients avoid catheter removal within 4-6 hours after dialysis

Pyogenic Reaction: Microbial/Endotoxin contamination: The presenting features are: fever chills hypotension
Contamination is caused by reuse of improperly processed Contamination is caused by reuse of improperly processed dialyzer or contaminated dialysate
Microbial contamination can occur during any of the reprocessing steps (rinsing, cleaning, testing, and sterilizing hollow fibre dialyzer), but most commonly, use of contaminated water is implicated
The use of bicarbonate dialysate and high-flux dialysis is associated with an increased risk of pyrogenic reaction

Pyrogenic Reaction:
Differential diagnosis includes: cannulation of infected fistulae or grafts dialyzer reaction early septicemia Management Investigate the cause Mild :supportive Severe :hospitalization may be required a cluster of similar cases should prompt a review of the water used for reprocessing and water distribution and dialysates

Air Embolism
Sources of air entry into the dialysis circuit include: pre-pump tubing segment intravenous infusion set other parts of the dialysis tubing other parts of the dialysis tubing air from the dialysate from an inadvertently opened end of a central venous catheter

Air Embolism
The signs and symptoms depend on the volume of air entering the vascular system and the position of the patient
If the patient is sitting upright air will enter the central If the patient is sitting upright air will enter the central nervous system causing fits
If the patient is recumbent, air enters the heart causing decreased cardiac output and sudden onset of dyspnoea, cough & central cyanosis
Air Embolism
Management of air embolism 1.Stop haemodialysis, clamp the venous return 2.Do not return blood to the patient 3.Place the patient in the left lateral Trendelenburg 3.Place the patient in the left lateral Trendelenburg position 4.Give 100% oxygen with or without mechanical ventilation

Air Embolism
Prevention 1.Dialysis should never be performed with the air alarm system inactivated 2.IV solution should be in collapsible bags 3.Catheter should be aspirated for return of blood and 3.Catheter should be aspirated for return of blood and flushed with saline before connection to the dialysis circuit 4.Dialyzer should be rinsed thoroughly with saline to expel air bubbles

Questions?

There is a part in the logbook about observing complications. This includes:

hypotension

hypoglycaemia (optional)

bleeding vascular access

thrombosed access

bleeding access (optional)

extravasation/haematoma of access

chest pain (angina) (optional)

Hypotension is to observed five times and the rest once. I presume optional means its ok if it is not observed.

So far I have seen none. The staff though have described events where one patient bled and the force of the bleed caused splash on the ceiling (yes, there is still a mark, believe it or not), and also another patient who bled and no one noticed because he had blanket on, so its important that the access is always visible through out the session.

Then saw a patient who seemed to be shivering during the end of a HD session. The MO was called to review the patient. He said he gets it often or has had it before (a bit of language barrier due to being non-Kelantanese). Its the air-conditioning. He has sweat though on his face and looks rather ill. Nurse checks temp. 37’C. They were observing him for a moment there.

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