complication of hemodialysis and their management (1)

7/26/2019 Complication of Hemodialysis and Their Management (1)

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D R S A N J I V M A H A J A N

Complications of hemodialysis

and their management


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Objectives

Understand the problems and complicationsencountered during hemodialysis The cause/s of each The signs and symptoms of each The management and intervention of each

Special attention to: Disequilibrium syndrome

ypotension !ir embolism


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"roblems and Complications

#onitoring during the dialysis treatment is done toprevent$ detect and treat complications

Observations should be recorded on the patients

hemodialysis treatment sheet$ progress notes orelectronic medical record

Continuous monitoring and early detection canreduce and may even prevent problems and

complications


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Common Complications


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"atient complications

ypotension %&'()'*+

#uscle Cramps

Disequilibrium Syndrome

,ausea and -omitingeadache

Chest "ain

.tching

ever and Chills

"yrogen reaction

ypertension


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ypotension

#ost common complication in hemodialysis Defined as lo0 blood pressure Decreased systolic blood pressure by 1&'()' mmg from

predialysis pressure Systolic blood pressure 23'' mmg


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.ntradialytic hypotension

Definition ! decrease in systolic 4" 5&' mm g or a decrease in

#!" 5 3' mm g associated 0ith symptoms6

Complication Cardiac arrhythmias$ coronary and/or cerebral

ischemic events

7ong(term side effects -olume overload due to suboptimal ultrafiltration$

7-$ and interdialytic hypertension

K-DOQI guildline


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Causes of ypotension


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Signs and Symptoms ofypotension

8radual or sudden decrease in 4/" .ncrease in pulse

Cold$ clammy s9in %diaphoresis+

,ausea/-omitingCramping

Chest pain/angina

a0ning$ feeling di;;y$ sleepy or 0ea9

"allorDecreasing mental status to loss of consciousness

Sei;ure


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Treatment of ypotension

Treat the symptoms "ay attention to ho0 the patient feels ,S bolus "lace patient in trendelenburg position Use Sodium modeling

"revention ( determine the cause


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Trendelenburg position


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#uscle Cramps

"ainful muscle spasms %usually in e>tremities+

Causes: !ssociated 0ith removal of large amounts of fluid

ypotension

Changes in electrolytes %blood chemistry+ =apid sodium removal

7o0 potassium levels

.naccurate fluid removal goal


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Signs and Symptoms of #uscleCramps

Can occur anytime in dialysis$ especially middle toend of treatment

#uscle cramping of e>tremities that can often be

seenypotension


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Treatment of #uscle Cramps

Treat the symptoms: ,ormal saline bolus =educe U= #assage or apply opposing force !ssess dry 0eight

"revention: Sodium modeling !ssess for accurate target 0eight


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Disequilibrium Syndrome

Defined as a set of systemic and neurologicsymptoms that include ,ausea ? vomiting eadache =estlessness ypertension Slurred speech Sei;ure and coma


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Cause of DisequilibriumSyndrome

Causes Slo0er transfer of urea from the brain tissue to the blood

luid shift into the brain due to removal of 0astes from the bloodstream causing cerebral edema

=apid changes in serum electrolytes$ especially in ne0 patients


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Treatment of DisequilibriumSyndrome

Treat the symptoms: #onitor ne0 patients carefully for hypertension Decrease 4= Treat ,/- and headache per protocol 4e alert for restlessness$ speech/mental changes

"revention: !ssess ne0 patients electrolyte levels Use a smaller dialy;er$ lo0er 4= and shorter dialysis time for

first fe0 treatments


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,ausea and -omiting

Causes: ypotension Uremia Disequilibrium Syndrome

Treatment the symptoms: ypotension A ,S bolus Determine relationship to dialysis

.s the patient sic9B

"revention Uremic patient or one 0ith Disequilibrium Syndrome require

careful pre(assessment and monitoring during the initialtreatments


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eadache

Causes: ypertension .naccurate dry 0eight 0ith too much fluid removed =apid fluid or electrolyte shift Disequilibrium Syndrome !n>iety/nervous tension Caffeine 0ithdra0al

Symptoms "ain in the head or facial area ypotension ,ausea or vomiting


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eadache Treatment

Treat the symptoms Unit policy for analgesics ypertension: 4" assessment ypotension ,S bolus

"revention: "atients require careful pre(assessment and monitoring during

treatments 8oal is to identify the cause and then prevent it in the future


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Chest "ain


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Causes of Chest "ain

.schemia to heart muscle %Coronary !rtery Disease+

!nemia

ypotension from fluid depletion

ypovolemia!n>iety(stress$ physical e>ertion$ illness

4lood flo0 rate increased too rapidly on patient 0ith9no0n cardiac disease


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!ngina and #. Symptoms


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Treatment

Treat the symptoms: ypotension !ngina pain 0ith ,itroglycerin #. pain requires analgesics !n>iety/stress

"revention !ccurate fluid removal and 0eight assessment


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.tching

Causes: Dry s9in Secondary hyperparathyroidism !bnormal levels of calcium$ magnesium and phosphorus in tissues

!llergies Uremia 0ith an elevated 4U,

Treatment: !dequate dialysis to regulate electrolyte levels

7otions or medications for dry s9in/allergies"revention: Control of uremia and secondary hyperparathyroidism !dequate dialysis to regulate electrolyte levels


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Chills and ever

Causes: .nfection or septicemia

-ascular access

=espiratory illness

Cold dialysate or malfunctioning thermostat "atient has sha9ing/shivering 0ithout fever

"yrogenic reaction


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Symptoms

.nfection: ever during dialysis eeling cold 0ith a fever =edness$ s0elling$ tenderness$ 0armth or drainage from access

site

Septicemia: ever$ chills$ vomiting and headache ypotensive shoc9

=espiratory "roductive cough


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"yrogenic =eaction

ever reaction due to presence of dead bacteriaendoto>ins 7o0 molecular 0eight endoto>in fragments may be able to

cross any membrane$ irrespective of membrane pore si;e

distribution

Caused by contamination of: 4icarbonate containers/system ater system #achine Dialy;er or bloodlines


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Symptoms of "yrogenic =eaction

Symptoms: Cold sensation upon treatment initiation %E'(F' minutes into treatment+ Sudden sha9ing chills$ then temperature elevation %3(& hours after chills+ (

resolves after end of treatment ,ote increased pulse before chills develop ypotension %drop in 4/" 1)' mm/g+ eadache/#uscle aches

Treatment: =emove from dialysis immediately

8ather samples of dialysate/blood per company policy"revention "roper disinfection/sterili;ation Use of aseptic technique


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ypertension

Causes: luid overload ,on(compliance 0ith blood pressure medications !n>iety =enin overproduction

Symptoms: %frequently asymptomatic+ 8radual or sudden rise in 4" eadache$ blurring vision ,ausea/-omiting Di;;iness

Sei;ureTreatment =evie0 of 4" medications !ssessment of target 0eight and fluid removal goal


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Technical Complications

Clotting

4lood lea9

"o0er failure

emolysis!ir


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Clotting in the tracorporealCircuit

ormation of blood clots in the dialy;er and bloodlines

Causes: .nadequate anticoagulation 7o0 blood flo0 rate !ir in blood lines

"oor priming techniques

7oose connections


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Clotting

Signs of Clotting: .ncreasing venous pressure readings Dar9 blood in lines or drip chambers ibrin in drip chambers %GfurryH appearance+

-isible clots or clumping of dar9 blood in the drip chamber ordialy;er

T#" alarm problems

Treatment:

!nticoagulation -ascular access

,eedle placement

C-C problems


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4lood 7ea9

Cause: #embrane rupture allo0ing =4CIs to cross over the membrane

into the dialysate

Signs: 4lood lea9 alarm "ositive test for blood in dialysate

.nterventions Chec9 dialysate outflo0 0ith 4lood lea9 strip .f positive$ stop treatment$ do not return blood .f negative may need to get different machine


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"o0er ailure

Cause:


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emolysis

4rea9do0n or destruction of =4CIs =eleases potassium from damaged cells into the blood stream Decreasing the o>ygen carrying capacity of the =4C

"otentially life threatening


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Causes of emolysis


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Signs of emolysis

Dialy;er/blood lines: Cherry colored blood in venous line

"atient: Shortness of breath Chest$ abdominal and/or bac9 pain Cardiac arrest

.ntervention

Stop dialysis and DO ,OT return blood to the patient 4y symptom


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!ir tracorpeal systemto stop circulation

Causes:


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Signs and Symptoms of !ir


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Treatment of !ir


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!ir in 4loodlines

Causes: Under filling drip chambers


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!ir in 4loodlines

Signs: !ir bubbles/foam in bloodlines !ir in blood alarm

.ntervention/prevention Jeep level of drip chambers up =eplace empty saline bags immediately Tighten connections 0hen priming Tape needles securely ollo0 correct priming procedure


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sanguination

treme blood lossCauses: 4lood line separation ,eedles dislodging from access =upture of access %at anastomosis or aneurysm+

Crac9 in dialy;er casing/=upture of dialy;er 7oose dialy;er caps/connections

Symptoms: 4lood on the floor or in the chair

Obvious bleeding source

ypotension #achine pressure change alarms Shoc9 Sei;ures Cardiac arrest


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Treatment of sanguination

.dentify the source of blood lossStop dialysis =eturn blood if possible %not contaminated system+

Treat the symptoms: ,ormal saline to support blood pressure O>ygen for shortness of breath


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Dialy;er =eactions

Causes irst use syndrome ypersensitivity to membrane


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Dialy;er =eactions


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Dialy;er =eactions

.ntervention Stop treatment if anaphylactic response

=espiratory distress

Cardiac distress

Symptom management"revention Use of synthetic membrane =euse of dialy;ers

"roper priming of reuse and ne0 dialy;ers


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KU


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Than!ou"

complication of hemodialysis and their management (1)

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