hemodialysis emergencies

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HEMODIALYSIS EMERGENCIES

ByKareem NagatyAssistant lecturer of internal medicine & nephrologyHEMODIALYSIS EMERGENCIES

1

Common complicationsLess common complications

HypotensionDisequilibrium syndrome Muscle CrampsDialyzer reactionsNausea and vomitingArrhythmiasHeadacheCardiac tamponade Chest pain SeizuresBack painHemolysisItchingAir embolismFever and chillsHypoxemia

Acute complications during hemodialysis

Incidence of acute complications commonly occur during routine hemodialysis treatments:

Common complicationsLess common complications

HypotensionDisequilibrium syndrome Muscle CrampsDialyzer reactionsNausea and vomitingArrhythmiasHeadacheCardiac tamponade Chest pain SeizuresBack painHemolysisItchingAir embolismFever and chillsHypoxemia

Acute complications during hemodialysis

Hypotension

Causes of IDH

UltrafiltrationOsmolality FallWarm DialysateBio-incom-patibilityEndotoxinAcetateInfusionVolumeVasopressorsVasodilatatorCell DysfunctionComplementActivation, Cytokine releaseHypoxemiaHeart DiseaseVascular DiseaseAutonomic DysfunctionHormonal DysfunctionMedicationsSepsisInfectionVasovagal stim.

HYPOTENSiONCARDIACOUTPUTPERIPHERAL RESISTANCE

PATHOGENESISMEDIATORSPATHOPHYSIOLOGYPATIENT

Volume overload due to suboptimal ultrafiltration, LVH, and interdialytic hypertension.

Fistula thrombosis.

Increased mortality and morbidity.Sequelae of frequent IDH:

PREVENTION

Accurate setting of the "dry weight.Minimize interdialytic weight gain.Steady, constant ultrafiltration.Increased dialysate sodium concentration.Bicarbonate dialysate buffer.Temperature control.Improvement in cardiovascular performance.Midodrine among patients with autonomic neuropathy.Avoidance of food ingestion during dialysis.No antihypertensive medications prior to treatment.

PREVENTION

Accurate setting of the "dry weight.Minimize interdialytic weight gain.Steady, constant ultrafiltration.Increased dialysate sodium concentration.Bicarbonate dialysate buffer.Temperature control.Improvement in cardiovascular performance.Midodrine among patients with autonomic neuropathy.Avoidance of food ingestion during dialysis.No antihypertensive medications prior to treatment.

PREVENTION

Accurate setting of the "dry weight.Minimize interdialytic weight gain.Steady, constant ultrafiltration.Increased dialysate sodium concentration.Bicarbonate dialysate buffer.Temperature control.Improvement in cardiovascular performance.Midodrine among patients with autonomic neuropathy.Avoidance of food ingestion during dialysis.No antihypertensive medications prior to treatment.

PREVENTION

Accurate setting of the "dry weight.Minimize interdialytic weight gain.Steady, constant ultrafiltration.Increased dialysate sodium concentration.Bicarbonate dialysate buffer.Temperature control.Improvement in cardiovascular performance.Midodrine among patients with autonomic neuropathy.Avoidance of food ingestion during dialysis.No antihypertensive medications prior to treatment.

PREVENTION

Accurate setting of the "dry weight.Minimize interdialytic weight gain.Steady, constant ultrafiltration.Increased dialysate sodium concentration.Bicarbonate dialysate buffer.Temperature control.Improvement in cardiovascular performance.Midodrine among patients with autonomic neuropathy.Avoidance of food ingestion during dialysis.No antihypertensive medications prior to treatment.

PREVENTION

Accurate setting of the "dry weight.Minimize interdialytic weight gain.Steady, constant ultrafiltration.Increased dialysate sodium concentration.Bicarbonate dialysate buffer.Temperature control.Improvement in cardiovascular performance.Midodrine among patients with autonomic neuropathy.Avoidance of food ingestion during dialysis.No antihypertensive medications prior to treatment.

PREVENTION

Accurate setting of the "dry weight.Minimize interdialytic weight gain.Steady, constant ultrafiltration.Increased dialysate sodium concentration.Bicarbonate dialysate buffer.Temperature control.Improvement in cardiovascular performance.Midodrine among patients with autonomic neuropathy.Avoidance of food ingestion during dialysis.No antihypertensive medications prior to treatment.

PREVENTION

Accurate setting of the "dry weight.Minimize interdialytic weight gain.Steady, constant ultrafiltration.Increased dialysate sodium concentration.Bicarbonate dialysate buffer.Temperature control.Improvement in cardiovascular performance.Midodrine among patients with autonomic neuropathy.Avoidance of food ingestion during dialysis.No antihypertensive medications prior to treatment.

PREVENTION

Accurate setting of the "dry weight.Minimize interdialytic weight gain.Steady, constant ultrafiltration.Increased dialysate sodium concentration.Bicarbonate dialysate buffer.Temperature control.Improvement in cardiovascular performance.Midodrine among patients with autonomic neuropathy.Avoidance of food ingestion during dialysis.No antihypertensive medications prior to treatment.

PREVENTION

Accurate setting of the "dry weight.Minimize interdialytic weight gain.Steady, constant ultrafiltration.Increased dialysate sodium concentration.Bicarbonate dialysate buffer.Temperature control.Improvement in cardiovascular performance.Midodrine among patients with autonomic neuropathy.Avoidance of food ingestion during dialysis.No antihypertensive medications prior to treatment.

PREVENTION

Accurate setting of the "dry weight.Minimize interdialytic weight gain.Steady, constant ultrafiltration.Increased dialysate sodium concentration.Bicarbonate dialysate buffer.Temperature control.Improvement in cardiovascular performance.Midodrine among patients with autonomic neuropathy.Avoidance of food ingestion during dialysis.No antihypertensive medications prior to treatment.

PREVENTION

The 2007 European best practice guidelines in hemodialysis recommend the following stepped approach to the prevention of IDH:

First-line approach The first-line approach includes dietary counseling (sodium restriction), no food intake during dialysis, clinical dry weight reassessment, bicarbonate as the dialysis buffer, dialysate temperature of 36.5C, and/or appropriate dosing and timing of antihypertensive agents.

PREVENTION

Second-line approach The second-line approach includes objective methods to assess dry weight, cardiac evaluation, gradual reduction of dialysate temperature from 36.5C (lowest 35C), consideration of blood volume controlled feedback, increase in dialysis time and/or frequency, and/or use of a high dialysate calcium concentration.

Third-line approach If other treatment options have failed, the guidelines recommend the third-line approach which involves consideration of midodrine or L- carnitine supplementation or peritoneal dialysis.

PREVENTION

Common complicationsLess common complications

HypotensionDisequilibrium syndrome Muscle CrampsDialyzer reactionsNausea and vomitingArrhythmiasHeadacheCardiac tamponade Chest pain SeizuresBack painHemolysisItchingAir embolismFever and chillsHypoxemia

Acute complications during hemodialysis

A cramp is a prolonged involuntary muscle contraction that occurs in a muscle which voluntarily contracts when it is already in its most shortened position.

Cramps tend to occur most frequently near the end of hemodialysis treatments.

Most commonly involve the muscles of the lower extremity, but the muscles of the hands, arms, and abdomen may also be affected. Cramps occur more often in older, nondiabetic, anxious patients. Low PTH values and high serum creatine phosphokinase concentrations are also more frequent among patients with dialysis-associated crampsMuscle cramps

Plasma volume contraction. Hyponatremia. Tissue hypoxia. Hypomagnesemia. Carnitine deficiency. Elevated serum leptin levels.

The etiology of hemodialysis-associated cramps

The reversal of low blood pressure.

Hypertonic saline or dextrose: triple saline or 50% dextrose are equally effective._hypertonic saline may be preferred among those with volume depletion._hypertonic dextrose may be the better therapeutic option (in nondiabetic patients) because it does not adversely affect salt and water balance.

Mannitol infusion: not preferred.

Local massage of the affected muscle and the application of moist heat

TREATMENT

Minimize interdialytic weight gains.Prevention of dialysis-associated hypotension.Higher dialysate sodium concentration.Carnitine supplementation.Quinine sulfate.Vitamin E.Others.PREVENTION

Minimize interdialytic weight gains.Prevention of dialysis-associated hypotension.Higher dialysate sodium concentration.Carnitine supplementation.Quinine sulfate.Vitamin E.Others.PREVENTION

Minimize interdialytic weight gains.Prevention of dialysis-associated hypotension.Higher dialysate sodium concentration.Carnitine supplementation.Quinine sulfate.Vitamin E.Others.PREVENTION

Minimize interdialytic weight gains.Prevention of dialysis-associated hypotension.Higher dialysate sodium concentration.Carnitine supplementation.Quinine sulfate.Vitamin E.Others.PREVENTION

Minimize interdialytic weight gains.Prevention of dialysis-associated hypotension.Higher dialysate sodium concentration.Carnitine supplementation:_ Carnitine may be given intravenously (20 mg/kg) after hemodialysis or orally (330 mg two to three times per day).Quinine sulfate.Vitamin E.Others.PREVENTION

Minimize interdialytic weight gains.Prevention of dialysis-associated hypotension.Higher dialysate sodium concentration.Carnitine supplementation.Quinine sulfate:_decreased excitability of the motor end-plate to nerv