Acute Complication of

Hemodialysis
Dr.Alaa Mohammed Fouad Mousli
Surgical Demonstrator

Objective
In this presentation we will review
briefly the causes, diagnosis and
treatment of the common acute
complications that we face during
hemodyalysis.

Acute complication HHCCBNF

Hypotension

25 to 55 %
Cramps 5 to 20 %
Nausea and vomiting 5 to 15 %
Headache 5%
Chest pain 2 to 5 %
Back pain 2 to 5 %
Itching 5 %
Fever and chills Less than 1 %

Hypotension
Usual

manifestation of
hemodynamic instability during
ultrafiltration dialysis (in which
fluid removal is the primary goal)
Why is it important?
Whatever the underlying cause,
patients with hemodialysisassociated hypotension appear to
have increased mortality.

Clinical Patterns
There

are TWO clinical patterns of

dialysis-associated hypotension:

Episodic

hypotension, which
typically occurs during the latter
stages of dialysis; this is
associated with vomiting, muscle
cramps, and other vagal
symptoms (such as yawning).

Clinical Patterns Cont

Chronic

persistent hypotension
in long-term patients with
predialysis systolic blood
pressures of less than 100
mmHg.

Etiology
Rapid

reduction in plasma osmolality,

which causes extracellular water to
move into the cells .
Rapid fluid removal in an attempt to
attain "dry weight"
Inaccurate determination of true "dry
weight".
Autonomic neuropathy (the role of
baroreceptors and a subsequent
increase in efferent sympathetic
activity).
Diminished cardiac reserve.

 Use

of acetate rather than bicarbonate as

a dialysate buffer. (Acetate accumulation
in the blood has vasodilator activity).
Intake of antihypertensive medications
that can impair cardiovascular stability.
Use of a lower sodium concentration in
the dialysate
Arrhythmias or pericardial effusion with
tamponade, which are volumeunresponsive causes of hypotension.
Reactions to the dialyzer membrane,
which may cause wheezing and dyspnea
as well as hypotension.

Increased

synthesis of
endogenous vasodilators, such as
nitric oxide.
Sudden release of adenosine
during organ ischemia
High magnesium concentrations
in the dialysate.
Failure to increase plasma
vasopressin levels.

Keep it in Mind
Plasma

osmolality.
True dry wight.
Autonomic Neuropathy.
Acetate & Nitric Oxide.
Na & Mg.
Cardiac Diseases.
Be patient in your management

DIAGNOSIS AND
TREATMENT
Although

occasionally
asymptomatic, patients with
hypotension may suffer from :

light-headedness.
muscle cramps.
Nausea & vomiting.
dyspnea.

The

acute management of low

blood pressure associated with
hemodialysis includes the following:

Ultrafiltration

should either be stopped

or the rate decreased.
The patient should be placed in the
Trendelenburg position.
The blood flow rate should be reduced.
Intravascular volume may be replaced
with mannitol or saline. Currently the
use of an intravenous bolus of saline is
the first-line therapy for hypotension.

PREVENTION
Accurate

setting of the "dry

weight"
Steady, constant ultrafiltration
Increased dialysate sodium
concentration and sodium
modeling
Bicarbonate dialysate buffer
Temperature control

Prevention Cont
Improvement

in cardiovascular
performancein cardiac patients.
Midodrine(the selective alpha-1
adrenergic agonist) in patients with
autonomic neuropathy and perhaps
others with severe hemodialysis
hypotension not responsive to the
above measures.
Carnitine.
Avoidance of food.
Adenosine receptor antagonist.
Vasopressin infusion.

Muscle Cramps
A

cramp is a prolonged involuntary muscle

contraction
common complication of hemodialysis
treatments and mostly involves the muscle
of the lower extremities in old non diabetic
anxious patient resulting in early termination
of a hemodialysis session.
Usually occur near the end of hemodialysis
treatments.
Low PTH Values and high serum Creatin
phosphokinase is frequent finding

Etiology
Plasma

volume contraction.
Tissue hypoxia
Hyponatremia.
Hypomagnesemia.
Carnitine deficiency.

Treatment.
Treatment

is directed at two

goals:
Reducing the frequency of cramps.
Relieving symptoms when they
occur.

Interventions to reduce the

frequency of cramps

Prevention of dialysis-associated
hypotension.
The use of high concentrations of sodium
in the dialysate.
Carnitine supplementation
Administration of quinine that decrease
the excitability of the motor end-plate to
nerve stimulation and increase muscle
refractory period, thereby preventing
prolonged involuntary muscle contraction.
All these may reduce the frequency of
dialysis-associated cramps.

Minimize inter-dialytic weight

gains
will avoid plasma volume contraction
and hypo-osmolality that occurs with
high rates of ultrafiltration required
to achieve the patient's dry weight
during a brief dialysis session.

Others
These

include short acting

benzodiazepines (eg, oxazepam),
nifidepine, phynetoin, creatine
monohydrate, carbamezapine,
amitryptalyin, and gabapentin.

Headach, Nausea &

Vomiting
The

longer treatment times

together with large degree of
urea removal and/or ultra
filtration significantly enhance
the incidence of headache,
nausea, and vomiting during
dialysis.
Longer dialysis time alone
doesnt cause these side effects.

 These

symptoms may be apart of dialysis

disequilibrium Syndrome (DDS) will be
discussed later.
Patients who have headaches on dialysis
in the absence of hypotension and
suspected dialysis disequilibrium should
be questioned about :
Caffien use, which can sometimes
precipitate headache
Metabolic disturbances (eg, hypoglycemia,
hypernatremia, hyponatremia),
Uremia
Subdural hematoma
Medication-induced headaches.

Dialysis disequilibrium
Syndrome DDS
central

nervous system disorder

described in dialysis patients
characterized by neurological
symptoms of varying severity that are
thought to be due primarily to cerebral
edema.
Usually occure in new patient started on
hemodialysis especially with hign BUN.
Other risk factor , sever metabolic
acidosis , extremes of age , presence of
other CNS diseases like seizure
disorders.

Pathogenesis
The

symptoms of DDS are

caused by water movement into
the brain, leading to cerebral
edema. Two theories have been
proposed to explain why this
occurs:
a reverse osmotic shift induced by
urea removal .
fall in intracellular pH.

Clinical Manifestation
The

classic DDS develops during or

immediately after hemodialysis. Early
findings include

Headache
Nausea
Disorientation
Restlessness
Blurred vision
Asterixis
More severely affected patients progress
to confusion, seizures, coma, and even
death.

Differential Diagnosis
Uremia
Subdural

hematoma

CVA
Meningitis
Metabolic

disturbances
Drug induced encephalopathy

Treatment
In

general, symptoms of DDS are self-limited and

usually resolve within several hours.
The management of mild nonspecific
disequilibrium symptoms, such as nausea,
vomiting, restlessness, and/or headache, is
symptomatic; however, in the acutely uremic
patient with such symptoms who is undergoing
dialysis, the blood flow rate should be slowed and
consideration should be given to stopping the
dialysis session.
Dialysis is stopped in the patient with seizures,
coma, and/or obtundation. Patency of the airway
should be ensured.
Severe DDS with seizures can be reversed more
rapidly by raising the plasma osmolality with either
5 mL of 23 percent saline or 12.5 g of hypertonic
mannitol.

CHEST PAIN
Chest

pain that occurs during dialysis

could be:
associated with hypotension
DDS
Angina
Hemolysis
Air or pulmonary embolism (rare).
The decision to continue or stop the
dialysis treatment because of chest pain
is based upon clinical findings, such as
hemodynamic stability, and the results
of the history and physical examination.

Angina
should

always be considered as those patients at

an increased risk of coronary disease. The
appropriate history, physical examination, and, if
clinically indicated, electrocardiogram and cardiac
enzyme evaluation should therefore be
performed.If dialysis is continued, the
administration of oxygen and aspirin, reduction of
the desired ultrafiltration and/or blood pump
speed, and administration of nitrates or morphine
should be considered on an individual basis.
Angina during dialysis may be prevented with the
administration of nitrates and/or beta blockers
prior to the treatment. However, the efficacy of
these agents is diminished since they commonly
result in hypotension, thereby reducing the ability
to effectively remove extracellular fluid.

Hemolysis

May present as chest pain and tightness, or back pain and If

it is not recognized early, severe hyperkalemia may happen
and lead to death.

Findings highly suggestive of hemolysis include:

A port wine appearance of the blood in the venous line

Complaints of chest pain, shortness of breath, and/or back

pain

A falling hematocrit

A pink color of the plasma in centrifuged specimens.

The etiology of hemolysis in hemodialysis patients is usually

related to problems with the dialysis solution These include:

Overheating
Hypotonicity due to an insufficient concentrate-to-water ratio

Red blood cell trauma like in kinking of the blood lines.

Cont hemolysis
The

initial treatment is to:

stop dialysis immediately
Clamp the blood lines (do not return the
blood to avoid hyperkalemia)
prepare to treat hyperkalemia and the
potentially severe anemia
investigate the cause
hospitalization for observation since lifethreatening hyperkalemia may develop after
dialysis has been terminated.

Air embolism

Rare but fatal cause of chest pain and dyspnea during

dialysis. (Foam in the venous blood line should rise
the suspicion that air is entering the dialysis system).
Disconnection of connecting caps and/or blood lines
can also lead to air embolism in patients being
dialyzed with central venous catheters.

Symptoms of the air embolism depend upon the

patient's position at the time of the event. In the
seated patient, air tends to migrate into the cerebral
venous system without entering the heart leading to
loss of consciousness and seizure while in those who
are recumbent, air tends to enter the heart and then
the lungs leading to dyspnea, cough, and perhaps
chest tightness.

Cont- Air embolism

Treatment of suspected air embolism includes:

Clamping the venous line and stopping the blood

pump

Positioning of the patient on the left side in a supine

position with the chest and head tilted downward.

Cardiorespiratory support

The administration of 100 percent oxygen by either

mask or endotracheal tube

The most important aspect of air embolism is

prevention by the adequate function of monitoring
devices on dialysis machines

THANK YOU