Critically care and patient safety in hemodialysis

Lestariningsih

Ruang hemodialisis

IPDI

Dr.
Arisan

Pasien
intradialisis
Sesak napas
mendadak

Hipotensi 25 to 55 %
kramp 5 to 20 %
Nausea and vomiting 5 to 15 %
Headache 5%
nyeri dada 2 to 5 %
Back pain 2 to 5 %
Itching/gatal 5 %
demam menggigil < 1 %

Hypotension
Hemodinamik yang tidak stabil, selama
proses ultrafiltrasi ( tujuan membuang cairan
mengurangi overhidrasi)
Hypotension

Mengapa hipotensi penting dipelajari?

Penyakit yang mendasari hipotensi, pasien
yang sering mengalami hipotensi
mempunyai risiko mortalitas yang besar

Clinical Patterns
Manifestasi klinik hipotensi :
Episodic hypotension, terjadi saat periode
hemodialisis ditandai mual muntah kramp
Chronic persistent hypotension
hipotensi jangka panjang , tekanan darah
predilin long-term patients with predialysis
systolic blood pressures of less than 100
mmHg.

Etiology
sintesis vasodilator endogen seperti nitric oxide
iskemik organ, pelepasan adenosine
High magnesium concentrations in the
dialysate.
Failure to increase plasma vasopressin levels.

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

Diagnosis dan terapi

asymptomatic :

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

terapi :

Penyebab hipotensi
intradialisis

Tata kelola

Ultrafiltration dikurangi dan distop

Position trendelenburg.
Flow rate dikurangi
mannitol or saline

 Accurate setting of the "dry weight

Steady, constant ultrafiltration
frekuensi dialisis ditambah
Bicarbonate dialysate buffer
Temperature control

Perbaikan performance kardiovaskular

Norepineprin : hemodialisis hipotension
Carnitine .
Dicegah makan
Adenosine receptor antagonist.
Minimize inter-dialytic weight
gains

Kramp
kontraksi otot yang berkepanjangan contraction,
komplikasi of hemodialysis, hemodialysis diakhiri
biasanya terjadi pada akhir periode hemodialisis
periksa PTH dan serum kalsium, fosfat

Plasma volume contraction.

Tissue hypoxia
Hyponatremia.
Hypomagnesemia.
Carnitine deficiency.
Interventions mengurangi frekuensi of cramps
Cegah hipotensi
Carnitine supplementation
Pemberian quinine , menurunkan excitability /
stimulation otot

HEADACHE, NAUSEA, AND VOMITING

The dialysis disequilibrium

syndrom
Faktor
risiko DDS :
hemodialisis pertama kali
Markedly elevated blood urea concentration
predialysis (
>175mg/dLor 60mmol/L)
Chronic kidney disease dengan acute kidney
injury
Severe metabolic acidosis
Older age
Pediatric patients
(head trauma, stroke, seizure disorder)
keadaan tertentu cerebral edema
(hyponatremia,
hepatic encephalopathy, malignant

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.

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.

TREATMENT (Dialysis disequilibrium

syndrome)
Dilakukan dialisis ulang dengan blood flow
rendah
DDS sedang tidak spesifik mild, nonspecific
DDS, nausea, vomiting,
restlessness,and/orheadache,
pasien high risk DDS, blood flow rendah

Treatment
In general, symptoms of DDS are self-limited and
usually resolve within several hours.
nonspecific disequilibrium symptoms : mual, muntah
gelisah , lemah , nyeri kepala hebat; QB dikurangi atau
hemodialisis diakhiri
Dialysis is stopped : pasien gaduh gelisah, koma,
bebaskan jalan napas
DDS berat cepat diberikan cairan hipertonik untuk
meningkatkan osmolaritas NaCL 3% NaCl atau 12.5 g
of hypertonic mannitol.

CHEST PAIN

Chest pain saat dialysis :

associated with hypotension
DDS
Angina
Hemolysis
Emboli paru
proses hemodialisis stop
atau diteruskan keadaan klinik pasien

Angina
Risiko jantung koroner : history,
pemeriksaan fisik, gejala klinik,
electrocardiogram, cardiac enzyme,
evaluasi, diberikan oksigen, nitrat and
aspirin, ultrafiltration dan QB
dikurangi
Angina saat dialysis, pada awal
diberikan nitrat dan atau beta blockers

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.

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
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.
air tends to enter the heart and then the lungs leading to
dyspnea, cough, and perhaps chest tightness.

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