COMPLICATIONS OF HEAMODIALYSIS AND THEIR MANAGEMENT

COMPLICATIONS OF HEAMODIALYSIS AND THEIR MANAGEMENT

1. COMPLICATIONS OF HEAMODIALYSIS

2. CLINICAL COMPLICATIONS OF HEAMODIALYSIS GELDINE CHIRONDA

3. HYPOTENSION Causes Taking BP pills before dialysis. Removing excess fluid causes hypovolemia: Decrease in the circulatory blood volume due to ultra filtration and fluid shift. Autonomic neuropathy: acute decrease in plasma volume results in a vasoconstriction. vasoconstriction increases peripheral resistance Clinical manifestations – low BP, dizziness, tachycardia(rapid pulse), loss of consciousness Management Nurse patient in Trendelenburg position (supine and elevate legs)- increased venous feedback and cardiac output Decreased UF Administer 0.9% NaCl 100 – 200ml bolus IVI

4. PREVENTION OF HYPOTENSION Calculate the fluid excess and Set the UF correctly (Use machine with UF controller) Get an accurate weight before a haemodialysis treatment Ask patients if they have taken BP pills. Educate the patient on fluid control methods and not to gain more than 1kg/ day Do not ultra filter a patient to below his or her dry weight Sodium Profiling (Keep dialysis solution sodium level at or above the plasma level) Advice patient to take HPT treatment post dialysis Prevent eating during dialysis (Esp. Patients prone to Hypotensive spells)

5. DIALYSIS DISEQUILIBRIUM SYNDROME Causes If the BUN is removed much faster from the blood than the brain, disequilibrium is created and fluid moves into the brain cells causing brain swelling. Often seen in patients who have Acute kidney disease or BUN of greater than 150mg/dl Patient will present with the following symptoms : restlessness, vomiting, severe headache, hypertension, confusion, stupor, coma and death.

6. DISEQUILIBRIUM SYNDROME The most serious manifestations of disequilibrium can continue for up to 2 – 3 days post dialysis Must be differentiated from CVA, subdural haematoma drug induced encephalopathy Treatment: The management of dialysis disequilibrium is largely aimed at prevention of its occurrence by gradually decreasing serum electrolytes such as Urea. Monitor the patient during treatment In patients with high BUN, a smaller dialyser or a slower flow is preferred.

7. MUSCLE CRAMPS Muscle cramps Caused by hypotension and excess fluid removal. Also caused by changes in blood chemistry especially sodium (Hyponatremia) Patient will present with painful muscle spasms. Treatment Get accurate fluid loss for the patient Administration of a bolus of hypertonic NaCI (ampoules of 23,4% NaCI – 1:1 dilution) Administer 12 – 24 ml IVI Administration of 50% DW; 1ml/kg/IV Reduce Ultrafiltration rates

8. FEVER Most common causes of fever during dialysis are: infections and pyrogen reactions Pyrogen reactions are generally due to endotoxemia from contaminated dialyzers, blood lines and contaminated water. Low molecular weight endotoxin fragments can penetrate the dialysis membrane and gain entrance to the blood. High flux membrane associated with higher incidence of pyrogen reactions (larger pores) Pyrogen reactions occur 45 – 75 min after the start of dialysis Rigors can last for up to 30 minutes Use of cold dialysate can also cause fever

9. Clinical manifestations of fever Fever during dialysis Redness Swelling Tenderness Drainage from the access site

10. MANAGEMENT OF FEVER Do blood Culture NB! The blood culture might be negative if the pyrogen reaction is due to breakdown products of dead bacteria and not living bacteria High colony counts in the dialysate reflect insufficient sterilisation of the water treatment plant. Antipyretics (paracetamol) Solu-Cortef 10mg IV Anti-biotics

11. PREVENTION OF FEVER Use aseptic technique to set up dialysis equipment Use aseptic technique when connecting patients on haemodialysis Check dialysate temperature before treatment Use the right process to disinfect the dialysis machine and the water components Test the water, equipment for bacteria, pyrogens and endotoxins

12. AIR EMBOLI Caused by a leak or loose connection in the blood lines Air emboli always remains a risk The amount of air necessary to cause death or significant morbidity depends on the rate and extend of air entry into the circulation Patient will complain of chest pain, tight feeling in chest and coughing Can result in: Cyanosis, confusion, Convulsions, Death.

13. MANAGEMENT OF AIR EMBOLI Stop the blood pump Clamp the venous line. The patient must be positioned with his head and thorax downwards ( Trendellenburg position) on his right side. This position ensures trapping of air in the apex of the right ventricle away from the outflow tract. Administer 100% O² with a mask (if necessary intubate and ventilate) In the event of massive pulmonary air embolism, the foam must be aspirated with a syringe. This is a must before to CPR. Contact the doctor Administer Dexamethasone as prescribed to decrease cerebral oedema. Administration Heparin or low molecular weight dextran as prescribed to improve microcirculation.

14. PREVENTION OF AIR EMBOLI Arm the air detector through out a treatment Tighten all connections in the extracorporeal circuit Prime the dialyzer and blood lines Check the normal saline level in the iv bag Return the patient blood with normal saline, with no air in the blood lines .

15. HYPERTENSION Caused by fluid overload Patient missing their blood pressure pills Dialysis disequilibrium syndrome Manifested by high blood pressure, headache and nervousness

16. MANAGEMENT OF HYPERTENSION Reduce pump speed Remove fluid until you reach patient’s dry weight to eliminate fluid overload Monitor blood pressure every 15 min until blood pressure reduces Administer medication as per prescription Advise patient on fluid restriction if hypertension is fluid related Re-evaluation of patient’s anti-hypertensive medication by the doctor

17. ANGINA Chest Pain due to low oxygen levels in the heart. Due to anaemia Hypotension Coronary artery disease Manifested by Pain in the chest Tightness in the chest Patient may be pale Sweating Ineffective breathing

18. MANAGEMENT OF ANGINA Notify the doctor Administer 100 % oxygen Decrease the pump speed Decrease UF rate Treat associated hypotension Place patient in Trendelenburg position Administer 0,9 % Sodium Chloride at a slow pace, Perform an ECG, If chest pain continuous, stop dialysis

19. CARDIAC ARYTHMIAS Caused by changes in ph. and electrolyte levels especially potassium Extreme Hypotension Clinical manifestation- Irregular pulse, Palpitations, low BP Management Connect patient to cardiac monitor for duration of dialysis, Check electrolyte levels Ensure that you use a dialysis solution with an adequate potassium concentration Reduce pump speed and dialysate flow rate Discontinue dialysis if arrhythmia worsen, Notify the doctor

20. CARDIAC ARREST Causes Extreme hypotension Hyperkalaemia Arrhymias Air embolism Severe blood los s Clinical manifestation- no pulse, no breathing, loss of consciousness Management is through prevention of the cardiac arrest

21. PERCUTANEOUS /VASCULAR CATHER CLOTTING Aspirate clots lodged in lumen with syringe Flush with heparinized sodium chloride If still unsuccessful contact doctor for prescription to insert streptokinase into lumen to dissolve clot Doctor to prescribe oral anti-coagulants if problem occurs regularly.

22. Other Clinical complications Seizures Pruritis Heparin overdose Anaphylaxis Failure of maturation

23. TECHNICAL COMPLICATIONS DR GELDINE CHIRONDA

24. AIR IN THE BLOOD LINES Air in the blood lines Under filling of drip chambers Empty saline bag Loose connections in the circuit Dialysis needle taken out while blood pump is on Air left in the blood lines after priming Management Clamp lines, Stop blood pump Remove air with syringe from venous chamber of venous line Tighten all the connection Tape needles securely Be sure the saline bag is not empty Prime correctly before initiating haemodialysis

25. DIALYZER CLOTTING Dialyzer Clotting Inadequate anticoagulation Low blood flow rate Air in the blood lines Signs of clotting Blood turns dark Clots in the blood lines Increase in venous pressure Management Flush with Sodium Chloride Clamp lines Stop blood pump Change clotted dialyzer as per protocol Commence dialysis

26. TYPE A MEMBRANE REACTION Type A reaction These reactions are due to immune reaction to membrane type. Ethylene oxide is used to sterilize dialyzers, so patient may react to it. Reaction to chemicals in the blood lines. Drug allergy eg heparin Occurs within minutes after initiating dialysis treatment. Severe allergic reaction or anaphylaxis Symptoms vary Dyspnoea, wheeze, a feeling of warmth, urticaria, unusual swelling, cough, hypotension, collapse or cardiac arrest.

27. MANAGEMENT OF TYPE A REACTIONS Stop dialysis Discard blood Administered: Solu-Cortef or Phenergan NB! Change the dialyser. Prevention Avoid drugs that patient is allergic too Rinse dialyzers and blood lines well For those patients on ACE inhibitors, do not use a dialyzer with polyacrilonitrile (PAN) membranes (Synthetic membranes).

28. TYPE B REACTIONS Cause is unknown but are believed to be mediated by complement system. The free hydroxyl groups on the dialysis membrane activate the alternate pathway of complement, leading to neutrophil activation. and subsequent sequestration in the pulmonary circulation. These changes are frequently associated with marked and transient neutropenia, beginning as early as one minute after the start of dialysis. This is followed by an increased number of immature neutrophils appearing in the circulation, returning the neutrophil count to predialysis values by one hour.

29. TYPE B REACTIONS Treat the symptoms, monitor the patient. The same membrane can be used but prime with at least 2 litres of Saline (open system) before initiating dialysis treatment .

30. HEAMOLYSIS Caused by several factors : 1. Dialysis related Inadequate water treatment that allows copper, chloramines or nitrate into the dialysate. formaldehyde in reused dialyzers will Inhibit red cell glycolycis and thus cause haemolysis 2. Hypertonic NaCI (23,4%): administered during dialysis for muscle spasms can cause osmotic haemolysis. 3. Heat: overheated dialysis solution (>42˚C) 4.Kinked blood lines

31. MANAGEMENT OF HEAMOLYSIS Clinical manifestations : Nausea, headache, bright red coloured blood, Dyspnoea, Chest pain, Syncope and Cardiac arrest Treatment : Stop the blood pump Clamp the bloodlines Do not give the blood back to the patient Supporting measures include: administration of 0² and if Hypotension occurs place patient in Trendelenburg position If necessary administer packed cells

32. REFERENCES Molzahn , A.E. and Butera, E., 2006. Contemporary nephrology nursing: Principles and practice. American Nephrology Nurses' Association. Bodin , S.M., 2017. Contemporary nephrology nursing (3rd ed., pp. 363-375). Pitman, NJ: American Nephrology Nurses Association. Medical education institute, 2006. Core curriculum for the dialysis Technicians. A comprehensive Review of Haemodialysis.