Hemodialysis: Chapter 8, Complications During Hemodialysis, Part 3 - Dr.Gawad

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1. Mohammed Abdel Gawad MD/PhD Neph, ESENeph
Nephrology Unit, School of Medicine, NewGiza University
Nephrology Consultant, Alexandria
Founder of NephroTube.com
Chair of AFRAN Web/Media Committee
ISN Education SoMe Team Member
Chapter 8
Complications During
Hemodialysis
Part 3
•Headache
•Nauseaand Vomiting
•Dialyzerreactions
•Chestpain
•Dyspnea
•Cardiacarrhythmia
•Syncope
•Itching(Pruritus)
•Headache
•Nausea and Vomiting
•Dialyzer reactions
•Chest pain

2. Watch the video recording of this lecture
on NephroTube YouTube channel
www.YouTube.com/NephroTube

3. Visit
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to get more Nephrology lectures
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4. •Headache
•Nausea and Vomiting
•Dialyzer reactions
•Chest pain
•Dyspnea
•Cardiac arrhythmia
•Syncope
•Itching (Pruritus)
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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Talk Outline: Chapter 8
Complications During Hemodialysis: Part 3

5. •Headache
•Nausea and Vomiting
•Dialyzer reactions
•Chest pain
•Dyspnea
•Cardiac arrhythmia
•Syncope
•Itching (Pruritus)
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
Talk Outline: Chapter 8
Complications During Hemodialysis: Part 3

6. •Headache
•Nausea and Vomiting
•Dialyzer reactions
•Chest pain
•Dyspnea
•Cardiac arrhythmia
•Syncope
•Itching (Pruritus)
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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Talk Outline: Chapter 8
Complications During Hemodialysis: Part 3
28% to 73% of patients during dialysis

7. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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8. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

9. •Headache
•Nausea and Vomiting
•Dialyzer reactions
•Chest pain
•Dyspnea
•Cardiac arrhythmia
•Syncope
•Itching (Pruritus)
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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Talk Outline: Chapter 8
Complications During Hemodialysis: Part 3

10. •Headache
•Nausea and Vomiting
•Dialyzer reactions
•Chest pain
•Dyspnea
•Cardiac arrhythmia
•Syncope
•Itching (Pruritus)
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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Talk Outline: Chapter 8
Complications During Hemodialysis: Part 3
9.8%–18.2% of dialysis treatments

11. Causes of nausea and vomiting during
hemodialysis session
•Hypotension.
•Disequilibrium syndrome.
•Type A and type B dialyzer reactions.
•Gastroparesis.
•Hemodialysis may aggravate gastric acid secretion in some patients.
•High sodium or calcium dialysate solution.
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12. Management of nausea and vomiting
•Treat associated hypotension or any other associated cause.
•Antiemetics can be prescribed to treat vomiting for reasons other
than hypotension.
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13. Prevention of nausea and vomiting
•Prevent the occurrence of IDH.
•In patients with excessive gastric acid secretion use of H2 receptor
antagonists or PPI before dialysis session.
•Metoclopramide (5–10 mg orally before dialysis session).
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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14. •Headache
•Nausea and Vomiting
•Dialyzer reactions
•Chest pain
•Dyspnea
•Cardiac arrhythmia
•Syncope
•Itching (Pruritus)
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
Talk Outline: Chapter 8
Complications During Hemodialysis: Part 3

15. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

16. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

17. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

18. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

19. •Headache
•Nausea and Vomiting
•Dialyzer reactions
•Chest pain
•Dyspnea
•Cardiac arrhythmia
•Syncope
•Itching (Pruritus)
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
Talk Outline: Chapter 8
Complications During Hemodialysis: Part 3

20. Causes of chest pain during hemodialysis
session
•Angina due to obstructive coronary artery disease.
•Angina without any coronary obstruction due to:
o Hypertrophied cardiomyopathy .
o High cardiac output.
•Hemolysis.
•Air embolism.
•Dialyzer reaction.
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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21. Stepwise approach to deal with chest pain
during hemodialysis session
I. Step 1: Immediate measures:
•Do the following at first:
o Stop ultrafiltration and decrease the blood flow rate to ≤200 mL/min.
o Put the patient in a recumbent position.
o Give oxygen.
o Record blood pressure, heart rate, and other vital signs.
•Exclude serious causes:
o Exclude air embolism.
o Exclude hemolysis.
o Exclude coronary disease.
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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22. Stepwise approach to deal with chest pain
during hemodialysis session
I. Step 1: Immediate measures:
•Do the following at first:
o Stop ultrafiltration and decrease the blood flow rate to ≤200 mL/min.
o Put the patient in a recumbent position.
o Give oxygen.
o Record blood pressure, heart rate, and other vital signs.
•Exclude serious causes:
o Exclude air embolism.
o Exclude hemolysis.
o Exclude coronary disease.
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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Diagnosis of dialyzer reaction (usually type B) is
one of exclusion after excluding other causes of
chest pain

23. Stepwise approach
to deal with chest
pain during
hemodialysis
session
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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II. Step
2
Chest pain and
hypotension
Manage
hypotension
If both the hypotension and
chest pain resolved
Continue dialysis.
Don’t resume ultrafiltration
till stable
Cardiac evaluation
Persistent chest pain
and/or persistent
hypotension with evidence
of cardiac ischemia
Discontinue dialysis
Administer aspirin / Avoid Nitrates
Transfer to the hospital by ambulance.
Cardiac evaluation
Chest pain without
hypotension with evidence
of cardiac ischemia
Discontinue dialysis
Administer Aspirin and
Nitrates
Transfer to the hospital by
ambulance.
Cardiac evaluation

24. •Headache
•Nausea and Vomiting
•Dialyzer reactions
•Chest pain
•Dyspnea
•Cardiac arrhythmia
•Syncope
•Itching (Pruritus)
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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Talk Outline: Chapter 8
Complications During Hemodialysis: Part 3

25. Causes of dyspnea during hemodialysis session
•Isotonic saline, which is typically given at the beginning of HD (even in
small doses), might cause dyspnea.
•Angina.
•Acute severe hypertension.
•Pericardial effusion with or without tamponade.
•Pulmonary embolism.
•Bacteremia (often associated with catheter infection).
•Hemolysis.
•Air embolism.
•Allergic reaction to heparin.
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26. Management of dyspnea
•Supply oxygen if there is evidence of hypoxia.
•Try to find the cause and treat it:
oIn patients with dyspnea and chest pain, manage as in chest pain.
oIf severe hypertension is the suspected cause, more ultrafiltration is needed.
oDo chest X-ray and cardiac evaluation for diagnosis of pericardial effusion.
oPulmonary angiography should be done if pulmonary embolism is suspected.
oCheck markers of infection if bacteremia is suspected.
oExclude air embolism.
oExclude hemolysis.
oAllergic reaction to heparin is a diagnosis of exclusion.
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27. Management of dyspnea
Dialysis continuation:
•If the patient’s vital signs are unstable or there is persistent hypoxia or
a life-threatening condition:
•Stop dialysis.
•Transfer the patient to the hospital by ambulance.
•Continue dialysis if the patient is stable and there is no hypoxia.
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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28. •Headache
•Nausea and Vomiting
•Dialyzer reactions
•Chest pain
•Dyspnea
•Cardiac arrhythmia
•Syncope
•Itching (Pruritus)
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
Talk Outline: Chapter 8
Complications During Hemodialysis: Part 3

29. Risk factors of cardiac arrhythmia in
hemodialysis patients
•Coronary artery disease and left ventricular hypertrophy.
•Arrhythmia is precipitated by the following:
oDialysate related factors:
✓Dialysate potassium is <3 mEq/L.
✓Low dialysate calcium.
oLong interdialytic period
oIntradialytic hypotension.
oAnemia.
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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30. Management of cardiac arrhythmia
•Stop dialysis.
•Blood should be carefully returned.
•Urgent cardioversion is indicated for all patients with an unstable
rhythm.
•Airway management and cardiac monitoring are essential.
•Administration of antiarrhythmic drugs.
•Cardiology consultation.
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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31. •Headache
•Nausea and Vomiting
•Dialyzer reactions
•Chest pain
•Dyspnea
•Cardiac arrhythmia
•Syncope
•Itching (Pruritus)
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
Talk Outline: Chapter 8
Complications During Hemodialysis: Part 3

32. Causes of syncope during hemodialysis session
•Severe hypotension.
•Arrhythmia.
•Myocardial infarction.
•Stroke.
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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33. Management of syncope
•Stop dialysis.
•Elevate the patient’s legs.
•Give oxygen.
•Record blood pressure and other vital signs.
•Administer a bolus (200 to 300 mL) of isotonic fluid for hypotensive
patients.
•Order an ECG.
•Do laboratory tests for electrolytes, troponin levels, and complete blood
count.
•Refer for syncope evaluation.
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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34. •Headache
•Nausea and Vomiting
•Dialyzer reactions
•Chest pain
•Dyspnea
•Cardiac arrhythmia
•Syncope
•Itching (Pruritus)
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
Talk Outline: Chapter 8
Complications During Hemodialysis: Part 3

35. Itching (Pruritus)
Itching that appears only during hemodialysis, especially if associated
with allergic symptoms, usually indicates a reaction to:
•Heparin
•Dialyzer
•Blood circuit components
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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36. Thank You