HEMODIALYSIS EMERGENCIES

Dr.Kareem Nagaty
Assistant lecturer of internal medicine & nephrology

1. By Kareem Nagaty Assistant lecturer of internal medicine & nephrology HEMODIALYSIS EMERGENCIES

2. Common complications Less common complications Hypotension Disequilibrium syndrome Muscle Cramps Dialyzer reactions Nausea and vomiting Arrhythmias Headache Cardiac tamponade Chest pain Seizures Back pain Hemolysis Itching Air embolism Fever and chills Hypoxemia Acute complications during hemodialysis

3. Incidence of acute complications commonly occur during routine hemodialysis treatments :

4. Common complications Less common complications Hypotension Disequilibrium syndrome Muscle Cramps Dialyzer reactions Nausea and vomiting Arrhythmias Headache Cardiac tamponade Chest pain Seizures Back pain Hemolysis Itching Air embolism Fever and chills Hypoxemia Acute complications during hemodialysis

5. Hypotension

6. Causes of IDH

7. Ultrafiltration Osmolality Fall Warm Dialysate Bio-incom- patibility Endotoxin Acetate Infusion Volume Vasopressors Vasodilatator Cell Dysfunction Complement Activation, Cytokine release Hypoxemia Heart Disease Vascular Disease Autonomic Dysfunction Hormonal Dysfunction Medications Sepsis Infection Vasovagal stim. HYPOTENSiON CARDIAC OUTPUT PERIPHERAL RESISTANCE PATHOGENESIS MEDIATORS PATHOPHYSIOLOGY PATIENT

8. Volume overload due to suboptimal ultrafiltration , LVH, and interdialytic hypertension. Fistula thrombosis. Increased mortality and morbidity. Sequelae of frequent IDH:

9. PREVENTION

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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 36.5ºC , and/or appropriate dosing and timing of antihypertensive agents . PREVENTION

22. Second-line approach — The second-line approach includes objective methods to assess dry weight , cardiac evaluation , gradual reduction of dialysate temperature from 36.5ºC (lowest 35ºC ), 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

23. Common complications Less common complications Hypotension Disequilibrium syndrome Muscle Cramps Dialyzer reactions Nausea and vomiting Arrhythmias Headache Cardiac tamponade Chest pain Seizures Back pain Hemolysis Itching Air embolism Fever and chills Hypoxemia Acute complications during hemodialysis

24. 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 cramps Muscle cramps

25. Plasma volume contraction. Hyponatremia . Tissue hypoxia. Hypomagnesemia . Carnitine deficiency. Elevated serum leptin levels. The etiology of hemodialysis -associated cramps

26. 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

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

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

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

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

31. 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

32. 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 nerve stimulation and increased muscle refractory period, thereby preventing prolonged involuntary muscle contraction. _not used due to side effects. Vitamin E. Others. PREVENTION

33. Minimize interdialytic weight gains. Prevention of dialysis-associated hypotension. Higher dialysate sodium concentration. Carnitine supplementation. Quinine sulfate. Vitamin E: _400 I.U alone or in combination with vitamin C. Others. PREVENTION

34. Minimize interdialytic weight gains. Prevention of dialysis-associated hypotension. Higher dialysate sodium concentration. Carnitine supplementation. Quinine sulfate. Vitamin E. Others: _short acting benzodiazepines, nifedipine , phenytoin , creatine monohydrate, carbamazepin , amitriptyline , and gabapentin . _they are still under investigations. PREVENTION

35. Common complications Less common complications Hypotension Disequilibrium syndrome Muscle Cramps Dialyzer reactions Nausea and vomiting Arrhythmias Headache Cardiac tamponade Chest pain Seizures Back pain Hemolysis Itching Air embolism Fever and chills Hypoxemia Acute complications during hemodialysis

36. Hypotension. Early manifestations of Disequilibrium syndrome. Gastroparesis (cause nausea and vomiting). High dialysate sodium or calcium (cause nausea and vomiting). Caffeine use (cause headache). Metabolic disturbances: eg . hypoglycemia, hypernatremia , and hyponatremia (cause headache). ETIOLOGY OF HEADACHE, NAUSEA, AND VOMITING

37. TTT of hypotension. Detection and management of Disequilibrium syndrome. Antiemetics : eg . Metoclopramide . Acetaminophen. TREATMENT

38. Prevention of hypotension. Decrease dialysate sodium. Metoclopramide : 10 mg prior to dialysis session if persistent vomiting. A cup of coffee in heavy caffeine user suffering from headache. Causious trial of magnesium supplementation in persistent headache. PREVENTION

39. Common complications Less common complications Hypotension Disequilibrium syndrome Muscle Cramps Dialyzer reactions Nausea and vomiting Arrhythmias Headache Cardiac tamponade Chest pain Seizures Back pain Hemolysis Itching Air embolism Fever and chills Hypoxemia Acute complications during hemodialysis

40. Non-specific back pain sometimes associated with chest pain. Chest pain may be: _mild non-specific _hypotension _ disequilibrium syndrome _angina _acute coronary syndrome _ hemolysis _air embolism _ pulmoary embolism CHEST PAIN & BACK PAIN

41. The presence of cardiovascular disease is an important predictor of mortality in patients with ESRD. Angina is the commonest presentation of CAD in dialysis patient. Frequent episodes of hypotension during hemodialysis may be the presentation of CAD. Exertional dyspnea , ( intradialytic or interdialytic ), sudden cardiac arrest or death, and arrhythmias are less common presentations. Angina

42. There is extremely poor prognosis in dialysis patients with an acute myocardial infarction (AMI), this may be due in part to a relatively increased number of "atypical clinical presentations " resulting in underdiagnosis and undertreatment . As an example, the presence of dyspnea alone due to an acute myocardial infarction in an individual scheduled to undergo a regular chronic dialysis procedure may be mistakenly attributed to volume overload. In addition, baseline abnormalities on the electrocardiogram, such as left ventricular hypertrophy, may mask characteristic changes with ischemia. ACUTE CORONARY SYNDROME

43. Extremely uncommon in dialysis patients during hemodialysis sessions. May be observed after manipulation of thrombus or occlusion of the dialysis access. Pulmoary embolism

44. Common complications Less common complications Hypotension Disequilibrium syndrome Muscle Cramps Dialyzer reactions Nausea and vomiting Arrhythmias Headache Cardiac tamponade Chest pain Seizures Back pain Hemolysis Itching Air embolism Fever and chills Hypoxemia Acute complications during hemodialysis

45. May be accompined by other minor allergic symptoms. May be low-grade hypersensitivity to dialyzer or blood circuit components. Antihistaminics may be given during dialysis session. Chronic pruritis may be due to uremia, elevated phosphorus level or viral hepatitis. Uremic pruritis may be treated by: increase dialysis dose, high flux membranes, EPO, Primrose oil or tacrolimus oint . ITCHING

46. Common complications Less common complications Hypotension Disequilibrium syndrome Muscle Cramps Dialyzer reactions Nausea and vomiting Arrhythmias Headache Cardiac tamponade Chest pain Seizures Back pain Hemolysis Itching Air embolism Fever and chills Hypoxemia Acute complications during hemodialysis

47. You should seek for the source of infection. Special consideration should be given to vascular access. Infection control practice should be followed in hemodialysis unit. FEVER & CHILLS

48. Common complications Less common complications Hypotension Disequilibrium syndrome Muscle Cramps Dialyzer reactions Nausea and vomiting Arrhythmias Headache Cardiac tamponade Chest pain Seizures Back pain Hemolysis Itching Air embolism Fever and chills Hypoxemia Acute complications during hemodialysis

49. A central nervous system disorder described in dialysis patients. It is characterized by neurologic symptoms of varying severity that are thought to be due primarily to cerebral edema. New patients just being started on hemodialysis are at greatest risk, particularly if the BUN is markedly elevated. Other predisposing factors include severe metabolic acidosis, older age, pediatric patients, and the presence of other central nervous system disease . Dialysis disequilibrium syndrome

50. Dialysis disequilibrium syndrome

51. Acute symptoms develop during or immediately after hemodialysis . Early findings include headache, nausea, disorientation, restlessness, blurred vision, and asterixis . More severely affected patients progress to confusion, seizures, coma, and even death. Milder signs and symptoms associated with dialysis — such as muscle cramps, anorexia, and dizziness developing near the end of a dialysis are also part of this syndrome. CLINICAL MANIFESTATIONS

52. Uremia. Subdural hematoma. Cerebral infarction. Intracerebral hemorrhage. Meningitis. Metabolic disturbances ( hyponatremia , hypoglycemia). DIFFERENTIAL DIAGNOSIS

53. Symptoms are self-limited and usually disappear within several hours. Mild nonspecific symptoms, such as nausea, vomiting, or headache, is symptomatic. Sever life thereatening symptoms: _ABC _Dialysis is stopped in the patient with seizures or coma. _raising the plasma osmolality with either hypertonic saline or 12.5 g of hypertonic mannitol . Some physicians administer 50 % dextrose solution. TREATMENT

54. Prevention is the mainstay of therapy in the DDS. A new dialysis patients with very high BUN concentrations or neurologic symptoms, The initial dialyses should be gentle: _the initial session not more than 2 hours. _low blood flow rate of 150 to 250 mL /min. _small surface area dialyzer. _concurrent rather than countercurrent blood and dialysate flow. _repeated daily for three or four days with gradual increase in time and blood flow rate. _marked fluid overload can be treated with ultrafiltration . PREVENTION

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