Complications of Hemodialysis

Complications of Hemodialysis. Reported by: Girlna Leah V. Reyes.

Objective:. Identify and discuss the causes, Signs and symptoms of complications encountered during hemodialysis. Discuss the management and nursing intervention for patient and technical complications Describe appropriate response for emergencies..

Discussion of the Topic:. Common Complications of Hemodialysis *Hypotension (20-50%) *Muscle Cramps (5-20%) *Nausea (5-15%) *Headache (5%) *Itching (5%) *Chest Pain/ Back Pain (2-5%) *Fever and Chills (<1%).

Problems and Complications. >Monitoring during the dialysis treatment is done to prevent, detect and treat complications. > Continuous monitoring and early detection can reduce and may even prevent problems and complications. > Observations should be recorded on the patients’ hemodialysis treatment sheet, progress notes or electronic medical record..

PATIENT COMPLICATION TECHNICAL COMPLICATIONS Hypotension (20-30%) Clotting Muscle Cramps Blood leak Chest Pain Dialyzer Reactions Itching Power failure Nausea and Vomiting Hemolysis Fever and Chills Exsanguination Pyrogen reaction Air embolism Hypertension Headache Disequilibrium Syndrome.

Complications of Hemodialysis. 1. HYPOTENSION >Most common complication in hemodialysis -it defined as low blood pressure -Decreased systolic blood pressure by >20-30mmHg from pre dialysis blood pressure -Systolic blood pressure <100mmHg.

Common Causes of HYPOTENSION. -Removing too much weight *inaccurate target weight *inaccurate pre-weight -Taking anti-hypertensive pills before dialysis (BP meds) -Heart disease *Myocardial Infarction (MI) or Arrhythmias -Septicemia- blood poisoning by germs such as bacteria, viruses, and fungi.

Less Common Causes of HYPOTENSION. -Anemia *Hemorrhage -Low weight gain or dehydration -Anaphylaxis- a severe, whole-body allergic reaction to a chemical that has become an allergen -Eating/Drinking during hemodialysis -Dialyzer Reaction -Air Embolism.

Signs and Symptoms of HYPOTENSION. -Gradual or sudden decrease in BP -increase in Pulse -Cold, Clammy skin (diaphoresis) -Nausea and Vomiting -Cramping -Chest pain/Angina -Yawning, Feeling Dizzy, Sleepy or weak -Pallor -Decreasing mental status to loss of consciousness -Seizure -Diaphoresis.

Treatment of HYPOTENSION. -Pay attention to how the patient feels. - NSS Bolus to support the Blood Pressure (100-200ml) -Place the patient to Trendelenburg Position to help venous return to the heart and restore adequate brain perfusion in individuals. - Use Sodium modeling (a stratedy to decrease the incidence of hypotension while on treatment) as per Doctors order. -Decrease Ultrafiltration rate..

Prevention of HYPOTENSION. -Determine the cause -Evaluate target and pre-weight for accuracy -Evaluate that fluid goal was correct -Review medication list for Blood pressure medication -Frequent monitoring of Vital signs..

2. MUSCLE CRAMPS. -Painful muscle spasms (usually in extremities) Causes of MUSCLE CRAMPS -Associated with removal of large amount of fluid/inaccurate fluid removal goal -Hypotension or sudden decrease of blood pressure -Changes in electrolytes (blood chemistry) -Rapid sodium removal -Low potassium levels.

Signs and Symptoms of MUSCLE CRAMPS. -Can occur anytime in dialysis, especially in the middle to end of the treatment -Muscle cramps of extremities that can often be seen on legs, feet or hands -Hypotension or sudden decrease in blood pressure. Treatment of MUSCLE CRAMPS -Normal saline bolus -Reduce Ultrafiltration Rate (UF) -Massage or apply opposing force -Assess dry weight -Administer hypertonic solution (D5050) as ordered by the Doctor..

Prevention of MUSCLE CRAMPS. -Sodium modeling as per Doctors Order Manage sodium intake—Limit sodium (salt) intake to 2,000 mg or less. Too much sodium can make it harder for your kidneys to balance the sodium and water in your body. That can mean feeling thirsty, which can lead to fluid weight gain -Assess for accurate target weight. Manage fluid gains between treatments—Follow your plan for daily intake of liquids to prevent fluid overload, also called hypervolemia.

3. DISEQUILIBRIUM SYNDROME. -Defined as a set of systemic and neurologic symptom that includes: >Nausea and vomiting >Headache >Restlessness >Hypertension >Slurred speech >Seizure and coma.

Causes of DISEQUILIBRIUM SYNDROME. -Slower transfer of urea from the brain tissue to the blood. -Fluid shift into the brain due to removal of wastes from the blood stream causing cerebral edema. -Rapid Changes in serum electrolytes, especially in new patients..

Causes of DIEQUILIBRIUM SYNDROME. -Elevated Blood Urea Nitrogen (BUN) >150 -High Blood Flow Rate -Too long treatment time -Dialyzer is too big for first treatment (too efficient).

Treatment of DISEQUILIBRIUM SYNDROME. -Monitor new patients carefully for hypertension -Decreased Blood Flow Rate (BFR) -Be alert for restlessness, speech/mental changes -Provide oxygen as needed.

Prevention of DISEQUILIBRIUM SYNDROME. -Assess new patients’ electrolyte level -Use smaller dialyzer, lower Blood Flow Rate (BFR) and shorter dialysis time for first few treatments..

4. NAUSEA AND VOMITING. Causes of NAUSEA AND VOMITING -Hypotension or sudden decreased in Blood pressure -Uremia or high levels of urea in the blood. -Disequilibrium Syndrome.

Treatment of NAUSEA AND VOMITING. -Hypotension or decreased blood pressure administer NSS Bolus (100ml) -Decrease Blood Flow Rate (BFR) -Administer antiemetic drug such as Metoclopramide as ordered by the doctor. -Determine relationship to dialysis (is the patient sick? pre dialysis).

Prevention of NAUSEA AND VOMITING. -Uremic patient or one with Disequilibrium Syndrome requires careful pre-assessment and monitoring during the initial treatments -Always do the close monitoring of patient status and vital signs every 30minutes.

5. HEADACHE. Causes of HEADACHE -Hypertension or increased Blood pressure -Inaccurate dry weight with too much fluid removed -Rapid fluid or electrolyte shift- Disequilibrium syndrome -Anxiety/Nervous tension -Caffeine withdrawal.

Symptoms of Headache. -Pain in the head or facial area -Hypotension/Hypertension -Nausea and vomiting.

Treatment of HEADACHE. -Give analgesic with doctors order -if hypertensive do blood pressure assessment -if Hypotension administer NSS Bolus (100-200ml) Prevention of HEADACHE -Patient require careful pre-assessment and monitoring during treatments -Goal is to identify the cause and then prevent it in the future treatment..

6. CHEST PAIN. ANGINA MYOCARDIAL INFARCTION -Chest Pain -Chest Pain -Caused by Ischemia -Caused From Ischemia -Lack of oxygen -results to tissue death to tissue -Resolved by -Not resolved by Nitroglycerin Nitroglycerin.

Causes of CHEST PAIN. -Ischemia to heart muscle (Coronary Artery Disease) -Anemia -Hypotension from fluid depletion -Hypovolemia -Anxiety-stress, Physical exertion, illness -Blood flow rate increased too rapidly on patient with known cardiac disease..

ANGINA AND MYOCARDIAL INFARCTION SYMPTOMS. ANGINA MYOCRDIAL INFARCTION -Pressure, Pain localized -Pressure, pain localized or May or may radiate to neck, radiate to neck, jaw shoulders, Jaw, shoulders arms arms may come and go may come and go -Apprehension -Apprehension -Choking/Strangling -Choking/Strangling sensation Sensation -Squeezing/Crushing/ -Squeezing/Crushing/ Pressure sensation Pressure sensation -Nausea -Nausea -Pallor, cool clammy skin -Pallor, cool clammy skin -Duration of Angina: 1-2min -Hypotension.

Treatment of CHEST PAIN. -Hypotension –NSS Bolus -Angina pain with Nitroglycerin as ordered by the Doctor -MI pain requires analgesics -Anxiety/Stress -Oxygen Inhalation.

Prevention of CHEST PAIN. -Accurate fluid removal and weight assessment -Assess for need for prophylactic O2 -Low Blood Flow Rate at the start of treatment -Avoid Rapid Return.

7. ITCHING. CAUSES -Dry skin -Secondary to hyperparathyroidism -Abnormal levels of calcium, magnesium and phosphorus in tissues -allergies -Uremia with an elevated Blood Urea Nitrogen..

Treatment for Itching. -Adequate dialysis to regulate electrolyte levels -Lotions or medications for dry skin/ allergies Prevention -Control of Uremia and secondary to hyperparathyroidism -Adequate dialysis to regulate electrolytes levels.

8. CHILLS AND FEVER. CAUSES OF CHILLS AND FEVER -Infection or Septicemia -Vascular Access -Respiratory Illness -Cold Dialysate or Malfunctioning thermostat -Pyrogenic reaction.

MANAGEMENT -Provide Droplight or Blanket for warmth -Administer antipyretic drug as ordered -Check the patients’ temperature and record SYMPTOMS Infection -Fever during dialysis -Feeling cold with a fever -Redness, swelling, tenderness, warmth or drainage from access site. Septicemia -Fever, chills, vomiting and headache -Hypotensive shock.

9. PYROGENIC REACTION. -Fever reaction due to presence of dead bacteria able to cross any membrane, irrespective of membrane pore size distribution..

Cause of PYROGENIC REACTION -Contamination of: -Bicarbonate containers/system -Water system -Machine -Dialyzer and Bloodlines -Not adhering to aseptic or sterile techniques.

SYMPTOMS OF PYROGENIC REACTION. -Cold Sensation upon treatment initiation (40-70 minutes during treatment) -Sudden shaking chills, the temperature elevation (1-2 hours after chills) usually resolves after end of treatment -Noted increase pulse before chills develop -Hypotension (drop in blood pressure >30mmHg) -Headache/Muscle aches.

Treatment OF Pyrogenic Reaction -Remove from dialysis immediately -Gather samples of dialysate/blood as per company policy. Prevention -Disinfection/Sterilization -Proper use of aseptic technique.

10. HYPERTENSION. CAUSES OF HYPERTENSION -Fluid overload -Non-compliance with blood pressure medications -Anxiety -Renin overproduction Symptoms of Hypertension -Gradual or sudden rise in blood pressure -Headache blurring vision -Nausea and vomiting -Dizziness -Seizure.

Treatment of Hypertension. -Review of Blood Pressure medication by Nephrologist -Assessment of target weight and fluid removal goal -Monitor blood pressure closely -Check dialysate sodium level, decrease to an acceptable level of high -Administer hypertensive drug as ordered by the Doctor..

Technical Complications. 1. Clotting 2. Power Failure 3. Blood leak 4. Hemolysis 5. Air Embolism 6. Exsanguination 7. Dialyzer Reaction.

1. CLOTTING IN THE EXTRACORPORAREAL CIRCUIT. >It is the formation of blood clots in the dialyzer and blood lines Causes of Clotting >Inadequate anticoagulation especially those patient who are not able to use heparin instead flushing of 100cc of PNSS > Low blood flow rate >Air in blood lines when the patient ports and line starts on sucking >Poor priming technique >Loose connections or their ports for patency.

SIGNS OF CLOTTING. >Increasing venous pressure and TMP readings >Dark blood in lines or drip chambers >Fibrin in drip chambers >Visible clots or clumping of dark blood in the drip chamber or dialyzer >TMP alarm problems. TREATMENT IN CLOTTING >Anticoagulation >Vascular Access -Needle or Catheter placement -Checking the patency of both ports or fistula access before the treatment -CBC problems.

2. BLOOD LEAK. CAUSES OF BLOOD LEAK >Membrane rupture allowing RBC’s cross over the membrane into the dialysate Signs of Blood Leak >Blood Leak alarm on machine >Positive test for blood in dialysate side. INTERVENTIONS >Check dialysate outflow with blood leak strip >If positive stop treatment do not return blood >If negative may need to get different machine.

3. POWER FAILURE. CAUSES OF POWER FAILURE >Electricity is disrupted to the machine. >Storm/Tornado/Fire/Constructions SIGNS OF POWER FAILIURE >Unable to mute alarms >Air detector trips, clamping venous lines INTERVENTION WHEN POWER FAILURE OCCURS >Know how to free venous line and hand crank blood return. >Company policy..

4. HEMOLYSIS. >Breakdown or destruction of RBC’s >Releases potassium from damaged cells into the bloodstreams >Decreasing the oxygen carrying capacity of the RBC >Potentially life threatening SIGNS OF HEMOLYSIS Dialyzer or Blood lines >Cherry colored blood in venous line Patients Symptoms >Shortness of breath >Chest, abdominal or back pain >Cardiac arrest.

INTERVENTION >Stop dialysis and clamp the bloodlines and DO NOT return blood to the patient >Monitor vital signs closely >Provide oxygen therapy >Notify the Doctor IMMEDIATELY.

5. AIR EMBOLISM. >Introduction of enough air into extracorpeal system to stop circulation. CAUSES >Empty IV Bag >Air leak in blood lines >Air detector not armed >Loose connections >Separation of Blood lines >Pre-safety checks not done or done improperly SIGNS AND SYMPTOMS OF AIR EMBOLISM EXTRACORPEAL SYSTEM >Air pocket or Foam in venous line.

PATIENT >When patient is Coughing, Shortness of breath >Chest pain or Chest Pressure >Tachycardia >Distended neck veins >Cyanosis/Gray Color >Slight paralysis on one side of body >Confusion, convulsion or coma >Possible Cardiac or respiratory arrest. TREATMENT OF AIR EMBOLISM >Clamp the blood lines and stop the Blood pump >Place the patient to Trendelenburg position turning them on their left side..

Treatment of Symptoms >Oxygen to address shortness of breath and chest pain >Normal saline to support blood pressure >Monitor vital signs closely >Notify the Doctor..