complications of HD case presentation

04/08/23 Dr. Abrar Ali Katpar 1

Case Presentation

Dr. Abrar Ali Katpar Resident Nephrology / MedicineKing Khalid Hospital,Hail, KSA

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Pt’s Profile

Name -------------------------DOB= 10/11/1406. A 23 years old Male Saudi patient from Hail. Blood Group = AB+ve Serology negative for HBsAg / HCV / HIV This patient was referred from PHC to ER KKH for renal

impairment on 14/04/1428 (the first yellow file was opened). Appointment was given to OPD on 21/04/1428. Through OPD he was admitted on 25/04/1428 to start early

dialysis which he refused & continued conservative treatment. He presented in ER with SOB + anorexia for 3 days. Found to have severe metabolic acidosis + hyperkalemia &

pulmonary edema on 07/02/1429.

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Pt’s Profile

He was admitted for investigations & management.

Found to have ESRD due to polycystic kidney disease PKD.

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U/S reported

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He was started urgent 1st HD with temporary catheter in right femoral vein on 07/02/1429 time 12:05 am in ICU.

1st time perm Cath. Was inserted on 12/02/1429.

Till Now he is on regular HD thrice a week for 4 hours a session.

His present access for HD is Left AVF Which is functioning well.

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After the medical record of the patient, we would like to present this case as our routine HD patient.

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Presentation of case for discussion

His pre HD Data: Dry weight =47kg B.P =129/78 Pulse =84/ min Temp =36.9 RR =14/min O2 Sat. =97% on RA

He was prescribed HD Session =4 hrs. Target wt. loss =3.5 kg Heparin only bollus =2000iu Dialysate = FC1+bicarb Dialysate temp =36 C Dialyzer = Pn5 hollow fiber Na + =134 Conductivity =14 Pump =300

Our this patient for maintenance regular HD, came ambulatory on 11/09/1429 at 8:30 am for a routine session of HD.

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Investigations

Pre HD CBC

HB = 8.56 WBC = 6.45 HCT = 25.3 PLT = 209

Biochemistry BUN = 10.79 CREAT= 415 URIC ACID = 257.1 ALB = 39.91 T.PROT.= 63.7 AST = 21 ALT = 24 ALP = 507 GLUC = 6.1

Post HD ECG = WNL CXR = CLEAR

BiochemistryBUN ----

4.32GLUC --7.7Na+ ---144.3K+ -----3.0

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12 lead ECG

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Started HD session

Initiated with antiseptic measure AVF pricked & dialysis started with out any problem till 3 hrs.

Patient was monitored as per routine every 30 minutes for Bp Pulse Arterial pressure Venous pressure General condition Complains And other parameters by programmed machine protocols.

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Patient presentation.Suddenly after 3 hours of HD he started complaining of:-

Dizziness Lightheadedness Sweating Nausea Cramps and he was About to collapse

His Vitals BP = 75/40 Pulse = 110/min&weak Temp = 36 C RR = 18/min O2 Sat. = 90% on RA

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Q. WHAT Is happening?

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Quick reflexesSEVERE HYPOTENSION?

well

Q. WHAT IS CAUSE OF HIS HYPOTENSION?

BEFORE ANSWER?

Let us GO through

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Complications that occur during Hemodialysis session.

Common complications1. Hypotension2. Muscle cramps3. Nausea and vomiting4. Headache5. Chest and back pain6. Febrile reactions7. First-use syndromes8. Pruritis

Uncommon but serious complications

1. Disequilibrium syndrome 2. Dialyzer reactions3. Arrhythmias 4. Cardiac tamponade5. Intracranial bleeding6. Seizures7. Hemolysis8. Air embolism9. Dialysis associated

neutropenia & compliment activation.

10. Hypoxemia.

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Frequency of common complications

1. Hypotension = 20 – 30 %2. Muscle cramps = 5 – 20 %3. Nausea & vomiting = 5 – 15 %4. Headache = 5%5. Chest pain = 2 – 5 % 6. Back pain = 2 – 5 %7. Febrile reactions = <1 %8. Itching = 5%9. Fever and Chills = < 1 %10. Cardiopulmonary arrest = < 1 %

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Causes of Hypotension during HD

Common causes1. Related to excessive decrease in blood volume

a) Fluctuation in U/F ratesb) High U/F ratec) Target dry weight set too low.

2. Related to lack of vasoconstrictiona. Acetate-containing dialysis

solution.b. Relatively warm dialysis

solution.c. Food ingestion d. Tissue ischemiae. Autonomic neuropathyf. Anti hypertensive medicine

3. Related to cardiac factors1. Cardiac output unusually

dependent on cardiac filling: diastolic dysfunction due to LVH, IHD, or other conditions.

2. Failure to increase cardiac rateI. Ingestion of beta blockersII. Uremic autonomic neuropathyIII. Aging

3. Inability to increase cardiac output for other reasons: poor myocardial contractility due to age, hypertension, atherosclerosis, myocardial calcification, valve disease, amyloidosis, etc

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Uncommon causesPericardial tamponade.Myocardial infarction.Occult hemorrhage.Septicemia.Arrhythmia.Dialyzer reaction.Hemolysis.Air embolism. Infections (severe & serious).

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Common causes of hypotension

a) Excessive or rapid decrease in the blood volume.i. Failure to use U/F controllerii. Large intra-dialytic weight gain or short treatment.iii. Excessive U/F below the pt’s “dry weight”.

b) Lack of vasoconstriction.i. Use of acetate-containing dialysis solutionii. Dialysis pt’s are often slightly hypothermic.iii. Food ingestion.iv. Tissue ischemia.v. Autonomic neuropathy.vi. Antihypertensive medication.

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Detection of hypotension

Most patients will complain of feeling dizzy, light headedness, or nauseated when hypotension occurs.

Some experience muscle cramps.Some times no symptoms whatsoever

until the BP falls to extremely low (and dangerous) levels.

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Management of hypotension

Fluid administration Slowing the blood flow rate

There are 2 potential reasons to lower the blood flow rate:

When U/F controller is not used, slowing the blood flow rate makes it easier to limit the amount of UF.

At very rapid blood flow rates and at a low cardiac out put, there may be a “steal” effect by the extracorporeal circuit, with diversion of blood from systemic tissue beds.

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Prevention of hypotension

1. Use machine with U/F controller when ever possible.2. Counsel patient to limit weight gain to < 1kg/day.3. Do not ultra filter a patient to below dry weight.4. Keep dialysis solution Na+ level at or above the

plasma level.5. Give daily dose of anti-hypertensive after, not

before, dialysis.6. Use Bicarb-containing dialysis solution when high

blood flow rate or high-efficiency dialyzers are used.7. In selected patients, try lowering the dialysis solution

when tempreture to 34-36 oC.8. Ensure that HCT is > 25-30% pre-dialysis.9. Do not give food or glucose orally during dialysis to

hypotensive-prone patients.

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Muscle cramps

Pathogenesis of muscle cramps during dialysis is unknown.

3 most important predisposing factors:HypotensionThe patient being below dry weight.Use of Na+poor dialysis solution.

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Management of cramps

For cramps with hypotensionN/S 0.9% is the best on which patient

responds quickly.In isolated cramps & acute status

Hypertonic solutionsHypertonic salineDextrose 50%. I V slowly calcium gluconate 10 to 20 ml

specially in hypocalcaemic patients.

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ANSWER is Now obvious.

This Pt. was having Acute Severe Hypotension with muscle cramps.

Dizziness + Light headedness + Nausea + Sweating + & generally he was about to collapse

because of sudden drop in BP. Due to removal of fluid more then his dry weight as

patient was young so he was tolerating up to dangerous level of low BP without any complain.

Due to good response of vascular system, the fluid shift from extra-vascular compartment to vascular compartment was taking place because of good vascular compliance.

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Management of this case We managed with:

Trendelenburg position. I.V bolus of NS 0.9% 200+300ml

over 15 min. Stopped U/F. Reduce Blood Flow pump from 300 to

250 Oxygen given 6 litters. Hypertonic solution Dextrose 50%

given. Dialysate Na+ increased to 138. Temperature decreased to 34.5C. Observation vitals. Investigations: Such as ECG + CXR

+ Hct+ biochemistry.

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Follow up

During all above measures patient became stable after 15 minutes his vitals were with in normal limits.

We monitored rest of time, HD continued with altering the prescription.

At the end of HD he was alright & left AKU ambulatory.

He came again for his scheduled next HD after a day.

While Going Home He said

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