Complications of Dialysis

Hypotension
Causes:
Excessive ultrafiltration Antihypertensive drugs Low blood volume Dehydration from vomiting or diarrhea Unstable cardiovascular condition

Signs/Symptoms: Interventions:
Gradual or sudden drop in blood pressure Flushing Yawning Dizziness Ringing in the ears Increase in pulse rate Anxious feeling Nausea Vomiting Seizures Possible death Assess blood pressure Discontinue UF Administer IV saline Place patient in Trendelenburg position

Prevention:
Frequent evaluation of dry weight Frequent BP monitoring Sodium modeling UF modeling

Hypertension
Causes:
Fluid overload Noncompliance in taking blood pressure medications Excessive Renin response Increase peripheral vascular resistance (possible side effect from EPO) Anxiety or tension

Signs/Symptoms:
Elevated blood pressure Headache Dizziness Edema Irritability Blurred vision Asymptomatic Nervousness

Interventions:
Evaluate for medication compliance, fluid overload, anxiety, high hematocrit or free renin levels Promote fluid and medication compliance Identify source of stressors and promote resolution

Muscle Cramping
Causes: Signs/Symptoms: Interventions:
Administer bolus of saline Reduce UFR until cramp subsides Apply ice Massage or apply opposing force Asses patient dry weight Rapid shifts in Painful muscle compartmentalized contractions in the fluid extremities or abdomen Shifts in concentrations of blood solutes Hyponatremia Hypokalcemia

Headache
Causes: Signs/Symptoms: Interventions:
Evaluate patient for hypertension or hypotension Evaluate patient for level of consciousness Administer medication as per facility protocol Fluid shifts Pain in head or facial area Solute shifts Hypertension and hypotension Changes in serum sodium concentration Anxiety Subdural hematoma

Nausea and Vomiting

Causes:
Hypotension Pyrogen reactions Gastrointestinal disease

Signs/Symptoms:
Headache Nausea Vomiting

Interventions:
Evaluate for cause of nausea Administer medication per facility protocol If due to hypotension administer saline until blood pressure stabilizes If due to pyrogenic reaction follow procedure for pyrogenic reactions If due to systemic illness notify physician

Fever and Chills

Causes: Signs/Symptoms: Interventions:
Evaluate patient for systemic infection or localized access infection Obtain blood cultures per facility protocol Administer antipyretics If suspected pyrogen reaction obtain cultures and LALs from dialyzer, dialysate per DaVita policy and procedure Systemic infections Temperature >99 F Access infections Involuntary chilling Contamination of the Hypotension extracorporeal system from non-sterile technique Contamination of bicarbonate Introduction of pyrogens or endotoxins for reprocessed dialyzers

Pruritus
Itching
Causes:
Uremia Dry skin Parathyroid dysfunction Excessive phosphorus Allergic reaction

Signs/Symptoms:

Interventions:

Generalized itching Oral medication Increase in serum Topical preparations that phosphorus are alcohol free Increased itching only when on dialysis

Clotted Dialyzer
Causes:
Inadequate anticoagulation therapy Heparin pump not functioning correctly Air left in the extracorporeal system Dehydration Low flow or no flow of blood in the extracorporeal system High hematocrit

Signs/Symptoms:

Preventions:

Visible clot in the venous Assure adequate drip chamber or line anticoagulation therapy Blood turning very dark in Check to see if heparin color pump is functioning correctly Unable to rinse back blood Assure that blood is not in the extracorporeal system sitting in blood lines and QB is adequate Rise in arterial pressure (post pump) and a decrease in venous Intervention: pressure Change Dialyzer

Accidental Blood Loss

Causes:
Arterial or venous blood line separation Dialyzer leak or rupture Needle dislodgment Clotting of the extracorporeal circuit

Signs/Symptoms:
Blood on floor, chair or clothing Blood detector alarm Low venous pressure alarm for needle dislodgment and line separations High venous pressure alarm for clotting TMP alarm Clots visible in the venous drip chamber Hypotension

Preventions:
Assure that all lines are tightly connected Assure cannulation needles are securely taped Be sure that heparin pump is working correctly

Intervention:
Dependent on cause

Air in Blood Lines

Causes: Signs/Symptoms: Preventions:
Use proper priming procedures Fill drip chambers to correct volume Assure all connections are tight Assure saline bag has sufficient volume when priming or washing back Arterial Line Collapses Visible air in the lines Underfilling of venous Visible foam in the blood drip chamber lines Underfilling of the saline drip chamber Residual air from improper priming procedure Loose connections Heparin line not primed properly Introduction of air during the dialysis treatment

Air Bubbles in the Blood Stream

Causes:
Unarmed air detector Empty saline bags Separation in the blood lines Very cold dialysate or saline solution Air left in the extracorporeal circuit Careless administration of IV medications Air leak in the blood tubing

Air Embolism
Signs/Symptoms:
Visible air in the venous blood line SOB and coughing Chest tightness or pain Cyanosis Restlessness Visual disturbances Seizures Coma Cardiac arrest

Interventions:
Stop blood pump, clamp all lines Call for help Place patient on LEFT side in Trendelenburg position Administer oxygen at 100% Monitor vital signs If patient arrests place in flat position and initiate CPR Document

Prevention:
Assure air detector is armed

Rupture of Red Blood Cells

Causes:
Improperly diluted dialysate Calibration error in blood pump Dialysate temperature in excess of 47 C Using untreated water in the dialysis procedure (chlorine & chloramines) Failure of conductivity monitor Exposure to reprocessing chemicals

Hemolysis

Signs/Symptoms:
Venous blood appears cranberry juice color Anxiety and restlessness Pain in access arm Nausea, vomiting, abdominal cramping Tightness in chest with difficulty breathing Hypotension Seizures Arrhythmias Weak, thready pulse Hyperkalemia Possible death Anemia

Interventions:
Stop blood pump and clamp all lines DO NOT RETURN THE BLOOD Assess patient Administer oxygen Notify physician Draw a blood specimen from both the arterial and venous lines for STAT potassium level Obtain samples of dialysate and test for conductivity, pH, temp, and residual disinfectant

Shriveling of Red Blood Cells

Causes:
Improperly mixed dialysate (too concentrated)

Crenation

Signs/Symptoms:
Very dark red blood Headache Nausea and vomiting Contracted or rapidly expanded intravascular volume

Interventions:
Stop blood pump and clamp all lines DO NOT RETURN THE BLOOD Assess patient Administer oxygen Notify physician Draw a blood specimen from both the arterial and venous lines for STAT potassium level Obtain samples of dialysate and test for conductivity

First Use Syndrome

Causes:
Complement activation Hypersensitivy

Signs/Symptoms:
Clinical Complex Back pain Chest pain Hypotension Pruritis Nausea Vague discomfort Hypersensitivy Anxiety Pruritis Dyspnea

Prevention:
Use synthetic membrane Reuse of dialyzers with cellulose membrane Pre-process to rinse out ETO

Cardiac Arrest
Causes:
Electrolyte imbalances (hyperkalemia) Myocardial Infarction Cardiac effusion that increases to tamponade Air embolism Hemolysis Large blood loss (exsanguination) Anaphylatic reaction

Signs/Symptoms:
Absence of apical or radial pulse Lack of respiration Patient unresponsive

Interventions:
Assess pulse, respiration, and responsiveness Call for help Initiate CPR Maintain one cannulation needle with saline drip

Immediate Allergic Reaction

Causes:
Hypersensitivity to dialyzer membranes Hypersensitivity to dialyzer disinfectant (ethylene oxide) Hypersensitivity to medications Hypersensitivity to disinfectant used in the reprocessing procedure

Anaphylaxis
Signs:
Acute respiratory distress Tightness in the chest Anxiety, restlessness Hypotension Flushing of the skin Low back pain Possible eruption of hives

Interventions:
Stop dialysis DO NOT RETURN BLOOD Assess patient condition Administer oxygen Administer drugs as per facility standing orders If patient arrests, initiate CPR

Prevention:
Preprocessed dialyzers Synthetic membranes Test for drug sensitivities prior to administration

Angina
Chest Pain
Causes:
Hypotension Sudden initiation of the dialysis treatment Severe anemia Anxiety

Signs/Symptoms:
Heavy, crushing pain in chest Difficulty breathing Nausea

Interventions:
Reduce QB Reduce TMP or UFR Administer oxygen Notify physician Monitor cardiac rhythms if possible

Prevention:
Monitor B/P and dry weight closely

Arrhythmia/Dysrhythmia
Irregular Heart Rhythm
Signs/Symptoms: Causes: Interventions:
Assess patient condition Notify physician Monitor cardiac rhythms if possible Change bath potassium concentration if indicated

Rapid changes in serum Slow or rapid irregular heart potassium rhythm concentrations Missed beats Hypotension Patient complaints of Myocardial infarction palpitations Volume overload Coronary Artery Disease

Disequilibrium Syndrome
Causes:
Too rapid changes in serum electrolytes, pH, and osmolarity BUN >150 mg/dl

Signs/Symptoms:
Hypertension Nausea and vomiting Headache Restlessness Convulsions Decrease in consciousness Coma Death

Interventions:
Reduction of BUN, electrolytes, pH and osmolarity in a slow gradual method

Heparin Overdose
Causes:
Error in calculation of heparin dose Error in heparin infusion pump setting Malfunction of heparin infusion pump

Signs/Symptoms:
Unusual bleeding around needle site during dialysis Prolonged bleeding post dialysis Formation of bruises or purpura under skin without severe injury Retinal bleeding with diminished vision Gastrointestinal bleeding

Interventions:
Evaluate heparin dosage Evaluate clotting time Notify physician Administer protomine sulfate per physician orders Administer fibrinolytics per facility protocol

Access Recirculation
Causes:
Needles placed too close together Poor needle stick or placement Poor blood flow through the access due to stenosis Inadequate flow in the vascular access

Signs/Symptoms:
Darkening of blood or black blood syndrome Saline present in arterial line during initiation or rinseback procedure Inappropriately high serum chemistries post dialysis Inappropriately low URR or Kt/V

Interventions:
Recirculation studies Fistulograms Shuntograms Doppler studies

Prevention:
Placing needles at least 2 inches apart Good cannulation technique

Seizures
Causes:

Signs/Symptoms:

Interventions:
Protect patient from harm Administer oxygen if indicated Treat low B/P with NS If no response DC treatment

Hypotension Convulsive movements Electrolyte imbalances Change in patient level of consciousness Disequilibrium syndrome Reactions to chemicals

Power Failures
Causes:
Electrical overload Local power outage Machine accidentally becomes unplugged

Signs:
Machine power alarm will sound

Interventions:
Determine cause of failure Remove venous line from venous clamp Terminate dialysis with hand crank

Accidental Disinfectant Infusion

Causes:
Inaccurate residual testing No residual testing Disinfectant rebound

Signs/Symptoms: Interventions:
Immediate pain in access Nausea SOB Flushing Chest pain, Low B/P Tingling around the mouth with formaldehyde Gasoline taste from Renalin Stop blood pump and clamp all lines DO NOT RETURN BLOOD Assess vital signs, give NS via gravity if B/P is low Administer oxygen Notify physician Draw blood specimen for toxicology and evaluation of serum potassium level per DaVita policy and procedure

Miscellaneous Occurrences
Line separations Dialysate hose reversal Needle dislodgment Clotted fistula Dialysis dementia Dialysis with incorrect bath Dialysis with incorrect dialyzer