Hemodialysis: Chapter 8, Complications During Hemodialysis, Part 2 - Dr.Gawad
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Hemodialysis: Chapter 8, Complications During Hemodialysis, Part 2 - Dr.Gawad
- 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 2 • Muscle cramps • Hemolysis • Air embolism • Disequilibrium syndrome • Seizures You can get this book free from www.NephroTube.com
- 2. Watch the video recording of this lecture on NephroTube YouTube channel www.YouTube.com/NephroTube
- 3. Visit www.NephroTube.com to get more Nephrology lectures (pdf and video recordings)
- 4. Talk Outline: Chapter 8 Complications During Hemodialysis: Part 2 • Muscle cramps: o Timing o Pathogenesis o Management o Prevention • Hemolysis: o Causes o Manifestations o Management • Air embolism: o Sites of air entry o Manifestations o Management NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com • Disequilibrium syndrome: o Manifestations o Acute and chronic dialysis o Pathogenesis o Diagnosis o Management o Prevention • Seizures: o Causes o Management
- 5. Talk Outline: Chapter 8 Complications During Hemodialysis: Part 2 • Muscle cramps: o Timing o Pathogenesis o Management o Prevention • Hemolysis: o Causes o Manifestations o Management • Air embolism: o Sites of air entry o Manifestations o Management NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com • Disequilibrium syndrome: o Manifestations o Acute and chronic dialysis o Pathogenesis o Diagnosis o Management o Prevention • Seizures: o Causes o Management
- 6. Talk Outline: Chapter 8 Complications During Hemodialysis: Part 2 • Muscle cramps: o Timing o Pathogenesis o Management o Prevention • Hemolysis: o Causes o Manifestations o Management • Air embolism: o Sites of air entry o Manifestations o Management NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com • Disequilibrium syndrome: o Manifestations o Acute and chronic dialysis o Pathogenesis o Diagnosis o Management o Prevention • Seizures: o Causes o Management Muscle cramps are commonly observed near the end of the dialysis session.
- 7. Talk Outline: Chapter 8 Complications During Hemodialysis: Part 2 • Muscle cramps: o Timing o Pathogenesis o Management o Prevention • Hemolysis: o Causes o Manifestations o Management • Air embolism: o Sites of air entry o Manifestations o Management NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com • Disequilibrium syndrome: o Manifestations o Acute and chronic dialysis o Pathogenesis o Diagnosis o Management o Prevention • Seizures: o Causes o Management
- 8. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com Pathogenesis of muscle cramps during hemodialysis session - Hypotension / hypovolemia - Hypo-osmolarity Electrolyte disturbance - Low-sodium dialysate - Hypocalcemia - Hypomagnesemia - Pre-dialysis hypokalemia Peripheral vascular disease
- 9. Talk Outline: Chapter 8 Complications During Hemodialysis: Part 2 • Muscle cramps: o Timing o Pathogenesis o Management o Prevention • Hemolysis: o Causes o Manifestations o Management • Air embolism: o Sites of air entry o Manifestations o Management NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com • Disequilibrium syndrome: o Manifestations o Acute and chronic dialysis o Pathogenesis o Diagnosis o Management o Prevention • Seizures: o Causes o Management
- 10. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com Management of muscle cramps Intravenous solutions 0.9% saline - When hypotension and muscle cramps occur concomitantly, - It does not always resolve the cramp Hypertonic glucose Physical therapy - Forced stretching - Massage - Local heat application Nasal administration of oxygen Nifedipine 10 mg sometimes in hemodynamically stable patients
- 11. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com Management of muscle cramps Intravenous solutions 0.9% saline - When hypotension and muscle cramps occur concomitantly, - It does not always resolve the cramp Hypertonic glucose Physical therapy - Forced stretching - Massage - Local heat application Nasal administration of oxygen Nifedipine 10 mg sometimes in hemodynamically stable patients
- 12. Talk Outline: Chapter 8 Complications During Hemodialysis: Part 2 • Muscle cramps: o Timing o Pathogenesis o Management o Prevention • Hemolysis: o Causes o Manifestations o Management • Air embolism: o Sites of air entry o Manifestations o Management NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com • Disequilibrium syndrome: o Manifestations o Acute and chronic dialysis o Pathogenesis o Diagnosis o Management o Prevention • Seizures: o Causes o Management
- 13. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com
- 14. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com
- 15. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com
- 16. Talk Outline: Chapter 8 Complications During Hemodialysis: Part 2 • Muscle cramps: o Timing o Pathogenesis o Management o Prevention • Hemolysis: o Causes o Manifestations o Management • Air embolism: o Sites of air entry o Manifestations o Management NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com • Disequilibrium syndrome: o Manifestations o Acute and chronic dialysis o Pathogenesis o Diagnosis o Management o Prevention • Seizures: o Causes o Management
- 17. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com Causes of hemolysis during hemodialysis session Faulty roller pump Obstruction and/or narrowing in bloodline, needle, or catheter Problems with dialysis solution - Overheated dialysate. - Hypotonic dialysate - Dialysate is contaminated with chloramines, chlorine, copper, or nitrates.
- 18. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com Causes of hemolysis during hemodialysis session Faulty roller pump Obstruction and/or narrowing in bloodline, needle, or catheter Problems with dialysis solution - Overheated dialysate. - Hypotonic dialysate - Dialysate is contaminated with chloramines, chlorine, copper, or nitrates.
- 19. Talk Outline: Chapter 8 Complications During Hemodialysis: Part 2 • Muscle cramps: o Timing o Pathogenesis o Management o Prevention • Hemolysis: o Causes o Manifestations o Management • Air embolism: o Sites of air entry o Manifestations o Management NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com • Disequilibrium syndrome: o Manifestations o Acute and chronic dialysis o Pathogenesis o Diagnosis o Management o Prevention • Seizures: o Causes o Management
- 20. Manifestations of hemolysis In cases of acute massive hemolysis: • Back pain, chest tightness and shortness of breath • Port-wine appearance of blood in the venous bloodline and a pink discoloration of the plasma in centrifuged blood samples. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com
- 21. Manifestations of hemolysis In cases of acute massive hemolysis: • Back pain, chest tightness and shortness of breath • Port-wine appearance of blood in the venous bloodline and a pink discoloration of the plasma in centrifuged blood samples. • Severe decrease in hematocrit • Hyperkalemia NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com
- 22. Manifestations of hemolysis In cases of acute massive hemolysis: • Back pain, chest tightness and shortness of breath • Port-wine appearance of blood in the venous bloodline and a pink discoloration of the plasma in centrifuged blood samples. • Severe decrease in hematocrit • Hyperkalemia NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com Chronic mild subclinical hemolysis diagnosis is challenging, and diagnostic investigations are usually needed
- 23. Talk Outline: Chapter 8 Complications During Hemodialysis: Part 2 • Muscle cramps: o Timing o Pathogenesis o Management o Prevention • Hemolysis: o Causes o Manifestations o Management • Air embolism: o Sites of air entry o Manifestations o Management NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com • Disequilibrium syndrome: o Manifestations o Acute and chronic dialysis o Pathogenesis o Diagnosis o Management o Prevention • Seizures: o Causes o Management
- 24. Management of hemolysis • Stop dialysis and hospitalize the patient • Order: Laboratory tests (K, CBC, reticulocyte count, LDH) and ECG • Manage: Blood transfusion and hyperkalemia • Search for the cause NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com
- 25. Talk Outline: Chapter 8 Complications During Hemodialysis: Part 2 • Muscle cramps: o Timing o Pathogenesis o Management o Prevention • Hemolysis: o Causes o Manifestations o Management • Air embolism: o Sites of air entry o Manifestations o Management NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com • Disequilibrium syndrome: o Manifestations o Acute and chronic dialysis o Pathogenesis o Diagnosis o Management o Prevention • Seizures: o Causes o Management
- 26. Sites of air entry during hemodialysis session NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com
- 27. Talk Outline: Chapter 8 Complications During Hemodialysis: Part 2 • Muscle cramps: o Timing o Pathogenesis o Management o Prevention • Hemolysis: o Causes o Manifestations o Management • Air embolism: o Sites of air entry o Manifestations o Management NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com • Disequilibrium syndrome: o Manifestations o Acute and chronic dialysis o Pathogenesis o Diagnosis o Management o Prevention • Seizures: o Causes o Management
- 28. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com Manifestations of air embolism Foam is observed in the venous bloodline position-dependent Seated patients: Air travels to the cerebral venous system and obstructs it Recumbent patients The air enters the heart (churning sound) and obstructs the right ventricular outflow Further air passage to the lungs obstructs pulmonary capillaries Further passage of air across the pulmonary capillary bed into the left ventricle can result in air embolization to the arteries of: - The brain, which causes acute neurologic. - The heart, which causes cardiac dysfunction
- 29. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com Manifestations of air embolism Foam is observed in the venous bloodline position-dependent Seated patients: Air travels to the cerebral venous system and obstructs it Recumbent patients The air enters the heart (churning sound) and obstructs the right ventricular outflow Further air passage to the lungs obstructs pulmonary capillaries Further passage of air across the pulmonary capillary bed into the left ventricle can result in air embolization to the arteries of: - The brain, which causes acute neurologic. - The heart, which causes cardiac dysfunction
- 30. Talk Outline: Chapter 8 Complications During Hemodialysis: Part 2 • Muscle cramps: o Timing o Pathogenesis o Management o Prevention • Hemolysis: o Causes o Manifestations o Management • Air embolism: o Sites of air entry o Manifestations o Management NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com • Disequilibrium syndrome: o Manifestations o Acute and chronic dialysis o Pathogenesis o Diagnosis o Management o Prevention • Seizures: o Causes o Management
- 31. Management of air embolism • Stop the blood pump. • Clamp the venous bloodline. • Don’t return the blood in the extracorporeal circuit to the patient. • Quickly position the patient in a left-sided recumbent position, with the head and chest bent downward. • Administer 100% oxygen by mask or endotracheal tube. • It may be necessary to evacuate air from the ventricle or atrium. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com
- 32. Talk Outline: Chapter 8 Complications During Hemodialysis: Part 2 • Muscle cramps: o Timing o Pathogenesis o Management o Prevention • Hemolysis: o Causes o Manifestations o Management • Air embolism: o Sites of air entry o Manifestations o Management NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com • Disequilibrium syndrome: o Manifestations o Acute and chronic dialysis o Pathogenesis o Diagnosis o Management o Prevention • Seizures: o Causes o Management
- 33. Manifestations of disequilibrium syndrome • Milder forms of the syndrome and early manifestations of the severe form: nausea, vomiting, restlessness, and headache. • More severe manifestations include seizures, obtundation, and coma. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com
- 34. Talk Outline: Chapter 8 Complications During Hemodialysis: Part 2 • Muscle cramps: o Timing o Pathogenesis o Management o Prevention • Hemolysis: o Causes o Manifestations o Management • Air embolism: o Sites of air entry o Manifestations o Management NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com • Disequilibrium syndrome: o Manifestations o Acute and chronic dialysis o Pathogenesis o Diagnosis o Management o Prevention • Seizures: o Causes o Management
- 35. Disequilibrium syndrome in acute and chronic dialysis • Disequilibrium syndrome occurs more in acutely uremic patients who are dialyzed aggressively. • Patients undergoing chronic dialysis may still develop milder manifestations of the disease. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com
- 36. Talk Outline: Chapter 8 Complications During Hemodialysis: Part 2 • Muscle cramps: o Timing o Pathogenesis o Management o Prevention • Hemolysis: o Causes o Manifestations o Management • Air embolism: o Sites of air entry o Manifestations o Management NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com • Disequilibrium syndrome: o Manifestations o Acute and chronic dialysis o Pathogenesis o Diagnosis o Management o Prevention • Seizures: o Causes o Management
- 37. Pathogenesis of disequilibrium syndrome 1. Rapid lowering of plasma osmolarity 2. Change is cerebrospinal fluid (CSF) pH: Paradoxical CSF acidosis 3. Idiogenic osmoles effect NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com
- 38. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com (3) Shift of water to brain intracellular space (1) Urea diffusion (2) Urea serum level decreases and plasma becomes hypotonic with respect to the brain cells Intravascular space
- 39. Pathogenesis of disequilibrium syndrome 1. Rapid lowering of plasma osmolarity 2. Change is cerebrospinal fluid (CSF) pH: Paradoxical CSF acidosis 3. Idiogenic osmoles effect NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com
- 40. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com (1) Rapid bicarbonate diffusion (2a) HCO3− + H+ → H2CO3 → CO2 + H2O Intravascular space CO2 + H2O → H2CO3 → HCO3− + H+ (4) Protein + Na+ (5) Protein + H+ (6) Na+ (2b) HCO3− (3) (7) Na+ osmose water into brain cells
- 41. Pathogenesis of disequilibrium syndrome 1. Rapid lowering of plasma osmolarity 2. Change is cerebrospinal fluid (CSF) pH: Paradoxical CSF acidosis 3. Idiogenic osmoles effect NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com
- 42. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com Intravascular space H+ (5) Protein + Na+ (6) Protein + H+ (7) Na+ (8) Na+ osmose water into brain cells Idiogenic osmoles (3) Osmoles osmose water into brain cells (4) (1) Urea diffusion (2) Urea serum level decreases and plasma becomes hypotonic with respect to idiogenic osmoles in the brain cells
- 43. Talk Outline: Chapter 8 Complications During Hemodialysis: Part 2 • Muscle cramps: o Timing o Pathogenesis o Management o Prevention • Hemolysis: o Causes o Manifestations o Management • Air embolism: o Sites of air entry o Manifestations o Management NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com • Disequilibrium syndrome: o Manifestations o Acute and chronic dialysis o Pathogenesis o Diagnosis o Management o Prevention • Seizures: o Causes o Management
- 44. Diagnosis of disequilibrium syndrome • Dialysis disequilibrium syndrome lacks a definitive diagnostic test. • Its diagnosis depends on clinical presentation. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com
- 45. Talk Outline: Chapter 8 Complications During Hemodialysis: Part 2 • Muscle cramps: o Timing o Pathogenesis o Management o Prevention • Hemolysis: o Causes o Manifestations o Management • Air embolism: o Sites of air entry o Manifestations o Management NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com • Disequilibrium syndrome: o Manifestations o Acute and chronic dialysis o Pathogenesis o Diagnosis o Management o Prevention • Seizures: o Causes o Management
- 46. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com Mild disequilibrium Severe disequilibrium (seizures and coma) • Symptomatic treatment. • The blood and dialysate flow rates should be reduced. • The ultrafiltration rate should be reduced too. • Glucose or hypertonic sodium chloride solutions may be given. • Early termination of the dialysis session should be considered, especially in acutely uremic patients. • Dialysis should be stopped. • First aid measures for seizure management must be taken. • Intravenous mannitol, hypertonic saline, or glucose may be of benefit. • If seizures and coma are due to disequilibrium syndrome, the patient should improve within 24 hours. Exclude other causes of seizures: Other causes of seizures in dialysis patients rather than disequilibrium syndrome should be excluded as early as possible, especially if the patient does not improve within a 24- hour period.
- 47. Talk Outline: Chapter 8 Complications During Hemodialysis: Part 2 • Muscle cramps: o Timing o Pathogenesis o Management o Prevention • Hemolysis: o Causes o Manifestations o Management • Air embolism: o Sites of air entry o Manifestations o Management NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com • Disequilibrium syndrome: o Manifestations o Acute and chronic dialysis o Pathogenesis o Diagnosis o Management o Prevention • Seizures: o Causes o Management
- 48. In case of acute dialysis for a patient with acute uremia • Avoid prescribing aggressive dialysis sessions • Urea reduction ratio (URR) target 30-40% • Severely acidotic patients: initial dialysis treatments should be with reduced dialysate bicarbonate • Avoid using low dialysate sodium (>2–3 mmol/L less than the plasma sodium level) • Hypernatremic patients: uremia and hypernatremia correction should not be attempted simultaneously. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com
- 49. In case of chronic dialysis • Using sodium dialysate of at least 140 mmol/L can minimize the incidence of disequilibrium syndrome. • Sodium modeling: Although it decreases the occurrence of disequilibrium syndrome, it has many drawbacks. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com
- 50. Talk Outline: Chapter 8 Complications During Hemodialysis: Part 2 • Muscle cramps: o Timing o Pathogenesis o Management o Prevention • Hemolysis: o Causes o Manifestations o Management • Air embolism: o Sites of air entry o Manifestations o Management NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com • Disequilibrium syndrome: o Manifestations o Acute and chronic dialysis o Pathogenesis o Diagnosis o Management o Prevention • Seizures: o Causes o Management
- 51. Causes of seizures during hemodialysis session • Disequilibrium syndrome. • Severe hypotension. • Hypertensive encephalopathy. • Metabolic causes: hypoglycemia, hypocalcemia, hypernatremia, or hyponatremia. • Intracranial hemorrhage. • Air embolism. • Aluminum encephalopathy. • Drugs that lower the seizure threshold. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com
- 52. Talk Outline: Chapter 8 Complications During Hemodialysis: Part 2 • Muscle cramps: o Timing o Pathogenesis o Management o Prevention • Hemolysis: o Causes o Manifestations o Management • Air embolism: o Sites of air entry o Manifestations o Management NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com • Disequilibrium syndrome: o Manifestations o Acute and chronic dialysis o Pathogenesis o Diagnosis o Management o Prevention • Seizures: o Causes o Management
- 53. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com Immediate management: - Terminate the dialysis session. - Secure vascular access. - Ensure the patient is not in danger of injury and is in a secure setting. - Administer intravenous fluids and oxygen as required. - The majority of seizures resolve spontaneously within five minutes. If a patient continues to seize: - Achieve airway protection and patient stabilization. - Administering intravenous benzodiazepines is the treatment of choice to terminate the seizures. - Refer the patient for neurology consultation. Immediate urgent management of seizures during hemodialysis session
- 54. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024 You can get this book free from www.NephroTube.com Immediate management: - Terminate the dialysis session. - Secure vascular access. - Ensure the patient is not in danger of injury and is in a secure setting. - Administer intravenous fluids and oxygen as required. - The majority of seizures resolve spontaneously within five minutes. If a patient continues to seize: - Achieve airway protection and patient stabilization. - Administering intravenous benzodiazepines is the treatment of choice to terminate the seizures. - Refer the patient for neurology consultation. Immediate urgent management of seizures during hemodialysis session After the seizure has been remitted, try to find the cause
- 55. Thank You