Nephrology Hypertension

Hemodialysis: Acute Complications - Intradialytic hemolysis

Does this patient have intrdialytic hemolysis?

Grossly translucent hemolyzed blood in the extracorporeal blood line

Symptoms vary depending on causes and severity

Causes

Mechanical

High blood flow rate, single-needle dialysis, small-gauge cannula, kinked blood line, highly negative arterial pressure, offset blood pump

Dialysate contamination

Chloramine: dyspnea, cyanosis (methemoglobinemia, not improved by oxygen therapy), malaise, headache, vomiting, palpitation

Nitrate: abdominal pain, diarrhea, cyanosis (methemoglobinemia, not improved by oxygen therapy)

Copper: skin flushing, abdominal pain, diarrhea, cyanosis (methemoglobinemia, not improved by oxygen therapy)

Fluoride: malaise, abdominal pain, chest pain, bradycardia, cardiac instability, hypocalcemia (tetany, seizure,coma), hypomagnesemia

Dialysate error

Hypotonic dialysate (hyponatremia)

Overheated dialysate

Failure to properly rinse reprocessed dialyzer

Hypochlorite

Formaldehyde

Hydrogen peroxide

Severity (mild to severe)

Nausea, vomiting, headache, abdominal pain, hypotension, cyanosis, confusion, seizure, sudden cardiac arrest (hyperkalemia)

What tests to perform?

Diagnosis by clinical judgment (grossly translucent hemolyzed blood)

Laboratory tests should be ordered to confirm diagnosis

Reticulocyte count

Haptoglobin

Lactate dehydrogenase

Blood smear

Coombs test

Serum potassium (exclude hyperkalemia)

Methemoglobin measurement

51Cr-labeled red blood cell survival (if recurrent)

Bone marrow examination (if recurrent)

Dialysate examination (chloramine, other contaminants)

How should patients with intradialytic hemolysis be managed?

Acute management

Stop dialysis

Do not return blood to patient

Assess severity of hemolysis

Provide symptomatic support (treat hyperkalemia)

Provide circulatory support if hypotension develops

Identify causes

Prevention

Dialysis prescription

Monitor arterial pressure in extracorporeal circuit (not to exceed -160 mmHg)

Avoid high blood flow rate if using small-gauge needle

Monitor rinsing of disinfectants/germicides from reprocessed dialyzers

Monitor dialysate conductivity

Monitor dialysate temperature

Maintain dialysate quality control

What happens to patients with intradialytic hemolysis??

Need for hospitalization

High mortality risk (if severe)

How to utilize team care?

1. Specialty consultations: Code team (if patient develops cardiac arrest); hematology (if recurrent episode)

2. Nursing - Close monitoring of high-risk patients.

Are there clinical practice guidelines to inform decision making?

Applications

2010 Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science. (Published by American Heart Association)

Other considerations

ICD-10-CM diagnosis code I97.3: Postprocedural hypertension

What is the evidence?

Sayre, MR, Koster, RW, Botha, M, Cave, DM, Cudnik, MT, Handley, AJ, Hatanaka, T, Hazinski, MF, Jacobs, I, Monsieurs, K, Morley, PT, Nolan, JP, Travers, AH. "Adult Basic Life Support Chapter Collaborators. Part 5: Adult basic life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations". Circulation. vol. 122. 2010. pp. S298-324.

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