INTRADIALYTIC HYPOTENSION

Arwedi Arwanto
 Intradialytic Hypotension

Hypotension is the most common problem

encountered during a dialysis session.
Sepsis
Hypoxemia
Membrane reactions
Acces recirculation
Air embolus
Haemolysis
Dialysis disequilibrium syndrome
 How to manage hypotension
during haemodialysis :
Immediate Management
• Slow or stop UF and blood flow
• Place the patient in the Trendelenberg
position
• Give a 200-300 mL bolus dose of IV saline
• Hypertonic glucose
 How to manage hypotension
during haemodialysis :
Evaluate for underlying cause
• Is hypotension a manifestation of shock due
to:
myocardial infaction, arrhythmia or pericardial
tamponade?
Pulmonary embolism?
Sepsis ?
Haemorrhage?
 How to manage hypotension
during haemodialysis :
Evaluate for underlying cause
• Is the rate or extent of fluid removal during
dialysis excessive?
is there excessive interdialytic weight gain (i.e.
more than 3 kg between dialysis treatments)?
Is the dry weight set correctly)?
Is the UF rate incorrect or erratic (this problem has
been largely overcome with the use of UF
controllers)?
Is the dialysate sodium set to low
 How to manage hypotension
during haemodialysis :
Evaluate for underlying cause
• Is there impaired haemodynamic compensation?
is there an underlying cardiac disease (impaired
ability to compensate for intravascular fluid
shifts)?
Is the patient taking antihypertensive medications
or beta-blockers (often withheld on the day of
dialysis)?
Has the patient had a meal prior to during
dialysis(this promote splanchnic blood flow and
may precipitate hypotension in patients with
cardiovascular disease)?
Does the patient have autonomic neuropathy?
 How to manage hypotension
during haemodialysis :
Prevention of hypotension during dialysis
• Reduce interdialytic weight gain (salt and
fluid restrict the patient)
• Reset the dry weight
• Treat anaemia Withhold antihypertensive
medications on dialysis days
• Avoid meals during or just prior to dialysis
• Consider adjustment of the dialysate sodium
or reduction of the dialysate temperature
 How to manage hypotension
during haemodialysis :
Prevention of hypotension during dialysis
• Use of UF controller
• Consider using a period of isolated UF (this causes
less haemodynamic instability)
• Consider using caffeine. Adenosine release by
subclinical visceral organ ischaemia during episodes
of hypotension may lead to vasodilatation and
further hypotension, resulting in a vicious cycle.
Caffeine, an adenosine agonist, may ameliorate this
effect
• Consider the use of midodrine, an alpha-adrenergic
agonist, for patients in whom hypotension is
refractory to the above measures