Having them bring a small thermos of strong coffee to drink during the last hour of dialysis can help. Caffeine blocks adenosine, which can cause vasodilatation. Likewise, support and encouragement from all of the dialysis team should be evident at each session. Probative questions can be asked to identify causes for variances in expected outcomes. UF profiling and dialysate temperature, if ordered, should be mentioned as they are programmed into the dialysis machine so that the patient is aware they are getting the individualized care that was discussed and ordered.
The dialysis staff should have training on assessment and evaluation of hypotension and options that they can use to decrease the risks of IDH. Automatically stopping UF or administering intravenous fluids can be counter-productive and should be avoided unless absolutely necessary.
If large weight gains continue to be an issue, encouraging a weekly food diary can be helpful so the dietitian can identify high-sodium foods the patient is eating that could be either decreased or eliminated from their diet.
Lower sodium alternatives can then be suggested. If transportation, inability to get prescriptions filled, changes in social support, openness for counseling or drug rehabilitation or other psychosocial problems are identified, the social worker can explore options with the patient and involve the medical team when necessary. When the medical team rounds, the same degree of concern about interdialytic weight gains, blood pressure, and other outcomes should be evident. Interventions that are either working well or need modification can be addressed chair-side with input from all parties.
Working together in a consistent, positive, focused manner promotes the caring environment needed to support change in these complex patients. The improved communication and education obtained through these interactions can also improve both patient and staff satisfaction.
Patients who continue to have frequent hypotensive episodes on dialysis despite maximal intervention may need longer treatment times to either decrease the ultrafiltration rate or allow time for isolated ultrafiltration at the beginning of dialysis. Also, extra dialysis sessions, usually up to two per month, could be done for volume overload.
For patients with heart failure or who are unable or unwilling to limit their fluid and salt intake, switching to a home dialysis modality where daily or almost daily treatments are done may be helpful. Patients identified as having resistant IDH should be evaluated further for causation. This project identified some simple measures that were found to be effective in improving fluid management in hemodialysis patients with frequent IDH.
Individualization of the hemodialysis prescription is needed but is often difficult for staff to consistently deliver. Staff compliance is a key factor, especially in changing dialysate temperature manually. Lowering the temperature on all patients, so individualization of dialysate temperature is not needed, may be a better approach. The major hindrance seen with this intervention was patient intolerance to the cooler dialysate, with resulting chills. This could be a major problem in winter months.
Medical devices that can monitor intradialytic blood volume so that ultrafiltration can be better managed could also be an effective strategy, but these are not available in our unit.
Preload dependence or a change in cardiac output in response to preload alteration is normal, whereas preload independence is pathologic, indicating that the heart is operating at the flat part of its function curve.
Hence, preload dependence does not indicate a need for more volume [ 5 ]. Preload is the muscle tension before contraction, best assessed as end-diastolic pressure [ 6 ]. The apparent preload independence could be due to three mechanisms: lack of true increase in preload by PLR, ongoing vasodilation, or cardiac function limitation.
Let us consider these mechanisms:. PLR is assumed to shift a volume of up to ml in the absence of overt hypovolemia [ 7 ]. Volume overload in acute kidney injury is very frequent [ 8 ]. Lack of volume shift in response to PLR therefore seems rather unlikely. PLR during ongoing vasodilatation may fail to increase preload. As in the study of Bitker et al. Finally, true cardiac function limitation with fluid overload [ 8 ] could have been present: the heart works on the flat part of its function curve, and the circulation is not limited by venous return.
In addition to fluid overload, acute kidney injury may induce myocardial dysfunction via various cytokines [ 9 ]. Myocardial stunning during hemodialysis with transient wall motion abnormalities was recently recognized in chronic kidney disease [ 10 ].
Hence, the pathophysiology of hypotension appears more complex. Notably, preload dependence before hemodialysis was only present in five instances. Volume overload [ 8 ] and decreased cardiac function [ 9 , 10 ] must have contributed to this.
Preload assessment before and during hemodialysis and individual responses would have allowed clarification of the hemodynamic mechanisms involved. We congratulate Bitker et al. Hypervolemia and impaired cardiac function were almost certainly highly prevalent [ 8 — 10 ]. Because hemodialysis can severely impair tissue perfusion without overt clinical signs [ 11 ] and fluid dynamics during ultrafiltration might be considerably different between ICU patients and chronic hemodialysis [ 12 , 13 ], individual hemodynamic assessment could be more comprehensive than PLR alone.
The assessment should include the clinical context, the hemodynamic status pre dialysis, and an independent judgment if a preload maneuver shows the expected effects. Prevalence and risk factors of hypotension associated with preload-dependence during intermittent hemodialysis in critically ill patients. Crit Care. Article Google Scholar. Results: Baseline levels did not show any significant differences. During dialysis systolic arterial pressure declined gradually in the H group from 30 minutes before the onset of hypotension.
There was a similar decrease of RBV and increase of heart rate in both groups with a large interindividual variation. Please RSVP below to receive information on how to join. Yes No. By Dori Schatell, Medical Education Institute One of the main jobs of dialysis is to remove excess water from your body. Dialysis and Water Removal Dialysis can only remove water that is in your blood. The Risks of Fluid Gain In the short term, if too much water is removed from your blood in a hour treatment, your body will become dehydrated dried out.
They program the machine to use more sodium salt in the dialysate at the start of a treatment when you have more fluid, and less at the end when little is left. The sodium helps pull fluid from the swollen tissues into the blood, so it can be dialyzed off. The sodium level is dropped at the end of the treatment to help return your blood sodium level back to normal.
Sodium modeling can reduce your chances of having low blood pressure 2 3 4 but there may be a cost. It may make you thirsty after treatment, so you gain more fluid and your blood pressure goes even higher. With ultrafiltration modeling UF profiling , the machine can be set to remove more fluid at the start of a treatment and less at the end.
This can be helpful if you often have a low blood pressure at the end of a treatment. But, if you take less fluid off, you will still have extra fluid in your body. During a treatment, if your blood pressure drops, the nurse or tech may give you saline salt water through your blood tubing. Normal saline has the same amount of salt as your blood.
It replaces blood volume, which improves your blood pressure. In some centers, hypertonic saline may be given. Hypertonic saline has more salt than your blood. It can help pull fluid from your tissues into your blood, which raises your blood pressure. If hypertonic saline were given near the end of the treatment, however, it could make you more thirsty.
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