NURSING SERVICES POLICY AND PROCEDURE

Title: Management of Complications during

Code: NSP/HM # 039.08
Hemodialysis
Effective Date: August 20, 2018 Replaces: NSP/HM # 039.08 August 2015
Applies To: Hemodialysis Unit Nature: Multidisciplinary

I. DEFINITIONS:

A. Hypotension - Any blood pressure that is below the normal expected for an
individual in a given environment BP of < 90/60.
Common causes of Hypotension to patient’s on Hemodialysis are as follows:
1. Excess decrease in blood volume.
• Too low dry body weight
• High UF and TMP
• Low conductivity drugs therapy
• Anti-hypertensive drugs therapy
• Acetate dialysis solution (not in use in Dialysis unit AGH-Al Ahsa)
• Hot dialysis fluid
• Eating food during dialysis

2. Other causes
• Due to cardiac failure and inability to increase cardiac rate.
• Due to hemorrhage.

B. Air Embolism - is the entry of air bubbles into the central venous system
(rarely arterial system) by direct or indirect access into the blood stream through
a central or peripheral route. The symptoms reflect the end organ affected.
C. Blood Leak - the principal sponsors for a true blood leak are defective
dialyser or rupture of dialyser membranes, excessive trans-membrane pressure,
and rarely hemolysis. A blood leak is classified as minor when microscopic
monitor detects blood, and confirmed by labstix if available. No visual blood is
seen.
A false blood leak results when the detector incorrectly identifies a blood leak.
This can result from debris in the area of the detector, or in the dialysate fluid,
or excessive air in the waste dialysate line. The management is to ensure that
there is no blood present, and to call for technical assistance. If it cannot be
cleared immediately, the machine must be withdrawn from service for
maintenance.
Title: Management of Complications during Hemodialysis
Code: Edition No: Date of Review: Date of Approval: Date of Next Review: Page No:
NSP/HM # 039.08 06 August 2018 August 2018 August 2021 1 of 6
 II. PURPOSES:

1. To ensure that a safe and hazard free dialysis treatment is delivered.

2. To identify any issues that requires further action and follows up to ensure that
the patient receives safe individualized therapy and thus maintain optimum
quality of care.
3. To prevent blood leak during Hemodialysis through attention to following
manufacturers instruction for the testing of Hemodialysis machines before
commencing Hemodialysis. To prevent complications related to blood leak e.g.
Hemodialysis, septicemia.

III. POLICY STATEMENTS:

1. The Hemodialysis Nurses must ensure all line are secured, ensure all alarm
systems are fully functioning, and continual observation of all dialysis circuit.
2. Hemodialysis nurses must be aware of the complications of hazards that may
Occur due to blood leak during dialysis and are able to differentiate a true leak
from a false one.
3. A functional test must be completed on all machines prior to commencing
Hemodialysis to ensure patient safety and well being.
4. All the circuit must be checked to ensure connections are secure (repeated if
there are changes made to the circuit during Hemodialysis.
5. A spare machine must be kept ready at all times for the use in case of
emergencies e.g. faulty blood leak down detector.
6. Ensure that the patient is aware of the hazard and reassure him/her to allay fears
and gain his/her confidence and cooperation.

IV. PROCEDURES AND RESPONSIBILITIES:

Item Responsible
PROCEDURE SEQUENCE
No Person/s
1. MANAGEMENT OF HYPOTENSION, NAUSEA & VOMITING &
CRAMPS: Nephrologists
• Keep the patient in Trendelenburg position except if nausea and Hemodialysis
vomiting is present Nurse
• Activate Minimum ultra filtration (UF) icon
• Check blood pressure and pulse.
• Administer 0.9% normal saline IV 200 ml as bolus.
• As an alternative to saline, Dextrose 50%, Mannitol, or albumin
solutions can be used.
• Do not reduce the blood flow rate
• Administer oxygen 2-4 L via nasal cannula

Title: Management of Complications during Hemodialysis

Code: Edition No: Date of Review: Date of Approval: Date of Next Review: Page No:
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Item Responsible
PROCEDURE SEQUENCE
No Person/s
Cont • If the patient vomits, turn him/her to the side and elevate slightly the
item patient head part of the bed. Administer antiemetic as per doctor’s
no 1 order.
• Apply forced stretching of the muscle involved (e.g., ankle flexion for
calf cramping). Communicate with the patient and reassure him.
• Once the hypotension is corrected and the patient is stable deactivate
the minimum UF icon.
• Educate the patient about his/her condition and prevention of
hypotension e.g. avoid taking anti hypertensive drugs on the day of
dialysis or advise to avoid taking his/ her meal during the treatment.
CHEST PAIN:
• Administer oxygen 2-4 L via nasal cannula
• Activate Minimum ultra filtration (UF)
• Assess and treat volume depletion
2. • Inform the doctor
• Perform 12 lead ECG , check cardiac markers and administer drugs as
per doctors order Nephrologists
• If blood results are positive terminate the HD treatment and transfer Hemodialysis
the patient to CCU for further management and investigations Nurse
according to the doctors order.
FEVER & CHILLS:
• If temp is 38 degree centigrade and above obtain the blood samples for
stat CBC and peripheral blood culture for patient with AVF / AVG.
3. • For patient with permicath obtain additional central blood culture from
each catheter lumen and swab from exit site along with the Peripheral
blood and CBC.
• Give antipyretics and antibiotics as for the doctor’s order.
DIALYZER REACTION:
• Stop the dialysis immediately, clamp the blood lines and discard the
4. dialyzer and the blood lines and do not return the contaminated blood
to the patient.
• According to the severity of the reaction treat the patient according to
the doctors order

Title: Management of Complications during Hemodialysis

Code: Edition No: Date of Review: Date of Approval: Date of Next Review: Page No:
NSP/HM # 039.08 06 August 2018 August 2018 August 2021 3 of 6
Item Responsible
PROCEDURE SEQUENCE
No Person/s
5. MANAGEMENT OF BLOOD LEAKING DURING HEMODIALYSIS:
A. MINOR BLOOD LEAK:
• When blood leak alarm occurs, check for faulty blood leak detector and
if so call for technician assistance.
• Explain the procedure to the patient. Allow him/her to ask questions.
• Check the Dialysate lines for discoloration.
• Collect 10 ml of Dialysate in a test tube and visually check for blood.
• Return the blood to the patient if a minor blood leak is verified.
• Return the dialysis line in the lock. The alarm should stop when the
line are clear (no blood).
• Put the machine on rinse program
• Re start the procedure as per the doctor’s orders.
B. MAJOR BLOOD LEAK
• If blood leak is massive and the blood cannot be returned, send a blood
Nephrologists
sample to check for hemolysis and inform the Nephrologists and
Hemodialysis
remember that when a blood leak occurs, there is a risk of blood
Nurse
contamination from unsterile Dialysate entering the compartment of the
Bio – med tech
dialyzer.
• Put the machine on rinse program
• Take and record vital signs.
• Re-assess the patient.
6. DISEQUILIBRIUM SYNDROME
• Reduce the blood flow rate
• Administer hypertonic sodium chloride, dextrose50% or Mannitol 20%
as per doctor’s order
• Treat symptomatic nausea & Vomiting
• Stop the dialysis if seizure or coma occurs
• Treat the seizure with anticonvulsive medication as per doctor’s order.
7. ARRHYTHMIAS
• Change to suitable Dialysate potassium concentrate
• Inform the doctor immediately
• Evaluate the presence of hypotension
• Monitor the heart rhythm by ECG
• Administer antiarrhythmic drugs as per doctor’s order.

Title: Management of Complications during Hemodialysis

Code: Edition No: Date of Review: Date of Approval: Date of Next Review: Page No:
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 Item Responsible
PROCEDURE SEQUENCE
No Person/s
8. HEMOLYSIS
• Immediately clamp the venous blood lines. Do not return the
hemolyzed blood.
• Discontinue the dialysis procedure, but leave one needle in place
• Monitor vital signs, and observe for dysrrhythmias, and shortness of
breath
• Administer oxygen 2-4 L via nasal cannula
• Immediately check the potassium and Hemoglobin levels.
• If needed, blood transfusion to be started as per doctors order
Nephrologists
• Admit the patient for observation for 24 hours as per doctors order Hemodialysis
9. AIR EMBOLISM Nurse
• Stop the infusion of air immediately
• Place the patient on His / Her left side in the Trendelenburg position
(Head down and Legs up)
a. Trap the air in the apex of the right ventricle
b. Prevent air from entering the pulmonary vein
c. Prevent air lock block in the pulmonary vein
d. Prevent air bubble movement into other organs.
• Administer oxygen may need intubation.
• If needed admit the patient for observation for 24 hours as per doctors
order
• Document all the incident, the action taken, outcome of the evaluation
in the patient medical records.

V. REFERENCES:

1. Clinical guidelines for Hemodialysis centers in the kingdom of Saudi Arabia first
edition 2013.
2. NSP/HM # 039.08, Management of Complications during Hemodialysis,
4thEdition, August 2015 (Deleted)

VI. DISTRIBUTIONS:

1. Nephrology Department
2. Hemodialysis Unit

Title: Management of Complications during Hemodialysis

Code: Edition No: Date of Review: Date of Approval: Date of Next Review: Page No:
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