HEMODIALISA

Tri Antika Rizki Kusuma Putri

Komplikasi INTRADIALYTIC HYPOTENSION
■ Hipotensi inradialisis dapat menyebabkan
Hemodialisis distressing symptoms dan poor long-term
outcomes.
Komplikasi yag paling sering ■ Pasien yang menunjukan adanya hipotensi
muncul selama hemodialysis intradialisis juga memiliki risiko mortalitas
yang meningkat, dan gangguan miokardial.
diantaranya:
■ Hipotensi intradialisis  Sistolik kurang
a. Hipotensi dari 90mmHg, penurunan sistolik 20-30
mmHg
b. Cramp
c. Mual muntah ■ Insidiensi hipotensi intradialisis terbanyak
pada pasien dengan TD rendah pada saat
d. Nyeri kepala predialisis.
e. Nyeri dada
■ TD predialisis yang rendah menandakan
f. Back pain adanya gangguan jantung maupun kondisi
g. Gatal-gatal thrombosis pada akses dialysis.
 INTRADIALYTIC HYPOTENSION
extending the weekly
time on dialysis
•decrease the required
ultrafiltration rate (same
weight loss, longer time)
•decrease the frequency
of IDH
•The KDOQI 2006
adequacy guidelines: 3
hours (for thrice-weekly reducing the weekly
dialysis) in patients with volume of fluid
little or no residual urine ingestion
output
Hipotensi intradialisis •The European Best
Practice Guidelines: 4
hours of therapy
 INTRADIALYTIC HYPOTENSION
increasing the volume of Avoid large interdialytic Use an appropriate
urine excreted weight gains. dialysis solution sodium
•Urine volume can be •Emphasizing salt restriction is level and blood volume
increased using diuretic far more effective in
therapy decreasing interdialytic
control devices with
weight gain (IDWG) feedback loop
INTRADIALYTIC HYPOTENSION
■ Hypotension related to lack of vasoconstriction  cardiac output is limited by
cardiac filling; a reduction in either peripheral vascular resistance or cardiac filling in
this setting can precipitate hypotension
– Lower dialysis solution temperature; 35.5°C– 36.0°C are better initial choices,
with adjustment made up or down depending on tolerance (chills) and
effectiveness (blood pressure).
– Avoid intradialytic food ingestion in hypotension-prone patients
– Minimize tissue ischemia during dialysis
– Pharmacology therapy; Midodrine, Sertraline, Antihypertensive medication
– Dialysis fluid potassium level
– Aldosterone
– Vasopressin
INTRADIALYTIC HYPOTENSION
■ Hypotension related to cardiac factors
– Diastolic dysfunction
– Heart rate and contractility
– Dialysis solution calcium
INTRADIALYTIC HYPOTENSION
■ Manajemen IDH
– Trendelenburg position (if respiratory status allows this)
– bolus of 0.9% saline (100 mL or more, as necessary)
– The ultrafiltration rate should be reduced to as near zero as possible.
– Saline, glucose, mannitol, or albumin solutions can be used to treat the
hypotensive
– Nasal oxygen administration
 MUSCLE CRAMPS

Komplikasi
■ EtiologyThe pathogenesis of muscle cramps during
dialysis is unknown.

Hemodialisis ■ The four mostimportant predisposing factors are

hypotension, hypovolemia (patient below dry weight),
Komplikasi yag paling sering muncul high ultrafiltration rate (large weight gain), and use of
selama hemodialysis diantaranya: low-sodium dialysis solution.
a. Hipotensi ■ These factors all tend to favor vasoconstriction,
resulting in muscle hypoperfusion, leading to
b. Cramp
secondary impairment of muscle relaxation.
c. Mual muntah
■ Muscle cramps most commonly occur in association
d. Nyeri kepala with hypotension, although cramps often persist after
seemingly adequate blood pressure has been
e. Nyeri dada
restored.
f. Back pain
■ The frequency of cramping increases logarithmically
g. Gatal-gatal with the weight loss requirements; weight losses of
2%, 4%, and 6% have been associated with cramping
frequencies of 2%, 26%, and 49%, respectively.
MUSCLE CRAMPS
■ Manajemen muscle cramps
– respond to treatment with 0.9% saline
– Hypertonic solutions (saline, glucose, mannitol)
– Nifedipine (10 mg) sometimes can reverse cramping.
– Forced stretching of the muscle involved
– Dialysate sodium.
– Dialysate magnesium.
– Biotin.
– Carnitine, oxazepam, and vitamin E. Carnitine supplementation
– Quinine.
Komplikasi
NAUSEA AND VOMITING
■ Etiology Nausea or vomiting occurs in up to 10% of
routine dialysis treatments.

Hemodialisis ■ Nausea or vomiting can also be an early

manifestation of the disequilibrium syndrome
described below. Both type A and type B varieties of
Komplikasi yag paling sering muncul dialyzer reactions can cause nausea and vomiting.
selama hemodialysis diantaranya:
■ Gastroparesis, very common in diabetes but also seen
in nondiabetic patients, is exacerbated by
a. Hipotensi hemodialysis and may play a role in some patients.
b. Cramp ■ Contaminated or incorrectly formulated dialysis
solution (high sodium, calcium) may cause nausea
and vomiting as part of a constellation of symptoms.
c. Mual muntah Dialysis patients appear to develop nausea and
vomiting more readily than other patients (e.g., with
d. Nyeri kepala an upper respiratory infection, narcotic usage,
hypercalcemia)
e. Nyeri dada ■ PreventionAvoidance of hypotension during dialysis
is of prime importance.
f. Back pain
■ Persistent symptoms unrelated to hemodynamics may
benefit from metoclopramide.
g. Gatal-gatal
Komplikasi
HEADACHE
■ Etiology Headache occurs in as many as 70% of
patients during dialysis; its cause is largely unknown.

Hemodialisis ■ It may be a subtle manifestation of the disequilibrium

syndrome
Komplikasi yag paling sering muncul ■ In patients who are coffee drinkers, headache may be
selama hemodialysis diantaranya: a manifestation of caffeine withdrawal as the blood
caffeine concentration is acutely reduced during the
dialysis treatment.
a. Hipotensi
■ Dialysis may precipitate migraine headaches in those
b. Cramp with a history of the disorder.
■ Management Acetaminophen can be given during
c. Mual muntah dialysis.

d. Nyeri kepala ■ Prevention Decreasing dialysis solution sodium may

also be helpful in patients being treated with high
sodium levels; A cup of strong coffee may help
e. Nyeri dada prevent (or treat) caffeine withdrawal symptoms.

f. Back pain ■ Patients suffering from headache during dialysis may

be magnesium deficient (Goksel, 2006).
g. Gatal-gatal
Komplikasi CHEST PAIN AND BACK PAIN
■ Mild chest pain or discomfort (often
Hemodialisis associated with some back pain) occurs in
1%–4% of dialysis treatments.
Komplikasi yag paling sering muncul
selama hemodialysis diantaranya: ■ The cause is unknown.
a. Hipotensi ■ There is no specific management or
prevention strategy, though switching to a
b. Cramp different variety of dialyzer membrane may
c. Mual muntah be of benefit.
d. Nyeri kepala ■ The occurrence of angina during dialysis is
common and must be considered in the
e. Nyeri dada differential diagnosis, along with numerous
f. Back pain other potential causes of chest pain (e.g.,
hemolysis, air embolism, pericarditis).
g. Gatal-gatal
Komplikasi
ITCHING
■ Itching, a common problem in dialysis patients, is sometimes
precipitated or exacerbated by dialysis. Itching appearing only

Hemodialisis
during the treatment, especially if accompanied by other
minor allergic symptoms, may be a manifestation of low-grade
hypersensitivity to dialyzer or blood circuit components.
■ More often than not, however, itching is simply present
Komplikasi yag paling sering muncul chronically, and is noticed in the course of the treatment while
selama hemodialysis diantaranya: the patient is forced to sit still for a prolonged period of time.
Viral (or drug-induced) hepatitis and scabies should not be
overlooked as potential causes of such itching.
a. Hipotensi
■ Chronically, general moisturizing and lubrication of the skin
using emollients is recommended, and this should be the first
b. Cramp line of therapy. One should make sure that dialysis is
adequate, and that a Kt/V of at least 1.2 and possibly higher
is being delivered, though the evidence that higher Kt/V
c. Mual muntah improves pruritus is not strong.

d. Nyeri kepala ■ Pruritus is often found in patients with elevated serum

calcium or phosphorus levels and/or substantially elevated
parathyroid hormone (PTH) level; reductions in phosphorus,
e. Nyeri dada calcium (to the lower end of the normal range), and PTH levels
are indicated.
f. Back pain ■ Standard symptomatic treatment using antihistamines is
useful. Gabapentin (or pregabalin), UVB (ultraviolet light B)
therapy, oral charcoal, or nalfuralfine might be the next line of
g. Gatal-gatal therapy, followed by naltrexone or tacrolimus ointment
DISEQUILIBRIUM SYNDROME
■ The disequilibrium syndrome is a set of systemic and neurologic symptoms often
associated with characteristic electroencephalographic findings that can occur
either during or following dialysis.
■ Early manifestations include nausea, vomiting, restlessness, and headache. More
serious manifestations include seizures, obtundation, and coma
■ Etiologi: Most believe it is related to an acute increase in brain water content. When
the plasma solute level is rapidly lowered during dialysis, the plasma becomes
hypotonic with respect to the brain cells, and water shifts from the plasma into brain
tissue.
DISEQUILIBRIUM SYNDROME
■ Mild disequilibrium
– Symptoms of nausea, vomiting, restlessness, and headache are nonspecific;
when they occur, it is difficult to be certain that they are due to disequilibrium.
Treatment is symptomatic.
– If mild symptoms of disequilibrium develop in an acutely uremic patient during
dialysis, the blood flow rate should be reduced to decrease the efficiency of
solute removal and pH change, and consideration should be given to
terminating the dialysis session earlier than planned.
– Hypertonic sodium chloride or glucose solutions can be administered as for
treatment of muscle cramps.
DISEQUILIBRIUM SYNDROME
■ Severe disequilibrium
– If seizures, obtundation, or coma occur in the course of a dialysis session,
dialysis should be stopped. The differential diagnosis of severe disequilibrium
syndrome should be considered
– The management of coma is supportive. The airway should be controlled and
the patient ventilated if necessary. Intravenous mannitol may be of benefit. If
coma is due to disequilibrium, then the patient should improve within 24 hours.
Patient Safety
The venous air trap and detector are very
important for patient safety.
The chamber traps any air that may have
entered the blood line before the blood is
returned to the patient.
Usually a level/air detector is placed
around the top of the drip chamber; any
increase in air (resulting in the drop of
blood level) triggers an alarm.
Careful procedures and documentation of the
functioning of each part of the water supply
system must be done.
Patient safety and precautions:
■ Appropriate patient selection, training, and
ongoing supervision are of utmost
importance to ensure patient safety at
home.
■ The dialysis machine screen should be
easily visible at all times, from whichever
position the patient dialyzes, and the
controls should be easily accessible.
PATIENT SAFETY
■ Some additional precautions include the following:
– Alarms and communication
– Proper cannulation technique
– Prevention of morbidity when lines disconnect
– Monitoring
PENGATURAN, PERSIAPAN
ALAT
PERSIAPAN
ADMINISTRASI,
PEMBUANGAN LIMBAH
ILUSTRASI HD Sederhana
HD
(Hemodialisis)
DARAH
DARAH
HEMO High-flux 250 ml/menit
“DARAH”
DIALISER

HEMODIALISIS
500ml
/menit
DIALISIS
DIALISAT DIALISAT
“PROSES”
FRESH SPENT
(fasilitas pilihan resirkulasi)

PROSES PEMISAHAN SOLUT DAN SOLVENT Keluar

DARI DARAH MELALUI MEMBRAN
SEMIPERMEABEL
Membrane Semi permeable
 Membrane semi permeable adalah suatu selaput atau lapisan yang sangat
tipis dan mempunyai lubang (pori) sub mikroskopis. Dimana partikel
dengan BM kecil & sedang (small dan middle molekuler) dapat melewati
pori membrane, sedangkan partikel dengan BM besar (large molekuler)
tidak dapat melalui pori membrane tersebut.

 Dializer merupakan suatu tabung yang terdiri dari 2 ruangan (2

kompartemen) yang dipisahkan oleh selaput semi permeable. Darah
mengalir di 1 sisi membrane dan dialisat pada membrane lainya.

 Di dalam dializer ini terjadi proses difusi, osmosis, dan ultrafiltrasi.

 Jenis Dializer
■ Dializer atau ginjal buatan 2 tipe :
1. Flat plate dialyzer
2. Hollow fiber dialyzer
■ Hollow fiber dialyzer 10.000 – 15.000 serat dalam satu berkas. Satu serat
diameter 200 – 300 mikron, tebal dinding 10 – 40 mikron.
■ Darah mengalir di dalam serat , sedang dialisat di luarnya.
 •Eritrosit •Na+
•Leukosit
•Trombosit •K+
•Hemoglobin

Cairan Dialisis
•Na+ •Ca++

(Dialisat)
•K+
Darah

•Ca++ •Mg++
•Mg++
•HCO3- •HCO3-
•Ureum
•Kreatinin •CH3COO-
•CH3COO-
•dll •dll
Dialiser

DIALISAT

BLOOD
Enday Sukandar - Nefrologi Klinik 2006
 Consumable :
• Dialisat (powder/cair)
• Dialiser berbagai
ukuran
• Bloodlines
• Arterio – Venous
fistula needle (AVF)
 Obat - obat dan alat
kesehatan
Berbagai sifat dializer :
■ Luas permukaan dializer
■ Ukuran besar pori atau permeabilitas ketipisanya
■ Koefisien ultrafiltrasi
■ Volume dializer
■ Kebocoran darah tidak boleh terjadi
■ Dapat di re-use tanpa merubah kemampuan klirens dan
ultrafiltrasinya.
■ Harga
Preskripsi Hemodialisis
Sebelum pasien dilakukan HD, sebelumnya harus direncanakan
dahulu hal-hal sebagai berikut:
– Lama & frekuensi dialysis
– Tipe dializer
– Kecepatan aliran darah
– Dosis antikoagulan / heparin
– Banyaknya UF & UFR
– Vaskulerisasi yang dipakai.
Konsep Pelayanan HD
Implementasi (prosedur HD) :
– Teknik streril
– Hand Hygiene ( 5 moment)
– Gunakan APD yang standar ( Gogle,
apron, masker, sarung tangan)
– Teknik Punksi dan kanulasi diperhatikan (
memberikan rasa aman dan nyaman bagi
pasien)
– Pemberian antikoagulansia
– Dokumentasi
Persiapan Administrasi
■ Pemeriksaan laboratorium
■ Persiapan transfuse
■ Surat izin tindakan
■ DNR*
Pembuangan Limbah
■ Limbah rumah sakit mengandung bermacam-macam mikroorganisme, bahan-
bahan organik dan anorganik.
■ Beberapa contoh fasilitas atau Unit Pengelolaan Limbah (UPL) di rumah sakit antara
lain sebagai berikut :
– Kolam Stabilisasi Air Limbah (Waste Stabilization Pond System)
– Kolam oksidasi air limbah (Waste Oxidation Ditch Treatment System)
– Anaerobic Filter Treatment System.