2. How to prevention and Management of Intradialytic Hypotension_ Nurse aspect

HowLOGO to Prevent and Management of Intradialytic Hypotension : Nurse aspect Patcharin Injan King Chulalongkorn Memorial Hospital (KCMH)

Definition of IDH Clin Kid J, 2021, 1-13

Definition of IDH K/DOQI clinical A decrease in SBP ≥20 mmHg or MAP Practice guidelines  ≥10 mmHg associated with to in (2005) symptoms: abdominal discomfort, yawning, sighing; nausea, vomiting, muscle cramps, restlessness, dizziness or fainting ขอ้ แนะนำเวช SBP ลดลงมำกกว่ำ 20 mmHg หรอื MAP ปฏบิ ตั ิกำรฟอกเลอื ด ลดลงมำกกว่ำ 10 mmHg ร่วมมอี ำกำรจำก ด้วยเครอื่ งไตเทยี ม ควำมดันโลหิตต่ำ ทีต่ อ้ งใหก้ ำรรกั ษำเพ่ิมเติม พ.ศ. 2557

Prevalence of IDH J Am Soc Nephrol. 2015 Mar; 26(3): 724–734.

Clinical manifestations of IDH ❖ Asymptomatic ❖Yawning/Sighing ❖ Lightheadedness ❖ Abdominal discomfort ❖ Nausea and vomiting ❖ Restlessness ❖ Muscle cramp ❖ Dizziness/Fainting ❖ Hoarseness Clin J Am Soc Nephrol . 2018 Aug 7;13(8):1297-1303.

Consequences of IDH ❖ Cardiac outcomes ▪ Cardiovascular mortality ▪ Myocardial infraction ▪ Hospitalization for HF/volume overload ▪ Ventricular arrhythmia ❖ Renal and dialysis outcomes ▪ AVF/AVG thrombosis ▪ Inadequate dialysis ▪ Decline in residual renal function Clin J Am Soc Nephrol . 2018 Aug 7;13(8):1297-1303.

Consequences of IDH ❖Neurological outcomes ▪ Cerebral ischemia ▪ Brain atrophy (frontal lobe atrophy) ❖ Gastrointestinal effect ▪ Mesenteric ischemia or liver ischemia ❖ Mortality outcomes ▪ All-cause mortality ▪ Cardiovascular mortality ❖ Distress, discomfort, weakness Clin J Am Soc Nephrol . 2018 Aug 7;13(8):1297-1303.

Critical consequence ❖ Stroke ❖ Myocardial infraction ❖ Bowel ischemia ❖ Shock

1. Excessive fluid Etiologies of IDH removal 2. Inadequate plasma refill 6. Specific IDH 3. Patient-related causes factors 5. Cardiac factors 4. Dialysis-related factors

Etiologies of IDH ❖ Excessive fluid removal ▪ UFR > 13 ml/kg/hr.-> increase risk to IDH ▪ Decrease in plasma volume >20% ❖ Inadequate plasma refilling ▪ Hypoglycemia ▪ Hyponatremia and/or low dialysate Na ▪ Hypoalbuminemia ▪ Anemia Clin J Am Soc Nephrol . 2018 Aug 7;13(8):1297-1303.

Etiologies of IDH ❖ Patient-related factor ▪ Autonomic neuropathy (DM, uremic neuropathy) ▪ Antihypertensive medication ▪ Food ingestion (splenic vasodilatation) ▪ Tissue ischemia (adenosine mediated) ▪ Bacterial sepsis ▪ Increase in core body temperature Clin J Am Soc Nephrol . 2018 Aug 7;13(8):1297-1303.

Etiologies of IDH ❖ Dialysis-related factor ▪Low dialysate sodium ▪Low calcium ▪Acetate dialysate -> vasodilation ▪Complement activation (C3a, C5a mediated) ▪Cytokine generation (interleukin-1, and nitric oxide mediated) Clin J Am Soc Nephrol . 2018 Aug 7;13(8):1297-1303.

Etiologies of IDH ❖ Cardiac factor ▪Myocardial infraction ▪Arrhythmias ▪Pericardial tamponade ▪Myocardial stunning ▪Acetate dialysate Clin J Am Soc Nephrol . 2018 Aug 7;13(8):1297-1303.

Etiologies of IDH ❖ Specific cause of IDH ▪ Hemorrhage • GI bleed • Disconnect of circuit ▪ Dialyzer reaction ▪ Air embolism ▪ Hemolysis Clin J Am Soc Nephrol . 2018 Aug 7;13(8):1297-1303.

Risk factors of IDH ❖ Older age ❖ Longer dialysis vintage ❖ Diabetes ❖ Low albumin ❖ Female gender ❖ Higher body mass index ❖ First dialysis session of the week ❖ Pre-HD SBP < 100 mmHg Clin J Am Soc Nephrol . 2018 Aug 7;13(8):1297-1303.

Prevention of IDH ❖ Reduce UFR ▪Increase dialysis time • Duration dialysis treatment: 4.30-5.0 hr. • Increase frequency: 3-4 times/week ▪Decrease inter-dialytic weight gain • Decrease sodium intake: dietary counselling, avoid Na loading during HD • Diuretic

Prevention of IDH ❖ Dialysate ▪Cool dialysate: 35.5-36.0 C ▪High dialysate Na: 140-145 mEq/L ▪High dialysate Ca: 3.0-3.5 mEq/L ❖ Isolated UF ❖ UF profiling

Prevention of IDH ❖ Supine position ❖ Hemo-diafiltration (HDF) ❖ Improve venous tone (compression stocking) ❖ Intradialytic exercise

Prevention of IDH ❖ Optimize dry weight ▪ History and symptoms ▪ Physical examination ▪ Blood pressure/home BP Bio-impedance ▪ Bio impedance ▪ Relative blood volume monitoring ▪ Chest X-ray ▪ Biochemistry marker: BNP/NT-proBNP

Prevention of IDH ❖ Improve anemia: keep Hct > 25% ❖ Hold antihypertensive drug ❖ Midodrine: dose 2.5-10 mg oral 30-60 min before HD (Avoid in patient with active MI and HF) ❖ Evaluate cardiac function: Echo Change dialysis mode > PD > palliative care advance care plan

Nursing process ❖ Assessment: risk, etiology - History, PE, Documentation ❖ Nursing diagnosis: risk to IHD ❖ Planning: UF, duration, dialysate ❖ Implementation ▪ Obtain v/s 30-60 min ▪ Monitor sign and symptoms ❖ Evaluation

Immediate management ❖ Stop/reduce ultrafiltration ❖ Intravascular volume replacement ▪ Isotonic saline ▪ Hypertonic glucose ▪ 5-20% albumin ▪ Mannitol ❖ Supine position ❖ Oxygen administration

Immediate management ❖ Persistence hypotension evaluate for serious cause ▪ Air embolism, hemolysis, dialyzer reaction, sepsis hemorrhage ❖ Vasoactive agents ▪ Norepinephrine (Levophed), Dopamine ▪ Dobutamine, epinephrine (adrenaline)

Summary ❖First-line ❖Second-line - Reassess DW - Evaluate cardiac function - Reassess UFR - Increase time or frequency - Review anti-HT regimen ❖Third-line - Review dialysate composition - Initiate midodrine before - Avoid food ingestion during HD HD 30 min - Advise fluid & dietary goal - Change dialysis mode

Thank you