Hypotension in the Dialysis Patient

Aka: Hypotension in the Dialysis Patient, Dialysis Hypotension, Dialysis Induced Hypotension, Hypotension in ESRD, End Stage Renal Disease related Hypotension

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II. Differential Diagnosis

  1. Dialysis Hypotensive Syndrome
    1. Secondary to Autonomic Dysfunction, rapid fluid removal, cellular Fluid Shifts and multiple other causes
    2. Small fluid challenges of 250 ml boluses and re-evaluation
      1. See Inferior Vena Cava Ultrasound for Volume Status for monitoring
  2. External Hemorrhage from AV Shunt
    1. Apply local pressure
    2. Avoid stitching if possible (risk of damaging shunt)
  3. Internal Hemorrhage
    1. Bleeding Diathesis due to Anticoagulation and Thrombocytopenia
    2. Consider occult sources of acute blood loss
  4. Sepsis
    1. Increased risk due to Immunocompromised status with frequent large bore IV Access
    2. Standard Sepsis management (e.g. cultures, Antibiotics)
    3. Give IV fluids in 250 ml increments
    4. Consult with nephrology, surgery or infectious disease per shunt management
    5. Avoid removing temporary shunts as source unless severe Septic Shock with cardiovascular collapse
      1. Temporary shunts can be salvaged in some cases with Antibiotics
  5. Cardiac Tamponade
  6. Hyperkalemia
    1. See Hyperkalemia Management
    2. See Emergency Care in ESRD
  7. Hypersensitivity Reaction
    1. Possible Antigens
      1. Dialysis membrane (Anaphylaxis)
      2. Phthalate from PVC tubing
      3. Ethylene oxide (dialyzer sterilization solution)
      4. Polyacrylonitrile in membrane (reaction exacerbated in patients taking ACE Inhibitors related to kinin metabolism inhibition)
    2. Management
      1. Presents with Wheezing, Dyspnea and anaphylactic shock
      2. Treat as Anaphylaxis with Epinephrine and supportive care
  8. Hyperlactatemia (uncommon now in U.S.)
    1. Presents with vasodilation, Headache and cardiac toxicity
    2. Uncommon now with use of bicarbonate dialysate (allows or acetate elimination)
  9. Subclinical myocardia ischemia
    1. May be a common phenomenon (currently being investigated)
  10. Other causes to consider
    1. Air Embolism (rare)
    2. Congestive Heart Failure
    3. Acute Coronary Syndrome
    4. Arrhythmia
    5. Electrolyte disturbance
      1. See Emergency Care in ESRD
      2. Hyperkalemia (see above)
      3. Hypermagnesemia
      4. Hypercalcemia
    6. Hypoxemia
    7. Opioid Analgesics
    8. Benzodiazepines
    9. Beta Blockers
    10. Thiamine deficiency (Wernicke's Encephalopathy)

III. Management: Bleeding Management

  1. Blood Product replacement
    1. Red Blood Cell Transfusion
    2. Platelet Transfusion
  2. Heparin reversal
    1. Not indicated if last Heparin dose was >2 hours prior to presentation
    2. Protamine
  3. Other measures (expert opinion)
    1. Desmopressin (DDAVP)
      1. Stimulates Von Willebrand Factor release
    2. Tranexamic Acid
      1. Consider in refractory bleeding with cardiovascular collapse

IV. References

  1. Glauser (2013) Crit Dec Emerg Med 27(10): 2-12
  2. Herbert and Bright in Majoewsky (2013) EM:Rap 13(4):8-9
  3. Sulowicz (2006) Kidney Int 70: S36–9 [PubMed]

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