University of Wisconsin Hospital and Clinics
TITLE: Management of Hemodialysis
treatment related complications
POLICY #: 3.8
REVISED: October 1, 2014
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Nurse Manager: Joan Watson, MS, RN
Director: Ann Malec, DNP, RN, NEA-BC
Medical Director: Alex Yevzlin, MD
A. To describe preventative measures taken to prevent treatment related complications.
B. To provide guidance on quickly identifying hemodialysis treatment related complications
and provide direction for immediate corrective actions.
i. Common treatment related complications include: hypotension, cramping.
ii. Less common but serious complications include: Dialyzer Membrane Bio-
incompatibility Reaction, Pyrogenic Reaction, Hemolysis, Air emboli, Blood
Leak, Exsanguination, and Disequilibrium Syndrome.
C. For other complications, e.g., angina, chest pain or sudden change in patient condition,
summon the appropriate assistance 262-0000.
i. Blue Cart - unresponsive or life threatening emergencies
ii. Rapid Response - early recognition and intervention for deteriorating conditions.
iii. Acute Stroke Team – sudden onset of symptoms of a stroke.
For details refer to UWHC Administrative Policy 7.36 Emergency Response Team or
UW Health Clinical Policy 5.1.5 Acute Stroke Response for Adults.
II. GENERAL INFORMATION
A. Pyrogenic reaction – Temperature elevation within the first 45-78 minutes of dialysis.
1. Signs and symptoms include: chills, involuntary shaking, complaint of feeling
cold after initiation of dialysis, hypotension and/or hemodynamic instability,
myalgia (muscle pain) , headache, nausea and vomiting
2. Potential source of bacteria and/or endotoxins contamination includes dialysate,
product water, and/or the extracorporeal system.
B. Dialyzer Membrane Bio-incompatibility reactions have two forms
1. Type A: Occurs in the first 5-10 minutes of initiating dialysis, can progress to
anaphylaxis. Signs and symptoms include: nausea, flushed warm feeling and
uneasiness, agitation, chest tightness, back pain, acute bronchial restriction,
dyspnea, respiratory stridor, wheezing, itching and watery eyes.
2. Type B: Occurs 20-40 minutes after initiation of dialysis, signs and symptoms
are less sever and include: back pain, hypotension and chest pain.
Symptoms usually will resolve after the first hour.
C. Hemolysis – Destruction of red blood cells so that the hemoglobin and potassium are
released into the surrounding fluid.
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1. Signs and symptoms include: flushed warm feeling, chest and abdominal pain,
dyspnea, hypotension, dysrhythmias, burning pain in the access extremity and
clear translucent “cherry pop” colored blood in the venous blood line.
2. Hemolysis may result from mechanical, chemical or osmotic injury.
D. Air Emboli – Occurs when a large volume of air or foam (microbubbles) is introduced
into the heart or vascular system.
1. Signs and symptoms include: chest pain or tightness, shortness of breath,
coughing, tachycardia or other arrhythmias, loss of consciousness, or convulsions.
2. Potential source: Loose connections, separation of blood line, empty normal
saline bag and central venous catheter was not clamped and open to air.
E. Disequilibrium Syndrome– set of neurological symptoms that occur with the first few
dialysis sessions in patients with acute renal failure, pediatric patients or patients with
high blood urea nitrogen (BUN) levels.
1. Signs and symptoms include: Headache, nausea, vomiting, restlessness, twitching
to more sever tremors, disorientation, convulsions.
F. Exsanguination – Extreme blood loss
1. Signs and symptoms include: obvious blood on the floor or surroundings,
machine pressure change alarms, severe hypotension, shock, cardiac arrest.
2. Potential sources: Blood line separation, needle dislodging from access, rupture of
arteriovenous access, loose caps on central venous catheter.
G. Blood Leak – dialyzer membrane rupture that allows the passage of red blood cells into
1. Signs and symptoms include: blood leak alarm, obvious frank blood in dialysate.
A. The following measures will be practiced in order to prevent treatment related
1. Water system monitoring – preformed at the beginning of every shift. If
treatments delivered in-center after hours the water system monitoring checks
need to be performed before the treatment begins. For details on water system
monitoring see HD Policy 2.0
2. Hemodialysis machine cleaning - Dialysis machines will be rinsed prior to first
use for the day and tested for residual disinfectant following routine cleaning
cycles where applicable. For details on cleaning and disinfection of hemodialysis
machines see HD Policy 2.6
3. Hemodialysis machine system alarm test - Alarm and pressure tests to insure
proper function of the dialysis machine will be conducted prior to each treatment.
4. Dialysate test - Dialysate pH and conductivity will be tested prior to each dialysis
treatment with an independent handheld meter and compared to machine readings
prior to each treatment.
5. Extracorporeal circuit & dialyzer – a visually inspection of the extracorporeal
circuit is conducted prior to or with initiation of each treatment and includes:
Checking expiration dates and blood lines for defect,
Blood line connections are secure,
Caps and clamps on the blood lines and patient access are working properly,
Venous line tubing is properly placed in line clamp,
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Hemodialysis needles are secured with tape and the blood lines are secured to
reduce pulling during treatment,
Dialysis should be initiated within 4 hours of being primed.
6. Systems checks during dialysis - special attention should be paid to the
extracorporeal circuit during initiation and discontinuation of dialysis for the
presence of air. Unless ordered to the contrary connect both arterial and venous
blood lines are connected to the patient’s access at initiation of hemodialysis.
Arterial and venous pressure readings are assessed and monitored during
treatment, the extracorporeal circuit is flushed to assess for clotting and the
normal saline administration line is to be double clamped during treatment.
B. Dialyzer Membrane Bio-incompatibility reaction
1. Dialyzers will be primed according to manufactures recommendations.
DIALYZER Membrane/Sterilant PRIMING SIZE (m
F3 Fresenius Polysulfone ® /Ethylene Oxide 24 ml 0.4
F4 42 ml 0.7
F5 63 ml 1.0
F6 82 ml 1.3
F8 110 ml 1.8
Revaclear Polyarylethersulfone, Polyvinylpyrrolidone
84 ml 1.4
Revaclear Max 100 ml 1.8
Polysulfone / Gamma Rays
Use for people with “allergic” reactions
112 ml 2.1
A. Hypotension/Cramping :
1. Administer normal saline, volume expanders, oxygen as ordered for signs/symptoms
2. Place patient in Trendelenburg as tolerated.
3. Pause ultrafiltration if no relief from symptoms with repeated normal saline boluses.
4. Consider use of ultrafiltration and/or sodium/conductivity profiles to adjust
ultrafiltration rate based on the patient’s symptoms.
5. Notify provider of assessment findings and patient’s response to interventions and
adjust hemodialysis prescription as ordered.
B. Pyrogenic reaction
Contact: Nurse Manager
Infection Control Practitioner
1. Obtain vital signs, including temperature
2. Access temperature of dialysate (34-36º C)
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3. Evaluate for other potential sources of infection, e.g., vascular access, wounds,
urinary or respiratory tract.
4. Administer antipyretics and antibiotics, treat symptoms as ordered.
5. Discontinue dialysis without returning the blood if 2 or more patients are complaining
of symptoms and/or a pyrogen reaction is suspect.
6. Obtain cultures of blood, treatment water, dialysate inlet and outlet.
7. Notify Infection Control Practitioner and/or Dialysis Solutions at 414-550-4622 to
obtain samples of treatment water and dialysate for bacteria and endotoxin (LAL).
C. Dialyzer Membrane Bio-incompatibility reactions
Contact: Nurse Manager
1. If Type A severe /anaphylaxis do NOT return blood. If Type B treatment does not
need to be terminated.
2. Notify provider immediately and provide supportive treatment of symptoms,
administer oxygen, antihistamines, or epinephrine, dependent upon severity.
D. Hemolysis :
Contact: Nurse Manage
Provider / Medical Director
1. Stop treatment, clamp all blood lines. Do NOT return the blood.
2. Notify provider immediately and obtain blood samples as ordered, i.e., electrolytes,
hemoglobin, hematocrit, bilirubin, haptoglobin, & LDH.
3. If ordered administer oxygen therapy, replacement fluids and/or blood transfusions.
4. Monitor BP, heart rate and rhythm.
5. Attempt to identify the cause:
a. collect dialysate fluid for analysis,
b. test dialysate conductivity, pH and temperature
c. examine extracorporeal circuit for occlusion,
d. examine dialysis machine system alarm function and blood pump occlusion
E. Air Emboli
1. Stop infusion of air immediately and clamp all blood lines.
2. Place patient in Trendelenburg position, and turn on left side if possible.
3. Notify provider immediately and administer oxygen at 100% per mask as ordered.
4. Assess vital signs, levels of consciousness, and place on a cardiac monitor.
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F. Exsanguination - Severe blood loss :
1. Stop bleeding at site, i.e., apply pressure to needle site, turn off blood pump, clamp
blood lines, catheter or access site tubing.
2. If appropriate return blood in extracorporeal circuit to patient.
3. If blood loss significant notify provider immediately and obtain blood samples as
ordered, i.e., hemoglobin/hematocrit, type and cross match.
4. Administer oxygen, IV fluids, volume expanders, and or blood transfusions as
G. Blood leak :
1. Visually inspect dialyzer and effluent hose for evidence of blood leak.
2. Disconnect venous dialysate line and check dialysate fluid for presence of blood with
a. If Hemastix is positive for blood leak and TMP is above zero, return the patient’s
b. If obvious frank blood in dialysate or TMP is less than zero, stop dialysis
immediately and do not return the patient’s blood.
c. If Hemastix is negative for blood leak. Reset alarm and continue dialysis. If
unable to reset the alarm, return the patient’s blood and change machines.
H. Disequilibrium Syndrome:
1. Administer hypertonic solutions as ordered, i.e., albumin, mannitol.
2. Notify provider of assessment findings and patient’s response to interventions and
adjust hemodialysis prescription as ordered.
A. Gomez, N. J., (Ed). (2011). Nephrology nursing scope and standards of practice (7
ed., pp. 123-144). Pitman, NJ: American Nephrology Nurses’ Association.