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1. Major Acute Hemodialysis
Complications
Hoping to Prevent
Mohammed Abdel Gawad
Nephrologist – Alexandria – Egypt
Founder & Chairman of NephroTube
drgawad@gmail.com
NephroShams: 11-13 Oct 2018

2. Talk Outline
• Anaphylactic Reactions (Water Contamination)
• Seizures (Disequilibrium Syndrome)
• Chest Pain (angina, Hemolysis, Air Embolism)
• Acute Arrhythmias & Sudden Cardiac Death
• Rupture AVF

3. Talk Outline
• Anaphylactic Reactions (Water Contamination)
• Seizures (Disequilibrium Syndrome)
• Chest Pain (angina, Hemolysis, Air Embolism)
• Acute Arrhythmias & Sudden Cardiac Death
• Rupture AVF

4. Handbook of dialysis, Daugirdas, 5th edition, 2015

5. Handbook of dialysis, Daugirdas, 5th edition, 2015

6. Handbook of dialysis, Daugirdas, 5th edition, 2015

7. Depending upon the level of contamination and the
specific contaminant, patients may have acute onset of
symptoms at the time of exposure or develop
symptoms over time, reflecting chronic exposure
Handbook of dialysis, Daugirdas, 5th edition, 2015

8. p

9. 2013 Jul-Aug; 26(4): 427–438
383,900 individuals in the
U.S. undergo maintenance
hemodialysis

10. 2018: https://www.cdc.gov/dialysis/reports-news/outbreaks.html

14. 2017 Feb 7;12(2):357-369

15. Talk Outline
• Anaphylactic Reactions (Water Contamination)
• Seizures (Disequilibrium Syndrome)
• Chest Pain (angina, Hemolysis, Air Embolism)
• Acute Arrhythmias & Sudden Cardiac Death
• Rupture AVF

16. Talk Outline
• Anaphylactic Reactions (Water Contamination)
• Seizures (Disequilibrium Syndrome)
• Chest Pain (angina, Hemolysis, Air Embolism)
• Acute Arrhythmias & Sudden Cardiac Death
• Rupture AVF

17. Handbook of dialysis, Daugirdas, 5th edition, 2015

19. Early symptoms include:
headache, nausea,
disorientation, restlessness,
blurred vision, asterixis.
However, may progress to
confusion, seizures, coma, and
even death.
2008 Sep-Oct;21(5):493-8

20. 2016 Jan-Dec; 5: 2048004016677687
There is no diagnostic test
for DDS, and the diagnosis
is one of exclusion
CNS imaging
Electrolytes and Glucose
assessment

21. • Symptomatic R + Dialysis should be stopped if the
patient develops seizures, coma, and/or obtundation
• Patency of the airway should also be ensured
• Hypertonic solution !!
2017 Feb 7;12(2):357-369

22. For high risk: Slow urea removal
• Therapy can be initiated with two ho of dialysis
• Low blood flow ra 150 to 250 mL/min
• URR: 40%
• (0.9 to 1.2 m2)
• Hypertonic solution !!
2017 Feb 7;12(2):357-369

23. Talk Outline
• Anaphylactic Reactions (Water Contamination)
• Seizures (Disequilibrium Syndrome)
• Chest Pain (angina, Hemolysis, Air Embolism)
• Acute Arrhythmias & Sudden Cardiac Death
• Rupture AVF

24. Talk Outline
• Anaphylactic Reactions (Water Contamination)
• Seizures (Disequilibrium Syndrome)
• Chest Pain (angina, Hemolysis, Air Embolism)
• Acute Arrhythmias & Sudden Cardiac Death
• Rupture AVF

25. pp 151-158

26. pp 151-158

27. pp 151-158
• Nasal oxygen
• If the anginal episode is associated with
hypotension: elevating the feet and
cautiously administering saline
• Sublingual nitroglycerin can be given if
the blood pressure has increased to a
clinically acceptable value
• Blood flow rate should be reduced and
UF should be stopped until the anginal
episode subsides
• ECG

28. pp 151-158

31. 2017 Feb 7;12(2):357-369

32. 2017 Feb 7;12(2):357-369

33. 2017 Feb 7;12(2):357-369

34. pp 151-158

35. 2017 Feb 7;12(2):357-369
Venous air embolism may arise from 4 possible areas of air entry into the dialysis circuit

37. • Treatment of suspected air embolism includes clamping
the venous line and stopping the blood pump.
• The patient should be positioned on the left side, in a
supine position, with the chest and head tilted
downward.
• Cardiorespiratory support.
• Administration of 100 percent oxygen by either mask or
endotracheal tube.
• Attempted percutaneous aspiration of air from the
ventricle may be required.

41. Talk Outline
• Anaphylactic Reactions (Water Contamination)
• Seizures (Disequilibrium Syndrome)
• Chest Pain (angina, Hemolysis, Air Embolism)
• Acute Arrhythmias & Sudden Cardiac Death
• Rupture AVF

42. Talk Outline
• Anaphylactic Reactions (Water Contamination)
• Seizures (Disequilibrium Syndrome)
• Chest Pain (angina, Hemolysis, Air Embolism)
• Acute Arrhythmias & Sudden Cardiac Death
• Rupture AVF

43. U.S. Renal Data System: USRDS 2013 Annual

44. vol.39 no.2
São Paulo Apr./June 2017

45. 2014 May;100(9):685-90

46. 2014 May;100(9):685-90

47. 2016 Dec 7;11(12):2210-2217

48. 2016 Dec 7;11(12):2210-2217
all-cause mortalitycardiovascular mortality

49. April 201, 8Volume 93, Issue 4, Pages 781–783

50. The treatment of arrhythmias that occur in dialysis
patients, either during or between dialysis sessions,
is similar to their treatment in the nondialysis patient
However, appropriate dosing of medications based
upon the absence of renal function is always
required

51. 2014;14(3):195-204

52. March 2012, Vol.33, No. 1-3

53. Talk Outline
• Anaphylactic Reactions (Water Contamination)
• Seizures (Disequilibrium Syndrome)
• Chest Pain (angina, Hemolysis, Air Embolism)
• Acute Arrhythmias & Sudden Cardiac Death
• Rupture AVF

54. Talk Outline
• Anaphylactic Reactions (Water Contamination)
• Seizures (Disequilibrium Syndrome)
• Chest Pain (angina, Hemolysis, Air Embolism)
• Acute Arrhythmias & Sudden Cardiac Death
• Rupture AVF July-August 2013, Vol. 40, No. 4

55. Aneurysms Stable Aneurysm

56. Aneurysms
• Thin, shiny skin
• Prolonged leaking
• Ulceration
• Rapid enlargement
Unstable Aneurysm
(Impending rupture)

57. Aneurysms
Unstable Aneurysm
(Impending rupture)

58. Home Messages

59. 2017 Feb 7;12(2):357-369
A basic scheme for root cause analysis (RCA) after an adverse event related to hemodialysis (HD)
Home Message

60. Thank You