Intradialytic hypotension & Its Managemnet


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It is a presentation on How to Manage Hypotension During Haemodialysis Sessions

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Intradialytic hypotension & Its Managemnet

  1. 1.  Nephrology Dialysis, Transplant (2007) 22 [Suppl 2]:
  2. 2.  Incidence Definition Significance Patho-physiology Prevention Treatment
  3. 3.  20% incidence of intra-dialytic hypotension is widely cited . incidence in cohort studies varies between 6% and 27% . In the largest cohort reported so far, 10% of patients had frequent hypotensive episodes whereas 13%occasionally had hypotensive episodes
  4. 4.  No universally accepted definition EEBPG working group stresses that both a reduction in BP, as well as clinical symptoms with need for nursing intervention should be present. A proposed definition is a decrease in › systolic BP 20mmHg › a decrease in mean arterial pressure (MAP) by 10mmHg › associated with clinical events and need for nursing interventions.
  5. 5.  IDH , a putative causal role in myocardial and cerebral ischemia. Independent and negative predictor of long-term fistula outcome Causative role in adverse outcome or is merely a marker of co morbid conditions, which increase the sensitivity for IDH. Impair solute clearance, due to compartmentalization of blood volume and premature termination of dialysis sessions
  6. 6.  Age, female Gender, Presence of diabetes mellitus, Hyperphosphataemia, Presence of coronary artery disease, Renal diagnosis other than glomerulonephritis use of nitrates
  7. 7.  Interplay of 04 factors1. Ultra-filtration2. Refill blood volume3. Dialysate –Na+,Ca++,Temp4. Patient sensitivity to volume withdrawn
  8. 8.  Autonomic neuropathy, which canbe assessed using standardized function. Bradycardia,so called Bezold-Jarish reflex observed during IDH episodes. Induction of cytokines, bioincompatibility of the dialysis membrane, the use of acetate as dialysate buffer.
  9. 9.  Hydration of Patient Dry Weight Radiological Inv., CT Ratio, IVC diameter Multi frequency Bio-impedance BNP level ,Cyclic GMP
  10. 10.  Checking of Heart rate Blood pressure Patient alarm
  11. 11.  Cardiac Evaluation Diastolic dysfunction Ejection Fraction Ischemia assessment Pericardium assessment
  12. 12.  Dietary Salt Food intake –Pre Dialysis During Dialysis …..??? Caffiene …No Benefit
  13. 13.  Pulsed Ultrafiltration…increases IDH. IntraDialytic Blood Volume monitoring Perfusion state ,Oxygenation and anti- coagulation Milieu
  14. 14.  Na+>> or equal 144mEq less chances Bicarbonate Ca++ low dialysate Mg++ low <.25 mMoL
  15. 15.  Bio-Compatibility Reuse of incompletely treated Inadequately washed
  16. 16.  Temperature primer defect Low temp can be used in cases of IDH .5 degree cent be reduced every 15-30 min(Never less than 35 Degree centigrade)
  17. 17.  Ultrafiltration Followed by Isovolumic Dialysis ……Not Rcommended
  18. 18.  Less common with slow ultra filtration. Ultrafiltration rate-<10ml/Kg/Hr Pt with 8hrs dialysis ,thrice a week <1% Saran R, Bragg-Gresham JL, Levin NW et al. Longer treatment time and slower ultrafiltration in hemodialysis: associations with reduced mortality in the DOPPS. Kidney Int 2006; 69:1222–1228
  19. 19.  Avoidance of antihypertensive drugs and prescription of vasoactive medication Antihypertensives ..Ca Channel blockers Nitrates …independent factor.
  20. 20.  Midodrine is an oral alpha-1 agonist. Its metabolite midodrine,desglymidodrine, induces constriction of both resistance and capacitance vessels. Dose 2.5 to 10mg 30 min before Dialysis Side effects-scalp parestehesias, heartburn, flushing, headach e, neck pain and weakness.
  21. 21.  Lysine vasopressine, Ergotamine, Methylene blue Dobutamine Insufficient data to make recommendation
  22. 22.  L-carnitine levels low. Because of reduced biosynthesis in the kidney and losses in the dialysate. Improves Systolic function Improved LVEF noted with supplementation A study n-223..low IDH After Dialyisis-20mg/Kg be given
  23. 23.  Dietary counselling (sodium restriction). Refraining from food intake during dialysis. Clinical reassessment of dry weight. Use of bicarbonate as dialysis buffer. Use of a dialysate temperature of 36.58C. Check dosing and timing of antihypertensive agents.
  24. 24.  Try objective methods to assess dry weight. Perform cardiac evaluation. Gradual reduction of dialysate temperature from 36.8 Deg C downward (lowest 35 Deg.C)
  25. 25.  Consider individualized blood volume controlled feedback. Prolong dialysis time and/or increase dialysis frequency. Prescribe a dialysate calcium concentration of 1.50 mmol/l. Mg Concentration .25 mmol/L
  26. 26.  Consider midodrine. Consider L-carnitine supplementation. Consider peritoneal dialysis.
  27. 27.  Trendelenburg position Stopping ultrafiltration Infusion fluids
  28. 28.  Blood Best Colloid Next Not available ..Crystalliod… Crystalliod –Dextrose 25%<10% Saline 3%< NS
  29. 29.  Peritoneal Dialysis Artificial Kidney
  30. 30.  Shri B N Bordoloi…….Art of Dialysis Faculty….Science of Nephrology Dr P J Mahanta ,DM(Nephro) Assistant Prof for entrusting me this seminar
  31. 31. Thank You Madam &Sir