This document outlines emergency procedures for a dialysis unit. It provides guidelines for responding to various medical emergencies that may occur during dialysis treatment, including cardiac arrest, air embolism, anaphylactic reaction, seizure, shortness of breath, cardiac arrhythmias, and chest pain. For each emergency, it describes signs and symptoms to look for and steps staff should take to assess and stabilize the patient, such as notifying the charge nurse, administering oxygen, treating hypotension, and contacting the patient's physician.

1. EMERGENCY PROCEDURES
BY:
LLOYD SMITH RN

2. EMERGENCY TRAINING
• Why is this important ?
• Who needs to be trained ?
• Who will it affect ?

3. Emergency Procedures
• Guidelines for Emergency
Transfer
• Cardiopulmonary Arrest
• Air Embolism
• Anaphylactic Reaction
• Seizure
• Shortness of Breath
• Cardiac Arrhythmias
• Chest Pain
• Crenation
• Hemolysis
• Disequilibrium Syndrome
• First-use Syndrome
• Blood Loss/Exsanguinations
• Dialyzer Blood Leak
• Clotted Dialyzer
• Pyrogenic Reaction
• Equipment Problems and
Alarms
• Hypertension
• Hypotension
• Hypoglycemia
• Muscle Cramps
• Using Patient Restraints

4. Guidelines for Emergency
Transfer
• For patient emergencies involving cardiac arrest, impending
cardiac arrests, or other potentially live threatening events, call 911
first, to request an ambulance for patient transport. Inform the
dispatcher of the urgency involved. Notify the physician on call as
soon as possible.
• For patient emergencies of a less urgent nature, call the patient’s
primary physician (or physician on call if the primary physician is
unavailable) for an order to transport. Then notify a local
ambulance service of the need to transport.
• The Charge Nurse should remain with the patient until he/she has
left the building.
• The unit secretary or other ancillary staff should prepare the
transfer information packet to accompany the patient to the
hospital. The packet should include:
• The last 3 hemodialysis records.
• Medication List
• Care Plans
• Code Summary (if applicable)
• If time does not permit, the information may be faxed to the
hospital as soon as possible after the transfer. This person should
also gather the patient’s belongings and send them with the
patient.

5. Guidelines for Emergency Transfer
(cont)
• Only those emergency response personnel needed should enter the
unit. First responders such as firemen often arrive before paramedics,
EMT’s and ambulance personnel. Their usefulness in the given
situation should be evaluated by the charge nurse.
• The patient care staff should assist the EMS staff in preparing the
patient for transfer. If additional staff is needed during the transport
process, a nurse may be sent with the EMS team at the discretion of
the EMS team and KCC Charge Nurse or Clinical Manager.
• The charge nurse should give a full report to the ambulance
personnel of the events leading up to the transfer.
• Once the patient has left the building the Charge Nurse should call
the emergency room triage nurse to notify him/her of the transfer.
The Charge nurse should give a full report of the events leading up to
the transfer.
• The Clinical Manager, Social Worker, or Charge Nurse should notify
the patient’s emergency contact of the transfer. Every effort should be
made to offer support and sensitivity to the family member receiving
the information

6. Cardiopulmonary Arrest
• A cardiac arrest, also known as cardiopulmonary arrest
or circulatory arrest, is the abrupt cessation of normal
circulation of the blood due to failure of the heart to
contract effectively during systole.
• Cardiac arrest is a medical emergency that, in certain
groups of patients, is potentially reversible if treated early
enough
• The staff member discovering the patient in cardiac arrest
should call for help without leaving the patient. The staff
person responding should page “all staff to the patient
care area stat” over the intercom.
• The patient’s blood should be returned immediately. As
soon as 3 staff persons are at the chair-side, the patient
should be placed in the floor, and CPR Started.

7. • The charge nurse will make assignments to the code team.
• Code Leader (Charge Nurse): Conveys a sense of order
in an emergency environment. Responsible for all
decisions in the absence of a physician or advanced
practitioner. Assigns other responsibilities. Performs all
aspects of electrical therapy. Identifies cardiac
arrhythmias and chooses appropriate algorithm and
medications based on facility policy. Communicates
activities to the person performing documentation.
• Medication Nurse (RN or LPN): Responsible for
accurate preparation and administration of all
medications. Communicates medications given to the
person performing documentation. Responsible for
achieving and maintaining IV access.
• Documentation (LPN or PCT): Responsible for accurate
documentation of al events and interventions during the
code.
• Compressions (CPR certified person): Responsible for
pulse checks and delivery of compressions during
cardiac arrest.

8. • Airway Management (CPR certified person):
Responsible for achieving and maintaining the airway.
Responsible for monitoring the delivery of O2 and the fill
level of the O2 tank.
• Communications (Unit Clerk or Ancillary Staff):
Responsible for paging physicians, calling 911, calling
the ER triage nurse and copying medical records in
anticipation of transport.
• Only those staff directly involved in the resuscitative
efforts should be in the immediate vicinity, all other staff
should monitor and reassure the other patients.
• EMS should be notified by dialing 911. Report to the
EMS dispatcher that CPR is in progress. Page the
patient’s physician, or physician on call.

9. • The patient should be placed on the cardiac defibrillator
monitor and any lethal arrhythmias identified.
• If defibrillation is appropriate, this should be performed
immediately.
• O2 delivery should be via ambu bag at
100 % at rate of 10 breaths per minute.
• IV access should be maintained via the patient’s vascular
access, and appropriate medications given per ACLS
Guidelines.
• Follow guidelines for emergency patient transport.

10. Ethical Issues
• Cardiopulmonary resuscitation and advanced cardiac life
support are not always in a person's best interest. This is
particularly true in the case of terminal illnesses when
resuscitation will not alter the outcome of the disease.
Properly performed CPR often fractures the rib cage,
especially in older patients or those suffering from
osteoporosis. Defibrillation, especially repeated several
times as called for by ACLS protocols, may also cause
electrical burns.
• Some people with a terminal illness choose to avoid such
measures and die peacefully. People with views on the
treatment they wish to receive in the event of a cardiac
arrest should discuss these views with both their doctor
and with their family. A patient may ask their doctor to
place a do not resuscitate (DNR) order in the medical
record. Alternatively, in many jurisdictions, a person may
formally state their wishes in an advance directive or
advance health directive (see POST form at KCC).

11. Air Embolism
• An air embolism, or more generally gas embolism,
is a medical condition caused by gas bubbles in the
bloodstream (embolism in a medical context refers to
any large moving mass or defect in the blood
stream). Small amounts of air often get into the blood
circulation accidentally during surgery and other
medical procedures (for example a bubble entering
an intravenous fluid line), but most of these air
emboli enter the veins and are stopped at the lungs,
and thus a venous air embolism that shows any
symptoms, is very rare.

12. Air Embolism
• The first step in treating Air Embolus is
prevention.
• Assure alarms test are performed pre-dialysis.
• Always change out the NS bag if < 300cc of NS remains.
• Never leave the patient when administering NS or
returning the blood.
• When administering medications or NS by gravity,
monitor the infusion closely.
• Always assure central catheter ports are clamped when
removing caps, syringes or lines.

13. • Identify signs and symptoms of air embolus which
may include: air or foam observed in the venous
line below the air detector, chest pain, SOB, cough,
seizure, visual disturbances, hemiparesis,
confusion and changes in mental status, or the
patient may describe a sense of impending doom.
• Immediately clamp the venous line and turn off the
blood pump.
• Place the patient in Trendelenburg position on their
left side.
• Note: This position will aid in trapping the air in
the right atrium, which may prevent it from
traveling to the lungs.
• Call for help and request the Charge Nurse.

14. • Assess patient. If marked changes in the patient’s
cardiopulmonary and/or mental status are noted, call for
the crash cart. Place patient on cardiac monitor and assess
O2 sat.
• Initiate emergency procedures as indicated by patient’s
condition.
• Recirculate the extracorporeal circuit. Flush the fistula
needles or catheter ports with NS.
• Notify the patient’s physician or physician on call.
• Return the patient’s blood if indicated/ordered.
• Once the patient is stabilized or transported, investigate
and identify the source of air. If no source is identified, or
if the dialysis machine may be implicated, pull the
equipment, place a service report on the machine and
label it “Not for Use”. Notify the Chief Tech.

15. Anaphylactic Reaction
• Anaphylaxis is a serious allergic reaction
that is rapid in onset and may cause death.
• What are the common causes of
anaphylaxis?
• Common causes of anaphylaxis include:
• Food
• Medication
• Insect stings
• Latex

16. • Identify the SIGNS AND SYMPTOMS’s of
anaphylactic reaction that may include: SOB, acute
bronchospasms or bronchoconstriction, chest pain,
back pain, hypotension, hypertension, anxiety,
thready-rapid pulse, diaphoresis, nausea, profound
shock, and/or cardiopulmonary arrest.
• Stop the infusion of medication or blood immediately.
If the product is being infused via the extracorporeal
circuit, stop the blood pump and clamp the venous
bloodline.
• Place the patient in Trendelenburg position if SIGNS
AND SYMPTOMS of shock are present.
• Call for help and request the Charge Nurse
• Assess the patient. If marked changes in the patient’s
cardiopulmonary status are noted, call for the crash
cart. Place the patient on the cardiac monitor and
assess O2 status.

17. • Attach the NS line directly to the patient’s vascular access.
Be prepared to provide NS for volume support if B/P
indicates.
• Initiate emergency procedures as indicated by patient’s
condition.
• Administer medications according to Physicians Standing
Emergency Orders.
• Note: Patients taking beta-blockers routinely may not respond
adequately to epinephrine.
• Recirculate the extracorporeal circuit and flush the unused
catheter ports or fistula needles.
• Notify the patient’s physician or physician on call.
• Once the patient is stabilized or transferred, identify the
causative agent and label the patient’s medical record
accordingly. Consider: medications, blood products,
dialyzer membranes, and/or dialyzer germicides.

18. Seizure
• A seizure is a sudden change in behavior due
to abnormal electrical activity in the brain
• Note: Seizure activity during dialysis is usually
the result of hypotension or a pre-existing seizure
disorder. Other possible causes are drug toxicity,
disequilibrium syndrome, air embolism or
hemolysis. Exact treatment will depend on the
cause

19. • Identify seizure activity.
• Quickly assess the venous bloodline for the presence of air
or hemolized blood. If present, stop the blood pump, clamp
the bloodlines and refer to the appropriate procedure.
• Call for help and request the Charge Nurse.
• Place the patient in Trendelenburg position with the head
supported to one side.
• Begin an infusion of NS into the extracorporeal circuit at a
rate of about 200 ml/min.
• Attempt to assess the patient’s blood pressure as soon as
seizure activity will allow. If patient is hypotensive, refer to
the appropriate procedure.
• If possible, insert an oral airway between the patient’s teeth.
Do not attempt to force the airway between clinched teeth.

20. • Prevent dislodgement of fistula needles or vascular access
catheters with hands on support if necessary.
• Notify the patient’s physician or the physician on call of the
event.
• Follow any medication or laboratory orders given by the
physician.
• As seizure activity subsides, maintain on open airway, and
continue to support the head to one side. Be prepared to
suction the patient if needed. Be prepared to provide
respiratory assistance if needed.
• Note: Hypotensive seizure activity is often followed by an episode of nausea
and vomiting.
• If the patient’s condition returns to baseline, reinitiate dialysis
as ordered.
• Note: Patient’s with a seizure disorder may appear profoundly lethargic after
a seizure.
• If the patient’s fails to return to baseline, follow physician
orders. See Guidelines for emergency transport if indicated.

21. Shortness of Breath
• Difficulty Breathing
• Note: SOB in dialysis patients is usually
the result of fluid overload, anxiety and/or
hypotension. Less often it may be related to
angina, MI, blood, medication or dialyzer
reactions. Rarely is it the result of air
embolus, hemolysis or crenation.

22. • Notify the Charge Nurse.
• Rule out the possibility of a dialyzer, medication, or
blood reaction. If SIGNS AND SYMPTOMS’s begin
immediately after beginning the administration of a
medication or blood, or starting the dialysis procedure,
stop the blood pump, and treat the patient according
to the appropriate anaphylactic or dialyzer reaction
procedure.
• Rule out the possibility of air embolus crenation or
hemolysis. Evaluate the venous bloodline for the
presence of bright cherry-colored, blood, dark blood or
air below the air detect, stop the blood pump and refer
to the appropriate procedure.
• Assess the patient’s blood pressure, and treat
hypotension if indicated. Reassess the patient after NS
administration.
• Measure O2 saturation. If O2 saturation is less than
90%, notify the patient’s physician or the physician on
call.

23. • Start O2 at:
• 2 liters/min per nasal cannula for patients with O2
saturation 95-100% on room air.
• 4 liters/min per nasal cannula for patients with O2
saturation 90-95%
• 10 liters/min per partial non-rebreather mask for
patients with O2 saturation < 90%.
• Assess the patient’s heart rate and rhythm. Place
patient on cardiac monitor if indicated. If the
symptoms appear cardiac in origin, return the
patient’s blood and notify the physician.
• Evaluate the patient’s fluid volume status. Check for
pitting edema in the extremities, NVD, auscultatate the
patient’s lungs.
• If FVO is suspected, review the treatment plan for
appropriate fluid removal.
• If unable to resolve the patient’s SIGNS AND
SYMPTOMS, notify the physician.

24. Cardiac Arrhythmias
• Cardiac arrhythmia is a term that denotes a
disturbance of the heart rhythm. Cardiac arrhythmias
can range in severity from entirely benign to
immediately life-threatening
• Note: Cardiac arrhythmias in dialysis patients are
usually caused by electrolyte disturbances, altered
medication levels, hypovolemia, anemia,
hypotension or underlying heart disease; rarely
arrhythmias may be related to irritation of the
heart’s conduction system by vascular access
catheters.

25. • Immediately notify the Charge Nurse of irregularities
noted in the patient’s heart rhythm.
• Place the patient on the cardiac monitor and assess the
patient for the presence of lethal arrhythmias and/or
chest pain.
• Note: Do not initiate the dialysis treatment if the patient is
unstable when he presents to the dialysis unit. Notify the
patient’s physician or the physician on call. In the presence
of lethal arrhythmias, or if the patient becomes
hemodynamically unstable while on dialysis, discontinue
the dialysis treatment and notify the patient’s physician or
the physician on call.
• Measure the patient’s O2 saturation, and start O2 as
indicated. Initiate emergency procedures when
indicated.
• Assess the patient’s blood pressure, and treat
hypotension if present.

26. • Evaluate the appropriateness of the patient’s dry weight
and ultrafiltration plan.
• Evaluate the patient’s past history of cardiac disease.
• Assess the patient for the SIGNS AND SYMPTOMS of
potassium imbalance.
• Evaluate the patient’s recent serum potassium levels.
• Note the potassium content of their current dialysate
prescription.
• Assess the patient’s food intake over the last 48 hours for high
potassium foods.
• Evaluate the patient’s cardiac monitor strip for peaked T waves
and/or a widened QRS complex.
• Evaluate the patient for other SIGNS AND SYMPTOMS of
hyperkalemia such as generalized muscle pain and weakness.
• Evaluate the patient’s compliance with prescribed
cardiac medications.
• Administer medications and/or draw labs as ordered by
the physician.

27. Transfusion Reaction
• Note: Transfusion reactions may occur immediately after
the start of the transfusion, any time during the
transfusion, or for up to 48 hours after the transfusion.
Types of transfusion reactions include:
• Pyrogenic: Usually results from bacterial contamination
of the blood. SIGNS AND SYMPTOMS’s include chills,
very high fever, hypotension and eventually shock. Less
severe febrile reactions caused by leukocyte antibodies or
other causes may be identified by chills and fever, muscle
aches, nausea and vomiting, headaches and flushing.
Pyrogenic reactions are usually gradual and may not be
seen until well into the transfusion.

28. • Hemolytic: Results from incompatibility of the donor’s blood to the
patient’s blood. The onset is sudden and includes SOB, low back pain,
chest pain, nausea and vomiting, headache and or fever with chills.
• Allergic: Probably due to the patient’s response to allergens in the
donor’s blood. They are characterized by itching that may be
accompanied by a rash or hives. Generally medicating the patient with
antihistamines relieves the symptoms.
• Fluid Overload: May result when the blood is administered too
quickly, or when the patient is significantly above their dry weight
already. SIGNS AND SYMPTOMS’s include SOB, rapid HR and/or
drop in blood pressure. SIGNS AND SYMPTOMS’s usually improve
with a decrease in the rate of infusion, or by withholding the
transfusion until a significant amount of ultrafiltration is achieved.

29. •
Identify the SIGNS AND SYMPTOMS’s of a possible transfusion
reaction. Any unusual symptom experienced by the patient should
be considered a possible reaction.
• Stop the blood transfusion. If SIGNS AND SYMPTOMS’s are
severe, stop the blood pump and recirculate the extracorporeal
circuit. DO NOT RETURN THE BLOOD. Flush the patient’s
fistula needles or catheter ports with NS.
• Call for assistance, if needed, and alert the Charge Nurse.
• Assess the patient. If marked changes in the cardiopulmonary status
are noted, call for the crash cart. Place the patient on the cardiac
monitor and assess the 02 status.
• Initiate emergency procedures as indicated
• Notify the patient’s physician or the physician on call.
• Administer medications per physician order.
• Notify Blood Assurance. Request a copy of the transfusion reaction
form via fax.
• Draw any labs ordered by the physician and/or Blood Assurance.
• Complete the reaction section of the blood tag, and complete the
transfusion reaction form.

30. Crenation
• Identify the SIGNS AND SYMPTOMS of crenation. These
include flushed face, SOB, sudden rise in blood pressure,
chest pain, abdominal cramps, restlessness, agitation,
convulsions in the presence of dark colored blood post
dialyzer.
• Immediately clamp the venous line and turn off the blood
pump.
• Notify the Charge Nurse.
• Assess the patient. Place on cardiac monitor. Be alert for
SIGNS AND SYMPTOMS of hyperkalemia.
• Start O2 at 2 l/min per nasal cannula. Treat other symptoms
and implement emergency procedures as indicated.
• Check the conductivity of the machine. If crenation has
occurred as a result of the dialysate, the conductivity will be
low.

31. • Notify the patient’s physician, or the physician on call.
• Check a stat potassium level on the patient. Preserve a
sample of dialysate for laboratory analysis.
• The extracorporeal circuit should be tossed.
• The machine should be pulled and labeled not for use.
• Notify the Chief Technician, and complete a service
report on the machine.
• Restart dialysis on a fresh machine and dialyzer as
ordered by the physician.
• Note: The patient’s potassium will probably be elevated.
Dialysis should be restarted for a minimum of 2 hours.

32. Hemolysis

33. • Identify the SIGNS AND SYMPTOMS of hemolysis. These
include patient complaints of a burning sensation in the
access extremity, SOB, hypotension, hyperkalemia, chest and
back pain, nausea and vomiting, convulsions and/or cardiac
arrhythmias or arrest in the presence of cranberry-colored
almost translucent blood post dialyzer.
• Immediately clamp the venous line and turn off the blood
pump.
• Notify the Charge Nurse.
• Assess the patient. Place on cardiac monitor. Be alert for
SIGNS AND SYMPTOMS of hyperkalemia.
• Start O2 at 2 l/min per nasal cannula. Treat other symptoms
and implement emergency procedures as indicated.
• Draw a sample of blood from the extracorporeal circuit and
place in a SST tube. Spin for 5-15 minutes and check for the
presence of pink serum indicating hemolysis.

34. • Consider the following causes of hemolysis:
• Inappropriate dialysate composition resulting in
hypotonic dialysate.
• Overheated dialysate, usually above 105º F or 40º C.
• Notify the patient’s physician, or the physician on call.
• Check a stat potassium level and H&H on the patient.
Preserve a sample of dialysate for laboratory analysis.
• The extracorporeal circuit should be tossed.
• The machine should be pulled and labeled not for use.
• Notify the Chief Technician, and complete a service
report on the machine.
• Restart dialysis on a fresh machine and dialyzer as
ordered by the physician.
• Note: The patient’s potassium will probably be elevated.
Dialysis should be restarted for a minimum of 2 hours.
Consider transport to acute facility.

35. Disequilibrium Syndrome
• Identify the SIGNS AND SYMPTOMS of disequilibrium
syndrome. These include patient complaints of a headache,
hypertension, increased pulse pressure, decreased level of
consciousness, nausea and vomiting, convulsions and/or
coma. Disequilibrium syndrome occurs most often when
the patient is very uremic with BUN above 150 mg/dl.
Generally signs and symptoms present early in the dialysis
treatment. Signs and symptoms should be differentiated
from first use syndrome.
• Note: Disequilibrium syndrome occurs when the blood
osmolarity falls faster than the osmolarity of the cerebrospinal
fluid. (This results from rapidly lowering the BUN.) Fluid shifts
from the vascular compartment to the cerebral spinal fluid
compartment and cerebral edema occurs. Patients known or
suspected of extremely elevated BUN levels should be dialyzed
cautiously in the outpatient setting. Prophylactic Mannitol,
sodium modeling, low initial blood flow rates and a low clearance
dialyzer are key.

36. • Immediately reduce the blood pump speed to 100
ml/min.
• Notify the Charge Nurse.
• Begin administration of Mannitol 25% 50ml IVP,
slowly via the venous drip chamber.
• Implement emergency procedures as indicated, and be
alert for signs of seizure activity.
• Notify physician if SIGNS AND SYMPTOMS are
severe or do not resolve with treatment.
• Note: Consider transport to an acute facility if SIGNS
AND SYMPTOMS’s are severe or if there is a change in
the patient’s mental status.
• Resume dialysis cautiously once symptoms subside.
Blood flow rates should not exceed 150-200 ml/min
initially

37. First Use Syndrome
• Recognize the symptoms of first-use syndrome and
differentiated those symptoms from the symptoms of
hemolysis, crenation, disequilibrium syndrome and dialyzer
reaction. The SIGNS AND SYMPTOMS of first-use syndrome
include itching, back pain and moderate hypotension.
• Note: With hemolysis and crenation you will see changes in the
appearance of the blood in the venous bloodline. With
disequilibrium Syndrome the patient should have some history to
indicate the presence of an elevated BUN, and the symptoms tend to
be more severe. With a dialyzer or sterilent reaction, the symptoms
tend to be more severe and SOB is a common feature. First- use
syndrome only occurs with a new, unprocessed dialyzer. First-use
syndrome results from complement activation by the new dialyzer
membrane, and it occurs more often with cellulosic membranes.

38. • Immediately reduce the blood pump speed to 100 ml/min.
• Notify the Charge Nurse.
• Evaluate the patient’s blood pressure and treat hypotension
with NS.
• If SIGNS AND SYMPTOMS do not resolve, return the
patient’s blood and purge the dialyzer and extracorporeal
circuit with 1000cc of NS.
• Restart dialysis cautiously with low blood pump speeds of
150-200 ml/min.
• Consider change in the patient’s dialyzer type or individual
pre-dialysis
preparation procedures as ordered by physician.

39. Blood Loss / Exsanguination
• Note: Blood loss during dialysis can occur on post blood pump
along the extracorporeal circuit. Manufacture’s defects have
occurred in the actual tubing and blood pump segments. Cuts have
been made in the tubing sets when opening packing boxes. Blood
loss can occur at the connection between the dialyzer and the
bloodline due to product defect or improper connection. Blood loss
can also occur from needle dislodgement or dialysis catheter
dislodgement. Every effort should be made by the dialysis staff to
secure against needle or catheter dislodgement.
• The staff member discovering the patient should immediately
clamp the venous bloodline and turn off the blood pump.
• Call for assistance and notify the Charge Nurse.
• Assess the patient for SIGNS AND SYMPTOMS of blood
loss. Administer NS, Albumin and oxygen in case of shock.
Implement emergency procedures if indicated.
• Establish the location of the break in the extracorporeal
circuit.

40. • If exsanguination is the result of fistula needle
dislodgement:
• Apply sterile gauze and clamp to the needle site.
• Clamp fistula needles and bloodlines.
• Remove the fistula needle from the bloodline and
dispose of it in a biohazard sharps container.
• Recirculate the extracorporeal circuit assessing for
the presence of air.
• Recannulate the vascular access.
• Restart dialysis.
• Assess probable cause of needle dislodgement
and take steps to avoid a recurrence.

41. • If exsanguination is the result of dialysis catheter
dislodgement:
• Apply pressure to catheter site with sterile gauze for at least
20 minutes.
• Observe the patient for possible SIGNS AND SYMPTOMS
of air embolus.
• Clamp catheter ports and bloodlines.
• Remove the dialysis catheter from the bloodlines and
dispose of it in a biohazard sharps container.
• Recirculate the extracorporeal circuit.
• Assess the patient for possible IV site for blood return and
return blood if possible.
• Notify physician of occurrence and follow arrange for
access replacement as ordered.
• Assess possible causes of catheter dislodgement and take
steps to prevent recurrence.

42. • If exsanguination is the result of a defect in the bloodlines or
dialyzer ports:
• Return patient’s blood if air in the circuit is not identified.
• Change bloodlines out, or change dialyzer out depending on
the nature of the break.
• Perform set-up per procedures.
• Restart dialysis.
Note product name and lot # in the medical record.
• Make all patient care staff aware of occurrence, and trend any
additional occurrences.
• Assess possible causes and take steps to prevent recurrence.
• If Clinical Manager is not present, and the cause of the
exsanguinations is unclear, preserve extracorporeal circuit for
evaluation.
• If a product failure is identified, notify Clinical and Technical
Manager.

43. Dialyzer Blood Leak
• If you have a blood leak warning, check a dialysate sample
from the drain line with a Hemastix test strip, by placing
the strip in the stream.
• Compare the strip to the results-key on the side of the
bottle.
• For Hemastix results that are Negative:
• You may continue the dialysis treatment if the Phoenix
Machine alarm continues Change settings on blood leak
detector to minimal
• If you continue to have a blood leak warning the machine
will need to be pulled and Complete a service report on
the machine and label it not for use.
• The machine should be cleaned and rinsed prior to use, for
either situation described above.

44. •For Hemastix results that are moderately positive, or hemolyzed, do
not attempt to return the blood.
•Turn off the blood pump.
•Clamp fistula needles or catheter ports and bloodlines.
•Disconnect the extracorporeal circuit, and place the bloodline
connector between the arterial and venous bloodlines.
•Flush the fistula needles or catheter ports with NS.
•Remove the extracorporeal circuit and dialyzer from the machine.
•Complete a service report on the machine and label it not for use.
•The machine should be cleaned and rinsed prior to its next use.
•Set patient up on a different machine, dialyzer and bloodline set per
procedure.Restart dialysis per procedure.
•For any actual dialyzer blood leak resulting in a positive Hemastix on
a re or pre-processed dialyzer, a Reprocessing Complaint must be
initiated.

45. Clotted Dializer
• Note: Clotting in the extracorporeal circuit is more likely when very low blood
flows are used, there are problems with adequate flow to or from the vascular access,
very high ultrafiltration rates are used, the patient’s hemoglobin is high, or very low
doses of heparin are used.
• Recognize the signs of clotting within the extracorporeal circuit, which
include: a darkening of the blood, clot formation within the drip chambers,
elevated venous pressure, and/or a rise in TMP.
• As soon as clotting is suspected, attempt to return the patients blood using
the NS line method.
• If the venous pressure continues to clime and returning the blood is not
possible, turn off the blood pump, clamp the bloodlines and catheter ports
or fistula needles.
• Disconnect the patient from the extracorporeal circuit.
• Flush the fistula needles or catheter ports with NS flushes.
• Set up a new dialyzer and bloodline set per procedure.
• Restart dialysis.
• Assess possible causes of the clotted circuit and take steps to prevent
recurrence.

46. Pyrogenic Reaction
• All patients will have their pre and post dialysis temperature
measured. In addition, any patient complaining of chills or
exhibiting signs of chills will immediately have their
temperature measured.
• Report any patient reporting chills, exhibiting signs of chills
or having a temperature of 100º F or greater to the Charge
Nurse immediately.
• Assess the patient for SIGNS AND SYMPTOMS of possible
febrile illness, including access infection, pulmonary
infections, urinary infections, flu SIGNS AND SYMPTOMS’s
or other indications of infection. Interview the patient for a
recent history of fever at home.
• Notify the patient’s physician or the physician on call.

47. • Collect 2 sets of blood cultures from the patient.
• Collect cultures of sputum, urine or the vascular access site if
SIGNS AND SYMPTOMS are present. Administer medications
or draw other lab tests as ordered by the physician.
• Consider transfer to acute care facility for patients with high
fevers or if the patient is unstable.
• Trend multiple episodes by patient and/or by date. Notify the
Medical Director immediately if multiple episodes or trends
develop.
• For any patient developing a fever during or post dialysis that
was asymptomatic pre-dialysis Collect a specimen of the
dialysate from the effluent end of the dialyzer in a urine cup.
Prepare the dialysate for culture and/or endotoxin evaluation
per procedure.

48. Hypertension
• Note: Hypertension in dialysis patients is most often associated with fluid volume
overload and medication non-compliance. It may also be aggravated by underlying
cardiac and/or renal disease, anxiety, substance abuse, and occasionally volume
contracture due to dehydration.
• Notify the Charge Nurse when a blood pressure exceeds 180/90 or anytime
the blood pressure is significantly different for a particular patient.
• Evaluate the patient’s usual trend in blood pressures.
• Evaluate the patient’s compliance with prescribed antihypertensive
medications. Reinforce compliance with prescribed medications if indicated.
• Evaluate the appropriateness of the patient’s dry weight, fluid volume
status and ultrafiltration plan. Reinforce fluid restriction if indicated.
• Notify the physician when the pre or intradialytic dialysis blood pressure
exceeds 210/110 and is unusual for that patient.
• Notify the physician when the post-dialysis blood pressure exceeds 180/100
and is unusual for that patient.
• Note: Patients whom are chronically hypertensive should have routine orders
established for medication administration and discharge criteria.
• Administer medications and instruct the patient on medication changes as
ordered by the physician.

49. Hypotension
• Note: Hypotension in dialysis patients is most often associated with fluid
removal from the patient’s vascular system at a rate, which exceeds the
vascular refill rate. It may also be aggravated by, underlying cardiac disease,
inaccurate dry weight assessment and occasionally dehydration.
• Notify the Charge Nurse when a blood pressure is less than 100/50,
anytime the blood pressure is significantly different for a particular
patient, or when the patient is symptomatic.
• Evaluate the patient’s usual trend in blood pressures and usual
tolerance to ultrafiltration.
• Evaluate the patient’s prescribed antihypertensive medications.
• Evaluate the accuracy of the patient’s pre-dialysis weight.
• Evaluate the appropriateness of the patient’s dry weight, fluid
volume status and ultrafiltration plan. Reinforce fluid restriction if
indicated.
• Utilize sodium modeling and other hyperosmolar agents to increase
the vascular refill rate. Such agents should be used prophylacticly in
patients chronically hypotensive during ultrafiltration.

50. • Notify the physician when profound hypotension does not
respond to appropriate therapy, or when changes in the
treatment plan are indicated.
• When the patient exhibits SIGNS AND SYMPTOMS of severe
hypotension (diaphoresis, nausea and vomiting, or seizure:
• Open the NS line and NS port and administer 150-250cc of NS.
• Lower the patient’s UFR to 0.3 l/min
• Reassess the blood pressure every 2-3 minutes until the patient
is stabilized.
• Be alert for respiratory and/or cardiac arrest and implement
emergency procedures as indicated.
• Notify the physician when the post-dialysis blood pressure is
less than 100/50 unless the patient has a specific order to be
discharged with a lower blood pressure.

51. Hypoglycemia
• Recognize the SIGNS AND SYMPTOMS of hypoglycemia in diabetic
patients. These include diaphoresis, decreased mental status, feeling
faint, irritability and or tremors.
• Evaluate the patient’s blood pressure to rule out hypotension.
• Check the patient’s blood glucose level using the glucometer.
• Notify the Charge Nurse when a blood sugar is less than 80, and/or
the patient is symptomatic.
• 50% dextrose may be administered at the discretion of the Charge
Nurse after evaluating the patient’s food intake and insulin usage.
• Patients who do not take insulin or oral hypoglycemic agents should
be encouraged to eat a small snack rather than receive 50% dextrose.
• Patients who have not eaten and taken their insulin should try to eat a
small snack in addition to receiving 50% dextrose.
• Patients who have eaten an appropriate amount of food and taken
insulin as prescribed should be evaluated individually when
considering 50% dextrose administration.
• Evaluate the patient’s prescribed hypoglycemic medications and
recent blood glucose levels.
• Notify the physician when profound hypoglycemia does not respond
to appropriate therapy, or when changes in the treatment plan are
indicated.

52. Muscle Cramps
• Note: Muscle Cramps in dialysis patients is most often associated
with fluid removal from the patient’s vascular system at a rate, which
exceeds the vascular refill rate. It may also be aggravated by,
underlying vascular disease, inaccurate dry weight assessment,
electrolyte imbalances and occasionally dehydration.
• Administer 150cc of NS to the extracorporeal circuit via the NS
line.
• Temporarily decrease the ultrafiltration rate to 0.3 l/hr.
• Notify the Charge Nurse when muscle cramps are unrelieved
by steps #1 and #2.
• Evaluate the patient’s usual trend in fluid volume weight gains
and their usual tolerance to ultrafiltration.
• Evaluate the accuracy of the patient’s pre-dialysis weight.
• Evaluate the appropriateness of the patient’s dry weight, fluid
volume status and ultrafiltration plan. Reinforce fluid
restriction if indicated.

53. • Note: Patients gaining more than 3 Kg’s between dialysis treatments are
more prone to experience side effects associated with ultrafiltration.
If the patient does not usually cramp and no unusual circumstances
are identified, consider recirculating the extracorporeal circuit and
weighing the patient in the dialysis chair.
• Note: The weight of all dialysis chairs is recorded on a sticker located on the
back of each chair. While rare, failure of the machines ultrafiltration system
is possible resulting in excessive ultrafiltration and dehydration of the
patient. Weighing the patient during the dialysis treatment should provide
an indication of the accuracy of the ultrafiltration.
• Utilize sodium modeling and other hyperosmolar agents to increase
the vascular refill rate. Such agents should be used prophylacticly in
patients who chronically have muscle cramps during ultrafiltration.
• Note: Mannitol or dialysate sodium adjustments may not be used during
the last hour of dialysis.
• Dextrose 50% 10-15cc IVP via the venous drip chamber may be used
to relieve cramps in non-diabetic patients during the last hour or post
dialysis.
• Notify the physician when profound muscle cramps do not respond
to appropriate therapy, or when changes in the treatment plan are
indicated.

54. Using Patient Restraints
• Note: Physical restraints may be used only when less restrictive
measures prove inadequate to prevent the agitated or disoriented
patient from injuring himself or others and to prevent the patient
from deleteriously interfering with medical treatment. The least
restrictive device appropriate for the patient should be used.
• Identify alternative means to avoid the need for restraints.
Consistently reinforce to the patient the importance of his
medical care. Enlist the assistance of ancillary personnel to sit
with the patient. Provide the patient with distractions such as
coloring books or magazines. Tape bloodlines out of the
patient’s direct line of vision. Place patients in the dialysis unit
to await transportation when additional supervision is needed.
• If the above measures fail, identify the least restrictive restraint
device appropriate for the patient and the situation.
• Contact the physician and obtain an order for the restraint.

55. • Complete the restraint order form.
• Contact the patient’s emergency contact and request
permission to use the restraint device. (The patient
must consent if competent.) Document their
permission to use the device on the Restraint Form.
• Apply the device and assure the patient’s safety and
comfort.
• Perform routine checks of the patient at least every 30
minutes to include the condition of the restrained
limb.
• Remove the restraint device as soon as the condition
justifying its use no longer exists.
• Document the condition of the extremity at the time
the restraint device is removed.

56. Questions & Answers
Thank You!