CCHT Interventions 2 — Questions and Answers
Question 1: A patient develops hypotension (BP 80/50) during dialysis with associated diaphoresis and pallor. After stopping ultrafiltration, what is the next immediate intervention?
- Administer 25% albumin solution
- Place patient in Trendelenburg position and administer a normal saline bolus (Correct answer)
- Increase blood pump speed to improve cardiac output
- Administer antihypertensive medications to stabilize BP
Correct answer: Place patient in Trendelenburg position and administer a normal saline bolus
Trendelenburg positioning (legs elevated) increases venous return to the heart, and saline bolus rapidly expands intravascular volume to treat dialysis-induced hypotension.
Dialysis-induced hypotension management: (1) Stop or reduce UF rate, (2) Trendelenburg or supine with legs elevated to increase preload, (3) IV NS bolus 100 to 250 mL for rapid volume expansion, (4) Reduce blood pump speed, (5) Notify nurse. If unresponsive: hypertonic saline (3%, 10 to 20 mL), 50% dextrose, or mannitol. Antihypertensives are CONTRAINDICATED during a hypotensive episode.
Question 2: What is the first-line intervention for a patient experiencing first-use syndrome during hemodialysis?
- Continue treatment as the reaction is mild and self-limiting
- Stop dialysis, clamp and discard blood lines, administer antihistamine and notify physician (Correct answer)
- Switch to a different dialyzer type without stopping treatment
- Increase ultrafiltration to remove the offending substances
Correct answer: Stop dialysis, clamp and discard blood lines, administer antihistamine and notify physician
First-use syndrome (Type A anaphylactic reaction) requires immediate treatment discontinuation with blood discarded (not returned), antihistamine administration, and physician notification.
First-use syndrome includes Type A (anaphylactic/anaphylactoid, within 5 min) and Type B (non-specific, within 20 to 40 min). Type A: bronchospasm, hypotension, pruritus, urticaria, potentially life-threatening. NEVER return blood as it may contain complement activation products. Administer epinephrine for severe reactions, diphenhydramine for milder reactions. Risk factors: sensitization to ETO sterilization, polyacrylonitrile membranes, ACE inhibitors.
Question 3: During hemodialysis, a patient develops sudden severe chest pain, dyspnea, and becomes cyanotic. The blood in the venous line appears pink/clear instead of dark red. What emergency is occurring?
- Pulmonary embolism from DVT
- Hemolysis (red cell destruction from mechanical or chemical causes) (Correct answer)
- Severe hypotension causing tissue hypoperfusion
- Air embolism from a disconnected blood line
Correct answer: Hemolysis (red cell destruction from mechanical or chemical causes)
Pink/clear blood (hemolyzed blood) indicates massive hemolysis, a life-threatening dialysis emergency where red blood cells are being destroyed.
Hemolysis in dialysis causes pink-tinged plasma as hemoglobin is released from destroyed RBCs. Causes: hypotonic dialysate (incorrect concentrate ratio), overheated dialysate (above 42 degrees C), formalin contamination, kinked blood lines, or chemical contamination of water (chloramines, copper, bleach). Actions: STOP treatment immediately, DO NOT return blood (free hemoglobin causes acute tubular necrosis, hyperkalemia), call physician.
Question 4: What is the appropriate response when a dialysis patient develops seizures during treatment?
- Restrain the patient to prevent injury and continue treatment
- Protect the patient from injury, stop UF, reduce blood pump speed, notify nurse/physician, and prepare to terminate treatment (Correct answer)
- Administer IV diazepam immediately without notifying the physician
- Increase blood pump speed to improve cerebral perfusion
Correct answer: Protect the patient from injury, stop UF, reduce blood pump speed, notify nurse/physician, and prepare to terminate treatment
Seizures during dialysis require patient protection from injury, immediate reduction in treatment intensity, and urgent notification of the nurse and physician.
Seizures during hemodialysis may be caused by: dialysis disequilibrium syndrome, severe hypotension/hypoxia, electrolyte imbalances (hypocalcemia, hyponatremia), uremic encephalopathy, or pre-existing seizure disorder. Never restrain the patient (causes fractures). Protect from falls, turn on side to prevent aspiration, call for immediate help. Disequilibrium prevention: use slower blood pump speeds and shorter first treatments for new dialysis patients.
Question 5: A patient on hemodialysis suddenly develops fever of 39.5 degrees C and shaking chills during treatment. What is the most likely cause and appropriate action?
- Dialysate temperature too high; reduce dialysate temperature and continue
- Pyrogen reaction or bacteremia; stop treatment, take blood cultures, notify physician, administer antipyretics as ordered (Correct answer)
- Normal response to fluid removal; apply cool compresses and continue
- Allergic reaction to heparin; stop heparin infusion and continue treatment
Correct answer: Pyrogen reaction or bacteremia; stop treatment, take blood cultures, notify physician, administer antipyretics as ordered
Fever with rigors during dialysis suggests pyrogen reaction (bacterial endotoxin contamination) or bacteremia from the vascular access, requiring immediate evaluation.
Fever and rigors during dialysis indicate either: (1) Pyrogenic reaction from endotoxin contamination of dialysate or blood circuit, or (2) Bacteremia/sepsis from infected vascular access. Both require: stop treatment if hemodynamically unstable, draw blood cultures from the access and peripheral site before antibiotics, notify physician, administer acetaminophen as ordered, monitor vitals closely.
Question 6: What is the correct initial management of a suspected air embolism during hemodialysis?
- Clamp the venous line, place patient in left lateral decubitus Trendelenburg position, stop blood pump, call for help (Correct answer)
- Increase blood pump speed to push air through the heart quickly
- Place patient upright to allow air to rise and exit the pulmonary circulation
- Continue treatment and monitor as small amounts of air are not clinically significant
Correct answer: Clamp the venous line, place patient in left lateral decubitus Trendelenburg position, stop blood pump, call for help
Left lateral decubitus Trendelenburg position traps air in the right atrium apex (away from pulmonary artery), while clamping the venous line and stopping the pump prevents further air entry.
Air embolism treatment: (1) Clamp venous blood line immediately, (2) Stop blood pump, (3) Do NOT return blood as lines may contain air, (4) Call emergency code and physician immediately, (5) Position patient left lateral decubitus (left side down) with Trendelenburg (head down) to trap air in the right atrium away from the pulmonary outflow tract, (6) Administer 100% oxygen, (7) Cardiac massage if needed to break up air lock. This is a code-level emergency.
CCHT Interventions 2
A patient develops hypotension (BP 80/50) during dialysis with associated diaphoresis and pallor.
After stopping ultrafiltration, what is the next immediate intervention?