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Does this patient have intrdialytic hemolysis?
Grossly translucent hemolyzed blood in the extracorporeal blood line
Symptoms vary depending on causes and severity
Causes
Mechanical
High blood flow rate, single-needle dialysis, small-gauge cannula, kinked blood line, highly negative arterial pressure, offset blood pump
Dialysate contamination
Chloramine: dyspnea, cyanosis (methemoglobinemia, not improved by oxygen therapy), malaise, headache, vomiting, palpitation
Nitrate: abdominal pain, diarrhea, cyanosis (methemoglobinemia, not improved by oxygen therapy)
Copper: skin flushing, abdominal pain, diarrhea, cyanosis (methemoglobinemia, not improved by oxygen therapy)
Fluoride: malaise, abdominal pain, chest pain, bradycardia, cardiac instability, hypocalcemia (tetany, seizure,coma), hypomagnesemia
Dialysate error
Hypotonic dialysate (hyponatremia)
Overheated dialysate
Failure to properly rinse reprocessed dialyzer
Hypochlorite
Formaldehyde
Hydrogen peroxide
Severity (mild to severe)
Nausea, vomiting, headache, abdominal pain, hypotension, cyanosis, confusion, seizure, sudden cardiac arrest (hyperkalemia)
What tests to perform?
Diagnosis by clinical judgment (grossly translucent hemolyzed blood)
Laboratory tests should be ordered to confirm diagnosis
Reticulocyte count
Haptoglobin
Lactate dehydrogenase
Blood smear
Coombs test
Serum potassium (exclude hyperkalemia)
Methemoglobin measurement
51Cr-labeled red blood cell survival (if recurrent)
Bone marrow examination (if recurrent)
Dialysate examination (chloramine, other contaminants)
How should patients with intradialytic hemolysis be managed?
Acute management
Stop dialysis
Do not return blood to patient
Assess severity of hemolysis
Provide symptomatic support (treat hyperkalemia)
Provide circulatory support if hypotension develops
Identify causes
Prevention
Dialysis prescription
Monitor arterial pressure in extracorporeal circuit (not to exceed -160 mmHg)
Avoid high blood flow rate if using small-gauge needle
Monitor rinsing of disinfectants/germicides from reprocessed dialyzers
Monitor dialysate conductivity
Monitor dialysate temperature
Maintain dialysate quality control
What happens to patients with intradialytic hemolysis??
Need for hospitalization
High mortality risk (if severe)
How to utilize team care?
1. Specialty consultations: Code team (if patient develops cardiac arrest); hematology (if recurrent episode)
2. Nursing – Close monitoring of high-risk patients.
Are there clinical practice guidelines to inform decision making?
Applications
2010 Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science. (Published by American Heart Association)
Other considerations
ICD-10-CM diagnosis code I97.3: Postprocedural hypertension
What is the evidence?
Sayre, MR, Koster, RW, Botha, M, Cave, DM, Cudnik, MT, Handley, AJ, Hatanaka, T, Hazinski, MF, Jacobs, I, Monsieurs, K, Morley, PT, Nolan, JP, Travers, AH. “Adult Basic Life Support Chapter Collaborators. Part 5: Adult basic life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations”. Circulation. vol. 122. 2010. pp. S298-324.
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