Implementation of an Algorithm Utilizing Saline Versus Albumin for the Treatment of Intradialytic Hypotension

2018 ◽  
Vol 53 (2) ◽  
pp. 159-164
Author(s):  
Ling Yin ◽  
Dennis Dubovetsky ◽  
Patricia Louzon-Lynch
Keyword(s):  
Blood Pressure ◽  
Treatment Failure ◽  
Pharmacy Education ◽  
Dialysis Session ◽  
Intradialytic Hypotension ◽  
Dialysis Patients ◽  
Total Cost ◽  
Treatment Failure Rate ◽  
Time Required ◽  
Algorithm Implementation

Background: Intradialytic hypotension (IDH) is the most commonly reported complication of hemodialysis (HD) treatment. At our institution, dialysis patients often have both 25% albumin and normal saline ordered as rescue options for management of IDH, without specification of which agent to use first. Objective: The purpose of this study was to determine the effect of an algorithm for IDH management. Methods: A retrospective study was conducted in HD patients who experienced IDH. The primary end point was to evaluate albumin use. Secondary end points included albumin costs, study fluid use per dialysis session, compliance with algorithm, efficacy of hypotension reversal to mean arterial pressure (MAP) ⩾60 mm Hg, percentage of target ultrafiltration achieved, time required to restore systolic blood pressure ⩾90 mm Hg, blood pressure post–study fluids, IDH treatment failure rate, and early termination of dialysis as a result of persistent IDH. Results: Implementation of the algorithm was observed in 94% of patients (n = 90). Total albumin use was significantly reduced from 11 400 to 4700 mL in the pre– (n = 90) and post–algorithm implementation group (n = 90; P < 0.001). The associated total cost of albumin was reduced by 59% ($10 534 vs $4343; P < 0.001). No statistical differences were observed between the 2 groups regarding efficacy of hypotension reversal to MAP ⩾60 mm Hg, early HD termination, or treatment failure rates (all P = 0.99). Conclusion and Relevance: Implementation of an evidence-based, standardized algorithm and pharmacy education to nursing staff can result in a reduction in albumin use and its associated drug costs for IDH management without compromising efficacy of IDH reversal.

Evidence of Profiled Hemodialysis Efficacy in the Treatment of Intradialytic Hypotension

1998 ◽  
Vol 21 (7) ◽  
pp. 398-402 ◽  
Author(s):  
L. Colì ◽  
G. La Manna ◽  
V. Dalmastri ◽  
A. De Pascalis ◽  
G. Pace ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Blood Volume ◽  
Sodium Concentration ◽  
Dialysis Session ◽  
Intradialytic Hypotension ◽  
Dialysis Patients ◽  
Non Invasive ◽  
Comparison Of The Results ◽  
Weight Decrease ◽  
Dialysate Sodium

In the last 10 years the percentage of dialysis patients suffering from clinical intradialytic intolerance has greatly increased. Profiled hemodialysis (PHD) is a new technical approach, alternative to standard hemodialysis (SHD) for the treatment of intradialytic symptomatic hypotension. It is based on intradialytic modulation of the dialysate sodium concentration, using a dialysate sodium concentration profile elaborated by a new mathematical kinetic model. The aim of PHD is to reduce the intradialytic blood volume decrease, thanks to a dialysate sodium profile, which allows a reduction in the plasma osmolarity decrease, thereby boosting intravascular fluid refilling. This work aims at clinically validating the PHD technique, by testing its ability, against SHD, to maintain a more stable intradialytic blood volume; this evaluation was supported by monitoring some hemodynamic parameters. Twelve dialysis patients on SHD treatment were selected because of their intradialytic symptomatic hypotension. Twelve SHD (one per patient) and 12 PHD sessions (one per patient) were performed to achieve the same sodium mass removal and body weight decrease on both PHD and SHD. During these sessions we monitored the blood volume variation % by the critline (a non invasive blood volume monitoring device), the mean blood pressure and heart rate directly and, finally, the stroke volume and cardiac output indirectly by bidimensional doppler-echocardiography. Comparison of the results obtained with the two techniques shows PHD to achieve a significantly more stable blood volume, blood pressure and cardiovascular function than SHD, in particular during the second and the third hour of the dialysis session.

Impaired sympathetic response before intradialytic hypotension: a study based on spectral analysis of heart rate and pressure variability

1999 ◽  
Vol 96 (1) ◽  
pp. 23-31 ◽  
Author(s):  
Gualtiero PELOSI ◽  
Michele EMDIN ◽  
Clara CARPEGGIANI ◽  
Maria Aurora MORALES ◽  
Marcello PIACENTI ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Systolic Blood Pressure ◽  
Pressure Fluctuations ◽  
Power Spectra ◽  
Low Frequency ◽  
Autonomic Response ◽  
Dialysis Session ◽  
Intradialytic Hypotension ◽  
Sympathetic Response ◽  
A Minor

The purpose of this study was to evaluate the autonomic response to standard haemodialysis and the changes associated with the onset of intradialytic hypotension in 12 normotensive patients with uraemia. Power spectra of R–R interval and of blood pressure fluctuations were obtained during a standard dialysis session and estimated in the low-frequency (LF, 30–150 ;mHz) and high-frequency (HF, 150–400 ;mHz) range. The absolute power of the LF component of blood pressure variations and the LF/HF ratio of R–R interval were assumed as indexes of sympathetic activity. Standard haemodialysis induced hypotension in six patients (unstable) while a minor pressure decline was present in the other six (stable). Normalized blood volume before dialysis and percentage volume reduction were similar in the two groups. Tachycardia in response to pressure and volume decrease was more pronounced in stable than in unstable patients, as evidenced by a higher slope of the relation between R–R interval and systolic blood pressure (7.9 versus 0.9 ;ms/mmHg, P< 0.01). Sympathetic tone was enhanced during early dialysis in all patients (+2±1 for R–R LF/HF ratio, +2.4±0.6 ;mmHg2 and +7.2±2 ;mmHg2 for absolute LF power of diastolic and of systolic blood pressure respectively, P< 0.05), compared with baseline predialysis values. During late dialysis, unstable patients showed an impairment of sympathetic activation which preceded hypotension and was maximal during the crisis (-2.9±1.4 for R–R LF/HF ratio, -2.7±1.4 ;mmHg2 and -8.6±4.0 ;mmHg2 for absolute LF power of diastolic and of systolic blood pressure respectively, P< 0.05). On the contrary, stable patients showed constantly elevated indexes (+3.7±1.4 for R–R LF/HF ratio, +5.9±2.7 ;mmHg2 and +13.3±6.2 ;mmHg2 for LF of diastolic and of systolic blood pressure, P< 0.05). Values returned to predialysis levels after the end of the dialysis session in all patients. We conclude that standard haemodialysis activates a marked and reversible sympathetic response in both stable and unstable uraemic patients. However, in unstable patients, such activation is impaired in late dialysis, therefore contributing to the onset of the hypotensive crisis.

scholarly journals P1242THE RELATIONSHIP BETWEEN INTRADIALYTIC HYPOTENSION AND DIFFERENT BRAIN COMPONENTS VOLUME/ COGNITIVE FUNCTION IN MAINTENANCE HEMODIALYSIS PATIENTS

2020 ◽  
Vol 35 (Supplement_3) ◽  
Author(s):  
Ke Zheng ◽  
Yujun Qian ◽  
Tianye Lin ◽  
Fei Han ◽  
Feng Feng ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Regression Analysis ◽  
Cognitive Impairment ◽  
Cognitive Function ◽  
Brain Atrophy ◽  
Intradialytic Hypotension ◽  
Dialysis Patients ◽  
Brain Nuclei ◽  
Posterior Cingulate ◽  
Maintenance Haemodialysis

Abstract Background and Aims Intradialytic hypotension (IDH) is common in maintenance haemodialysis patients, which is associated with disabling symptoms and interrupted treatment. Blood pressure fluctuations during haemodialysis may affect cerebral perfusion and subsequently brain atrophy and cognitive impairment. This study aimed to explore the correlation of IDH with brain atrophy and cognitive impairment. Method IDH was defined when the patients showed obvious hypotension symptoms during the dialysis procedure, such as dizziness, sweating or loss of consciousness, accompanied by blood pressure decrement, and needed to be treated by clinicians in the past one year. All patients received 3.0T MRI examination and cognitive function evaluation. We used the voxel-based morphometry (VBM) method to evaluate the changes of brain multi-component volume. All of the brain region (including gray and whiter matter, brain nuclei, ect.) volumes were measured by calculating the total number of voxels in each image data, with resampling voxel size of 1 mm. A wide range of cognitive tests was administered to evaluate cognitive function, including MMSE, MoCA, Philadelphia word learning test, Boston Naming Test, and trial making test. The cognitive function and brain multi-component volume of were compared between patients with and without IDH (IDH and no-IDH groups), and the correlation between brain volume and IDH was investigated by regression analysis. Results Totally 119 maintenance haemodialysis patients enrolled our study. 22 dialysis patients had the experience of IDH, and the prevalence is 18.5%. The patients with IDH had higher prevalence of diabetes and longer dialysis vintage (40.9% vs 16.5, p=0.011; 70.0 vs 41.0 months, p=0.054), they also had a lower post-dialysis SBP and DBP. The MMSE scores and MoCA scores of patients with IDH and without IDH were similar (29.0 vs 29.0, p= 0.621; 23.5 vs 24.0, p= 0.273). There was no difference in gray matter and white matter between IDH and no-IDH groups. But as for some important brain nuclei and parts associate with emotion and vision, like amygdala, cuneus and posterior cingulate, patient with IDH were smaller than patients without IDH (1.6±0.2 vs 1.7±0.2 mm3, p=0.009; 6.9±0.8 vs 7.4±1.0 mm3, p=0.031; 6.9±0.8 vs 7.4±0.9 mm3, p=0.024). The multiple-regression analysis showed that IDH was significantly associated with the volume atrophy of amygdala, cuneus and posterior cingulate (β=-0.12, p=0.009; β=-0.48, p=0.031; β=-0.48, p=0.026). Conclusion IDH was not rare in maintained dialysis patients. IDH may cause some specific brain components atrophy which may relative to emotion and visual changes in dialysis patients but was not associated with cognitive impairment and cognitive relative brain components.

scholarly journals Intradialytic Hypotension and Cardiac Remodeling: A Vicious Cycle

2015 ◽  
Vol 2015 ◽  
pp. 1-7 ◽  
Author(s):  
Chia-Ter Chao ◽  
Jenq-Wen Huang ◽  
Chung-Jen Yen
Keyword(s):  
Blood Pressure ◽  
Left Ventricular Hypertrophy ◽  
Cardiac Remodeling ◽  
Ventricular Hypertrophy ◽  
Hemodynamic Instability ◽  
Left Ventricular ◽  
Chronic Dialysis ◽  
Intradialytic Hypotension ◽  
Dialysis Patients ◽  
Compensatory Mechanisms

Hemodynamic instability during hemodialysis is a common but often underestimated issue in the nephrologist practice. Intradialytic hypotension, namely, a decrease of systolic or mean blood pressure to a certain level, prohibits the safe and smooth achievement of ultrafiltration and solute removal goal in chronic dialysis patients. Studies have elucidated the potential mechanisms involved in the development of Intradialytic hypotension, including excessive ultrafiltration and loss of compensatory mechanisms for blood pressure maintenance. Cardiac remodeling could also be one important piece of the puzzle. In this review, we intend to discuss the role of cardiac remodeling, including left ventricular hypertrophy, in the development of Intradialytic hypotension. In addition, we will also provide evidence that a bidirectional relationship might exist between Intradialytic hypotension and left ventricular hypertrophy in chronic dialysis patients. A more complete understanding of the complex interactions in between could assist the readers in formulating potential solutions for the reduction of both phenomena.

scholarly journals Relationship between Dose of Bolus Dialysate Infusion and Blood Pressure in Intermittent Infusion Hemodiafiltration

2019 ◽  
Vol 48 (1) ◽  
pp. 27-32
Author(s):  
Shigeru Otsubo ◽  
Kei Eguchi ◽  
Michio Mineshima ◽  
Ken Tsuchiya ◽  
Kosaku Nitta
Keyword(s):  
Blood Pressure ◽  
Intermittent Infusion ◽  
Dry Weight ◽  
Optimal Dose ◽  
Fluid Volume ◽  
Maintenance Hemodialysis ◽  
Dialysis Session ◽  
Intradialytic Hypotension ◽  
Bolus Infusion ◽  
The Difference

Background: Intermittent infusion hemodiafiltration is a recently developed convective method of renal replacement therapy using cyclic back-filtration infusion. Quick and regular infusion prevents intradialytic hypotension. However, the optimal dose of bolus dialysate infusion required to stabilize blood pressure has not been reported. Here, we investigated the relationship between the dose of bolus dialysate infusion and blood pressure. Summary: A total of 77 patients on maintenance hemodialysis were enrolled in this study. Dialysate was infused rapidly by backward filtration at a rate of 150 mL/min at 30-min intervals using an automated dialysis machine. The effects with two bolus infusion volumes (100 and 200 mL) were compared, each for an observation period of 2 weeks. Systolic blood pressure (SBP) was measured at the start and at the end of each dialysis session, and the highest SBP and lowest SBP measurements were also recorded. Patients were divided according to dry weight into a <52 kg group and a ≥52 kg group, and various parameters were compared between the 100 and 200 mL bolus infusion volumes in each group. Among patients in the <52 kg group, SBP did not vary at any of the time points. However, for patients in the ≥52 kg group, SBP at the end of treatment was significantly lower in the 100-mL group than in the 200-mL group (141 ± 20 vs. 144 ± 21 mm Hg, p = 0.041), and the minimum SBP was also lower in the 100-mL group than in the 200-mL group (127 ± 17 vs. 131 ± 18 mm Hg, p = 0.010). Key Messages: Among patients with a dry weight of ≥52 kg, blood pressure was more stable when a bolus fluid volume of 200 mL was used, compared with a volume of 100 mL. However, for patients with a dry weight of <52 kg, the significance of the difference in bolus fluid volumes disappeared. Thus, the replacement fluid volume might be better determined based on the patient’s dry weight. Trial Registration: UMIN 000028145, Registered July 10, 2017.

scholarly journals FACTORS ASSOCIATED WITH INTRADIALYTIC HYPOTENSION IN HEMODIALYSIS PATIENTS AND WAYS OF ITS CORRECTION. CLINIC EXPERIENCE

2017 ◽  
pp. 20-22
Author(s):  
L. Snisar ◽  
L. Liksunova ◽  
N. Aleksieieva
Keyword(s):  
Blood Pressure ◽  
Systolic Dysfunction ◽  
Pressure Profile ◽  
Hemodialysis Patients ◽  
Intradialytic Hypotension ◽  
Dialysis Patients ◽  
Improvement Project ◽  
Factors Associated ◽  
Blood Pressure Profile ◽  
Clinic Experience

Results of studies in recent years show a worse survival rate of dialysis patients who have frequent episodes intradialytic hypotension (IDH), as opposed patients without IDH. The purpose of this quality improvement project was to study the factors associated with intradialytic hypotension in these patients and institute appropriate measures to mitigate this issue. Patients and methods. In our clinic, we identified that 14.3% of dialysis patients experienced a decrease in their systolic blood pressure (SBP) to below 80 during dialysis. Results. The results were studied for 3 months. We found that 57.1% of patients experienced an improvement in their blood pressure profile over the period of the study. Conclusions. Factors associated with IDH are hypocalcemia, heart failure with systolic dysfunction, increase mterdialytic body weight over 2.5 kg and hospitalizations more than 2 times/year. Suggesting that simple changes to dialysis prescription can result in a significant reduction in the incidence of IDH.  

scholarly journals Validity of Intermittent Infusion Hemodiafiltration

2019 ◽  
Vol 48 (1) ◽  
pp. 7-10
Author(s):  
Michio Mineshima ◽  
Kei Eguchi
Keyword(s):  
Medical Staff ◽  
Intermittent Infusion ◽  
Peripheral Circulation ◽  
Dialysis Session ◽  
Water Removal ◽  
Intradialytic Hypotension ◽  
Dialysis Patients ◽  
Lower Blood ◽  
Group 3 ◽  
Rapid Drop

Background: Intermittent infusion hemodiafiltration (I-HDF) has been developed to prevent a rapid drop in blood pressure during a dialysis session and to improve peripheral circulation. In Japan, >10,000 dialysis patients underwent treatment with I-HDF in 2017, and the number of dialysis patients is increasing year by year. I-HDF involves the intermittent infusion of ultrapure dialysis fluid or sterile nonpyrogenic substitution fluid, for example, at a volume of 200 mL and a rate of 150 mL/min by backfiltration every 30 min during treatment. The total infusion volume can therefore be estimated at 200 (mL) × 7 (infusions) or 1.4 L/session. I-HDF may be regarded as online HDF with a very small replacement volume. Summary: Several clinical trials of I-HDF have been conducted in Japan. (1) In a 2007 study, despite there being no differences noted in the volume of water removal between hemodialysis (HD) and I-HDF, a significantly lower rate of reduction in the time-averaged blood volume was seen in I-HDF than in HD, so the plasma refilling rate was greater during I-HDF. (2) In a 2015 study, at 13 weeks after a switch from HD, I-HDF was found to be significantly superior to HD in terms of the incidence of events needing intervention by medical staff. However, significantly lower blood β2-microglobulin (MG) and α1-MG levels were observed in the predilution online HDF (pre-HDF) group than in the I-HDF group, and the amount of albumin leak was lower in the I-HDF group than in the pre-HDF group. (3) In a 2017 study, compared with HD, I-HDF was associated with a reduced number of interventions for intradialytic hypotension and less severe tachycardia, suggesting less sympathetic stimulation during I-HDF. Key messages: I-HDF is a valid treatment option because it is associated with an increased plasma refilling rate and fewer interventions needed by medical staff.

scholarly journals Low dose magnesium sulphate regimen and maternal outcome of patients with eclampsia

2022 ◽  
Author(s):  
Palvi Banotra
Keyword(s):  
Blood Pressure ◽  
Treatment Failure ◽  
Recurrence Rate ◽  
Failure Rate ◽  
High Blood Pressure ◽  
Magnesium Sulphate ◽  
Low Dose ◽  
Safety Margin ◽  
Maternal Outcome ◽  
Treatment Failure Rate

Background: Preeclampsia, a serious pregnancy complication which is commonly characterized by high blood pressure, presence of protein in the urine and sometimes swelling in women's feet, legs and hands. With this condition, patient’s high blood pressure often results in seizures. Generally, the outcome remains good, however, eclampsia can be life threatening and disastrous.Methods: This cross-sectional study considered 114 patients who meet inclusion criteria and agreed to will-fully participate in the study were evaluated for different parameters. Patients who developed eclampsia during intra-natal and postnatal period were included in the study. The aim of the study was to evaluate the maternal outcome among all patients of eclampsia treated with low magnesium sulphate dosage therapy.  Results: The present study revealed, very low fit recurrence rate, low mortality rate, zero treatment failure rate, no toxicity and (99.12%) success rate.Conclusions: Apart from zero percent treatment failure rate, Low maternal mortality and fit recurrence rate encouraged us to continue the treatment with low dose MGSO4 regimen. Thus, low dose magnesium sulphate has been found very effective in treating the eclmpsia and at the same time maintains the high safety margin.

scholarly journals Hemodynamic and Metabolic Tolerance of Acetate-Free Biofiltration in Mechanically Ventilated Critically Ill Patients: A Real-Life Study

2021 ◽  
Vol 10 (24) ◽  
pp. 5729
Author(s):  
Anna Gouin ◽  
Pierre Tailpied ◽  
Olivier Marion ◽  
Laurence Lavayssiere ◽  
Chloé Medrano ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Dialysis Session ◽  
Co2 Removal ◽  
Intradialytic Hypotension ◽  
Vasoactive Agent ◽  
Mechanically Ventilated ◽  
Mechanically Ventilated Patients ◽  
Ventilated Patients

Intradialytic hypotension can lead to superimposed organ hypoperfusion and ultimately worsens long-term kidney outcomes in critically ill patients requiring kidney replacement therapy. Acetate-free biofiltration (AFB), an alternative technique to bicarbonate-based hemodialysis (B-IHD) that does not require dialysate acidification, may improve hemodynamic and metabolic tolerance of dialysis. In this study, we included 49 mechanically ventilated patients requiring 4 h dialysis (AFB sessions n = 66; B-IHD sessions n = 62). Whereas more AFB sessions were performed in patients at risk of hemodynamic intolerance, episodes of intradialytic hypotension were significantly less frequent during AFB compared to B-IHD, whatever the classification used (decrease in mean blood pressure ≥ 10 mmHg; systolic blood pressure decrease >20 mmHg or absolute value below 95 mmHg) and after adjustment on the use of vasoactive agent. Diastolic blood pressure readily increased throughout the dialysis session. The use of a bicarbonate zero dialysate allowed the removal of 113 ± 25 mL/min of CO2 by the hemofilter. After bicarbonate reinjection, the global CO2 load induced by AFB was +25 ± 6 compared to +80 ± 12 mL/min with B-IHD (p = 0.0002). Thus, notwithstanding the non-controlled design of this study, hemodynamic tolerance of AFB appears superior to B-IHD in mechanically ventilated patients. Its use as a platform for CO2 removal also warrants further research.

scholarly journals Effect of Intravenous Fluids on Blood Pressure Course during Hemodialysis in Hypotensive-Prone Patients

2000 ◽  
Vol 11 (3) ◽  
pp. 550-555
Author(s):  
FRANK M. VAN DER SANDE ◽  
ANTINUS J. LUIK ◽  
JEROEN P. KOOMAN ◽  
VIC VERSTAPPEN ◽  
KAREL M. L. LEUNISSEN
Keyword(s):  
Blood Pressure ◽  
Hypertonic Saline ◽  
Blood Volume ◽  
Acute Treatment ◽  
Dialysis Session ◽  
Intravenous Fluids ◽  
Dialysis Patients

Abstract. Hypertonic and hyperoncotic solutions are generally used as acute treatment for symptomatic hypotension during dialysis. Administration of hydroxyethylstarch (HES) was recently shown to be an effective substitution fluid in preserving blood volume (BV) and systolic BP (SBP) in a group of stable dialysis patients during dialysis. In this study, in nine cardiac-compromised dialysis patients with frequent symptomatic hypotensive episodes, the efficacy of three fluids (hypertonic saline [3%], albumin [20%], and HES [10%]) was assessed during three treatment sessions with combined ultrafiltration and hemodialysis, which only differed in the type of fluid administered intravenously. Changes in SBP and relative BV were compared. Fluids were given when SBP was less than 100 mmHg or when the decrease in SBP was more than 25 mmHg versus the start of the treatment. The ultrafiltration was continued at the same rate. When comparing SBP at the end of the dialysis session (t = end) with that at the time of infusion (t = iv), SBP decreased with saline, increased with albumin, and increased significantly with HES. The change in SBP in t = end versus t = iv was significantly greater when using saline compared with HES, and tended to decrease more when using saline compared with albumin (P = 0.09). Between albumin and HES there were no significant differences. BV decreased significantly (t = end) versus baseline (t = 0) during ultrafiltration and hemodialysis in all three treatment sessions. The decrease was significantly higher when using saline compared with albumin and saline compared with HES. Between albumin and HES there were no significant differences. When the values at t = end were compared with those at t = iv, BV decreased, although not significantly, with saline and albumin, but remained unchanged with HES. It is concluded that HES is an effective fluid in maintaining SBP and preserving BV in hypotensive-prone dialysis patients, comparable to albumin but superior to hypertonic saline.

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