Hypotension during Hemodialysis

Intradialytic Hypotension and Reactions – Crash Card (Adult HD)

P1: Rapid actions and differentiation | P2: Algorithms | P3: Expanded dosing

Immediate Steps (seconds to 1 minute)

• - Set ultrafiltration (UF) rate to 0 mL/hr; keep dialysis running to prevent circuit clotting.
• - Lay supine/Trendelenburg; apply O2; give 100 to 200 mL IV normal saline; reassess and repeat as needed.
• - Check rhythm, symptoms, access and lines, machine alarms.
• - If still unstable after one small bolus: begin vasopressor (norepinephrine infusion).

How To Tell What Is Happening (chairside cues)

Anaphylaxis (dialyzer or drug)

• - Onset: within first 5 to 20 minutes of run or immediately after exposure.
• - Skin/airway: pruritus, hives, flushing, angioedema, wheeze or stridor, hypotension.
• - Action: STOP dialysis; DO NOT return blood; treat with IM epinephrine.

Hemolysis (machine, water, or line problem)

• - Symptoms: back, chest, or abdominal pain; nausea; dyspnea; headache.
• - May see "port-wine" blood in venous line or pink plasma; hyperkalemia risk.
• - Action: STOP dialysis; CLAMP; DO NOT return blood; check K+, LDH, plasma-free Hgb; manage hyperkalemia.

Typical IDH (volume or UF related)

• - Lightheadedness, cramps, nausea without allergic features; improves with UF off plus small saline bolus.
• - Action: Continue dialysis with UF off; lengthen session; consider cool dialysate (35 to 36 C).

When To Terminate The Run

• - Persistently unstable despite UF off plus fluids with or without pressor.
• - Suspected anaphylaxis, hemolysis, major blood leak, air embolus, or dialyzer reaction.
• - If stopping: RINSE-BACK blood unless reaction, hemolysis, or contamination is suspected; in those cases DO NOT return blood.

Pressor Quick Reference (for crash hypotension)

• - Norepinephrine infusion (first-line): start about 0.05 to 0.1 mcg/kg/min (or 5 to 15 mcg/min) and titrate to MAP 65 or higher.
• - Phenylephrine push-dose bridge while starting norepi: 50 to 200 mcg IV bolus; may repeat every 1 to 3 minutes as needed.
• - Avoid push-dose epinephrine unless experienced and protocols allow; prefer norepinephrine infusion for vasodilatory shock.

Suspected Anaphylaxis On Dialysis - Action Plan

1. Stop dialysis immediately. DO NOT return circuit blood. Call for help.
2. Position supine; high-flow O2; large-bore IV or IO; continuous monitor.
3. EPINEPHRINE (first-line): IM 0.3 to 0.5 mg (1 mg/mL) into lateral thigh; repeat every 5 to 10 minutes if needed. If refractory or impending collapse: start IV epinephrine infusion 0.05 to 0.1 mcg/kg/min and titrate (typical range 0.05 to 0.5 mcg/kg/min).
4. Rapid IV fluids: 1 to 2 liters normal saline as tolerated.
5. Adjuncts (after epinephrine): diphenhydramine 25 to 50 mg IV; famotidine 20 mg IV; methylprednisolone 125 mg IV; albuterol nebulizer for wheeze.
6. If on beta-blocker and poor response: glucagon 1 to 5 mg IV over 5 minutes, then 5 to 15 mcg/min infusion.
7. Investigate trigger (dialyzer membrane or sterilant, medication). Document and switch to alternative membrane next session; consider premedication per nephrology or allergy.

Suspected Hemolysis - Action Plan

1. Stop dialysis; CLAMP lines. DO NOT return circuit blood.
2. Draw STAT labs: K+, hemoglobin/hematocrit, LDH, plasma-free hemoglobin, haptoglobin, bilirubin; type and screen.
3. ECG and treat hyperkalemia per protocol (for example: calcium, insulin with dextrose, beta-agonist) and support ABCs.
4. Notify biomedical and water treatment immediately; check dialysate temperature or mixture, chloramine or copper, tubing kinks, blood leak.
5. Stabilize, then arrange monitored re-dialysis when safe; replace implicated components.

Default IDH Pathway (no reaction or hemolysis)

• - UF off -> 100 to 200 mL NS -> reassess.
• - Keep dialysis running (lower blood flow if needed); consider cool dialysate (35 to 36 C).
• - Resume at lower UF or extend time once stable; review antihypertensive timing and interdialytic weight gain.

Bradycardia Plus Hypotension (add-on)

• - If symptomatic bradycardia with hypotension: give ATROPINE 1 mg IV push; repeat every 3 to 5 minutes to a maximum total dose of 3 mg.
• - If atropine ineffective or high-degree AV block: begin transcutaneous pacing without delay.
• - Consider EPINEPHRINE infusion 2 to 10 mcg/min or DOPAMINE infusion 5 to 20 mcg/kg/min while arranging pacing and treating the cause.
• - Phenylephrine may worsen bradycardia; prefer norepinephrine or epinephrine when vasopressor support is needed in bradycardic patients.

Notes

• - DO NOT return blood if anaphylaxis, hemolysis, major leak, or contamination is suspected.
• - Document the event; flag the chart; arrange allergy and nephrology follow-up; change dialyzer or membrane as advised.
• - Units: keep premixed norepinephrine available; standardize phenylephrine push-dose concentration; educate on recognition signs.

Medication Dosing - Expanded (Adults)

Epinephrine (anaphylaxis)

• - IM: 0.3 to 0.5 mg (1 mg/mL) into lateral thigh; repeat every 5 to 10 minutes as needed.
• - IV infusion for refractory anaphylaxis: start 0.05 to 0.1 mcg/kg/min; usual range 0.05 to 0.5 mcg/kg/min; titrate to perfusion.
• - Avoid IV push in anaphylaxis unless in cardiac arrest.

Norepinephrine (first-line for vasodilatory shock)

• - Start 0.05 to 0.1 mcg/kg/min or 5 to 15 mcg/min; titrate to MAP 65 or higher.
• - Peripheral start is acceptable if needed; monitor for extravasation.

Phenylephrine

• - Push-dose: 50 to 200 mcg IV bolus; may repeat every 1 to 3 minutes as needed.
• - Infusion: 0.5 to 2 mcg/kg/min; avoid as sole agent in bradycardia.

Atropine (symptomatic bradycardia)

• - 1 mg IV push; repeat every 3 to 5 minutes to a maximum total dose of 3 mg.

Epinephrine (bradycardic hypotension when pacing not yet available)

• - IV infusion 2 to 10 mcg/min; titrate to perfusion.

Dopamine (alternative for bradycardia with hypotension)

• - 5 to 20 mcg/kg/min IV infusion; titrate; avoid in tachyarrhythmias.

Glucagon (beta-blocker associated anaphylaxis)

• - 1 to 5 mg IV over 5 minutes, then 5 to 15 mcg/min infusion; titrate to effect.

Anaphylaxis adjuncts

• - Diphenhydramine 25 to 50 mg IV.
• - Famotidine 20 mg IV.
• - Methylprednisolone 125 mg IV.
• - Albuterol nebulizer 2.5 to 5 mg; may repeat.

Hyperkalemia rescue (if hemolysis suspected)

• - Calcium gluconate 1 g IV over 5 to 10 minutes (may repeat). If central access, calcium chloride 1 g IV.
• - Insulin regular 10 units IV + dextrose 25 g IV; monitor glucose.
• - Nebulized albuterol 10 to 20 mg (for K+ shift); consider sodium bicarbonate 50 mEq IV if acidotic.
• - Re-dialysis urgently once stabilized.

This content is for trained clinicians and does not replace local protocols or clinical judgment.