Clinical management of intradialytic hypotension: survey results.
One-on-one telephone interviews between a nephrology nurse researcher and 12 hemodialysis clinic nurse managers were conducted to explore and identify important issues in the management of IDH. The nurse managers were randomly selected from the Centers for Medicare and Medicaid Services Renal Providers List (Centers for Medicare and Medicaid Services [CMS], 2003). A cash incentive was awarded to all interviewees.
All interviewees were asked 9 open-ended questions about the management of IDH episodes in their clinics. The questions were developed by two nephrology nurses and a nephrologist. The questions included: (a) In your clinic, how is IDH defined? (b) About what proportion of patients would you say has IDH on a given shift? (c) What do you believe are the reasons for the IDH you see in your clinic? (d) How big of a problem is IDH for the staff in your clinic? (e) What is your clinic's protocol for treating IDH? (f) Do you treat every instance of IDH? (g) Does your center do any sort of proactive management to prevent IDH? The results of the interviews were used to guide the development of the mail survey instrument.
An 18-item survey was developed based on the responses from the 12 interviews. The survey was reviewed for content validity by two nephrology nurses and a nephrologist. The items were forced choice with elective comment sections for seven items and focused on the present clinical management of IDH in clinics (see Table 1). The surveys were mailed to the nurse managers/charge nurses of 2,000 randomly selected dialysis clinics in the continental United States from the CMS Renal Providers List (CMS, 2003) with a cover letter stating the purpose of the survey. The survey questionnaires were not coded so that individual participants were not identifiable in any manner. A separate postcard was included in the mailing for respondents to register for a random incentive drawing for 14 cash awards. Three hundred forty-six surveys were returned for a response rate of 17%.
A majority of the respondents had 10 or more years (59%) of experience in nephrology and were employed in hemodialysis clinics (92%) and as clinic managers (71%). The mean number of patients in the clinics was 74 (range 6-450).
Definition of IDH
The most common definitions of IDH were either "a sudden drop in blood pressure associated with symptoms" (42%) or "definition individualized for each patient" (44%). Sixty-six percent of respondents answered that IDH was treated if a patient was asymptomatic but met the clinic's definition of IDH. The majority of clinics (63%) reported that less than 20% of their patients had two or more episodes of IDH within a 30-day period, while 12% of the clinics indicated that 50% or more of their patients experienced two or more episodes in a 30-day period (see Figure 1).
Based on a yes/no question, 83% of respondents answered that they adequately understood the causes/ mechanisms of IDH. The ranking of causes/mechanisms associated with IDH were the rate of ultrafiltration exceeds cardiovascular compensation (1st), cardiac dysfunction (2nd), and a decline in plasma osmolality and extracellular fluid volume (3rd) (see Table 2). Respondents also identified access clotting, infections, medication mismanagement, food consumption, estimated dry weight not accurate, diabetes, and effects of anti-hypertensive medications as causes/mechanisms associated with IDH. A majority of respondents (81%) agreed that frequent episodes of IDH decreased the adequacy of dialysis.
The average time to manage an episode of IDH was 10.5 minutes (range 1-75 minutes), and 74% of respondents answered that it takes less than 15 minutes to manage an episode of IDH during hemodialysis.
The majority of clinics responding to the survey (88%) had either standing orders or protocols in their clinics to manage IDH episodes. The ranking of the interventions to manage an IDH episode are listed in Table 3. Other interventions listed included administering oxygen, using sodium modeling, notifying the physician, monitoring or adjusting the dry weight, decreasing dialysate temperature, administering levocarnitine, and administering midodrine. The maximum amount of normal saline given during one dialysis treatment to manage an episode of IDH ranged from 100-1000 ml, with 200-500 ml the most frequent.
Multiple proactive interventions are used to manage IDH episodes (see Table 4). Other responses included: administering midodrine, assessing antihypertensive therapy, increasing length of treatment, and administering levocarnitine. A majority of clinics (61%) utilize medication to proactively manage IDH episodes (see Figure 2).
A majority of respondents (83%) answered that it is standard procedure to document episodes of IDH in the progress notes, and a majority of respondents (80%) stated that they contacted physicians 1-5 times during the course of a month with a range of 0 to greater than 10 times per month to address incidents of IDH.
The first step in examining the management of IDH in dialysis clinics is to determine how IDH is defined. The definitions of IDH by respondents in this survey were, "a sudden drop of blood pressure with symptoms" and "defined individually per patient." Each of these definitions can be found in the literature (Henrich, 1999; Schreiber, 2001a).
The prevalence of IDH varies widely in the literature from 10% to 50o/o of dialysis treatments (Henrich, 1999; Schreiber, 2001a). The definition of IDH prevalence for the survey was defined as two or more IDH episodes per patient in a 30-day period. The responses were comparable to the published prevalence rates, with the majority of respondents answering that less than 20% of their patients have two or more episodes of IDH in a 30-day period. Interestingly, 12% of respondents reported that 50% or more of their patients had two or more episodes of IDH in a 30-day period. Based on this survey, there is room for improvement in managing IDH.
A majority of respondents agreed that they adequately understood the causes/mechanisms of IDH. Respondents were given a list of the causes/mechanisms of IDH and allowed to check as many as applied (Daugirdas, 2001). Three of the five answers were identified as causes/ mechanisms of IDH by the majority of respondents, even though all of the answers are causes/mechanisms of IDH. These responses suggest the need for education on the pathophysiology of IDH.
The second step in examining the management of IDH in dialysis clinics is to identify the clinical management of IDH episodes. A majority of respondents had standing orders or protocols in their clinics for management of an episode of IDH. Physicians were contacted 1-5 times a month regarding issues relating to IDH issues. The average time it took to manage an episode of IDH was 10.5 minutes. Depending on the prevalence of IDH in a specific clinic, managing IDH episodes may take up a large amount of staff time and decrease the efficiency in the dialysis clinic. Patients with high incidence of IDH may be prone to sign-off of treatment early due to the symptoms of IDH and increased risk of cardiac morbidity (Schreiber, 2001a).
The primary interventions used to manage an episode of IDH are administering normal saline, placing the patient in Trendelenburg position, increasing the rate of blood pressure monitoring, decreasing the ultrafiltration rate, and turning off the ultrafiltration rate. The survey identified the primary interventions to manage an episode of IDH as recognized in the literature (Salai, 1998; Schreiber, 2001b). The use of mannitol, which has been documented to accumulate in the extracellular fluid and, therefore, be used with caution (Levin & Ronco, 2002), was still reported as an intervention.
Interventions to treat frequent episodes of IDH include modification to the dialysis treatment and pharmacologic options. The most common interventions identified for the treatment of frequent episodes of IDH are dry weight adjustments, education on fluid intake, sodium modeling, ultrafiltration profiling, lower dialysate temperature, and extra dialysis treatment. All of the interventions identified are recognized in the literature in managing episodes of IDH (Levin & Ronco, 2002; Schreiber, 2001b).
A majority of the clinics utilize medications to manage IDH episodes, with levocarnitine and midodrine being the most prescribed. Levocarnitine and midodrine are efficacious and well tolerated for the management of IDH episodes (Perazella, 2001).
Nephrology nurses have the primary responsibility to prevent, detect, and provide interventions for IDH episodes. Nephrology nurses should, therefore, be aware of the causes/ mechanisms of IDH and be able to assess patients for these potential causes/mechanisms and the effect of interventions on the frequency of IDH episodes.
Patient assessment is a critical component in identifying patients at risk for frequent episodes of IDH. At the start of treatment, the patient's blood pressure, medication status (did the patient take antihypertensive medication prior to dialysis), and the percentage of interdialytic weight gain (weight gain of > 3% is at higher risk for IDH episodes) should be assessed (Schreiber, 2001b). Symptoms of IDH episodes are: nausea, sweating, cramping, visual abnormalities, and chest pain (Schreiber, 2001b). The patient's dry weight should be frequently evaluated (Salai, 1998).
Staff and patients should be educated about IDH and the impact to the dialysis treatment. Nurses should understand the causes/mechanisms of IDH to enable assessment of high-risk patients, interventions, and patient education implications. Patients should be educated on the symptoms of IDH and to notify staff as soon as possible. Patients should also be educated on the consequences of high weight gain between dialysis treatments and counseled on fluid restrictions (Salai, 1998).
Depending on the frequency of IDH episodes in the clinic, the staff time to manage IDH episodes may be significant. The development of a continuous quality improvement project should be used to decrease the amount of IDH episodes.
The survey showed that IDH is common and requires significant staff time to manage. There is room for improvement of care. Results also suggest a need for education on IDH. A weakness of the survey is that it gathered only basic information about the management of IDH. Information gathered from this survey can be used to develop further studies regarding the management of IDH and increase awareness of IDH as a problem that needs to be addressed in dialysis clinics.
Table 1 Mail Survey Questions * How many years have you practiced in nephrology? * What is your primary practice setting? * What is the affiliation of your clinic? * What is your position? * How many patients does your clinic treat? * How does your clinic define IDH? * If a patient meets your clinic's definition of IDH but is asymptomatic, does your center treat it? * What percent of your clinic's patients have two or more episodes of IDH within a 30-day period? * Which of these morbidities do you associate with IDH? * How many minutes does it take for your staff to manage an average episode of IDH? * Does your clinic have standing orders or a protocol to manage IDH episodes? * Which of the following steps does your clinic take to manage IDH episodes? * How does your clinic proactively manage IDH to prevent IDH episodes before they occur? * What medications are prescribed proactively to manage IDH in your clinic? * Is it a standard procedure to document episodes of IDH in the progress notes? * Do you feel that you adequately understand the causes/mechanisms of IDH? * How often do you contact your physician(s) to address incidents of IDH in a month? * In your opinion, do frequent episodes of IDH decrease the adequacy of dialysis? Table 2 Causes/Mechanisms of IDH Number of Causes/Mechanisms of IDH responses Rate of ultrafiltration (UF) exceeds cardiovascular compensation 300 Cardiac dysfunction 277 Decline in plasma osmolality and extracellular fluid volume 209 Autonomic dysfunction 96 Release of vasodialators such as adenosine or nitric oxide 60 Other 18 Note: Respondents could check more than one answer. Table 3 Interventions Taken to Manage IDH Episodes Number of Intervention responses Administer normal saline 341 Place patient in Trendelenburg 334 Increase blood pressure (BP) monitoring 298 Decrease UF rate 294 Turn off UF 248 Administer hypertonic saline 170 Administer mannitol 54 Other 40 Administer albumin 17 None of the above 0 Note: Respondents could check more than one answer. Table 4 Proactive Interventions to Manage IDH Episodes Number of Intervention responses Dry weight adjustments 331 Patient education on fluid intake 325 Sodium modeling 322 Ultrafiltration profiling 256 Lower dialysate temperature 182 Extra dialysis treatment for ultrafiltration only 179 Use of Crit lines 60 Other 17 None of the above 0 Note: Respondents could check more than one answer. Figure 1 Percent of Patients With Two or More Episodes of IDH in a 30-Day Period 50+ 12% 40-49 2% 30-39 8% 20-29 15% 10-19 27% 0-9 36% Note: Table made from pie chart. Figure 2 Medications Prescribed for IDH Other 1% None of the above 38% Zoloft 3% Carnitor 26% ProAmitine 32% Note: Table made from pie chart.
Centers for Medicare and Medicaid Services (CMS). (2003). National listing of renal providers by state, city. Retrieved May 24, 9003, from www.cms.hhs.gov/esrd/8.asp
Daugirdas, J.T. (2001). Pathophysiology of dialysis hypotension: An update. American Journal of Kidney Disease, 38(4), S11-S17.
Henrich, W.L. (1999). Hemodynamic stability during dialysis and cardiovascular disease in end stage renal disease patients. American Journal of Kidney Disease; 33(6), xlix-liii.
Levin, N.W., & Ronco, C. (2002). Common clinical problems during hemodialysis. In A.R. Nissensen & R.N. Eine (Eds.), Dialysis therapy (3rd ed.) (pp. 171-175). Philadelphia: Hanley & Belfus, Inc.
Perazella, M.A. (2001). Pharmacologic options available to treat symptomatic intradialytic hypotension. American Journal of Kidney Disease, 38(4), S26-S36.
Salai, RB. (1998). Hemodialysis. In J. Parker (Ed.), Contemporary nephrology nursing (pp. 525-577). Pitman, NJ: American Nephrology Nurses' Association.
Schreiber, M.J., Jr. (2001a). Clinical dilemmas in dialysis: Managing the hypotensive patient setting the stage. American Journal of Kidney Disease, 3a(4), S1-S10.
Schreiber, M.J., Jr. (2001b). Clinical case based approach to understanding intradialytic hypotension. American Journal of Kidney Disease, 38(4), $37-$47.
This offering for 1.0 contact hour is being provided by the American Nephrology Nurses' Association (ANNA), ANNA is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. ANNA is a Provider approved by the California Board of Registered Nursing, provider number CEP 00910.
The Nephrology Nursing Certification Commission (NNCC) requires 60 contact hours for each recertification period for all nephrology nurses. Forty-five of these 60 hours must be specific to nephrology nursing practice. This CE article may be applied to the 45 required contact hours in nephrology nursing.
Susan M. Hossli, MSN, RN, is Vice President, Clinical Marketing, The Synephros Group, Madison, WI. She is a member of ANNA's Windy City Chapter.
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|Title Annotation:||Continuing Education|
|Author:||Hossli, Susan M.|
|Publication:||Nephrology Nursing Journal|
|Date:||May 1, 2005|
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