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Clinical management of intradialytic hypotension: survey results.

Intradialytic hypotension (IDH) is one of the most common complications of hemodialysis treatment. Published incidence of IDH varies from 10% to 50% of hemodialysis treatments (Henrich, 1999; Schreiber, 2001 a). Numerous publications address the pathophysiology, effect of frequent episodes, and clinical management of IDH, but no recent publication has studied how IDH is managed in dialysis clinics. Interviews and a mail survey were conducted to develop a better understanding of the clinical issues and concerns surrounding the management of hemodialysis patients who experience episodes of IDH.

Methods

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%.

Results

Demographics

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.

IDH management

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.

Discussion

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).

Nursing Implications

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.

Summary

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.


References

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
Geographic Code:1USA
Date:May 1, 2005
Words:2514
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