CHHS18/053

Canberra Hospital and Health ServicesClinical Procedure Intradialytic Hypertension Management in AdultsContents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................2

Background............................................................................................................................... 2

Alerts.........................................................................................................................................2

Scope........................................................................................................................................ 2

Section 1 – Identification and initial action...............................................................................3

Section 2 – Dialysate sodium adjustments................................................................................4

Section 3 – Monitoring..............................................................................................................5

Implementation........................................................................................................................ 5

Related Policies, Procedures, Guidelines and Legislation.........................................................6

References................................................................................................................................ 6

Search Terms............................................................................................................................ 7

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Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS18/053

Purpose

This procedure provides clinicians with the process for the management of patients experiencing high blood pressure during haemodialysis. Hypertension is defined as: >220mm systolic, >110 diastorlic or having symproms of hypertension, independent of the pressure (ie headache, altered conscious state)/…..

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Background

A rise in systolic blood pressure of > 10mmHg more at the end of treatment compared to the beginning is associated with increased mortality during follow-up, although the available evidence disagrees on the effect of pre-dialysis blood pressure (BP) on this outcome.1, 2 Treatment of intradialytic hypertension may induce intradialytic hypotension, which is also associated with increased mortality when defined > 30% of dialysis sessions with either; a pre-dialysis systolic BP < 160 mmHg and a systolic BP nadir to < 90 mmHg or a pre-dialysis BP ≥ 160mmHg and a systolic nadir of <100 mmHg.3

A major factor driving intradialytic hypotension is ultrafiltration goal, with higher goals generally increasing the risk of hypotension but often patients with significant intradialytic hypertension suffer further rises in blood pressure if the ultrafiltration goal is increased.The optimal pre-dialysis systolic BP range for dialysis patients is unknown but probably lies somewhere within the range 115 to 150 mmHg.4

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Scope

Alerts

All patients with a blood pressure higher than 220 systolic or 110 diastolic while receiving haemodialysis must be discussed urgently with a renal physician or their delegate. All patients suspected to have symptomatic hypertension (associated headaches, confusion or altered conscious state), at any pressure, should also be discussed urgently with a renal physician. For example, a patient with blood pressure 180/105 mmHg and severe headache must be discussed urgently with a renal physician.

In patients with uncontrolled diabetes mellitus (current blood glucose >15 mmol/Lthe reduction in dialysate sodium may be more likely to result in hypotension.

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This Standard Operating Procedure (SOP) describes for staff the process to

CHHS18/053

This document pertains to patients over the age of 18 years that receive satellite or in-hospital dialysis under the care of ACT Health, in the ACT (does not apply to NSW satellite units or to self care dialysis patients).

It applies to 3 groups of patients as defined by their blood pressure:1. patients with a median rise in BP of > 10 mmHg during dialysis over the preceding 2 week

period AND an average pre-dialysis systolic BP >150 mmHg (Group 1)2. patients with a median rise in BP of > 10 mmHg over the preceding 2 week period AND

an average pre-dialysis systolic BP between 115 mmHg and 150 mmHg (Group 2)3. patients with a median rise in BP of > 10 mmHg over the preceding 2 week period AND

average pre-dialysis systolic BP <115 mmHg (Group 3)

It will be determined by means of a 6 monthly analysis of the renal electronic medical record which patients meet the definitions for the above groups. This query will be timed to approximately coincide with the routine monthly dialysis blood tests.

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Section 1 – Identification and initial action

If patients meet the definitions above, their respective dialysis units and Renal Advanced Trainee managing outpatients will be notified.

Dialysis nurses will be requested by the treating clinician to measure and record the pre-dialysis capillary glucose of identified patients on 3 consecutive occasions.

Patients are asked to make an appointment within the next 4 weeks with either their nephrologist or the Renal Advanced Trainee Registrar for clinical review.

Patients who have a pre-dialysis capillary glucose >15 mmol/L will be referred by the treating clinician to their usual diabetic service provider to determine if any adjustments are required to optimise diabetic control. The following is recommended for consideration during review by the Nephrologist or Renal Advanced Trainee: Group 1

o Medication and post-dialysis weight adjustment targeting a reduction in pre-dialysis BP into the range 115mmHg to 150mmHg while avoiding intradialytic hypotension.

Group 2 o Use of non-dialyzable antihypertensives and alteration of the timing of

antihypertensive dosing to reduce intradialytic blood pressure without substantial impact on pre-dialysis blood pressure.

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CHHS18/053

Group 3o Medication and dry weight review. Cardiac function assessment.

2 months after initial identification the renal electronic medical record will be analysed to determine which of the patients previously identified as belonging to Group 1 or Group 2 still fit those categories and have been reviewed by the Nephrologist or Renal Advanced Trainee.

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Section 2 – Dialysate sodium adjustments

Procedure Staff will offer patients that meet criteria for inclusion in group 1 or 2 after following their review by a Nephrologist or renal advanced trainee an individualised sodium prescription.

The 2 dialysate sodium (Na) titration sessions to determine each patient’s optimal dialysate sodium will be performed at the Canberra Community Dialysis Centre (CCDC, Gaunt Place, Garran), by accredited dialysis nurse(s).

Subsequent dialysis sessions will be completed at their usual dialysis location. Titration will be done as follows:

First Assessment Dialysis Session (D1)Dialysis nurse hands patient completes the Thirst Visual Analogue Scale to be completed early in the dialysis session. Pre-dialysis capillary blood glucose measured by the dialysis nurse. Dialysis nurse performs Step 1 to Step 8 below. Treating doctor performs Step 9 below.Step 1 Collect 5 arterial blood gas (ABG) syringes and label “blood initial”, “dialysate blue”,

“dialysate red”, “blood arterial”, “blood venous”. Step 2 Cannulates patientStep 3 Connect cannulas to primed dialysis circuitStep 4 Commence anticoagulant as per usual prescriptionStep 5 Commence blood pump at usual blood flow rate and circulate for 3 minutes.Step 6 Collect ABG labelled “blood initial” from red arterial blood port. Step 7 Set dialysate sodium at 140, commence dialysis with ultrafiltration or

haemodiafiltration as per current prescription Step 8 Wait 60 seconds then, using the labelled ABG syringes, collect:

o Dialysate from red and blue ports (only applicable where dialysate sampling ports are present)

o Blood from arterial and venous portStep 9 Using 60 second post commencement values, calculate the new dialysate Na (DbNa)

o DbNa = 140 + ([Na]arterial - [Na]venous)o If DbNa<135mmol/L then DbNa=135mmol/Lo If DbNa>145mmol/L then DbNa==145mmol/L

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Step 10 Dialysis nurse to adjust dialysate sodium to DbNa value and note time of adjustment in dialysis record

Step 11 At completion of dialysis session dialysis nurse to send notification, using renal electronic medical record, for advanced trainee or renal physician review of intradialytic BPs during D1 session.

Second Study Dialysis Session (D2) Step 1 to Step 6 as in D1 session. Step 7 as in D1 session but set the dialysate sodium at DbNa Step 8 as in D1 session Step 9

o Using 60 sec post commencement values, calculate the new dialysate Na (DcNa)o DcNa = DbNa + ([Na]arterial - [Na]venous)o If DcNa<135mmol/L then DcNa=135mmol/Lo If DbNa>145mmol/L then DcNa==145mmol/L

Step 10 Adjust dialysate sodium to DcNa value and note time of adjustment in dialysis record

Step 11 At completion of dialysis session send notification, using renal electronic medical record, for renal advanced trainee or renal physician review of intradialytic BPs during D2 session.

Subsequent dialysis sessions Continue dialysis sessions using DcNa settings at the patient’s usual dialysis facility (no

longer a requirement to be performed at CCDC). Nurse to notify renal advanced trainee and nephrologist to review medication and target

post-dialysis weight at during the second week of individualised sodium treatment.

All dialysis parameters may be adjusted by the patient’s usual Renal Physician or advanced trainee at any time or may be adjusted by the patient’s dialysis nurse acting within their scope of practice.

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Section 3 – Monitoring

One month after patient completes the steps outlined in section 2, the usual dialysis location will request the patients completes a renal thirst Lichart scale.

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Implementation

Communication will be to Clinical Nurse Consultants in each dialysis unit who will provided direct education to staff as needed.

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Education in CCDC will be via a series of face to face in-service education sessions provided by a nephrologist, working with the clinical nurse consultant of CCDC unit. The new protocol will be discussed with the Renal Advisory Meeting group for dissemination to patients.

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Related Policies, Procedures, Guidelines and Legislation

Policies Health Directorate Nursing and Midwifery Continuing Competence Policy Consent and Treatment

Procedures CHHS Healthcare Associated Infections Clinical Procedure CHHS Patient Identification and Procedure Matching Policy CHHS Clinical Procedure, Renal Replacement Therapies for Adults

Guidelines CHHS Fasting Guidelines – Elective and Emergency Surgery

Legislation Health Records (Privacy and Access) Act 1997 Human Rights Act 2004 Work Health and Safety Act 2011

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References

1 Inrig JK, Patel UD, Toto RD, Szczech LA. Association of Blood Pressure Increases During Hemodialysis With 2-Year Mortality in Incident Hemodialysis Patients: A Secondary Analysis of the Dialysis Morbidity and Mortality Wave 2 Study. American journal of kidney diseases : the official journal of the National Kidney Foundation. 2009; 54: 881-90.

2 Park J, Rhee C, Sim JJ, Kim Y-L, Ricks J, Streja E, et al. A comparative effectiveness research study of the change in blood pressure during hemodialysis treatment and survival. Kidney international. 2013; 84: 795.

3 Flythe JE, Xue H, Lynch KE, Curhan GC, Brunelli SM. Association of Mortality Risk with Various Definitions of Intradialytic Hypotension. Journal of the American Society of Nephrology. 2015; 26: 724-34.

4 Levin NW, Kotanko P, Eckardt K-U, Kasiske BL, Chazot C, Cheung AK, et al. Blood pressure in chronic kidney disease stage 5D-report from a Kidney Disease: Improving Global Outcomes controversies conference. Kidney International. 2010; 77: 273-84.

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Search Terms

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CHHS18/053

Haemodialysis, Intradialytic hypertension.

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Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Policy Team ONLY to complete the following:Date Amended Section Amended Divisional Approval Final Approval 24/01/2018 New Document ED Medicine CHHS Policy Committee

This document supersedes the following: Document Number Document Name

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Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register