12/30/22, 9:48 AM Arterial and venous pressure monitoring during hemodialysis - Document - Gale Academic OneFile

Arterial and venous pressure monitoring

during hemodialysis
Author: Glenda D. Graves
Date: Feb. 2001
From: Nephrology Nursing Journal(Vol. 28, Issue 1)
Publisher: Jannetti Publications, Inc.
Document Type: Article
Length: 3,224 words

Abstract: 

While hemodialysis machines measure and display arterial and venous pressures and notify operators
when these pressures fluctuate outside of an established alarm limit, caregivers are responsible for
correctly interpreting these readings. Caregivers mast determine how effectively or safely a treatment
is being performed and when to initiate appropriate interventions. This article will help nurses
recognize arterial or venous pressures during hemodialysis that indicate potential complications with
the patient's vascular access or the extracorporeal circuit.

Goal:

To recognize arterial or venous pressures during hemodialysis that indicate a potential complication
with the patient's vascular access or the extracorporeal circuit.

Objectives:

1. Identify the clinical information available from interpretation of prepump arterial, postpump arterial,
delta, and venous pressure monitoring.

2. Discuss the complications of excessive pressures in the extracorporeal circuit.

3. Identify symptoms and potential causes of hemolysis related to the hemodialysis treatment.

Full Text: 

One of the functions of a hemodialysis machine is to measure and display arterial and venous
pressures as well as to notify the operator when these pressures fluctuate outside of an established
alarm limit. It is, however, the responsibility of the caregiver who monitors and interprets these
pressure readings to determine how effectively or safely a treatment is being performed and to initiate
appropriate interventions. A comparison of pressure readings from the patient's previous treatments at
like blood pump speeds should be done each treatment to determine if the currently displayed
pressures are typical or may be an indication of a problem. It is this comparison and the knowledge of
acceptable pressure limits that enable caregivers to provide quality care for hemodialysis patients.

Arterial and venous pressure monitoring provides information regarding vascular access and the
extracorporeal circuit in which a patient's blood is circulating. Correct interpretation of these pressures
can:

1. prevent hemolysis and microbubbles in the blood tubing set from excessive negative pressure;

2. assess vascular access for adequate blood flow or problems such as venous stenosis; and
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3. ensure accurate blood flow through the dialyzer for optimal dialysis therapy (Bosch & Ronco, 1993;
Cogan & Schoenfeld, 1991; Francos et al., 1983; Keen, Lancaster, & Binkley, 1995; Levy, Sherman, &
Nosher, 1992; National Kidney Foundation [NKF], 1997a, 1997b; Polaschegg, 1995; Twardowski,
Haynie, & Moore, 1999).

To increase dialysis efficiency, high blood pump speeds are frequently used. With the limited
diameters of fistula needles or catheters, high pressure gradients are created in the blood lines and
high blood velocities in the narrow segments. This high blood velocity increases shear forces, which
can hemolyze red blood cells. If a kink or occlusion occurs in the extracorporeal circuit, the velocity of
the blood may be increased so much that, without warning (depending on the location of the kink or
occlusion), massive hemolysis may occur. Symptoms of hemolysis include malaise, nausea, chest
pain, shortness of breath, abdominal pain, back pain, emesis, cyanosis, headache, and increased [or
decreased] blood pressure. Gallstones and pancreatitis frequently develop after a hemolytic episode
(Twardowski et al., 1999).

To determine if hemolysis is occurring, place a blood sample into a clot tube and spin to separate the
serum. If the serum appears pink, the test may be positive for hemolysis. The pink serum is due to the
presence of free hemoglobin, a very high concentration of serum lactate dehydrogenase, and almost
complete disappearance of haptoglobin (Twardowski et al., 1999). To confirm hemolysis, repeat this
test. If you again see pink serum, send a blood specimen to the laboratory to verify hemolysis. While
awaiting the laboratory results, notify the physician of the potential of hemolysis.

Arterial Pressure Monitoring

Arterial pressures can be monitored either prepump or postpump depending on the type of
hemodialysis machine and the blood tubing being used (see Figure 1). The pressure readings for
prepump versus postpump arterial monitors provide different information regarding the hemodialysis
treatment and/or the patient's access. If the caregiver has the opportunity to choose which type of
arterial pressure monitoring is to be performed (based on machine's pressure monitoring capabilities
and blood tubing availability), the choice should be based on the type of information needed to best
address a patient's condition. For example, arterial vascular access problems are best denoted with
prepump arterial monitoring whereas clotting problems are best denoted with postpump arterial
monitoring.

Prepump Arterial Pressure Monitoring

Prepump arterial pressure monitoring (see Figure 2) reflects the pressure exerted to pull blood from
the arterial limb of the patient's vascular access to the blood pump. Due to this "pulling" effect or
suction, the prepump arterial pressure reading is a negative number. This arterial pressure reading
describes the amount of suction needed to achieve the blood pump speed set on the hemodialysis
machine and best describes the blood flow from the patient's vascular access into the extracorporeal
circuit.

Interpretation of the prepump arterial pressures can identify poor arterial flow from the patient's
vascular access by displaying higher (more negative) pressures. Possible causes of higher prepump
arterial pressures are:

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1. kink, clamp, or occlusion in the arterial blood line prior to the prepump pressure monitoring device;

2. vascular catheter issues, such as positioning or clotting;

3. poor positioning, clotting, or infiltration of the arterial fistula needle;

4. clotting of the vascular access;

5. inadequate arterial supply of blood to the hemodialysis machine (stenosis of the arterial
anastomosis of a graft or clotting of the arterial limb of the vascular access) or poor cardiac status;

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6. blood pump speed greater than the arterial blood supply from the patient's vascular access;

7. spasms or vasoconstriction of the vessel (fistula only);

8. hypotension;

9. increased blood viscosity due to ultrafiltration;

10. higher hematocrit; and

11. high blood flow rate through a small needle gauge (for example, 500 mL/min blood pump speed
and the use of 16 gauge needles) (Cogan & Schoenfeld, 1991; Daugirdas & Ing, 1994; Keen et al.,
1995).

Levels of negative pressure that may induce hemolysis are debatable. The ANNA Core Curriculum
(Keen et al., 1995, p. 224) states that prepump arterial pressures should be less negative than -260
mmHg (for example, -180 mmHg, -200 mmHg, etc.) to prevent the possibility of hemolysis due to high
vacuum. However, Twardowski et al. state that "... hemodialyses with negative arterial chamber
pressures greater than -350 mmHg cause slightly higher hemolysis than dialyses with less negative
arterial chamber pressures, but this increased hemolysis is not associated with an increased
requirement of erythropoietin dose" (Twardowski et al., 1999, p. 50). Chambers et al. (1999) found
that negative pressure is not a significant hemolytic factor in flowing blood. However, Polaschegg
(1995) points out that "while low arterial pressure (high negative pressure) is not hazardous by itself, it
indicates high shear rates and probable turbulence at the cannula or catheter entrance that might
cause hemolysis." Hemolysis due solely to high negative pressure and the level of negative pressure
necessary to cause hemolysis remains controversial in the literature.

The National Kidney Foundation (NKF) Dialysis Outcomes Quality Initiative (DOQI), Clinical Practice
Guidelines for Hemodialysis Adequacy (1997) states that negative pressures greater than -260 mmHg
decrease dialysis clearance due to decreased delivery of blood to the dialyzer. Twardowski et al.
(1999) note that actual blood flow to the dialyzer was lower than that set at the hemodialysis machine
with negative pressures at -350 mmHg. Therefore, a conservative approach to quality care for
hemodialysis patients would be to keep the prepump arterial pressure less negative than -260 mmHg.
This would ensure an adequate delivery of blood to the dialyzer and decrease the potential of
hemolysis due to shear stress or negative pressure.

Risks associated with excessive negative pressure as monitored by the prepump arterial pressure
monitor device are:

1. hemolysis due to excessive negative pressure and shearing of the blood cells;

2. microbubbles in the blood tubing due to pulling of air into the extra-corporeal circuit and degassing
of the blood; and

3. inadequate dialysis from decreased blood flow through the dialyzer due to poor reexpansion of the
blood pump segment and inaccurate delivery of blood at the requested blood pump speed (Bosch &
Ronco, 1993; Cogan & Schoenfeld, 1991; Daugirdas & Ing, 1994; Francos et al., 1983; NKF, 1997b;
Polaschegg, 1995; Twardowski et al., 1999).

Lower (less negative) prepump arterial pressures can indicate:

1. separation of the arterial blood line from the patient's access, either a disconnect of the arterial
blood line from the needle or catheter or a dislodgment of the needle or catheter from the patient's
arterial vascular access;

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2. air leak between the patient's vascular access and the arterial blood line or at some point along the
arterial blood line; and

3. decreased blood pump speed set at the hemodialysis machine (Cogan & Schoenfeld, 1991;
Daugirdas & Ing, 1994; Keen et al., 1995).

Postpump Arterial Pressure Monitoring

Postpump arterial pressure monitoring (see Figure 3) reflects the pressure in the extracorporeal circuit
from the pressure monitoring device through the dialyzer and to the venous drip chamber. This
pressure reading is a positive number due to the propelling of the blood from the blood pump through
the extracorporeal circuit. This pressure reading describes the pressure exerted in the blood
compartment predialyzer and is useful in detecting clotting at the dialyzer.

Interpretation of postpump arterial pressures may identify poor arterial flow through the dialyzer by
denoting higher pressures. Possible causes of higher postpump arterial pressures are:

1. kink, clamp, or occlusion in the arterial line between the pressure monitoring device and the
dialyzer;

2. clotting in the dialyzer;

3. increased blood pump speed set on the hemodialysis machine;

4. poor positioning or infiltration of the venous fistula needle;

5. increased blood viscosity due to ultrafiltration;

6. higher hematocrit; and

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7. high blood flow rate through a small needle gauge (for example, 500 ml/min blood pump speed
requested on the hemodialysis machine and the use of 16 gauge needles) (Cogan & Schoenfeld,
1991; Daugirdas & Ing, 1994; Keen et al., 1995).

Risks as a result of excessive pressure, defined in the ANNA Core Curriculum as greater than 400
mmHg (Keen et al., 1995, p. 225), at the post-pump arterial pressure monitor are:

1. hemolysis due to excessive pressure and shearing of the blood cells; and

2. blood leak from any loose connections due to positive pressure pushing the blood out of the extra-
corporeal circuit (Keen et al., 1995; Polaschegg, 1995).

Lower postpump arterial pressures can indicate:

1. separation in the arterial line between the pressure monitoring device and the dialyzer; and

2. kink, clamp, or occlusion in the blood line between the blood pump and the pressure monitoring
device (Daugirdas & Ing, 1994; Keen et al., 1995).

The difference between the postpump arterial pressure reading and the venous pressure reading can
be used to estimate the [delta] pressure across the dialyzer and serve as an indicator of clotting and
its location. Delta pressures can indicate the following: (a) increased postpump arterial
pressure/decreased venous pressure--an indication of clotting in the arterial drip chamber or in the
dialyzer; (b) increased postpump arterial pressure/increased venous pressure-an indication of clotting
prior to or in the venous drip chamber; and (c) if clotting is extensive, the rise in pressure readings will
rise sharply (Daugirdas & Ing, 1994, p. 121).

Venous Pressure Monitoring

Venous pressure monitoring (see Figure 4) reflects the pressure from the venous drip chamber
returning to the patient's vascular access. This pressure is a positive number due to the propelling of
the blood from the blood pump through the circuit. It will be lower than the postpump arterial pressure
reading. This pressure reading best describes the blood flow from the extracorporeal circuit returning
to the patient's vascular access.

Interpretation of high venous pressures may identify poor needle placement or possible vascular
access problems. Possible causes of higher venous pressures are:

1. kink, clamp, or occlusion in the venous blood line;

2. venous catheter issues such as positioning or clotting;

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3. poor positioning or infiltration of venous fistula needle;

4. clotting at the venous drip chamber, venous needle, or the venous limb of the vascular access;

5. increased blood pump speed;

6. spasms, vasoconstriction, or stenosis of the venous limb of the vascular access;

7. increased blood viscosity due to ultrafiltration;

8. higher hematocrit; and

9. high blood flow rate through small needle gauge (for example, 500 blood pump speed with 16
gauge needles) (Cogan & Schoenfeld, 1991; Daugirdas & Ing, 1994; Keen et al., 1995; Levy et al.,
1992; NKF, 1997a).

Venous pressure readings are an inexpensive means of monitoring for venous stenosis of the
patient's graft or fistula. The NKF-DOQI, Clinical Practice Guidelines for Vascular Access (1997)
recommends weekly monitoring of the dynamic venous pressure. They state "trends in either dynamic
or static venous dialysis pressure measurements are more predictive of access stenosis than any
single pressure measurement.... Shortcomings of venous pressure techniques are the need to
standardize for blood tubing, needle size, and hemodialysis machine" (NKF, 1997a, pp. 37-38).

The protocol recommended by DOQI for venous pressure monitoring is:

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* "establish a baseline by initiating measurements when the access is first used."

* "measure venous dialysis pressure from the hemodialysis machine at a 200 ml/min blood pump
speed during the first 2 to 5 minutes of hemodialysis at every hemodialysis session."

* "use 15-gauge needles (or establish own protocol for different needle size)."

* "assure that the venous needle is in the lumen of the vessel and not partially occluded by the vessel
wall."

* "pressure must exceed the threshold three times in succession to be significant."

* "assess at same level relative to hemodialysis machine for all measurements" (NKF, 1997a, p. 37).

"Three measurements in succession above the threshold are required to eliminate the effect of
variation caused by needle placement.... Trend analysis is more important than any single
measurement. Upward trends in hemodialysis pressure over time are more predictive than absolute
values. Each unit should establish its own venous pressure threshold values. Patients with
progressively increasing pressures or those who exceed the threshold on three consecutive
hemodialysis treatments should be referred for venography" (NKF, 1997a, p. 37).

The risks associated with excessive venous pressure are:

1. blood leak from any loose connections;

2. excessive ultrafiltration if an ultrafiltration-controlled hemodialysis machine is not used; and

3. blood flow through the dialyzer may be less than the displayed blood pump speed resulting in
inaccurate delivery of dialysis (Daugirdas & Ing, 1994; Polaschegg, 1995).

Possible causes of lower venous pressures are:

1. separation in the venous line between the pressure monitoring device and the patient;

2. kink, clamp, or occlusion in the blood line between the blood pump or the postpump arterial
monitoring device and the venous pressure monitoring device;

3. clotting of the dialyzer or filter in the venous drip chamber; and

4. decrease in blood pump speed set on the hemodialysis machine (Keen et al., 1995; Polaschegg,
1995).

Assessment and Intervention

With the knowledge of causes of abnormal prepump arterial pressure monitoring, postpump arterial
pressure monitoring, and venous pressure monitoring, the caregiver can systematically determine the
source of the abnormal pressure reading for intervention. The intervention may involve removing kinks
and clamps, repositioning of fistula needles or catheters for better flow, replacing clotted fistula
needles, using a larger gauge fistula needle, declotting of vascular catheters, replacing the clotted
extracorporeal circuit, decreasing the blood pump speed set on the hemodialysis machine temporarily
or for the remainder of the treatment, or tightening connections on the blood tubing set to stop blood
leak from or air entry into the blood tubing set.

Pressure Alarms on Hemodialysis Machines

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One function of the hemodialysis machine is to read, display, and provide alarm limits around
displayed pressures, not to determine if a pressure reading is safe or to interpret the pressure
readings. The nurse should set an alarm limit (usually +50 mmHg) around any displayed pressure and
the machine should alarm when the pressure fluctuates to or beyond that limit.

The source of most of the flow resistance in the extracorporeal circuit is from the access needle. A
needle dislodgment from the patient's access may not create enough of a pressure change to cause a
machine pressure-related alarm (Polaschegg, 1995). This is particularly true with venous fistula
needles. It is always recommended that the patient's access sites be visible to the caregiver at all
times.

Conclusion

The hemodialysis machine measures and displays arterial and venous pressures, however, it is the
caregiver who monitors and interprets these pressures to ensure quality care for hemodialysis
patients. The caregiver must be educated concerning pressure monitoring and interpretation of
pressure readings. Hemolysis, microair emboli, inadequate dialysis delivery, and blood loss from
rupture or dislodgment of the extracorporeal circuit can be prevented by ensuring that excessive
pressures are avoided during the hemodialysis treatment.

References

Bosch, J.P., & Ronco, C. (1993). High-efficiency treatments: Risks and common problems
encountered in their clinical application. In J.R Bosch & J.H. Stein (Eds.), Hemodialysis--High
efficiency treatments (pp. 209-224). New York: Churchill Livingstone.

Chambers, S.D., Ceccio, S.L., Annich, G.A., & Bartlett, R.H. (1999). Extreme negative pressure does
not cause erythrocyte damage in flowing blood. ASAIO Journal, 45, 431-435.

Cogan. M.G., & Schoenfeld, P. (1991). The blood circuit. In M.G. Cogan & P. Schoenfeld (Eds.),
Introduction to dialysis (2nd edition) (pp. 31-33). New York: Churchill Livingstone.

Daugirdas, J.T., & Ing, T.S. (1994). Handbook of dialysis (2nd edition). Boston/New York: Little, Brown,
and Company.

Francos, G.C., Burke, J.F., Jr., Besarab, A., Martinez, J., Kirkwood, R.G., & Hummel, L.A. (1983). An
unsuspected cause of acute hemolysis during hemodialysis. Trans American Society of Artificial
Internal Organs, XXIX, 140-145.

Keen, M.L., Lancaster, L.E., & Binkley, L.S. (1995). Section IX--Hemodialysis. In L.E. Lancaster (Ed.),
ANNA core curriculum for nephrology nursing (Third edition) (pp. 207-258).

Levy, S.S., Sherman, R.A., & Nosher, J.L. (1992). Value of clinical screening for detection of
asymptomatic hemodialysis vascular access stenoses. Angiology-The Journal of Vascular Diseases,
43(5), 421-424.

National Kidney Foundation (NKF). (1997a). NKF-DOQI Clinical practice guidelines for vascular
access (pp. 35-39). New York: National Kidney Foundation.

National Kidney Foundation (NKF). (1997b). NKF-DOQI Clinical practice guidelines for hemodialysis
adequacy (pp. 70-73). New York: National Kidney Foundation.

Polaschegg, H.D. (1995). The extracorporeal circuit. Seminars in Dialysis, 8(5), 229-304.

Twardowski, Z.J., Haynie, J.D., & Moore, H.L. (1999). Blood flow, negative pressure, and hemolysis
during hemodialysis. Home Hemodialysis International, 3, 45-50.
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This offering for 1.7 contact hours is being provided by the American Nephrology Nurses' Association
(ANNA), which is accredited as a provider and approver of continuing education in nursing by the
American Nurses' Credentialing Center-Commission on Accreditation (ANCCCOA). This educational
activity is approved by most states and specialty organizations that recognize the ANCC-COA
accreditation process. ANNA is an approved provider of continuing education in nursing by the
California Board of Registered Nursing, BRN Provider No. 00910; the Florida Board of Nursing, BRN
Provider No. 27F0441; the Alabama Board of Nursing, BRN Provider No. P0324; and the Kansas
State Board of Nursing, Provider No. LT0148-0738. This offering is accepted for RN and LPN
relicensure in Kansas.

This article qualifies for the credit toward the 30 contact hours of fundamental nephrology nursing
education required to take the CNN Examination effective January 1, 2000. To receive continuing
education credit, you must read the information in this article, complete and return the answer form on
page 30 and appropriate fee to the ANNA National Office. Please refer to the answer form for the
appropriate fee and address of the National Office,

Glenda D. Graves, BSN, RN, CNN, is Clinical Studies Manager, Gambro Renal Products, Lakewood,
CO.
Copyright: COPYRIGHT 2001 Jannetti Publications, Inc.
http://www.ajj.com
Source Citation (MLA 9th Edition)   
Graves, Glenda D. "Arterial and venous pressure monitoring during hemodialysis." Nephrology
Nursing Journal, vol. 28, no. 1, Feb. 2001, pp. 23+. Gale Academic OneFile,
link.gale.com/apps/doc/A133704631/AONE?u=googlescholar&sid=bookmark-
AONE&xid=eac7fc92. Accessed 29 Dec. 2022.

Gale Document Number: GALE|A133704631

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