Dialysis

Paramedic AEMT EMT EMR

Introduction
Hemodialysis remains the primary treatment for kidney failure, short of a kidney transplant, and allows the body to perform
all its necessary functions after renal failure has reached a point where the kidneys can no longer perform their duties. This
includes waste excretion, urine concentration, electrolyte balance, pH balance, and blood pressure stabilization.

The process of hemodialysis itself involves being attached to a hemodialysis machine for several hours a few times a
week, where the blood is filtered through a machine that rids the body of toxic wastes it otherwise couldn't. During the
process of dialysis, a patient's blood is transferred out of the body with a machine known as a dialyzer, taken to a secondary
container where it is purified and filtered before being returned to the body, cleansed of wastes and electrolytes balanced.1

Patients needed to be transported to a dialysis appointment are, generally, not experiencing an emergency. However, if a
patient misses one or more dialysis appointments, they might start experiencing a true life-threatening emergency.

Before the process of regular dialysis appointments can begin an access point must be obtained. In this, there are a few
options modern-day medicine can pick from, specific to the needs of the patient.

Dialysis Vascular Access

A dialysis shunt is used to connect the hemodialysis access point to a major artery. The shunt itself is just the means of
connection. An Atrioventricular (AV) fistula is a surgically connected artery and vein, utilized for dialysis access. The access
point needs to be durable enough to withstand frequent access, several times a week, without becoming structurally
compromised. The placement of an AV fistula is an operation in itself and changes the anatomical structure of the patient's
extremity (usually the arm). The AV fistula is often considered the best long-term solution for dialysis patients because of its
low rates of infection. However, it can take some time for them to properly mature and be utilized for hemodialysis.2
 Alternatively, a patient might have an AV graft which is a surgical connection of an artery and vein created by interposing
graft materials, biological or synthetic, between them. Unlike fistulas, grafts require no maturation stage, meaning they are
ready to perform their duty shortly after placement. Grafts are chosen over fistulas on a case-by-case basis, often related to
life expectancy, and other factors. They are also used for secondary access while waiting for a fistula to heal or develop, or
while waiting for a kidney transplant.

Once a suitable shunt has been selected, a patient may submit to hemodialysis, during which the patient's blood is filtered
through a solution known as dialysate. After being removed into the dialyzer, the blood is exposed to dialysate which,
through a chemical process, separates the blood from its wastes, before being returned to the body. Dialysate is a fluid
composed of water, electrolytes, and salt.

Peritoneal Dialysis is an alternative method of artificially reproducing the kidney's duties artificially. During peritoneal
dialysis, the abdominal cavity is saturated with large amounts of dialysis fluid. The fluid will remain in the cavity for 1-2 hours,
to allow for waste to be absorbed completely, and is then drained. Peritoneal dialysis has the advantage of being able to be
performed at home, unlike hemodialysis, which requires a clinic, however, it also comes with a significantly increased risk of
peritonitis.

Special Considerations: Overhandling of a patient with an extremity graft or fistula can result in damaging the access
point. Blood pressures and IV access should only be done on an extremity that has no shunt, or damage can occur, requiring
the patient to undergo further surgery for a new, secondary access point. Many of these patients have a central line, a
permanently fixed IV access port, meaning that secondary IV access is not always mandatory for these patients. Review your
protocols and consult with the patient before utilizing this established access point.

Complications/Adverse reactions to Dialysis

Dialysis is an effective procedure that extends the life of many patients by years and even paves the way to full recovery in
some patients. However, that does not mean it is not without drawbacks, and not every patient responds positively to the
treatment. Some common problems and even medical emergencies associated with dialysis treatment in of itself include
hypotension, hemorrhage from a fistula or shunt, access site infection, potassium/electrolyte imbalances, air embolisms, even
machine dysfunctions, or disequilibrium syndrome (which is a collection of its own symptoms, including nausea, fatigue,
headaches, convulsions, and disturbed consciousness). Further, patients undergoing regular dialysis treatment are more at
risk for other chronic health issues, including heart failure, myocardial infarction with cardiac dysrhythmias, hypertension,
pericardial tamponade, and uremic pericarditis.3

These are potentially serious symptoms and conditions that the dialysis patient could suffer, however, the alternative isn't
much better. Missed dialysis appointments, even one missed appointment in particularly frail patients, could lead to
hyperkalemia with associated ECG changes, severe weakness, and pulmonary edema. If they continue to go with dialysis,
they will go into total renal failure, which has its own collection of very dire symptoms, up to and including death.

Management of the Patient with a Dialysis Emergency

First and foremost, manage the basics: airway, breathing, and circulation. In a highly acute dialysis emergency, one of these
fundamentals could be compromised, so never fail to return to these. If the patient is suffering from hypotension, consider
administering fluids. If the patient is hemorrhaging from a fistula or shunt, apply direct pressure to control the bleeding, and
consider using a clamp - a common tool found at most dialysis clinics.

In the case of an electrolyte imbalance, treat any EKG changes as protocols indicate. Typically, hypokalemic bradycardia
is treated with atropine, while symptomatic hyperkalemia is treated with calcium or sodium bicarbonate - but as always, refer
to your standing orders.

If the patient is experiencing severe pulmonary edema, treat with positive pressure if needed and elevate the patient's
torso. Conversely, if the patient is presenting with hypoperfusion symptoms, consider laying the patient flat.

However, as in most cases, the dialysis patient requires supportive care and transport to a system that can manage their
long-term health needs.

Resources

Caroline, N. L., ed, P. A. N. series, Elling, B., & Smith, M. (2013). Nancy Caroline's emergency care in the Streets, vols. 1
& 2. Jones & Bartlett Learning.

Marsh, A. M. (2021, July 25). Dialysis fistula. StatPearls [Internet]. Retrieved September 29, 2021, from
https://www.ncbi.nlm.nih.gov/books/NBK559085/.

Saha, M., & Allon, M. (2017, February 7). Diagnosis, treatment, and Prevention of Hemodialysis emergencies. Clinical
journal of the American Society of Nephrology: CJASN. Retrieved September 29, 2021, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5293333/#:~:text=These%20emergencies%20include%20dialysis%20disequilibriu