Dialysis Pro — Complication Protocols v2

📉

Intradialytic Hypotension

IDH · ~5–30% of treatments (definition-dependent; ~12% by nadir SBP <90)

Nadir SBP <90 mmHg Drop in SBP ≥20 mmHg Drop in MAP ≥10 mmHg + associated clinical event / nursing intervention

ℹDefinition note: KDOQI and European Best Practice Guidelines define IDH as a fall in SBP ≥20 mmHg (or MAP ≥10 mmHg) accompanied by a clinical event requiring nursing intervention. The nadir SBP <90 mmHg threshold is the definition most strongly associated with increased mortality.

⚡Watch for the vagal prodrome: yawning, sighing, and hoarseness may precede the measurable BP drop. Usual symptoms: lightheadedness, muscle cramps, nausea, vomiting, dyspnoea. May be asymptomatic — monitor BP every 30 min minimum.

⚡ Immediate Actions

Supine position with legs elevated (passive leg raise)
Stop or reduce ultrafiltration to minimum
Reduce blood flow rate if needed
IV isotonic saline 200–300 mL bolus — standard first-line
Record vital signs; assess symptoms
Do not stop dialysis unless BP critically low after bolus

1

IV fluid — first-line treatment

Isotonic saline (0.9% NaCl) 200–300 mL IV is the standard intervention. Reassess BP at 5–10 minutes.

0.9% NaCl (Normal Saline) — standard 200–300 mL IV bolus · Repeat once if no response at 5–10 min

Hypertonic saline or Mannitol ⚠ SELECTED USE — not routine for IDH — Hypertonic saline: only if symptomatic hyponatremia is a contributing factor, per unit protocol
— Mannitol 20%: only if dialysis disequilibrium syndrome is co-suspected (see DDS protocol)
Neither is a routine or first-line IDH treatment.

2

Assess response at 10 minutes

Recheck BP. Evaluate for reversible precipitants.

Response to saline bolus

✓ Responds

Resume at reduced BFR and UFR. Recalculate remaining UF. Identify root cause.

✗ No response / SBP <80

Stop dialysis. ECG. Rule out ACS, PE, tamponade, arrhythmia. Vasopressors if unstable. Transfer to ED if outpatient.

3

Identify precipitant — four cause categories

Most IDH occurs without serious underlying disease, but always exclude the cardiac and systemic causes first.

Category	Specific causes	Action
Excessive fluid removal	UFR >13 mL/kg/h (≈ >0.35 mL/min/kg, ~1.5 L/h in 70 kg); plasma volume drop >20%; overestimated dry weight; large interdialytic weight gain	Extend time; reduce UF goal; reassess dry weight (↑ 0.5–1 kg if no overload)
Patient-related	Autonomic neuropathy (common in maintenance HD, especially diabetes); antihypertensive timing; food ingestion (splanchnic vasodilation); sepsis; anaemia; tissue ischaemia; venous pooling	Hold AM antihypertensives on HD days; avoid food 2h pre-HD; midodrine; treat anaemia/sepsis
Dialysis-related	Acetate dialysate; low dialysate Na⁺; low dialysate / ionised Ca²⁺; high Mg²⁺; dialysate temperature > body temperature; complement / cytokine activation	Review dialysate composition; use bicarbonate buffer; cool dialysate 35–36°C; Ca²⁺ 2.5 mEq/L
Cardiac	Myocardial infarction; structural heart disease / low EF; arrhythmia; pericardial tamponade	ECG; echo; do not attribute to volume until cardiac cause excluded

⚠️Diminished cardiac reserve markedly increases IDH risk — prior heart failure, cardiomegaly, or ischaemic heart disease impair the compensatory rise in cardiac output during ultrafiltration.

🛡 Prevention — for recurrent IDH

Cooler dialysate 35–36°C
Na⁺ modelling (ramped ↓)
UFR profiling / session extension
Midodrine 2.5–10 mg PO 30 min pre-HD
Increase frequency or session duration
Blood volume / biofeedback monitoring

Midodrine: avoid if hypertension, urinary retention, or thyrotoxicosis.

Higher-risk patients to flag for proactive prevention: older age, longer dialysis vintage, diabetes, high interdialytic weight gain, low pre-dialysis BP, low albumin.

⚡

Intradialytic Cramps

Muscle cramps · Frequent · Usually calf or foot · Often co-occurs with IDH

ℹAlmost always related to rapid fluid removal or low plasma osmolality. Always check BP simultaneously — IDH and cramps frequently co-exist and should be managed together.

⚡ Immediate Actions

Reduce or temporarily stop ultrafiltration
Passive stretching of the affected muscle
Warm compress to cramping area
Check BP — treat concurrent IDH if present (see IDH protocol)
IV isotonic saline 100–200 mL if IDH co-exists

🛡 Prevention — address root causes first

Reassess dry weight
Reduce UFR (target ≤10 mL/kg/h)
Longer or more frequent sessions
Review dialysate Na⁺ (target 138–140 mEq/L)
Review interdialytic weight gain / fluid compliance
Optimise nutrition if malnutrition present

Vitamin E SELECTED USE 400 IU PO daily — modest RCT evidence; low risk profile

L-Carnitine SELECTED USE 20 mg/kg IV post-HD 3×/week — if carnitine deficiency suspected

Gabapentin SELECTED USE 100–300 mg post-HD — also addresses uremic restless legs; adjust for HD clearance

Quinine — not recommended. FDA black-box warning (thrombocytopenia, arrhythmia, hypoglycaemia); no formal dialysis indication. Excluded from this protocol.

💓

Intradialytic Arrhythmia

K⁺ shift · Ca²⁺ change · pH rise · Structural heart disease

🚨Rapid electrolyte shifts — particularly falling K⁺ during HD — are the key arrhythmia trigger. Patients with structural heart disease, LVH, or prolonged QTc are at highest risk.

⚡ Immediate Actions

Obtain 12-lead ECG if available; start continuous cardiac monitoring
Assess BP, O₂ saturation, HR, patient symptoms
Confirm cardiac output is maintained (palpate pulse)
If hemodynamically unstable → stop dialysis, activate emergency response

1

If hemodynamically unstable → emergency

Stop dialysis. ACLS protocol. Defibrillation (200J biphasic) for shockable rhythms. Call emergency services if outpatient.

2

If hemodynamically stable — identify rhythm and treat

Rhythm	HD mechanism	First action
AF (new onset)	Rapid K⁺ fall, fluid shifts	Rate control; optimise dialysate K⁺; cardioversion if <48h and haemodynamically compromised
VT (sustained)	Hypokalemia, ischaemia	Stop HD; optimise dialysate K⁺; antiarrhythmic per ACLS
Bradycardia / AV block	Digoxin toxicity, vagal	Atropine; check digoxin level; pacing if refractory
Frequent PVCs	Hypokalemia, hypoxia	Adjust dialysate K⁺; optimise O₂

⚠️ IV K⁺ replacement in ESRD requires extreme caution. Fixed IV potassium dosing is not appropriate in a general bedside protocol — risk of fatal hyperkalemia in oliguric/anuric patients. If IV K⁺ replacement is clinically indicated, manage per pharmacy/clinical protocol with continuous cardiac monitoring. The primary intervention for hypokalemia-driven arrhythmia during HD is dialysate K⁺ optimisation.

Amiodarone (sustained stable VT) SELECTED USE — per ACLS 150 mg IV over 10 min, then 1 mg/min × 6h

Atropine (symptomatic bradycardia) 0.5–1 mg IV; repeat q3–5 min; max 3 mg

🛡 Prevention — dialysate electrolyte optimisation

Avoid dialysate K⁺ <2 mEq/L in at-risk patients
Prefer K⁺ 3–3.5 mEq/L dialysate when pre-HD K⁺ not critically elevated
K⁺ profiling (gradual removal) if available
Dialysate Ca²⁺ 2.5 mEq/L standard
Review QT-prolonging medications; baseline and annual QTc

🧠

Dialysis Disequilibrium Syndrome

DDS · Cerebral oedema · Highest risk: first sessions + very high BUN

⚠️Osmotic gradient drives water into brain when urea cleared faster from blood than brain. Rare once established on HD. Severity ranges from headache to seizures.

⚡ Immediate Actions

Reduce BFR to 150–200 mL/min immediately
Reduce DFR or switch to lower-efficiency mode
Extend session rather than shorten — slower clearance is the goal
Assess neurological status frequently

1

Severity spectrum

Mild: Headache, nausea, restlessness, blurred vision
Moderate: Confusion, hypertension, muscle twitching
Severe: Seizures, coma — neurological emergency

2

Osmotic support — selected use

Mannitol 20% SELECTED USE — when DDS clinically confirmed 1 g/kg IV over 20 min (typically 50–100 mL)
For confirmed or strongly suspected DDS — not prophylactic for all high-BUN patients

Hypertonic saline SELECTED USE — per unit protocol 10–30 mL of 23.4% IV over 10 min — alternative; use with caution

✱Elevating dialysate Na⁺ (e.g. to 145–148 mEq/L) may be considered in selected high-risk cases on an individualised basis — not a blanket recommendation for all new HD starts.

3

Seizure management — stop dialysis, emergency

Lorazepam — first-line 0.05–0.1 mg/kg IV (typically 2–4 mg); repeat q5 min if needed

Diazepam — alternative 5–10 mg IV if lorazepam unavailable

🛡 Prevention — new-start patients

Session 1: BFR 150–200 mL/min max
Limit first session to ≤2 hours
Limit urea reduction to ~30–40% in Session 1
Neurological check every 15 min
Mannitol prophylaxis: very high BUN + neurological symptoms/frailty only

❤️

Chest Pain and Dyspnoea

Broad differential · Sequential exclusion · Causes frequently overlap

🚨Never attribute chest pain to a benign cause without first excluding life-threatening diagnoses. HD patients carry markedly elevated cardiovascular risk. Chest pain and dyspnoea frequently coexist.

⚡ Immediate Actions — perform simultaneously

Stop ultrafiltration
Reduce blood flow rate to ≤200 mL/min
Lay the patient flat; administer oxygen
Record vital signs (BP, HR, O₂ sat, temperature)
Visually inspect venous line for air or foam
Visually inspect venous line for port-wine (cherry-red) appearance
Check if other patients in the unit have similar symptoms simultaneously — if yes, suspect systemic dialysate or water problem
Obtain 12-lead ECG if available
Draw blood from arterial line: electrolytes, troponin, CBC (save extra tubes)

🔀 Sequential Decision Algorithm

1

Is the patient hypotensive?
Yes → Supine with legs elevated + isotonic saline 200–300 mL IV. If both hypotension AND chest pain resolve: continue dialysis without UF; arrange outpatient cardiac evaluation. If either persists → Step 2.

2

Features of cardiac ischaemia? (ST changes on ECG, pressure-type pain, radiation, diaphoresis, arrhythmia)
Yes → Stop dialysis immediately. Cardiology consultation. If outpatient: emergency transfer. Do not delay for HD completion.

3

Features of hemolysis? (Port-wine venous blood, similar symptoms in multiple unit patients simultaneously, pink plasma in centrifuged specimen, falling Hb)
Yes → See Hemolysis protocol. Do not return blood.

4

Features of air embolism? (Neurological change, seizure, or focal deficit in a seated patient; air or foam visible in venous line)
Yes → See Air Embolism protocol. Clamp venous line immediately.

5

None of the above → Stop dialysis. Transfer to ED if outpatient. Evaluate for: PE, pericarditis, pericardial tamponade, first-use reaction, aortic dissection, musculoskeletal (diagnosis of exclusion only).

Diagnosis	Key distinguishing feature	Action
ACS / STEMI	ST elevation, pressure-type, diaphoresis	Stop HD. Activate cath lab. Dual antiplatelet. Cardiology urgently.
NSTEMI / UA	ST depression; rising troponin trend (see note)	Stop HD. Aspirin, nitrates. Cardiology urgently.
Pericarditis	Pleuritic, positional, friction rub, saddle ST, PR depression	NSAIDs + colchicine. More frequent HD if uremic. Avoid anticoagulation.
Pericardial tamponade	Beck's triad: hypotension, muffled sounds, JVD; pulsus paradoxus	Stop HD. Urgent echo. Pericardiocentesis.
Hemolysis	Cherry-red blood, other patients affected	See hemolysis protocol
Air embolism	Neurological signs, air in line	See air embolism protocol
First-use / anaphylaxis	First session, urticaria, wheeze, within 30 min	See anaphylaxis protocol

ℹTroponin in ESRD: Troponin T is chronically elevated due to reduced renal clearance — absolute values are less meaningful. A rising trend (>20% over 3h) is the clinically significant signal. Troponin I less affected by renal clearance; preferred if available.

💨

Air Embolism

Rare · Time-critical · Venous air detector failure or disconnection

🚨Even small air volumes can be fatal if reaching the pulmonary vasculature or crossing a PFO (paradoxical embolism). Signs in a seated patient: sudden mental status change, seizure, focal neurological deficit. Air or foam visible in the venous line.

⚡ Immediate Actions — in order

Clamp the venous return line immediately
Stop blood pump
Do NOT return blood from extracorporeal circuit
Call for emergency assistance
Durant manoeuvre: left lateral decubitus + Trendelenburg (head down 15–30°) — traps air in right atrial apex, prevents passage to pulmonary vasculature
100% O₂ via non-rebreather mask — accelerates nitrogen reabsorption from embolus
If CVC tip in right atrium/ventricle: experienced personnel may attempt air aspiration
Outpatient: call emergency services immediately for hospital transfer

🛡 Prevention — four air entry mechanisms to inspect pre-session

#	Entry point	Mechanism	Prevention
1	Arterial luer connection	Negative intraluminal pressure draws air if loose or broken	Inspect and tighten all luer connections before every session
2	Arterial tubing	Hole or break sucks air under negative pressure	Visual inspection of full arterial line length pre-session
3	Anticoagulant / saline injection site	Air injected inadvertently during syringe administration	Purge all syringes; never disconnect while pump running
4	Dialyzer / inadequate priming	Residual air from priming enters circuit	Adequate saline prime per manufacturer protocol; visual check

Venous air detector active and calibrated before every session
Never leave blood lines unclamped and unattended

🩸

Intradialytic Hemolysis

Rare but dangerous · Dialysate or mechanical problem · Fatal hyperkalemia risk

🚨Causes: overheated dialysate (>42°C), hypotonic dialysate (conductivity error), chloramine/disinfectant contamination, kinked blood tubing (shear stress). Lysed RBCs release massive K⁺ — cardiac arrest risk without urgent management.

⚡ Immediate Actions

Stop blood pump; clamp arterial and venous lines
Do NOT return blood — lysed RBCs carry life-threatening K⁺ load
If multiple patients affected simultaneously → dialysate/water system problem: alert biomedical engineering and stop other machines in unit
STAT: serum K⁺, CBC, plasma Hb (pink plasma in centrifuged specimen = hemolysis confirmed), LDH
Continuous cardiac monitoring
Outpatient: call emergency services immediately

1

Confirm hemolysis

Bedside: cherry-red (port-wine) venous blood line.
Laboratory: pink/red plasma in centrifuged specimen (haemoglobinaemia); elevated LDH; low haptoglobin; falling Hb on CBC.
Do not wait for all results before acting — treat clinically.

2

Treat hyperkalemia emergently — assume K⁺ will rise rapidly

Calcium gluconate 10% — cardiac membrane stabilisation (first) 10–20 mL IV over 2–5 min

Regular insulin + Dextrose 50% — K⁺ shift 10 units insulin IV + 50 mL D50W; monitor glucose closely

Sodium bicarbonate — if metabolic acidosis present 50–100 mEq IV

Salbutamol (Albuterol) nebulised — adjunct K⁺ shift 10–20 mg nebulised

3

Identify root cause — mandatory reporting

Dialysate conductivity error (hypotonic)
Overheated dialysate (>42°C)
Chloramine in water system
Disinfectant contamination
Kinked blood tubing (shear stress)

Report to biomedical engineering and water quality team. Do not restart dialysis on that machine until cause is identified and corrected.

🔌

Catheter Dysfunction

Poor flow · Fibrin sheath / intraluminal thrombus · Malposition

BFR <300 mL/min with pump alarms Arterial pressure ≤ −250 mmHg Venous pressure ≥ +250 mmHg Unable to draw blood

1

Exclude mechanical causes first — always

Check	Action
Patient position	Raise arms, turn head, cough, change position
External kink	Inspect full visible catheter length; unclamp, untwist
Heparin lock volume	Aspirate lock volume (1.0–1.8 mL per lumen) before assessing flow
Port reversal	Try reversing arterial/venous — reduces Kt/V ~10%; document if used
Dressing compression	Inspect exit site and dressing
Tip malposition	CXR if tip position in doubt

After mechanical causes excluded

✓ Suboptimal but functional

Complete session at reduced BFR. Plan thrombolytic dwell at end of session or next session.

✗ Cannot dialyse

Proceed to thrombolytic instillation (Step 2). If fails ×2 → interventional radiology referral.

2

Thrombolytic dwell — instillation technique

Alteplase (tPA) — first-line 2 mg/2 mL per lumen · Fill exact lumen volume (check label: typically 1.3–1.8 mL/lumen)
Short dwell: 30–60 min → aspirate and discard 3–5 mL → gentle NS flush if flow restored
Extended dwell: 4–6h for resistant clot — per unit protocol
Repeat once if no response

Tenecteplase (TNK) — alternative 1 mg/mL · Fill exact lumen volume · Dwell 30 min → aspirate

Urokinase — alternative where available 5,000–25,000 IU per lumen · Dwell 30–60 min

Systemic low-dose tPA infusion — not a standard approach; requires inpatient setting and specialist oversight. Not included as a routine step.

⚠️Never forcefully flush against resistance — risk of catheter rupture or clot dislodgement. Aspirate first; flush only after free flow confirmed.

After 2 thrombolytic attempts

✓ Flow restored

Resume dialysis. Document. Review lock strategy.

✗ Still dysfunctional

Interventional radiology: fibrin sheath stripping, guidewire exchange, or new catheter at alternate site.

🛡 Prevention — catheter locking after each session

Unfractionated heparin (standard) 1,000–5,000 U/mL · Fill exact lumen volume
Risk: systemic leakage (bleeding); HIT with prolonged use

Trisodium citrate 4% (preferred if HIT risk or bleeding) Fill exact lumen volume · Better safety profile; antimicrobial properties

Prophylactic tPA lock SELECTED USE — recurrent dysfunction only 1 mg/mL per lumen · For catheters with recurrent dysfunction — not default practice for all catheters

🌡️

Fever / CRBSI Suspicion

Catheter-Related Bloodstream Infection · High morbidity and mortality

🚨CRBSI carries significant morbidity and mortality — outcomes vary by organism, clinical setting, and speed of management. S. aureus is the most dangerous pathogen. Empiric antibiotics must start promptly after cultures are obtained.

1

Triage — does the patient need immediate ED transfer?

🚨 Transfer to ED immediately if any of:

Exit-site infection signs (ESI): pus, new tenderness, or new erythema at exit site
Suspected metastatic infection: new bone pain, new cardiac murmur
Persistent haemodynamic instability / sepsis despite IV fluids

ℹIf none of the above apply and patient is haemodynamically stable → empiric antibiotics + antibiotic lock + planned guidewire exchange strategy can be initiated without immediate ED referral.

If urgent HD is needed during workup → dialyse once through the infected catheter, then reassess ESI status to guide catheter decision.

2

Blood cultures before antibiotics — timing determines strategy

Scenario	Culture strategy
Symptoms between sessions	1 sample from dialysis catheter + 1 from peripheral vein (or HD circuit if on dialysis)
Symptoms during HD treatment	2 samples from HD circuit, OR 1 from circuit + 1 from peripheral vein
Between sessions; HD not planned for hours; no peripheral vein accessible	2 samples from dialysis catheter drawn 10–15 min apart

Differential time-to-positivity (catheter culture positive ≥2h before peripheral) supports CRBSI. Do not delay antibiotics >1–2h waiting for cultures.

3

Classify infection level

Category	Definition	Catheter implication
Exit-site infection	Erythema, tenderness, purulence at skin exit ≤2 cm; no systemic signs	May be salvageable with antibiotics if no bloodstream involvement
Tunnel infection	Erythema, pain, induration >2 cm along tunnel tract	Remove catheter — tunnel infections cannot be salvaged
CRBSI (bloodstream)	Fever ≥38°C, rigors, no other source; positive cultures	Organism-guided decision at 48–72h (see Step 5)
Complicated CRBSI	Persistent bacteraemia >72h, endocarditis, metastatic infection	Remove catheter; 4–6 weeks IV antibiotics; echocardiography

4

Empiric antibiotic therapy

Vancomycin — MRSA / gram-positive cover (first-line empiric) Loading: 25 mg/kg IV (max 3g) over 60–90 min
Maintenance: AUC/MIC or trough-guided dosing (typically 15–20 mg/kg q48–72h in HD) — supplement post-HD; significantly dialysed off
De-escalate to cefazolin if MSSA confirmed — superior outcomes for MSSA vs vancomycin

+ Ceftazidime or Cefepime — gram-negative cover (add if septic or high-risk) Ceftazidime 1g IV post-HD OR Cefepime 1g IV post-HD

Daptomycin — alternative (VRE suspected or vancomycin intolerant) 6–10 mg/kg IV post-HD once per session

✓De-escalate at 48–72h per culture sensitivities. MSSA: switch vancomycin → cefazolin. Gram-negative: narrow per report. Avoid broad-spectrum continuation beyond what culture results support.

5

Catheter decision at 48–72 hours

Organism, ESI status, and clinical response guide decision

✓ Guidewire exchange / salvage

Criteria (all must apply): CoNS or gram-negative rod · No ESI or tunnel infection · No metastatic infection · Haemodynamically stable · Asymptomatic >48h

Guidewire exchange: Once asymptomatic >48h (never for S. aureus or Candida)

Antibiotic lock (ALT): Same antibiotic as systemic therapy, instilled as catheter lock for the same duration (typically 14 days total)

✗ Remove catheter

Any of: S. aureus · Candida/fungi · Pseudomonas · Tunnel infection · ESI present · Haemodynamic instability · Metastatic infection · No improvement at 72h · Persistent bacteraemia >72h

Remove. Temporary non-tunneled catheter if urgent HD needed. New tunneled catheter at new site once cultures negative ≥48–72h.

6

Antibiotic duration

Scenario	Duration
CoNS CRBSI, catheter salvaged or exchanged	14 days systemic + ALT for same duration
CoNS CRBSI, catheter removed	5–7 days after removal
S. aureus, uncomplicated, catheter removed	Minimum 14 days IV (many centres: 28 days)
S. aureus, complicated (endocarditis, osteomyelitis)	4–6 weeks IV
Gram-negative, catheter removed	7–14 days
Candida CRBSI	14 days after last positive culture; catheter must be removed

7

S. aureus — mandatory additional workup

Echocardiography (TEE preferred) Spine MRI if back pain Ophthalmology consult (endophthalmitis) Bone scan if focal bone pain Serial blood cultures at 48–72h

🛡 Prevention

Mupirocin nasal ointment — MRSA decolonisation per local protocol
Chlorhexidine exit-site care
Citrate lock preferred over heparin
Minimise CVC use — prioritise AVF/AVG
Strict aseptic technique at every connection and dressing change

🧬

Anaphylaxis / First-Use Syndrome

Type A (IgE-mediated) · Type B (complement-mediated) · Within first 30 min

⚠️Type A (severe, within minutes): EtO sterilant allergy; AN69 membrane + ACE inhibitor (bradykinin release). Type B (milder, within 20 min): complement activation; cellulose membranes; usually self-limited.

⚡ Immediate Actions

Stop dialysis; clamp lines
Do NOT return blood if Type A anaphylaxis suspected
Assess airway, breathing, circulation
Type A → Epinephrine IM immediately (Step 1 below)
Type B → Supportive care (Step 2 below)

1

Type A — Anaphylaxis protocol

Epinephrine (Adrenaline) — FIRST LINE, give immediately 0.3–0.5 mg IM (1:1,000) lateral thigh · Repeat q5–15 min as needed
IV route (1:10,000): 0.1 mg slow IV if hypotensive/pulseless

Diphenhydramine (H1 blocker) 25–50 mg IV

Famotidine (H2 blocker) 20 mg IV

Methylprednisolone — prevents biphasic reaction 125 mg IV

Salbutamol — if bronchospasm present 2.5–5 mg nebulised

2

Type B — Supportive management

Usually self-limited. Slow dialysis speed. Supplemental O₂. Antihistamines if symptomatic. Epinephrine not required. Often resolves without stopping dialysis entirely.

🛡 Prevention for future sessions

Switch to synthetic high-flux membrane (polysulfone, polyamide)
Rinse new dialyzer with ≥1L saline before use
Hold ACE inhibitor on HD day if using AN69 membrane
Pre-medicate with antihistamine if Type B recurrent

🔒

Clotted Extracorporeal Circuit

Inadequate anticoagulation · High haematocrit · Blood stasis

⚡ Immediate Actions

Recognise: dark blood in lines/dialyzer, rising venous pressure, dialyzer darkening, pump alarms
Early partial clotting: NS flush 100–200 mL rapidly through arterial limb
Fully clotted circuit: do not force — abandon circuit
Do not return blood from clotted circuit
Set up new circuit and resume dialysis
If significant blood loss estimated (>100 mL RBC): check Hb; consider transfusion if already anaemic

1

Review and adjust anticoagulation

Scenario	Approach
Standard patient, heparin used, circuit clotted	Increase UFH bolus or infusion rate; check ACT target (200–250s if monitored)
Post-operative or active bleeding risk	Heparin-free HD: NS flushes 100–200 mL q20–30 min; maximise BFR; limit session duration
HIT confirmed or strongly suspected	Stop ALL heparin immediately. Switch to direct thrombin inhibitor (argatroban) or citrate anticoagulation — per anticoagulation service / pharmacy protocol. Haematology input.
High haematocrit (>40%)	Optimise EPO; increase NS flush rate; consider predilution HDF

⚠️HIT: Argatroban (direct thrombin inhibitor) is appropriate. Exact infusion rate, dose adjustments, and monitoring targets should be governed by local anticoagulation service or pharmacy protocol — not a fixed bedside dose. Do not attempt to manage HIT anticoagulation from this reference alone.

2

Standard anticoagulation dosing reference

UFH — individualise to patient Bolus: 500–2,000 U IV pre-session (lower end for bleeding risk)
Infusion: 500–1,500 U/h during session; stop 30–60 min before end
Target ACT 200–250s if monitoring available

Heparin-free HD (high bleeding risk) NS flushes 100–200 mL q20–30 min · Maximise BFR · Shorter sessions

Regional citrate anticoagulation Citrate 4% pre-filter; calcium replacement post-filter · Machine-specific protocol required

🛡 Prevention

Pre-session ACT check in recurrent clotters
Avoid stopping blood pump during session (promotes stasis)
Adequate NS prime of circuit
Review anticoagulation adequacy at each session in high-risk patients

Intradialytic Complications v2.0