Managing Hypotension During Hemodialysis

Hypotension during hemodialysis is a common acute complication, typically defined as a systolic blood pressure drop below 90 mmHg or a decrease in mean arterial pressure of more than 30 mmHg compared to pre-dialysis levels. Effective interventions include positional adjustments, intravenous fluid administration, lowering dialysate temperature, using vasopressor medications, and fluid replacement therapy.

Positional Adjustments

To manage hypotension, healthcare providers may pause ultrafiltration and place the patient in a supine position. In certain situations, a Trendelenburg position (head lower than feet) may be used to enhance myocardial blood supply. Oxygen therapy via nasal cannula is often administered simultaneously to improve oxygenation.

Intravenous Fluid Administration

A rapid intravenous infusion of normal saline, typically 100 mL or more, is often the first-line treatment. If symptoms persist, hypertonic solutions such as 20–40 mL of high-concentration dextrose or 20% mannitol may be administered to help increase intravascular volume and stabilize blood pressure.

Lowering Dialysate Temperature

By leveraging the principle of thermal expansion and contraction, reducing the temperature of the dialysate can cause vasoconstriction, which helps maintain blood pressure even when blood flow remains constant. This method is particularly effective in preventing hypotension during the dialysis session.

Vasopressor Medications

When to Consider Vasopressors

If blood pressure does not improve after volume expansion, it is important to identify and address other potential causes of hypotension. In such cases, vasopressor medications may be introduced, and dialysis should be discontinued temporarily. Additional treatments may include plasma expanders or albumin infusions to support circulatory stability.

Fluid Replacement Therapy

In severe cases where patients exhibit neurological symptoms such as seizures or syncope, immediate fluid resuscitation is crucial. Medical professionals may administer intravenous solutions like sodium chloride or glucose injections to rapidly correct the hypotensive state and prevent further complications.

Preventive and Targeted Approaches

While managing acute hypotension is essential, it is equally important to identify the underlying causes of blood pressure drops during hemodialysis. Tailored interventions based on individual patient factors can significantly reduce the risk of recurrence and improve overall dialysis outcomes.