Digoxin: easy nursing-style summary

1. Indications: why digoxin is used

1. Heart failure with reduced pumping function
   • Used in selected adults with symptomatic heart failure, usually when symptoms persist despite standard heart-failure treatment.
   • It may improve symptoms and reduce heart-failure admissions, but does not improve survival.
2. Chronic atrial fibrillation
   • To slow the ventricular or pulse rate, particularly when the patient also has heart failure or is relatively sedentary.
   • It controls the rate, but does not normally convert AF to normal sinus rhythm.

2. Contraindications: when not to give it

• Ventricular fibrillation is present.
• The patient has atrial fibrillation with Wolff-Parkinson-White syndrome (WPW) or another accessory pathway, unless a cardiologist specifically directs it. Digoxin can dangerously speed conduction through the accessory pathway.
• Previous serious allergy/hypersensitivity to digoxin.

Use only with great caution / discuss with prescriber

• Very slow pulse, sinus-node disease, or second/third-degree AV block without a pacemaker
• Kidney impairment, older age, low body weight
• Low potassium, low magnesium, or high calcium
• Recent myocardial infarction/ischemia
• Thyroid disease
• Taking interacting medicines, especially amiodarone, verapamil, diltiazem, quinidine, macrolide antibiotics, some antifungals, or certain diuretics.

3. Symptoms of digoxin toxicity

4. Dose: simple guide

Important

• Age
• Lean body weight
• Kidney function and creatinine clearance
• Heart rhythm and indication
• Other medicines
• Serum digoxin concentration and clinical response

Common adult maintenance dose

• Oral: often 0.125 mg once daily
• Some adults may receive 0.25 mg once daily
• Frail older adults or patients with reduced kidney function may need 0.0625 mg once daily or less.

IV loading dose, if rapid effect is prescribed

• Typical adult total loading dose: 8 to 12 micrograms/kg IV, calculated using lean body weight.
• Give in divided doses:
  • Give about 50% first
  • Then 25% every 6 to 8 hours, after reassessing pulse, ECG rhythm, and response.
• Loading is not always needed. Many patients are started cautiously on maintenance dosing only.

• 250 micrograms first
• Then 125 micrograms after 6-8 hours if required
• Then 125 micrograms after another 6-8 hours if required

5. How to give IV digoxin

Before giving

1. Check the medication order and concentration.
2. Check apical pulse for a full minute, blood pressure, ECG/rhythm, potassium, magnesium, calcium, and renal function.
3. Check for nausea, visual symptoms, confusion, or arrhythmia.
4. If pulse is very slow, rhythm is abnormal, or toxicity is suspected, withhold and contact the prescriber according to local protocol.

Many institutions use a hold parameter such as pulse below 60 beats/min in adults, but follow the prescriber's order and your local policy.

IV administration

• IV route is preferred over IM.
• Give slow IV over at least 5 minutes.
• Do not give as a rapid IV push/bolus.
• Monitor the patient and ECG during administration when possible.
• Do not mix digoxin with other drugs in the same syringe, bag, or line at the same time unless compatibility is confirmed.

6. How much to dilute

• 250 micrograms/mL
• Ampoule/vial may contain 500 micrograms in 2 mL

• Use Sterile Water for Injection, 0.9% sodium chloride, or 5% dextrose.
• Add at least a 4-fold volume of diluent.

Easy example

• 1 mL digoxin = 250 micrograms

• 4 mL diluent

• 5 mL total

• 2 mL digoxin = 500 micrograms

• 8 mL diluent

• 10 mL total

One-line memory aid

Digoxin: easy way to remember

1. Mechanism of action

1. Makes the heart squeeze stronger
   • Blocks the sodium-potassium ATPase pump
   • This increases calcium inside heart cells
   • More calcium = stronger heart contraction
   • Called positive inotropic effect
2. Makes the heart rate slower
   • Increases vagal effect on the heart
   • Slows conduction through the AV node
   • Therefore slows the ventricular rate in atrial fibrillation
   • Called negative chronotropic and negative dromotropic effect

2. Indications

1. Heart failure with reduced ejection fraction
   • For selected patients with continuing symptoms despite usual treatment.
   • Helps symptoms and can reduce hospital admissions.
2. Atrial fibrillation or atrial flutter
   • To control a fast ventricular rate, especially if the patient also has heart failure or cannot tolerate other rate-control drugs.

3. Contraindications

Do not give in:

• Ventricular fibrillation
• Known allergy to digoxin/digitalis
• Atrial fibrillation with WPW syndrome or an accessory AV pathway, unless specifically prescribed by a cardiologist. It may cause a dangerously fast ventricular rhythm.

Give very carefully / notify prescriber if:

• Pulse is slow, significant sinus bradycardia
• Second- or third-degree heart block without a pacemaker
• Kidney impairment
• Older patient or very low body weight
• Low potassium, low magnesium, or high calcium
• Patient takes amiodarone, verapamil, diltiazem, quinidine, macrolide antibiotics, or loop diuretics

4. Symptoms of digoxin toxicity

5. Dose

Common adult maintenance dose

• 0.125 mg orally once daily is common.
• 0.25 mg once daily may be used in some patients.
• Older adults or renal impairment: often 0.0625 mg once daily or less.

IV loading dose, only if prescribed

• 8 to 12 micrograms/kg IV, based on lean body weight.
• Usually divided into doses:
  • 50% initially
  • 25% after 6 to 8 hours
  • Remaining 25% after another 6 to 8 hours, depending on ECG and response.

6. How to give IV digoxin

Before administration

• Apical pulse for a full minute
• ECG/rhythm if available
• Blood pressure
• Potassium and magnesium
• Kidney function
• Symptoms of toxicity

IV method

• IV is preferred over IM.
• Give slow IV over at least 5 minutes.
• Never rapid IV push or bolus.
• Do not mix it with other medicines in the same syringe or IV container.
• Avoid giving simultaneously through the same IV line unless compatibility has been confirmed.

7. How much to dilute

• 500 micrograms in 2 mL
• Therefore, 250 micrograms/mL

Use at least 4 times the volume of diluent.

• Sterile water for injection
• 0.9% normal saline
• 5% dextrose

Easy dilution examples

One-line revision

Dopamine: easy nursing summary

1. Mechanism: how it works

2. Indications

• Shock with low blood pressure and poor perfusion, after correcting low circulating volume where possible
• Selected cases of cardiogenic shock / low cardiac output
• Sometimes used for hypotension with bradycardia when directed by an experienced clinician

In septic shock, current critical-care practice often prefers norepinephrine as the initial vasopressor. Dopamine may cause more tachyarrhythmias, so it is not routinely the first choice.

3. Contraindications and major cautions

Do not give dopamine in:

• Pheochromocytoma
• Known allergy to dopamine or product ingredients, including sulfites in some formulations

Use with great caution / inform prescriber if:

• Uncorrected low blood volume: give fluids/blood as appropriate first
• Tachycardia or existing arrhythmias
• Ischemic heart disease or recent myocardial infarction
• Peripheral vascular disease, Raynaud phenomenon, or severe limb ischemia
• Diabetes
• Patient has used an MAOI within the previous 2 to 3 weeks: a lower starting dose may be needed
• Patient is receiving general anesthesia with cyclopropane or halogenated hydrocarbon anesthetics, due to arrhythmia risk

4. Dose

Adult and pediatric starting dose

• Start 2 to 5 micrograms/kg/minute IV infusion
• Titrate according to BP, MAP, urine output, perfusion, heart rate, rhythm, and clinical response.
• Increase in 5 to 10 micrograms/kg/minute steps.
• Maximum usual labeled rate: 50 micrograms/kg/minute

Example calculation

• Dose per minute = 5 × 60 = 300 micrograms/min
• Dose per hour = 300 × 60 = 18,000 micrograms/hour

5. How to dilute dopamine

• 200 mg in 5 mL
• 400 mg in 10 mL
• Both are 40 mg/mL

Common easy dilution

• 0.9% sodium chloride
• 5% dextrose
• Dextrose-saline solutions
• Lactated Ringer's, if allowed by local policy

Important incompatibilities

• Sodium bicarbonate or other alkaline solutions: dopamine is inactivated
• Blood products
• Iron salts

6. How to administer

1. Verify the prescription, patient weight, dilution, and pump calculation with another qualified clinician.
2. Correct fluid loss, hypoxia, and acidosis first if applicable.
3. Administer via a large vein, preferably a central venous line for prolonged or high-dose infusion.
4. Use an infusion pump. Never bolus.
5. Continuously monitor:
   • BP or MAP
   • ECG and heart rate
   • Peripheral perfusion, skin color and temperature
   • Urine output
   • IV site for pain, blanching, swelling, or leakage
6. Titrate only according to the prescriber's order and local protocol.
7. Taper gradually when stopping if the patient has received prolonged infusion.

Extravasation warning

• Stop the infusion immediately
• Leave the IV catheter in place initially
• Aspirate drug if possible
• Inform the clinician urgently
• Follow local extravasation protocol, which may include phentolamine infiltration

One-line revision

Dobutamine: easy way to remember

1. Mechanism: how it works

• Beta-1 stimulation -> more calcium enters heart muscle cells
• Heart contracts more strongly
• Cardiac output increases
• It can also make the heart rate faster

2. Indications: why it is given

• Acute decompensated heart failure with low cardiac output
• Cardiogenic shock with poor heart contractility
• Low cardiac output after cardiac surgery
• Selected patients with poor tissue perfusion despite adequate fluid status
• Sometimes used during a dobutamine stress echocardiogram, under specialist supervision

3. Contraindications: when not to give

Do not give if:

• Idiopathic hypertrophic subaortic stenosis, also called obstructive hypertrophic cardiomyopathy
• Known serious allergy/hypersensitivity to dobutamine or the preparation

Use very carefully if:

• Fast heart rate or existing arrhythmia
• Atrial fibrillation with rapid ventricular response
• Ischemic heart disease or acute myocardial infarction, because it raises myocardial oxygen demand
• Low blood pressure due to low blood volume: correct hypovolemia first
• Patient is on beta-blockers: effect may be reduced
• History of sulfite sensitivity or asthma, as some preparations contain sodium metabisulfite

4. Symptoms and adverse effects to watch for

Common / important effects

Tell the prescriber immediately if there is:

• New or worsening chest pain
• Marked tachycardia
• New irregular rhythm
• Significant fall or rise in BP
• Reduced urine output or worsening peripheral perfusion
• IV-site pain, swelling, blanching, or leakage

5. Dose

• Start: 2 to 5 micrograms/kg/minute
• Usual range: 2 to 20 micrograms/kg/minute
• Titrate to cardiac output, BP, perfusion, urine output, heart rate, and ECG rhythm.

Important

• Give only by continuous IV infusion
• Never give IV bolus / IV push
• Use an infusion pump
• Dose is written in micrograms/kg/minute, not mg/minute.

6. How to dilute

• 250 mg in 20 mL
• Concentration: 12.5 mg/mL

Easy common dilution

• 5% dextrose
• 0.9% sodium chloride
• 5% dextrose with 0.45% or 0.9% sodium chloride
• Lactated Ringer's, depending on product and local policy

Example pump calculation

• Concentration = 1,000 micrograms/mL

• 5 × 60 = 300 micrograms/minute
• 300 × 60 = 18,000 micrograms/hour
• 18,000 ÷ 1,000 = 18 mL/hour

7. How to give: simple steps

1. Check the prescription, patient weight, vial concentration, dilution, and pump rate.
2. Assess BP, pulse, ECG rhythm, oxygenation, urine output, and signs of poor perfusion.
3. Correct hypovolemia if present before relying on dobutamine.
4. Dilute correctly and label the infusion.
5. Infuse through a large peripheral vein or central line, using an infusion pump.
6. Monitor ECG and BP continuously, preferably in ICU/HDU or another closely monitored setting.
7. Titrate only according to the prescriber’s order and local protocol.
8. Reduce or stop and seek review if serious tachyarrhythmia, angina, severe hypertension, or hypotension occurs.

One-line revision

Heparin in hemodialysis: easy guide

Important: Dialysis heparin must be prescribed and set according to the dialysis unit protocol. The dose varies with bleeding risk, body size, access, session length, and whether the circuit clots.

1. What heparin does

• It enhances antithrombin
• Antithrombin blocks clotting factors, mainly thrombin (IIa) and factor Xa
• Result: prevents blood from clotting in the patient and in the dialysis circuit

2. Indications

General indications

• Treatment or prevention of deep-vein thrombosis and pulmonary embolism
• Acute coronary syndrome
• Prevention of clotting in extracorporeal circuits, including cardiopulmonary bypass and hemodialysis
• Maintaining patency of some vascular devices, when specifically prescribed

In hemodialysis

• Clotting in the blood lines
• Clotting in the dialyzer
• Early termination of dialysis due to circuit clotting

3. Contraindications: do not give

Absolute or major contraindications

• Active uncontrolled bleeding
• Severe thrombocytopenia
• Current or previous heparin-induced thrombocytopenia (HIT), unless specialist-directed
• Known serious allergy to heparin, pork products, or product ingredients
• Inability to monitor coagulation when full-dose systemic heparin is needed

Dialysis situations requiring no or minimal heparin

• Recent surgery or invasive procedure
• Recent intracranial bleed, stroke, or neurosurgery
• Active gastrointestinal bleeding
• Bleeding from dialysis access
• Severe uncontrolled hypertension
• Very low platelet count
• Pericarditis/pericardial effusion
• High bleeding risk after renal biopsy

4. Symptoms and signs to watch for

Bleeding signs

• Bleeding from fistula, graft, catheter site, gums, or nose
• Blood in urine
• Black stool or blood in stool
• Vomiting blood or coffee-ground material
• Large bruises, petechiae, or prolonged bleeding after needle removal
• Severe headache, weakness, confusion, or fall in BP, which may suggest internal bleeding

HIT warning signs

• Platelet count falling by about 50% or more from baseline
• New unexplained clotting
• Repeated clotting of the dialysis circuit
• Painful skin lesions or redness at injection sites

5. Common dialysis heparin dose

Standard intermittent hemodialysis regimen

Low-bleeding-risk versus high-bleeding-risk approach

6. How to dilute heparin

• 1,000 units/mL
• 5,000 units/mL
• Higher strengths for special uses

Example only: 25,000 units in 250 mL normal saline

• Take 25 mL of heparin 1,000 units/mL = 25,000 units
• Add to a final volume of 250 mL of 0.9% normal saline
• Final concentration = 100 units/mL

Pump-rate examples with 100 units/mL solution

Always use the concentration and pump library approved by your dialysis unit. Do not use this example to replace the local protocol or a prescribed dialysis order.

7. How to give heparin during dialysis

1. Check the prescription, patient identity, allergies, platelet count, bleeding history, and most recent dialysis record.
2. Confirm the purpose: circuit anticoagulation versus catheter lock.
3. Prepare and label the prescribed dilution using an independent double check.
4. Give the ordered loading bolus into the arterial bloodline/circuit, usually at dialysis initiation, as per unit protocol.
5. Start the prescribed continuous infusion using the dialysis machine pump or approved infusion pump.
6. Inspect the circuit for fibrin, dark streaking, rising venous pressure, or clotting.
7. Monitor access-site bleeding, BP, heart rate, and clinical bleeding signs.
8. Stop the infusion at the prescribed time, often 30 minutes before completion.
9. At the end, apply firm pressure to fistula/graft needle sites until bleeding stops and document the dose, circuit condition, and bleeding.

8. Very important: circuit heparin versus catheter lock

One-line revision

Intradialytic hypotension (IDH): what it is

• Fall in systolic BP by 20 mmHg or more, or
• Fall in mean arterial pressure by 10 mmHg or more
  plus symptoms such as cramps, nausea, dizziness, yawning, restlessness, fainting, or anxiety. KDOQI definition

Why does it happen?

Fluid is removed faster than the body can refill the blood vessels or compensate with heart and blood-vessel responses.

Simple example

• Patient gains 4 kg between dialysis sessions.
• The prescription tries to remove almost 4 L in 4 hours.
• The ultrafiltration rate may be too high.
• Blood volume falls.
• Patient develops cramps, nausea, dizziness, and hypotension.

Signs and symptoms

Early symptoms

• Yawning, sighing, restlessness
• Feeling hot or cold
• Weakness, fatigue
• Muscle cramps, especially legs or abdomen
• Nausea, vomiting
• Anxiety
• Dizziness or blurred vision

Later or severe symptoms

• Pallor, sweating, cold clammy skin
• Tachycardia or bradycardia
• Chest pain
• Shortness of breath
• Confusion
• Syncope or loss of consciousness
• Seizures
• Shock

Causes of IDH

A. Dialysis-related causes

B. Patient-related causes

• Large interdialytic weight gain
• Elderly patient
• Diabetes with autonomic neuropathy
• Heart failure or low ejection fraction
• Ischemic heart disease
• Arrhythmias
• Valvular heart disease, especially aortic stenosis
• Pericardial effusion or tamponade
• Sepsis or fever
• Anemia
• Diarrhea, vomiting, poor oral intake, GI bleed
• Taking antihypertensive medicines shortly before dialysis
• Vasodilators, nitrates, or sedatives
• Starting dialysis already below dry weight

C. Timing gives a clue

• Early in dialysis: think pre-existing low volume, sepsis, bleeding, vomiting, diarrhea, poor intake, antihypertensive medication, or a cardiac event.
• Later in dialysis: think excessive ultrafiltration or dry weight set too low.

Immediate management: dialysis therapist actions

Step 1: Recognize and assess

1. Respond immediately to symptoms or low BP alarm.
2. Check BP manually if possible and repeat it.
3. Assess:
   • Consciousness and orientation
   • Pulse and rhythm
   • Respiratory distress and oxygen saturation
   • Chest pain or back pain
   • Skin color, sweating, cramps, nausea
   • Blood loss from needles, lines, dialyzer, or floor
4. Check the machine:
   • Current UF rate
   • UF removed and UF remaining
   • Target weight
   • Blood flow rate
   • Dialysate temperature
   • Conductivity and sodium setting
   • Arterial and venous pressures
   • Evidence of clotting, hemolysis, or blood leak

Step 2: Stop fluid removal

• Immediately reduce UF to zero or pause UF.
• Do not continue removing fluid while the patient is hypotensive.
• Do not routinely reduce the blood-flow rate just because BP falls. It may reduce dialysis adequacy and has not shown routine benefit for IDH.

Step 3: Position the patient

• Lay the patient supine.
• Use leg elevation or Trendelenburg position as allowed by your unit protocol.
• This temporarily improves venous return to the heart.

Step 4: Give normal saline if prescribed by protocol

• Give 0.9% sodium chloride, commonly 100 mL bolus.
• Reassess BP and symptoms after each bolus.
• Repeat according to local policy and the nephrologist's order.

Step 5: Reassess continuously

• BP every 2 to 5 minutes until stable
• Heart rate and rhythm
• Symptoms
• Oxygen saturation if unwell
• Access and circuit for bleeding
• Need to restart UF, at a lower rate only if clinically appropriate

When to call the nephrologist or urgent medical team

• Persistent hypotension despite stopping UF and saline
• Syncope, reduced consciousness, seizure, or shock
• Chest pain, dyspnea, new arrhythmia, or ECG changes
• Suspected bleeding
• Suspected sepsis
• Severe abdominal or back pain
• Suspected hemolysis, air embolism, dialyzer reaction, or anaphylaxis
• New neurological deficit
• Repeated IDH requiring frequent saline boluses
• Inability to achieve dialysis safely

What not to do

• Do not ignore cramps, nausea, or yawning. They can be early IDH signs.
• Do not continue high UF while BP is falling.
• Do not give fluid blindly without checking for bleeding, sepsis, cardiac symptoms, or an incorrect UF goal.
• Do not routinely decrease blood flow as the first IDH treatment.
• Do not discharge a patient who remains dizzy or has post-dialysis orthostatic hypotension.
• Do not repeatedly give large saline volumes without informing the nephrologist. The patient may leave fluid overloaded.

Prevention for the next dialysis session

1. Review target weight and fluid gain

• Check whether the prescribed dry weight is too low.
• Compare pre-dialysis weight with usual target weight.
• Review recent weight loss, illness, diarrhea, poor intake, or hospitalization.
• Counsel on reducing salt intake and excessive fluid gain between sessions.

2. Reduce ultrafiltration stress

• Lower the UF rate.
• Extend dialysis time if possible.
• Consider an extra dialysis session if fluid gain is too large.
• Avoid trying to remove all excessive fluid in one short session.

3. Adjust the dialysis prescription

• Cooler dialysate, often individualized around 35 to 36°C or below body temperature
• UF profiling or blood-volume-guided UF where available
• Sodium profiling or individualized dialysate sodium, with caution because higher sodium can increase thirst and interdialytic weight gain
• Avoidance of low dialysate calcium in vulnerable cardiac patients
• Longer or more frequent dialysis
• Hemodiafiltration in selected patients

4. Review medications and meals

• Review timing of antihypertensive medicines with the prescriber.
• Avoid short-acting BP-lowering drugs immediately before dialysis if they contribute to IDH.
• Avoid large meals during dialysis.
• Do not independently stop prescribed BP medication. Escalate for a medication review.

5. Consider midodrine only with prescription

Simple bedside algorithm

1. Check patient and BP
2. Stop or reduce UF to zero
3. Lay flat and elevate legs
4. Give 0.9% saline bolus as per protocol
5. Recheck BP, symptoms, pulse, oxygenation, circuit, and access
6. Escalate if persistent, severe, chest pain, dyspnea, bleeding, altered consciousness, or arrhythmia
7. Document the episode and review dry weight, UF rate, medications, food intake, and dialysis prescription before the next session

One-line memory aid

During the low-BP episode

1. Set UF rate to 0 mL/hour
   • Stop ultrafiltration immediately.
   • This is the most important machine action.
2. Do not routinely reduce blood-flow rate
   • Keep the prescribed blood-flow rate unless there is another issue, such as access malfunction, severe instability, or a medical order.
   • Reducing blood flow usually does not correct IDH and reduces dialysis adequacy.
3. Check UF settings
   • Verify prescribed target UF volume.
   • Check how much UF has already been removed.
   • Check whether the target weight is likely too low.
   • When stable, only restart UF at a lower rate if prescribed.
4. Check dialysate temperature
   • For recurrent IDH, the prescription may be changed to a cooler dialysate, commonly 36°C or lower.
   • Do not make an unprescribed temperature change outside protocol.
5. Check conductivity / dialysate sodium
   • Confirm conductivity matches the prescription.
   • Do not independently raise dialysate sodium.
   • Sodium profiling may help selected patients but can cause thirst, higher interdialytic weight gain, hypertension, and fluid overload. It needs a nephrologist-approved plan.
6. Check for machine or circuit problems
   • Confirm no blood leak, air alarm, hemolysis concern, dialysate-conductivity alarm, line disconnection, or visible circuit blood loss.
   • Check arterial and venous pressures, access needles, and bloodlines.

For recurrent IDH: changes to request in the next prescription

Short bedside memory

• UF = OFF
• Put patient flat, raise legs
• Give normal saline as unit protocol
• Check target UF, temperature, conductivity, circuit and bleeding
• After recovery: restart UF only if ordered, at a lower rate

Intradialytic hypotension (IDH) during hemodialysis

• Systolic BP falls by 20 mmHg or more, or mean arterial pressure falls by 10 mmHg or more
• Plus symptoms or an intervention is needed, such as stopping ultrafiltration (UF) or giving saline.

1. Common symptoms

• Yawning, sighing, restlessness
• Muscle cramps
• Nausea or vomiting
• Feeling hot, cold, sweaty, pale
• Dizziness, blurred vision, weakness
• Anxiety
• Tachycardia or sometimes bradycardia
• Chest pain or shortness of breath
• Confusion, fainting, loss of consciousness

2. Why IDH happens

Most common cause

• Too much UF or UF rate too high
• Target weight may be too low
• Large interdialytic weight gain means a large amount of fluid must be removed in a short time

Other important causes

• Patient came to dialysis already dehydrated: diarrhea, vomiting, poor intake, fever, bleeding
• Antihypertensive medication taken shortly before dialysis
• Large meal during dialysis
• Warm dialysate causing vasodilation
• Diabetes with autonomic neuropathy
• Heart failure, ischemic heart disease, arrhythmia, valvular disease
• Pericardial effusion/tamponade
• Sepsis
• Blood loss from needle, bloodline, dialyzer, or access

• Early IDH: consider dehydration, bleeding, sepsis, medications, cardiac problem.
• Late IDH: often excessive UF or target weight too low.

3. Immediate management by the dialysis therapist

Immediate actions: simple sequence

1. Assess patient and confirm BP

• Stop and attend the patient.
• Recheck BP, preferably manually if the reading seems incorrect.
• Assess consciousness, pulse/rhythm, oxygen saturation, chest pain, dyspnea, cramps, nausea, and bleeding.
• Inspect access, needles, tubing, dialyzer, and floor for blood loss.

2. Change the machine: UF OFF

• Set UF rate = 0 mL/hour or use the machine's UF pause/stop function.
• This is the first and most important machine intervention.
• Do not keep removing fluid while the patient is hypotensive.

3. Position

• Lay the patient supine.
• Raise legs or use Trendelenburg position if allowed by your unit protocol.

4. Give fluid according to protocol

• Give 0.9% normal saline, often an initial 100 mL bolus.
• Reassess BP and symptoms.
• Repeat only as your unit policy or prescriber permits.

5. Reassess every 2-5 minutes

• BP, heart rate/rhythm, symptoms, oxygen saturation
• Access/circuit for blood loss or clotting
• Total saline given
• UF volume removed and remaining
• Need for doctor/nephrologist review

6. Restarting UF

• Do not restart UF until BP and symptoms recover.
• If UF is restarted, it should be at a lower rate, according to the revised prescription or authorized unit protocol.
• Sometimes the safe decision is to finish dialysis with no further UF and accept a higher post-dialysis weight.

4. What to change in the hemodialysis machine

A. Changes during an acute IDH episode

B. Machine/prescription changes for recurrent IDH

5. What to check on the machine and circuit

UF and prescription

• Pre-dialysis weight
• Target weight
• UF goal
• UF rate
• UF removed so far
• Remaining treatment time
• Was the patient below target weight at the start?

Dialysate

• Temperature
• Conductivity
• Correct dialysate concentrate
• Sodium, potassium, calcium, bicarbonate prescription
• Alarms or water/dialysate abnormality

Extracorporeal circuit

• Arterial and venous pressures
• Needle position and access blood flow
• Bloodline disconnection or leak
• Dialyzer blood leak alarm
• Visible clots
• Dark blood, foam, or possible hemolysis signs
• Blood loss in lines, dialyzer, or on the floor

6. Prevention before the next session

1. Review dry/target weight
   • Reassess after illness or weight loss.
   • Do not force fluid removal if the target weight is no longer appropriate.
2. Reduce interdialytic weight gain
   • Counsel on salt restriction and fluid management.
   • High salt intake increases thirst and fluid gain.
3. Avoid high UF rate
   • Extend treatment time if possible.
   • Consider additional dialysis rather than removing a large volume rapidly.
4. Review BP medicines
   • Ask the nephrologist to review timing of antihypertensives.
   • Do not independently tell the patient to stop medication.
5. Avoid large meals during dialysis
   • Food shifts blood flow to the gut and can trigger hypotension.
6. Use cool dialysate if prescribed
   • Often one of the best machine-based strategies for recurrent IDH.
7. Consider prescribed midodrine
   • For recurrent symptomatic IDH despite prescription changes, the nephrologist may prescribe midodrine before dialysis.

7. When to stop dialysis and call for urgent help

• BP remains low despite position change and saline
• Chest pain, ECG changes, new arrhythmia, or severe dyspnea
• Loss of consciousness, seizure, or new neurological symptoms
• Suspected blood loss, hemolysis, air embolism, dialyzer reaction, or anaphylaxis
• Fever, rigors, or suspected sepsis
• Severe abdominal or back pain
• Recurrent severe IDH requiring repeated saline boluses

Practical bedside memory

IDH machine action: U-F OFF

• U: UF off, set UF rate to 0 mL/hour
• F: Flat position, legs raised
• O: Observe BP, rhythm, access, circuit, bleeding
• F: Fluid, 0.9% saline as prescribed/protocol

Intradialytic hypertension: simple meaning

A repeated rise in systolic BP of more than 10 mmHg from pre-dialysis to post-dialysis, especially when the post-dialysis BP remains high.

1. First assess if it is an emergency

Urgent medical review / emergency response if BP is very high with:

• Chest pain
• Severe headache, confusion, seizure, new weakness, visual loss
• Acute dyspnea, pulmonary edema, low oxygen saturation
• New arrhythmia
• Suspected stroke
• Severe hypertension per your unit escalation threshold

2. Why BP rises during dialysis

Main causes

1. Fluid overload or target weight too high

2. Sodium gain during dialysis

• Thirst
• Larger interdialytic fluid gain
• Fluid overload
• Higher BP during and between dialysis

3. Blood vessels constrict during dialysis

4. Antihypertensive medicines are removed by dialysis

5. Other causes to consider

• High salt intake and large interdialytic weight gain
• Erythropoiesis-stimulating agent, especially IV ESA given during HD
• Pain, anxiety, caffeine, smoking, or poor sleep
• Incorrect BP measurement: cuff size, arm position, measurement over access arm
• Incorrect dialysate prescription or concentrate
• Missed BP medicine doses
• Volume overload from heart failure

3. What a dialysis therapist should do during the session

Immediate checklist

1. Repeat BP correctly
   • Use correct cuff size.
   • Ensure arm is supported at heart level.
   • Do not use the fistula/graft arm.
   • Compare with baseline and repeat manually if unexpected.
2. Assess the patient
   • Headache, chest pain, shortness of breath, confusion, visual symptoms.
   • Look for fluid overload: edema, raised JVP if assessed by trained staff, crackles, increased work of breathing.
   • Check oxygen saturation.
3. Check machine and prescription
   • Prescribed target weight and total UF goal
   • UF removed so far and UF rate
   • Dialysate conductivity and sodium prescription
   • Dialysate temperature
   • Correct acid and bicarbonate concentrate
   • Correct patient treatment profile
   • BP trend, not one isolated reading
4. Notify nephrologist/charge nurse according to local policy
   • Especially if the BP continues to rise, is severe, or happens repeatedly.

4. UF setting: what to change

Do not blindly increase UF rapidly

• Intradialytic hypotension
• Cramps
• Myocardial ischemia or "stunning"
• Poor organ perfusion
• Early termination of dialysis

Safer UF approach

If the patient is stable and fluid overloaded

• A gradual reduction in target weight, often over several treatments
• An adjusted UF goal
• Longer dialysis time
• An extra dialysis session
• More frequent dialysis

UF rate

UF rate below about 10 mL/kg/hour

Example

5. Sodium setting: important for intradialytic hypertension

Key principle

What to do

• Confirm the dialysate sodium prescription and conductivity.
• Do not use sodium profiling routinely in a patient with intradialytic hypertension.
• Ask the nephrologist to review and individualize dialysate sodium based on the patient's serum sodium, BP pattern, thirst, and interdialytic weight gain.
• Avoid simply setting a high sodium bath to prevent cramps or hypotension in a patient who has hypertension and fluid overload.

Do not use one universal sodium number

6. Dialysate flow rate: should it be changed?

Usually, no

• Qd is mainly adjusted for solute clearance.
• Lowering Qd does not reliably treat high BP.
• Increasing Qd may increase dialysis efficiency and more rapid solute/osmotic shifts in some settings, but it is not a primary BP-control strategy.

Practical action

• Keep Qd at the prescribed value, commonly according to machine, dialyzer, and unit protocol.
• Do not alter Qd solely to treat intradialytic hypertension unless specifically ordered by the nephrologist.

7. Dialysate temperature: what to set?

• Cool dialysate is mainly used to reduce intradialytic hypotension.
• For routine standardized HD, a dialysate temperature of 36°C or lower is commonly recommended to avoid heat-related vasodilation and improve hemodynamic stability.
• Do not make major temperature changes as an acute treatment for hypertension without a prescription.

8. Other dialysis prescription settings to review

9. Medication issues to report for review

• Whether antihypertensive medicines are being removed during HD
• Timing of antihypertensive medicines
• Whether a poorly dialyzable antihypertensive may be appropriate
• ESA dose, route, and timing
• Salt-containing medications or IV infusions
• NSAID use
• Decongestants or stimulants

10. Practical dialysis therapist plan

During dialysis when BP rises

1. Recheck BP correctly and assess symptoms.
2. Check for emergency signs: chest pain, pulmonary edema, neurological symptoms.
3. Check UF goal, UF rate, target weight, sodium prescription, conductivity, and dialysate concentrate.
4. Do not rapidly increase UF rate by yourself.
5. Continue treatment only if the patient is stable and according to protocol.
6. Escalate to nephrologist for severe, symptomatic, or repeated BP elevation.
7. Document:
   • Pre-, intra-, and post-dialysis BP
   • Symptoms
   • UF goal, removed volume, and UF rate
   • Dialysate sodium, temperature, and conductivity
   • Weight gain and post-dialysis weight
   • Actions taken and provider instructions

For recurrent intradialytic hypertension

1. Target weight and chronic volume status
2. Interdialytic salt/fluid intake
3. UF goal, UF rate, and treatment duration
4. Dialysate sodium and sodium gradient
5. Antihypertensive regimen and dialyzability
6. ESA use
7. Cardiac status and home/interdialytic BP

One-line memory aid

Intradialytic hypotension (IDH) during hemodialysis

What is IDH?

• Systolic BP falls by 20 mmHg or more, or mean arterial pressure falls by 10 mmHg or more
• With symptoms such as cramps, nausea, dizziness, restlessness, fainting, or need to stop UF/give saline.

Why it happens

Main cause: high UF stress

• High interdialytic weight gain
• Large UF target
• Short session time
• UF rate too high
• Target weight set too low

Other causes

Symptoms to recognize early

• Yawning, sighing, restlessness
• Muscle cramps
• Nausea, vomiting
• Weakness, dizziness, blurred vision
• Anxiety
• Pallor, sweating, cold clammy skin
• Tachycardia or bradycardia
• Low BP
• Chest pain, breathlessness
• Syncope, confusion, seizure

Immediate management by dialysis therapist

Simple emergency sequence: UF OFF

1. Assess immediately

• Check BP again, preferably manually if unexpected.
• Check pulse, rhythm, oxygen saturation, consciousness.
• Ask about chest pain, dyspnea, cramps, nausea, dizziness.
• Look for bleeding at needles, bloodlines, dialyzer, access, and floor.
• Check the machine alarms and circuit.

2. Stop UF

• Set UF rate to 0 mL/hour or press the machine's UF pause/stop function.
• Do not keep removing fluid while the patient is hypotensive.

3. Position

• Lay patient supine.
• Raise legs or use Trendelenburg position if permitted by your protocol.

4. Give normal saline as per unit protocol

• A common initial intervention is 0.9% sodium chloride 100 mL IV bolus.
• Reassess BP and symptoms.
• Repeat only according to local protocol or medical instruction.
• Record every saline bolus because it decreases net fluid removal.

5. Recheck frequently

• BP every 2-5 minutes until stable
• Pulse/rhythm and oxygen saturation
• Symptoms
• UF removed and remaining UF target
• Circuit/access for blood loss, clotting, dislodgement, or other problem

6. Restarting UF

• Restart only after symptoms and BP have recovered.
• If authorized, restart at a lower UF rate.
• Sometimes no further UF is safe, and the patient must leave above target weight with a revised fluid plan.

What to change on the hemodialysis machine

A. During an acute IDH episode

UF setting for prevention of recurrent IDH

1. Calculate UF rate

Example

• UF goal = 2,800 mL
• Weight = 70 kg
• Time = 4 hours

2. Safer changes

• Reduce UF goal if target weight is likely too low.
• Reduce the UFR.
• Increase treatment time.
• Add an extra dialysis session if required.
• Accept staged fluid removal rather than force all excess fluid off in one session.
• Review interdialytic weight gain and salt intake.

UF profiling

• More fluid removal earlier
• Less fluid removal later when vascular refill may be poorer

Dialysate sodium: how to set it

Main principle

• Patient's serum sodium pattern
• BP trend
• Cramps/IDH frequency
• Thirst
• Interdialytic weight gain
• Residual urine output and volume status

Sodium and IDH

• More thirst
• Larger interdialytic weight gain
• More edema
• Hypertension
• Higher UF requirement at the next session

Practical approach

• Confirm the prescribed sodium and machine conductivity.
• Do not independently increase sodium because the patient has one hypotensive episode.
• Avoid routine high sodium bath or routine sodium profiling.
• For recurrent IDH, request review of the dialysate-to-serum sodium gradient and consider a prescribed individualized sodium strategy.
• Avoid net positive sodium balance.

Dialysate temperature

Best machine-related intervention for recurrent IDH

Common approach

• Standardized dialysate temperature: 36°C or lower
• For recurrent IDH: individualized cool dialysate, often 35°C to 36°C, depending on tolerance and prescription.

Dialysate flow rate, Qd

Does Qd treat IDH?

• Typical Qd is often around 500 mL/min, but depends on machine, dialyzer, prescription, and unit protocol.
• Lowering Qd is not standard acute treatment for IDH.
• Increasing Qd is also not a standard way to correct IDH.

What to do

• Keep Qd at the prescribed value.
• Do not alter Qd solely because BP falls.
• If repeated IDH occurs, nephrology may review the overall intensity of solute removal, session duration, dialyzer choice, and prescription. This is not a therapist-only adjustment.

Other important prescription checks

Patient factors to correct before next session

1. Review antihypertensive medication timing
   • Report if the patient takes short-acting antihypertensives just before HD.
   • Do not independently stop the medicine.
2. Avoid large meals during HD
   • Food increases blood flow to the gut and can trigger IDH.
3. Reduce interdialytic salt and fluid gain
   • Less sodium intake means less thirst and a lower UF requirement.
4. Investigate anemia, infection, bleeding, cardiac disease, and arrhythmias
   • Repeated or unexplained IDH is not always caused by UF.
5. Discuss midodrine with nephrologist
   • For recurrent symptomatic IDH despite correcting dry weight, UF and temperature, a prescriber may consider midodrine before HD.

When to stop and urgently escalate

• BP remains low despite UF stop, position and saline
• Chest pain, dyspnea, low oxygen saturation
• New arrhythmia
• Syncope, seizure, confusion, or focal neurological deficit
• Suspected blood loss, hemolysis, air embolism, dialyzer reaction, or anaphylaxis
• Fever, rigors, suspected sepsis
• Severe abdominal or back pain

Practical machine checklist

During IDH

1. UF OFF: 0 mL/h
2. Check UF target and volume removed
3. Lay flat, legs raised
4. Saline bolus as protocol
5. Check BP, circuit, access, bleeding, alarms, dialysate conductivity and temperature
6. Do not routinely change Qb or Qd
7. Restart UF only after recovery and at a lower authorized rate

For next treatment

1. Recheck target weight
2. Reduce UF goal or UFR
3. Extend session / add treatment if needed
4. Use prescribed cool dialysate, usually 35-36°C for recurrent IDH
5. Review sodium prescription and avoid sodium gain
6. Review medicines, meals, cardiac status and interdialytic weight gain