Sections View Full Chapter Figures Tables Videos Full Chapter Figures Tables Videos Supplementary Content ++ KEY FEATURES ++ ESSENTIALS OF DIAGNOSIS ++ Marked decrease (> 30 mm Hg systolic) in blood pressure or a systolic blood pressure of < 90 mm Hg during dialysis Symptoms of decreased cerebral perfusion ++ GENERAL CONSIDERATIONS ++ More common in those with diabetes, atherosclerosis, and hypertension Usually occurs in the setting of aggressive ultrafiltration to reduce intradialytic weight gain Hypotension limits the achievement of diuresis during dialysis ++ CLINICAL PRESENTATION ++ SYMPTOMS AND SIGNS ++ Symptoms of decreased cerebral perfusion: – Somnolence – Dizziness – Syncope ++ PHYSICAL EXAM FINDINGS ++ Systolic blood pressure drop of > 30 mm Hg or systolic blood pressure < 90 mm Hg Cool clammy skin ++ DIFFERENTIAL DIAGNOSIS ++ Pericardial effusion due to uremia or other causes Left ventricular diastolic dysfunction due to hypertrophy Autonomic dysfunction, often due to diabetes Myocardial ischemia or infarction (may be produced by hypotension also) Overzealous use of antihypertensive agents Cardiac arrhythmias Severe left ventricular systolic dysfunction Low dry weight of patient Decreased plasma osmolarity Splanchnic vasodilation due to a large meal Characteristics of the dialysate (eg, acetate) ++ DIAGNOSTIC EVALUATION ++ LABORATORY TESTS ++ CBC: anemia frequently a contributing factor ++ ELECTROCARDIOGRAPHY ++ Left chamber enlargement signs Cardiac arrhythmias ++ IMAGING STUDIES ++ Echocardiography: – Usually shows left ventricular hypertrophy and left atrial enlargement – Reduced systolic left ventricular function may be present ++ TREATMENT ++ CARDIOLOGY REFERRAL ++ When simple measures do not correct the problem Suspected cardiac disease ++ HOSPITALIZATION CRITERIA ++ Inability to safely dialyze ++ MEDICATIONS ++ Identify and treat myocardial ischemia Carefully adjust antihypertensive medications Prevent cardiac arrhythmias Treat heart failure Administer vasoconstrictors in refractory cases ++ THERAPEUTIC PROCEDURES ++ Myocardial revascularization when appropriate Identify and remove pericardial fluid if present ++ MONITORING ++ Blood pressure during dialysis ECG as appropriate ++ DIET AND ACTIVITY ++ Renal disease diet Low-fat diet Activity as tolerated ++ ONGOING MANAGEMENT ++ HOSPITAL DISCHARGE CRITERIA ++ Resolution of problem ++ FOLLOW-UP ++ According to dialysis routine As appropriate for underlying diseases ++ COMPLICATIONS ++ Myocardial infarction Stroke Cardiac arrhythmias Death ++ PROGNOSIS ++ In general, hypotension during dialysis is a poor prognostic sign ++ PREVENTION ++ Decrease fluid removal in patients with low dry weight Adjust sodium in dialysate to > 135 mmol/L to prevent hypo-osmolarity Use cooled bicarbonate dialysate Frequent shorter dialysis sessions with less aggressive ultrafiltration... GET ACCESS TO THIS RESOURCE Sign In Username Error: Please enter User Name Password Error: Please enter Password Forgot Username? Forgot Password? Sign in via OpenAthens Sign in via Shibboleth Get Free Access Through Your Institution Contact your institution's library to ask if they subscribe to McGraw-Hill Medical Products. What is MyAccess? Create a FREE MyAccess profile to: Use this site remotely Bookmark your favorite content Track your self-assessment progress and more! GET ACCESS TO THIS RESOURCE Subscription Options Pay Per View Timed Access to all of AccessCardiology 24 Hour $34.95 (USD) Buy Now 48 Hour $54.95 (USD) Buy Now Best Value AccessCardiology Full Site: One-Year Individual Subscription $595 USD Buy Now View All Subscription Options