Pe

VS: BP 80/50 mm Hg (was 142/88 mm Hg at the start of hemodialysis), P 92 bpm; T 35.1°C (95.1°F); wt 65.9 kg (145 lb)

Chest: RRR, normal S1, S2 present

What are the potential causes of her hypotension?

What are the treatment alternatives for hypotension in the patient?

What are potential alternatives to avoid hypotension in future dialysis sessions?

Hypotension may be related to alterations in levocarnitine levels during dialysis. Patients who have low levels of levocarnitine may benefit from supplementation. Le-vocarnitine is administered as doses of 20 mg/kg IV at the end of each dialysis session. However, levocarnitine should not be used as a first-line agent for the treatment of hypotension because of the significant cost associated with the treatment. Patients receiving levocarnitine should be evaluated every 3 months for response to therapy.68 Other preventive measures that have not been well studied include caffeine, sertraline, or fludrocortisone.

Muscle Cramps

Pathophysiology. Muscle cramps can occur with up to 20% of dialysis sessions.69 The cause is often related to excessive ultrafiltration, which causes hypoperfusion of the muscles. Other contributing factors to the development of muscle cramps include hypotension and electrolyte and acid-base imbalances that occur during hemodialysis sessions.

Treatment. Nonpharmacologic treatments of muscle cramping that occurs during hemodialysis include decreasing the ultrafiltration rate and accurately determining the "dry weight." Pharmacologic measures include vitamin E, which is administered at doses of 400IU daily. Other options that are not as well studied include oxazepam and prazosin.

Thrombosis

Thrombosis associated with hemodialysis most commonly occurs in patients with venous catheter access for dialysis and is a common cause of catheter failure. However, thrombosis can occur in synthetic grafts and less frequently in AV fistulas.

Nonpharmacologic management of thrombosis in a hemodialysis catheter involves saline flushes. Smaller clots may be managed by balloon angioplasty to mechanically open the catheter. In severe cases in whom clots cannot be removed by either mechanical or pharmacologic therapy, the catheter may require replacement.

Pharmacologic management of thrombosis includes local administration of throm-bolytic agents. Alteplase (2 mg per port) and reteplase (0.5 unit per port) are the two most commonly used agents today. Urokinase has been used in the past, but after its reintroduction to the U.S. market, the larger dosed vial size makes it less cost effective than the newer agents.

Infection

Infections are an important cause of morbidity and mortality in patients receiving hemodialysis. The cause of infection is usually related to organisms found on the skin, namely Staphylococcus epidermidis and S. aureus. Other organisms have also been found to cause access-related infections. The greatest risk to patients receiving hemodialysis is the development of bacteremia. As with thrombosis, venous catheters are most commonly infected, followed by synthetic AV grafts, and finally AV fistulas.

Blood cultures should be obtained for any patient receiving hemodialysis who develops a fever. Nonpharmacologic management of infections involves preventive measures with sterile technique, proper disinfection, and minimizing the use and duration of venous catheters for hemodialysis access.

Pharmacologic management of infections should cover the Gram-positive organisms that most frequently cause access-related infections. Patients who have positive blood cultures should receive treatment tailored to the organism isolated. Preventive measures for access-related infections include mupirocin at the exit site and povidone-iodine ointment. The recommendations of the NKF for treatment of infections associated with hemodialysis are listed in Table 26-10.

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