This case involves an elderly man in New Jersey with a past medical history significant for end-stage renal disease, diabetes, and the amputation of his right leg, who had received dialysis treatments multiple times a week for several years. Traditionally, the man had taken a community van to and from the dialysis clinic to undergo treatment. After completing his treatment on the date of the incident in question, he was left unattended while waiting for the van after undergoing treatment, at which point he fell out of his wheelchair and onto his head. According to records obtained from the dialysis center, the patient’s blood pressure dropped significantly during the course of his treatment. During the course of treatment for his fall, the man’s treating physicians determined that he had suffered a hemorrhagic stroke. The question remained whether the man’s fall caused his stroke, or if the stroke, suffered as a complication of his dialysis treatment, caused his fall. According to the man’s treating physicians, the likelihood of a stroke was increased by his blood pressure fluctuation during and after dialysis treatment, as well as several previous instances of transient ischemic attacks the man had suffered after dialysis.
Question(s) For Expert Witness
- 1. Is the patient's low blood pressure in this instance indicative of dialysis induced hypotension/intradialytic hypotension?
- 2. Can dialysis induced hypotension cause or contribute to ischemic stroke and, if so, what can be done to reduce the risk of ischemic stroke?
- 3. What are typical policies, procedures, and protocols, if any, pertaining to "handing off" dialysis patients from dialysis clinic to transport van, particularly if the patient is hypotensive or otherwise exhibits adverse effects from treatment?
- 4. Do pre-existing conditions such as diabetes, hypertension and coronary artery disease place a dialysis patient at increased risk for dialysis-induced hypotension and, if so, what steps, if any, should be taken to reduce or eliminate such risks?
Expert Witness Response E-007683
During hemodialysis the volume removal creates an expected decrease in both systolic blood pressure and diastolic blood pressure. In order to assess and treat induced hypotension, the nurse would treat the patient based on symptoms and trends versus objective blood pressure values. Any form of hypotension can contribute to ischemic stroke, including induced hypotension. In order to reduce hypotension, thus reducing the risk of ischemic stroke TIA, a nurse can reduce or vary the ultra filtration rate, decrease the fluid reduction goal, decrease the dialysate temperature, and/or increase the dialysate sodium concentration. The potential interventions are typically written as standing orders or PRN orders by the prescribing physician and used based on the nurse’s assessment and judgment. Depending on the state, most dialysis units are required to have a transfer agreement between the transportation company and the unit. Typically, the responsibility for initiating the agreement lies on the transportation company, however depending on the state the dialysis unit is responsible for having them as well. After the dialysis treatment is completed, a post-assessment by the nurse is also completed and if a patient is not “stable” to leave they are not to be discharged. There should be documentation stating that the patient is stable and okay to leave. Certain dialysis units/companies have established guidelines to determine patient stability prior to discharge.
Diabetes and hypertension are the leading causes of end stage renal failure in the United States. Rarely are patients on dialysis that do not have co-morbid conditions that place them at a number of increased risks for induced hypotension. The goal of renal replacement therapy (dialysis) is to filter toxins and remove excess fluid. The removal of excess fluid results in total volume depletion, and thus lowers blood pressure. Depending on the rate of fluid removal, patient volume status, cardiac status, and any nursing interventions the effects can be benign or induce hypotension. A proper pre-treatment nursing assessment can identify potential problems which can trigger nursing interventions to reduce or eliminate the risk of induced hypotension.
Expert Witness Response E-007188
The typical goal of hemodialysis is to avoid having the systolic blood pressure drop more than 30 points. It’s expected to have a drop in blood pressure with dialysis, due to fluid removal of between 1 to 6kg of fluid. Usually the patient’s vital signs, including the blood pressure, should be stabilized prior to transfer or discharge from the center. Hypotension from low volume with fluid removal can lead to complications such as stroke. Once blood pressure drops, volume support such as IV saline or albumin can be given to increase blood pressure to within normal limits. Rinsing the patient’s blood after hemodialysis with saline can also replenish blood pressure. If the patient is leaving the hospital, a member of hospital staff must accompany them until they are picked up. Usually, transfer from department to department requires a written report to the receiving nurse and a verbal disclosure of the patient’s status as well, if there are complications or follow-up required. Having 2 or more co-morbid conditions can place dialysis patients at risk. Treatment and prevention is key based on the cause.