Emergency Services

Rationale

The process of HD is akin to a major surgical operation. At any given time, a fixed amount of blood is in the extracorporeal circuit which is not under the physiological control and the normal feedback mechanisms of the patient. Although most dialysis machines are equipped with a fail-safe mode, a self-test, alarms, and a safety profile of <1 event/100 million treatments, emergencies related to personal error and patients intrinsic condition ranging from minor discomfort to cardiac arrests on HD have been reported in dialysis units. The following guideline elaborates the personnel protocols and equipment required for managing emergencies in the dialysis unit.

Description

HD unit may be located in the premises of a hospital or it may be a stand-alone HD unit.

We recommend that emergency equipment, personnel, and medicines are to be kept ready in the unit for urgent use before the patient is shifted to the intensive care unit (ICU), irrespective of the location of the dialysis unit.

The common HD emergencies are:

• Hypotension

• Dialyzer reactions

  1. Type A (anaphylactic reaction)
  2. Type B (nonspecific reaction)

• Hemolysis

  • Air embolism

• Disequilibrium syndrome

• Chest pain and myocardial infarction (MI)

• Arrhythmias

• Sudden cardiac arrest.

Personnel

• Nephrologist

• Resident doctors – One per shift in three shifts

• Dialysis technologists – one per three machines – in three shifts. Nurses – one per six patients

• Anesthesiologists on call

• Anesthesia technician on call.

  1. We recommend that the nephrologist (DM/DNB) should be available round the clock or at least on call, for managing emergencies.
  2. We recommend that resident doctors should be trained in identifying cardiac arrhythmias, cardioversion, and intubation technique.
  3. We recommend that dialysis nurses should be able to handle electrocardiogram (EKG) machine and cardiac monitors.
  4. We recommend that all dialysis staff should be BLS basic life support certified and at least one personnel per shift should be (ACLS) advanced cardiac life support certified.
  5. We recommend that all dialysis doctors be ACLS accredited
  6. An anesthesiologist should be available on call.
  7. We recommend that the equipment listed below should be available at all times in dialysis units.

Equipment required to prevent and treat these emergencies:

• An accurate weighing scale to exactly measure weight.

• Dialysis machines with UF controller and sodium modeling to prevent hypotension (see section on machines for details)

• We recommend that a standby HD machine be available in cases of machine malfunction or emergencies, where immediate dialysis may be lifesaving.

• Micro-hematocrit tube for manual measurement

• Activated clotting time machine.

• Glucometer.

• Multichannel cardiac monitor, signal-averaged ECG, and defibrillator.

• Laryngoscopes, endotracheal tubes, suction apparatus or wall-mounted suction, central oxygen supply and suction tubes, mouth gag, and AMBU bag Ryles tube.

• Arterial blood gas analysis machine (may be part of a hospital laboratory) 24-h emergency power generator to ensure UPS.

We suggest that the following additional equipment be available either in the unit or easily accessible in a hospital in which the unit is located:

Equipment not required for an emergency, but useful in preventing an emergency:

1. Implantable cardioverter defibrillator.

2. Ambulatory BP monitoring (AMBP).

3. Portable ultrasound for abdominal emergencies.

4. Handheld Doppler device for vascular access assessment.

We suggest that these are optional and may be made available depending on the size of the unit.

We recommend that the below-listed medicines are absolutely essential in a dialysis unit.

Medicines to be available for emergency use:

1. Ionotropes: Injections: Dopamine, dobutamine, nor-adrenaline, and vasopressin

2. Solutions: 25% dextrose; 3% saline; and 5% dextrose

3. Injection protamine

4. Injections lignocaine and amiodarone

5. Injection hydrocortisone

6. Injection adrenaline

7. Injection atropine

8. Injection and tablet pheniramine maleate

9. Capsule and tablet nifedepine

10. Tablets: Clonidine, paracetamol, and sorbitrate

11. Injection nitroglycerine and sodium nitroprusside

12. Injections: Ondansetron, metoclopramide, pantoprazole, and ranitidine

13. Injection Vitamin K

14. Anticonvulsants midozolam and phenytoin/fosphenytoin

15. Salbutamol.

We recommend that all medicines are to be stacked in crashcarts in adequate quantities depending on patient load. Principles of Look alike, sound alike should be followed during storage:

• We recommend that expiry dates of medicines be verified periodically.

• We recommend that stocks be verified every morning and replaced.

• We recommend that high-risk medications be verified and administered by two qualified personnel at all times.

• We recommend that an ICU and a respiratory care unit be within reach so that a critically ill patient may be shifted there, without delay.

• We recommend that personnel in the dialysis unit be familiar with the hospital/unit policy regarding whom to call in case of an emergency, for example, the “code blue” call indicating requirement of a resuscitation team.

Important emergency numbers should be clearly displayed close to the unit telephone.