A quality improvement project: Strategies to reduce intradialytic hypotension in hemodialysis patients.

Intradialytic hypotension is defined as a decrease in systolic blood pressure by ≥ 20 mm Hg or a decrease in mean arterial pressure by 10 mm Hg, and is associated with symptoms that include abdominal discomfort, yawning, sighing, nausea, vomiting, muscle cramps, restlessness, dizziness or fainting, and anxiety. The incidence of a symptomatic reduction in blood pressure during (or immediately following) dialysis ranges from 15-50% of dialysis sessions. It is a major cause for morbidity in elderly hemodialysis patients and those with cardiovascular compromise. It impairs patient well-being, limits ultrafiltration, and increases the risk for coronary and cerebral ischemic events as well as vascular access thrombosis. Several studies have shown a poorer survival in dialysis patients who experience frequent hypotensive episodes on dialysis as opposed to those who do not. In our outpatient dialysis unit, we identified that 9% of our dialysis patients experienced a decrease in their systolic blood pressure to below 80 during dialysis. The purpose of this quality improvement project was to study the factors associated with intradialytic hypotension in these patients and institute appropriate measures to mitigate this issue. Another aim was to educate the dialysis staff on how to manage these patients. Patients were selected using data from weekly rounding reports and orders were written for interventions including ultrafiltration profiling, cool (36 degrees C) dialysate, weight-based ultrafiltration, etc. Outcomes were studied over a period of 3 months. We found that up to 40% of patients experienced an improvement in their blood pressure profile over the period of the study, suggesting that simple changes to dialysis prescription can result in a significant reduction in the incidence of intradialytic hypotension.