Education Use Only
For educational use only — The physician’s written order and the unit protocol always govern
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Dialysis Nursing Reference Card  ·  Maintenance Hemodialysis

N12 — Chair-Side Emergencies

Eight things that go wrong in the chair: recognize each one and make the first move.
Andrew Bland, MD, FACP, FAAP Reviewed September 2026 · v1.0 draft Prints on one sheet, front and back
N12 — Chair-Side Emergencies FRONT
Front · at the chair

When: something goes wrong during treatment.

Do this

Every emergency: call for help and call the nephrologist now. Activate emergency response (911 or code) per your unit protocol for no pulse, uncontrolled bleeding, air embolism, anaphylaxis, or seizure.

Emergency Recognize First moves
High potassium K 6.5 or higher, or high K with weakness, palpitations, slow pulse, or ECG change Monitor and 12-lead ECG. IV calcium, insulin with dextrose, and albuterol ready per order. Dialyze promptly on the ordered bath; continuous rhythm monitoring if below 2K [6].
Chest pain New chest pain on treatment Stop UF; check BP, pulse, rhythm; follow your chest-pain protocol. Think: low BP, hemolysis, air, dialyzer reaction, high K.
Hemolysis Chest tightness, back or belly pain, dyspnea, BP rise; “port-wine” or cherry-red venous blood; several patients on one shift Stop the pump and clamp; don’t return the circuit blood. Stat K and hemolysis labs; monitor [7]. Check conductivity, temperature, pH, concentrate, kinked lines. Quarantine machine, tubing, and concentrate lot; check the rest of the shift; call water treatment and biomed [2].
Access hemorrhage Bleeding from a needle site, aneurysm, graft, or catheter Stop the pump. Firm direct pressure on the bleeding point. Still bleeding from an aneurysm or graft: compress the inflow, at or just above the arterial anastomosis [8].
Air embolism Air in the line with sudden dyspnea, chest pain, hypotension, or neurologic change Clamp the line or catheter; stop the pump; code; 100% oxygen. Venous air: left side down, head down [4].
Dialyzer reaction Within the first 20 minutes: itching, flushing, hypotension, wheeze, face or throat swelling Stop the pump and clamp. Moderate or severe: don’t return the blood; anaphylaxis protocol. Record ACE inhibitor use, dialyzer, and drugs given [5].
Disequilibrium Headache, nausea, restlessness, confusion, or seizure — usually an early treatment in a very uremic patient [9] Slow or stop per the nephrologist; check conductivity and glucose.
Cramps Painful cramps, often with falling BP Hypotension response (N5: Intradialytic Hypotension: Chair-Side Response). Check conductivity and the ordered sodium and magnesium (N2: Dialysate Prescription Check).

Call the nephrologist when

  • Any item on this card — every time, even if it resolved.
  • At rounds: recurrent cramps or hypotension needing repeated saline.

Don’t

  • Don’t press on the vein downstream of a bleeding point [8].
  • Don’t sit up a patient with suspected air embolism. Arterial air with stroke signs: keep flat and supine [4].
  • Don’t reuse the machine, concentrate, or lot after hemolysis until the cause is found.
  • Don’t wait for a binder in a potassium emergency, and don’t give potassium because the post-dialysis value looks low [6].
  • Don’t start a very uremic patient’s first treatment without a gentle order: reduced clearance and a lower bicarbonate bath [9].
N12 — Chair-Side Emergencies BACK
Back · why, and the evidence

Why

  1. In implanted-monitor recordings, dangerous rhythms in dialysis patients were overwhelmingly slow: 1,461 bradycardias and 14 asystole episodes versus 1 sustained ventricular tachycardia [1].
  2. In a CDC-investigated outbreak traced to narrowed blood tubing, 36% of affected patients needed intensive care and two died [2].
  3. Of 88 fatal access hemorrhages, 78% happened at home or in a nursing home [3] — teach patients to press and call 911.
  4. The lethal adult air dose is estimated at 200–300 mL, and a 14-gauge opening can pass 100 mL per second [4].
  5. Of 236 patients dialyzed on AN69 membranes, 9 had anaphylactoid reactions — all 9 recently started on an ACE inhibitor [5].

Go deeper

References

  1. Roy-Chaudhury P, et al. Primary outcomes of the Monitoring in Dialysis Study indicate that clinically significant arrhythmias are common in hemodialysis patients and related to dialytic cycle. Kidney Int. 2018;93:941-951. PubMed 29395340
  2. Duffy R, et al. Multistate outbreak of hemolysis in hemodialysis patients traced to faulty blood tubing sets. Kidney Int. 2000;57:1668-1674. PubMed 10760102
  3. Ellingson KD, et al. Vascular access hemorrhages contribute to deaths among hemodialysis patients. Kidney Int. 2012;82:686-692. PubMed 22695325
  4. McCarthy CJ, et al. Air embolism: practical tips for prevention and treatment. J Clin Med. 2016;5:93. PubMed 27809224
  5. Verresen L, et al. Angiotensin-converting-enzyme inhibitors and anaphylactoid reactions to high-flux membrane dialysis. Lancet. 1990;336:1360-1362. PubMed 1978172
  6. Ahmed J, Weisberg LS. Hyperkalemia in dialysis patients. Semin Dial. 2001;14:348-356. PubMed 11679104
  7. Tharmaraj D, Kerr PG. Haemolysis in haemodialysis. Nephrology (Carlton). 2017;22:838-847. PubMed 28749067
  8. Lok CE, et al. KDOQI clinical practice guideline for vascular access: 2019 update. Am J Kidney Dis. 2020;75(4 Suppl 2):S1-S164. PubMed 32778223
  9. Mistry K. Dialysis disequilibrium syndrome prevention and management. Int J Nephrol Renovasc Dis. 2019;12:69-77. PubMed 31118737

Reviewed by Andrew Bland, MD, FACP, FAAP · v1.0 draft 2026-09-26. For education; the physician’s written order and the unit protocol always govern.