N5 — Intradialytic Hypotension: Chair-Side Response

When: BP falls or symptoms start during treatment.

Do this

1. Trigger: symptoms (dizziness, cramps, nausea, yawning, blurred vision) or systolic BP (SBP) below 90 — or below 100 if pre-dialysis SBP was 160 or higher — with or without symptoms [1].
2. Stop UF or set it to minimum. Legs up and head down if tolerated. Recheck BP now.
3. Look for red flags (below). If none and BP recovers within 5 minutes, resume UF at a lower rate and recheck every 15 minutes.
4. Not recovered: normal saline bolus per standing order; recheck in 5 minutes; repeat once if needed [3].
5. Check the machine: temperature per your unit protocol, UF goal and rate, dialysate sodium as ordered.
6. Document nadir SBP, time into treatment, fluid given, and UF achieved versus goal.

Call the nephrologist when

• Any red flag: chest pain, new irregular rhythm, confusion, fever or rigors, bleeding, air in the lines, or symptoms in the first minutes of treatment (possible dialyzer reaction — N12: Chair-Side Emergencies).
• BP has not recovered after a second saline bolus, or treatment must end early.
• Hypotension in the first hour of treatment [4].
• A second episode this week, or nadir SBP below 90 in 30% or more of sessions this month [1,2].
• The patient took BP medicines right before treatment and drops repeatedly.
• Recurrent episodes — ask whether cooler dialysate is appropriate under your unit protocol.

Don’t

• Don’t ignore a low BP because the patient “feels fine” [1].
• Don’t give albumin instead of saline [3].
• Don’t restart UF at the rate that caused the drop.
• Don’t give food during treatment to patients who drop often [7].
• Don’t hold all BP medicines on dialysis days without an order — hold only what the nephrologist specifies.