# N12 — Chair-Side Emergencies

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 \[[6](https://urinenephrology.org/mastery/maintenance-hd/nursing/N12-Chair-Side-Emergencies.html#n12-ref-6)\]. |
| **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 \[[7](https://urinenephrology.org/mastery/maintenance-hd/nursing/N12-Chair-Side-Emergencies.html#n12-ref-7)\]. Check conductivity, temperature, pH, concentrate, kinked lines. Quarantine machine, tubing, and concentrate lot; check the rest of the shift; call water treatment and biomed \[[2](https://urinenephrology.org/mastery/maintenance-hd/nursing/N12-Chair-Side-Emergencies.html#n12-ref-2)\]. |
| **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 \[[8](https://urinenephrology.org/mastery/maintenance-hd/nursing/N12-Chair-Side-Emergencies.html#n12-ref-8)\]. |
| **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** \[[4](https://urinenephrology.org/mastery/maintenance-hd/nursing/N12-Chair-Side-Emergencies.html#n12-ref-4)\]. |
| **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 \[[5](https://urinenephrology.org/mastery/maintenance-hd/nursing/N12-Chair-Side-Emergencies.html#n12-ref-5)\]. |
| **Disequilibrium** | Headache, nausea, restlessness, confusion, or seizure — usually an early treatment in a very uremic patient \[[9](https://urinenephrology.org/mastery/maintenance-hd/nursing/N12-Chair-Side-Emergencies.html#n12-ref-9)\] | 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](https://urinenephrology.org/mastery/maintenance-hd/nursing/N5-Intradialytic-Hypotension-Response.html)). Check conductivity and the ordered sodium and magnesium ([N2: Dialysate Prescription Check](https://urinenephrology.org/mastery/maintenance-hd/nursing/N2-Dialysate-Prescription-Check.html)). |

### 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 \[[8](https://urinenephrology.org/mastery/maintenance-hd/nursing/N12-Chair-Side-Emergencies.html#n12-ref-8)\].
- Don’t sit up a patient with suspected air embolism. Arterial air with stroke signs: keep flat and supine \[[4](https://urinenephrology.org/mastery/maintenance-hd/nursing/N12-Chair-Side-Emergencies.html#n12-ref-4)\].
- 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 \[[6](https://urinenephrology.org/mastery/maintenance-hd/nursing/N12-Chair-Side-Emergencies.html#n12-ref-6)\].
- Don’t start a very uremic patient’s first treatment without a gentle order: reduced clearance and a **lower** bicarbonate bath \[[9](https://urinenephrology.org/mastery/maintenance-hd/nursing/N12-Chair-Side-Emergencies.html#n12-ref-9)\].

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 \[[1](https://urinenephrology.org/mastery/maintenance-hd/nursing/N12-Chair-Side-Emergencies.html#n12-ref-1)\].
2.  In a CDC-investigated outbreak traced to narrowed blood tubing, 36% of affected patients needed intensive care and two died \[[2](https://urinenephrology.org/mastery/maintenance-hd/nursing/N12-Chair-Side-Emergencies.html#n12-ref-2)\].
3.  Of 88 fatal access hemorrhages, 78% happened at home or in a nursing home \[[3](https://urinenephrology.org/mastery/maintenance-hd/nursing/N12-Chair-Side-Emergencies.html#n12-ref-3)\] — 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 \[[4](https://urinenephrology.org/mastery/maintenance-hd/nursing/N12-Chair-Side-Emergencies.html#n12-ref-4)\].
5.  Of 236 patients dialyzed on AN69 membranes, 9 had anaphylactoid reactions — all 9 recently started on an ACE inhibitor \[[5](https://urinenephrology.org/mastery/maintenance-hd/nursing/N12-Chair-Side-Emergencies.html#n12-ref-5)\].

### Go deeper

- Mastery page: [Hyperkalemia on HD: interdialytic control, binders, emergencies](https://urinenephrology.org/mastery/maintenance-hd/hyperkalemia-hemodialysis.html)
- Mastery page: [Dialysate calcium, bicarbonate, magnesium, and glucose](https://urinenephrology.org/mastery/maintenance-hd/dialysate-calcium-bicarbonate-magnesium.html)
- Mastery page: [Examining and Cannulating the AVF and AVG](https://urinenephrology.org/mastery/maintenance-hd/avf-avg-exam-cannulation.html)
- Mastery page: [Catheter Care, Lock Solutions, and Bloodstream Infection](https://urinenephrology.org/mastery/maintenance-hd/catheter-care-crbsi.html)
- [All dialysis nursing reference cards](https://urinenephrology.org/mastery/maintenance-hd/nursing/index.html)

### 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](https://pubmed.ncbi.nlm.nih.gov/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](https://pubmed.ncbi.nlm.nih.gov/10760102/)
3.  Ellingson KD, et al. Vascular access hemorrhages contribute to deaths among hemodialysis patients. *Kidney Int.* 2012;82:686-692. [PubMed 22695325](https://pubmed.ncbi.nlm.nih.gov/22695325/)
4.  McCarthy CJ, et al. Air embolism: practical tips for prevention and treatment. *J Clin Med.* 2016;5:93. [PubMed 27809224](https://pubmed.ncbi.nlm.nih.gov/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](https://pubmed.ncbi.nlm.nih.gov/1978172/)
6.  Ahmed J, Weisberg LS. Hyperkalemia in dialysis patients. *Semin Dial.* 2001;14:348-356. [PubMed 11679104](https://pubmed.ncbi.nlm.nih.gov/11679104/)
7.  Tharmaraj D, Kerr PG. Haemolysis in haemodialysis. *Nephrology (Carlton).* 2017;22:838-847. [PubMed 28749067](https://pubmed.ncbi.nlm.nih.gov/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](https://pubmed.ncbi.nlm.nih.gov/32778223/)
9.  Mistry K. Dialysis disequilibrium syndrome prevention and management. *Int J Nephrol Renovasc Dis.* 2019;12:69-77. [PubMed 31118737](https://pubmed.ncbi.nlm.nih.gov/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.


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[Website version](https://urinenephrology.org/mastery/maintenance-hd/nursing/N12-Chair-Side-Emergencies.html) · Markdown synchronized October 3, 2026.