# N5 — Intradialytic Hypotension: Chair-Side Response N5 — Intradialytic Hypotension: Chair-Side Response FRONT Front · at the chair **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** \[[1](https://urinenephrology.org/mastery/maintenance-hd/nursing/N5-Intradialytic-Hypotension-Response.html#n5-ref-1)\]. 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 \[[3](https://urinenephrology.org/mastery/maintenance-hd/nursing/N5-Intradialytic-Hypotension-Response.html#n5-ref-3)\]. 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](https://urinenephrology.org/mastery/maintenance-hd/nursing/N12-Chair-Side-Emergencies.html)). - BP has not recovered after a second saline bolus, or treatment must end early. - Hypotension in the **first hour** of treatment \[[4](https://urinenephrology.org/mastery/maintenance-hd/nursing/N5-Intradialytic-Hypotension-Response.html#n5-ref-4)\]. - A second episode this week, or nadir SBP below 90 in 30% or more of sessions this month \[[1](https://urinenephrology.org/mastery/maintenance-hd/nursing/N5-Intradialytic-Hypotension-Response.html#n5-ref-1),[2](https://urinenephrology.org/mastery/maintenance-hd/nursing/N5-Intradialytic-Hypotension-Response.html#n5-ref-2)\]. - 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” \[[1](https://urinenephrology.org/mastery/maintenance-hd/nursing/N5-Intradialytic-Hypotension-Response.html#n5-ref-1)\]. - Don’t give albumin instead of saline \[[3](https://urinenephrology.org/mastery/maintenance-hd/nursing/N5-Intradialytic-Hypotension-Response.html#n5-ref-3)\]. - Don’t restart UF at the rate that caused the drop. - Don’t give food during treatment to patients who drop often \[[7](https://urinenephrology.org/mastery/maintenance-hd/nursing/N5-Intradialytic-Hypotension-Response.html#n5-ref-7)\]. - Don’t hold all BP medicines on dialysis days without an order — hold only what the nephrologist specifies. N5 — Intradialytic Hypotension: Chair-Side Response BACK Back · why, and the evidence ### Why 1. A nadir SBP below 90 — even without symptoms — had the strongest link to death; symptom-based definitions added nothing \[[1](https://urinenephrology.org/mastery/maintenance-hd/nursing/N5-Intradialytic-Hypotension-Response.html#n5-ref-1)\]. KDIGO: any symptomatic fall or a nadir below 90 should prompt review \[[2](https://urinenephrology.org/mastery/maintenance-hd/nursing/N5-Intradialytic-Hypotension-Response.html#n5-ref-2)\]. 2. Saline worked as well as 5% albumin in a randomized trial; recurrent hypotension was 36% in both arms \[[3](https://urinenephrology.org/mastery/maintenance-hd/nursing/N5-Intradialytic-Hypotension-Response.html#n5-ref-3)\]. 3. Hypotension early in the session is not explained by fluid removal and is linked to worse survival \[[4](https://urinenephrology.org/mastery/maintenance-hd/nursing/N5-Intradialytic-Hypotension-Response.html#n5-ref-4)\]. 4. Frequent intradialytic hypotension is linked to hospitalized mesenteric ischemia (OR 1.82) \[[5](https://urinenephrology.org/mastery/maintenance-hd/nursing/N5-Intradialytic-Hypotension-Response.html#n5-ref-5)\] and new dementia (HR 1.36) \[[6](https://urinenephrology.org/mastery/maintenance-hd/nursing/N5-Intradialytic-Hypotension-Response.html#n5-ref-6)\]. 5. Eating during treatment caused more symptomatic drops in hypotension-prone patients (13 vs 2 episodes) \[[7](https://urinenephrology.org/mastery/maintenance-hd/nursing/N5-Intradialytic-Hypotension-Response.html#n5-ref-7)\]. ### Go deeper - Mastery page: [Intradialytic hypotension and dialysate cooling](https://urinenephrology.org/mastery/maintenance-hd/intradialytic-hypotension-cooling.html) - [All dialysis nursing reference cards](https://urinenephrology.org/mastery/maintenance-hd/nursing/index.html) ### References 1. Flythe JE, et al. Association of mortality risk with various definitions of intradialytic hypotension. *J Am Soc Nephrol.* 2015;26:724-734. [PubMed 25270068](https://pubmed.ncbi.nlm.nih.gov/25270068/) 2. Flythe JE, et al. Blood pressure and volume management in dialysis: conclusions from a KDIGO Controversies Conference. *Kidney Int.* 2020;97:861-876. [PubMed 32278617](https://pubmed.ncbi.nlm.nih.gov/32278617/) 3. Knoll GA, et al. A randomized, controlled trial of albumin versus saline for the treatment of intradialytic hypotension. *J Am Soc Nephrol.* 2004;15:487-492. [PubMed 14747397](https://pubmed.ncbi.nlm.nih.gov/14747397/) 4. Keane DF, et al. The time of onset of intradialytic hypotension during a hemodialysis session associates with clinical parameters and mortality. *Kidney Int.* 2021;99:1408-1417. [PubMed 33607178](https://pubmed.ncbi.nlm.nih.gov/33607178/) 5. Seong EY, et al. The relationship between intradialytic hypotension and hospitalized mesenteric ischemia. *Clin J Am Soc Nephrol.* 2018;13:1517-1525. [PubMed 30237215](https://pubmed.ncbi.nlm.nih.gov/30237215/) 6. Assimon MM, et al. Cumulative exposure to frequent intradialytic hypotension associates with new-onset dementia among elderly hemodialysis patients. *Kidney Int Rep.* 2019;4:603-606. [PubMed 30993235](https://pubmed.ncbi.nlm.nih.gov/30993235/) 7. Sherman RA, et al. Postprandial blood pressure changes during hemodialysis. *Am J Kidney Dis.* 1988;12:37-39. [PubMed 3389352](https://pubmed.ncbi.nlm.nih.gov/3389352/) 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. --- [Website version](https://urinenephrology.org/mastery/maintenance-hd/nursing/N5-Intradialytic-Hypotension-Response.html) · Markdown synchronized October 3, 2026.