How frequent is frequent? Monitoring for intradialytic hypotension

Background Intradialytic hypotension (IHD) is a common and serious complication associated with haemodialysis. The frequency of haemodynamic assessment by nurses is variable and international guidelines offer limited advice about the frequency of assessment for IDH. Aims To audit the incidence of IDH and the types of nursing interventions performed when IDH occurs. Methods A 34 question audit tool was completed by nursing staff over 4 weeks across three haemodialysis (HD) units to capture information about every chronic HD session for 132 patients (n=1,584 sessions). Results Nurses returned 876 audits (55.3% response rate). Most patients were male (59.4%) receiving haemodialysis (90.5%) for 5 hours (42.8%). There were 8.4% actual episodes of IDH with 9.1% episodes where nurses recorded intervening to prevent IDH. IDH most commonly occurred in the second or third hours of treatment (33 or 44.6% respectively). Hourly monitoring of blood pressure was being performed on most occasions (70.3%) prior to an actual or potential episode of IDH. In almost half of the IDH a trend in blood pressure (40.5%) triggered increasing the frequency of monitoring to every 5-15 minutely during the event, and then 15 - 30 minutely following the event. Nurse initiated interventions were mostly decreasing ultrafiltration goal (51.6%) or ceasing ultrafiltration (36.9%). On 38.5% occasions nurses reported doing more than one intervention. Conclusion Individualised assessment of patients is required with more frequent monitoring required in the second or third hours of treatment, especially in patients with multiple co-morbidities, shorter treatment times, and higher ultrafiltration rates.