What is the recommended dialysis strategy in patients requiring dialysis during Cardiopulmonary Resuscitation (CPR)?

Dialysis Strategy During Cardiopulmonary Resuscitation

Emergency hemodialysis should be initiated during ongoing CPR for patients with severe hyperkalemia-induced cardiac arrest when conventional therapies (calcium, insulin/glucose, bicarbonate, beta-agonists) have failed to restore spontaneous circulation after initial resuscitation attempts. 1

Clinical Context and Evidence

The question of dialysis during CPR primarily applies to a specific clinical scenario: hyperkalemia-induced cardiac arrest in dialysis-dependent patients. This is not a routine consideration for all cardiac arrests during dialysis sessions, but rather an extraordinary intervention for refractory situations. 1

When to Consider Dialysis During CPR

Initiate emergency hemodialysis during CPR when:

• Cardiac arrest is clearly secondary to severe hyperkalemia (typically K+ >7.0-8.0 mEq/L) 1
• Conventional hyperkalemia treatments have been administered without return of spontaneous circulation 1
• CPR has been ongoing with adequate chest compressions (external cardiac compression can support sufficient blood flow for hemodialysis) 1
• The patient has not achieved ROSC after initial standard ACLS interventions 1

Physiologic Rationale

External chest compressions during CPR generate adequate blood flow to support hemodialysis function, allowing for rapid potassium removal while maintaining perfusion. 1 A documented case demonstrated successful restoration of spontaneous heartbeat 20 minutes after initiating hemodialysis during CPR, following 100 minutes of failed conventional resuscitation. 1

Standard CPR Management in Dialysis Patients

For cardiac arrests not related to severe hyperkalemia, dialysis patients should receive standard ACLS protocols identical to the general population, including: 2

• High-quality chest compressions (at least 2 inches depth, 100-120/min rate, complete recoil) 2
• Early defibrillation for shockable rhythms (VF/pVT) 2
• Epinephrine 1 mg IV/IO every 3-5 minutes 2
• Amiodarone (300 mg first dose, 150 mg second dose) or lidocaine for refractory VF/pVT 2
• Advanced airway management with continuous waveform capnography 2

Medication Considerations

Critical caveat: Avoid low molecular weight heparins in dialysis patients during acute coronary syndrome management due to altered clearance in kidney failure. 2 Standard unfractionated heparin or bivalirudin (with dialysis-specific dosing) should be used instead. 2

Post-Resuscitation Dialysis Timing

For patients who achieve ROSC after cardiac arrest (with or without dialysis during CPR), the timing of subsequent dialysis in the first 48 hours requires individualized assessment considering: 2

• Volume status and pulmonary edema severity
• Electrolyte disturbances (particularly ongoing hyperkalemia)
• Bleeding risk from anticoagulation
• Hemodynamic stability and vasopressor requirements 2

Adjust dialysis prescriptions to minimize hypotension risk during this vulnerable post-arrest period through slower ultrafiltration rates, cooler dialysate temperature, and potentially shorter treatment times. 2

Prognostic Considerations for Informed Decision-Making

Dialysis patients and their families should understand that CPR outcomes in dialysis patients are poor: only 8% survive to hospital discharge, and only 3% remain alive at 6 months. 3 Of successfully resuscitated dialysis patients, 78% die within a mean of 4.4 days, with 95% requiring mechanical ventilation in the ICU at time of death. 3

Despite these sobering statistics, 87% of dialysis patients want CPR attempted, though 13% prefer do-not-resuscitate status. 4 Patients who decline CPR tend to be older, have more comorbidities, possess living wills, and are more likely to be widowed or reside in nursing homes. 4

Critical Implementation Gap

Only 35% of dialysis patients who did not want CPR had confirmed DNR orders in their dialysis charts, representing a significant patient safety and ethical concern. 4 Dialysis units must systematically document resuscitation preferences and ensure staff awareness before each treatment session.

Practical Algorithm for Dialysis During CPR

1. Initiate standard ACLS immediately for any cardiac arrest in dialysis unit 2
2. Obtain rapid potassium level if hyperkalemia suspected (recent missed dialysis, dietary indiscretion, medication non-compliance)
3. Administer conventional hyperkalemia treatments while continuing CPR: calcium chloride/gluconate, insulin with D50, sodium bicarbonate, albuterol 1
4. If no ROSC after 20-30 minutes AND severe hyperkalemia confirmed, consider emergency hemodialysis during ongoing CPR 1
5. Ensure adequate chest compression quality to maintain dialysis circuit blood flow 1
6. Continue CPR throughout dialysis initiation until ROSC achieved or resuscitation terminated 1

Common pitfall: Delaying consideration of dialysis during CPR until after prolonged unsuccessful resuscitation. If hyperkalemia is the clear etiology, earlier initiation (after conventional measures fail) may improve outcomes. 1