What is the management protocol for a code blue during hemodialysis in a patient with impaired renal function?

Managing Code Blue During Hemodialysis

Immediately stop the hemodialysis session without blood restitution, disconnect the patient from the circuit, initiate standard ACLS protocols, and ensure the dialysis staff follows a systematic life support approach while addressing hemodialysis-specific complications. 1, 2, 3

Immediate Actions When Code Blue is Called

Stop Dialysis and Secure the Patient

• Immediately stop the blood pump and clamp all blood lines without returning blood to the patient to prevent potential complications from hemolysis, air embolism, or other circuit-related emergencies 2, 3
• Disconnect the patient from the dialysis circuit completely 1, 3
• Position the patient supine and ensure airway patency 1

Initiate Standard Resuscitation Protocol

• Begin chest compressions immediately if pulseless, following current ACLS guidelines with compressions at 100-120 per minute and depth of 5-6 cm 1
• Establish or verify IV access separate from the dialysis access if possible 1
• Attach defibrillator pads and analyze rhythm 1
• Administer epinephrine 1 mg IV every 3-5 minutes during cardiac arrest, recognizing that epinephrine may cause renal vasoconstriction and oliguria but this should not preclude its use in life-threatening situations 4

Hemodialysis-Specific Considerations During Resuscitation

Assess for Dialysis-Related Emergencies

• Check for air embolism by examining the dialysis circuit for visible air and positioning the patient in left lateral decubitus with Trendelenburg position if suspected 2
• Evaluate for acute hemolysis by inspecting blood in the circuit for dark discoloration, checking for kinked tubing, and examining pre-pump and post-pump pressures 2, 3
• Consider dialyzer reactions (Type A hypersensitivity) if onset was within first 30 minutes of dialysis, manifesting as chest pain, dyspnea, and cardiovascular collapse 2
• Assess for dialysis disequilibrium syndrome in patients receiving their first few dialysis treatments, presenting with altered mental status progressing to seizures and coma 2

Vascular Access Management

• Do not use the dialysis vascular access for resuscitation medications unless no other access is available, as this is the patient's lifeline 5
• If the arteriovenous fistula or graft must be used, access it with standard IV technique rather than dialysis needles 5
• For tunneled dialysis catheters, follow proper sterile technique and withdraw any heparin lock before medication administration 6

Electrolyte and Metabolic Considerations

Hyperkalemia Management

• Assume hyperkalemia is present in hemodialysis patients who arrest, especially if the code occurs on a non-dialysis day or before scheduled dialysis 5, 7
• Administer calcium chloride 10% 10 mL IV immediately for cardioprotection 5
• Give insulin 10 units IV with dextrose 50% 50 mL (if not hyperglycemic) to shift potassium intracellularly 5
• Consider sodium bicarbonate 50 mEq IV if metabolic acidosis is suspected 5
• Prepare for emergent dialysis if return of spontaneous circulation is achieved, as this is the definitive treatment for severe hyperkalemia 5, 7

Fluid Status and Hemodynamic Instability

• Recognize that hemodialysis patients may be volume depleted from recent ultrafiltration, requiring aggressive fluid resuscitation if hypotension contributed to the arrest 1, 7
• Conversely, some patients may be volume overloaded with pulmonary edema, requiring careful fluid management 7
• Monitor blood pressure frequently if epinephrine is used, as these patients often have underlying hypertension and coronary artery disease 4

Post-Resuscitation Management

Immediate Stabilization

• Transfer to intensive care unit for continuous monitoring 3
• Initiate emergent hemodialysis if return of spontaneous circulation is achieved and severe electrolyte abnormalities, volume overload, or uremic complications are present 5, 7
• Consider continuous renal replacement therapy (CRRT) rather than intermittent hemodialysis if the patient remains hemodynamically unstable 6

Investigation of Underlying Cause

• Obtain blood samples for complete blood count, comprehensive metabolic panel, cardiac enzymes, and arterial blood gas 1, 2
• Check for hemolysis markers (free hemoglobin, haptoglobin, LDH) if hemolysis is suspected 2, 3
• Perform 12-lead ECG to evaluate for acute coronary syndrome or arrhythmias 1, 2
• Inspect the dialysis machine, water treatment system, and circuit for mechanical problems 2

Equipment and Circuit Analysis

• Preserve the dialysis circuit and dialyzer for analysis if hemolysis, dialyzer reaction, or contamination is suspected 2
• Check dialysate composition and water treatment system for errors 2
• Review machine alarms and pressure readings that occurred before the arrest 6, 2

Prevention of Future Events

Risk Stratification and Monitoring

• Recognize that hemodialysis patients have exceptionally high cardiovascular mortality risk, with cardiac arrest being a leading cause of death 1, 7
• Ensure continuous monitoring of vital signs during dialysis sessions 1
• Maintain staff training in recognition of early warning signs of deterioration 1

Dialysis Prescription Optimization

• Avoid excessive ultrafiltration rates that may precipitate hypotension and cardiac arrhythmias 6, 7
• Consider longer or more frequent dialysis sessions for patients with large interdialytic weight gains or hemodynamic instability 6
• Ensure adequate delivered dialysis dose (Kt/V ≥1.2) to prevent uremic complications 6

Critical Pitfalls to Avoid

• Never attempt to return blood from the dialysis circuit to the patient during a code, as this may worsen hemolysis, introduce air emboli, or delay resuscitation 2, 3
• Do not assume the arrest is unrelated to dialysis—always consider dialysis-specific emergencies first 1, 2
• Avoid using the dialysis vascular access for medications unless absolutely necessary, as damage to this access has severe long-term consequences 5
• Do not delay chest compressions to investigate the dialysis circuit—resuscitation takes priority over equipment assessment 1
• Never overlook hyperkalemia as a reversible cause, as it is extremely common in this population and requires specific treatment beyond standard ACLS 5, 7