What is the best course of action for a patient with a hemodialysis catheter who develops chills and severe hypertension during or after hemodialysis?

Management of Chills and Severe Hypertension in a Hemodialysis Catheter Patient

This patient requires immediate empirical broad-spectrum antibiotics covering both gram-positive and gram-negative organisms, blood cultures from the catheter and peripherally if possible, and urgent blood pressure control with intravenous antihypertensives while investigating for catheter-related bloodstream infection (CRBSI).

Immediate Infection Management

Empirical Antibiotic Therapy

• Start vancomycin plus gram-negative coverage (third-generation cephalosporin, carbapenem, or β-lactam/β-lactamase combination) immediately after obtaining blood cultures 1
• The combination of chills during dialysis with a tunneled catheter carries a 33.5% rate of bacteremia and 60.2% rate of infection overall 2
• Patients with vascular catheters as dialysis access have a 6.2-fold increased odds of bacteremia compared to those with fistulas or grafts (OR 6.2; 95% CI, 3.2-12.0) 2

Blood Culture Strategy

• Obtain peripheral blood cultures from vessels not intended for future fistula creation (e.g., hand veins) 1
• If peripheral access is unavailable, draw blood cultures from the hemodialysis catheter bloodlines during dialysis 1
• The presence of fever increases bacteremia risk by 1.6-fold (OR 1.6; 95% CI, 1.1-2.3) 2

Catheter Management Decision

• Remove the catheter immediately if cultures grow S. aureus, Pseudomonas species, or Candida species, and insert a temporary catheter at a different anatomical site 1
• For other pathogens (coagulase-negative staphylococci or gram-negative bacilli other than Pseudomonas), initiate empirical antibiotics and observe for 2-3 days 1
• If symptoms resolve within 2-3 days without metastatic infection, the catheter can be exchanged over a guidewire 1
• If symptoms persist beyond 2-3 days or metastatic infection develops, remove the catheter 1

Hypertensive Crisis Management

Understanding the Paradoxical Hypertension

• This represents "paradoxical rise of blood pressure during dialysis," a recognized phenomenon in hemodialysis patients that occurs in a small subset 1
• The mechanism involves excessive stimulation of the renin-angiotensin system or sympathetic nervous system activation precipitated by volume changes 1
• At times, excessive volume depletion during ultrafiltration paradoxically results in hypertension rather than hypotension due to compensatory vasoconstriction 1

Immediate Blood Pressure Control

• Administer intravenous labetalol as the preferred agent for acute blood pressure reduction in this setting 3
• Initial dose: 20 mg IV (corresponding to 0.25 mg/kg for an 80 kg patient), followed by additional doses of 40-80 mg at 10-minute intervals up to a cumulative dose of 300 mg 3
• Maximal effect occurs within 5 minutes of each dose 3
• Labetalol is approximately 50% protein bound and is NOT significantly removed by hemodialysis (<1%), making it safe to use during dialysis 3

Critical Positioning Precaution

• Keep the patient supine or semi-recumbent during labetalol administration, as the alpha-blocking activity causes greater blood pressure reduction in standing versus supine position 3
• Do not allow the patient to move to an erect position unmonitored until their ability to do so is established 3
• If excessive hypotension occurs, place the patient supine with legs raised and administer vasopressors (norepinephrine is the drug of choice) 3

Ultrafiltration Adjustment

Modify the Dialysis Prescription

• Reduce or temporarily stop ultrafiltration given the severe hypertensive response, which may indicate excessive volume depletion triggering compensatory mechanisms 1
• Reassess the estimated dry weight target—increase by 0.3-0.5 kg if hypotension or paradoxical hypertension occurs 4
• Consider that the patient may have reached or gone below their actual dry weight, triggering the hypertensive response 4

Avoid Common Pitfalls

• Do not administer normal saline reflexively, as this will worsen volume overload and prevent achievement of volume removal goals 4
• Avoid excessive ultrafiltration rates (>10 ml/h/kg), which can precipitate hemodynamic instability 4
• If large interdialytic weight gains are present, extend dialysis time rather than accelerating ultrafiltration rate 4

Ongoing Management Strategy

Antibiotic Duration

• Continue antibiotics for 2 weeks if symptoms resolve quickly and catheter is retained with negative follow-up cultures 1
• Extend to 4-6 weeks if bacteremia persists >72 hours after catheter removal or if complications develop (endocarditis, suppurative thrombophlebitis) 1
• Switch from vancomycin to cefazolin (20 mg/kg after dialysis) if methicillin-susceptible S. aureus is identified 1

Blood Pressure Management Post-Crisis

• Once acute crisis is controlled, initiate or optimize oral antihypertensive regimen with ACE inhibitors or ARBs as first-line agents 1, 5, 6
• Add calcium channel blockers, beta-blockers, or combined alpha-beta blockers as needed for resistant hypertension 1, 6
• Note that labetalol, carvedilol, CCBs, and ARBs are NOT significantly removed by dialysis, making them suitable for chronic management 1

Follow-Up Surveillance

• Obtain surveillance blood cultures 1 week after completing antibiotic course if catheter was retained 1
• Monitor for signs of metastatic infection (endocarditis, vertebral osteomyelitis, septic arthritis) 1
• Reassess volume status between dialysis sessions looking for edema, hypertension, or elevated jugular venous pressure 4