# A nurse is caring for a client receiving hemodialysis. Which assessment finding would be the most concerning and require immediate intervention?

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## 문제

A nurse is caring for a client receiving hemodialysis. Which assessment finding would be the most concerning and require immediate intervention?

## 보기

1. Blood pressure of 90/60 mmHg with mild dizziness
2. Sudden onset of chest pain with shortness of breath **✔ 정답**
3. Access site with slight redness and warmth
4. Mild hypotension with fatigue

**정답: 2**

## 해설

Sudden chest pain with shortness of breath during hemodialysis suggests air embolism, a life-threatening emergency requiring immediate intervention. Other findings are less urgent complications.

## 심화 해설

Understanding Dialysis Disequilibrium Syndrome (DDS)

Dialysis disequilibrium syndrome is a serious neurological complication of hemodialysis. The underlying pathophysiology involves rapid osmotic shifts during the procedure. In patients with severe uremia, the blood is quickly cleared of urea and other osmoles. However, the brain is slower to clear these substances. This creates an osmotic gradient, drawing water into brain cells and causing cerebral edema and increased intracranial pressure (ICP) [2, 3]. This syndrome is most common during the initiation of dialysis in patients with extreme azotemia [1, 3].

Analysis of the Correct Answer

The most critical indicator is sudden onset of severe headache with altered mental status. DDS is fundamentally a neurological syndrome stemming from cerebral edema [2, 3]. The clinical presentation is a constellation of neurological symptoms. A severe headache reflects rising intracranial pressure, and an altered mental status—which can range from confusion and decreased responsiveness to staring spells as noted in clinical reports—signals direct brain parenchymal involvement [1, 2]. These signs indicate that the central nervous system is acutely compromised, making this a potentially fatal emergency if not recognized immediately [4]. Early recognition of these subtle neurological signs is essential to prevent progression to seizures, coma, or death [1].

Analysis of Incorrect Answers

Option 2: Sudden onset of severe muscle cramping in the lower extremities. Muscle cramps are a common complication of hemodialysis, typically related to rapid fluid and electrolyte shifts, particularly hypovolemia or hyponatremia. While distressing, they do not directly indicate the life-threatening cerebral edema that defines DDS.

Option 3: Sudden onset of severe hypotension with dizziness. Hypotension is a frequent intradialytic complication caused by rapid fluid removal and decreased intravascular volume. Dizziness can be a symptom of cerebral hypoperfusion. Although DDS can present with non-specific symptoms, hypotension is a hemodynamic event, not a primary neurological manifestation of the osmotic brain injury central to DDS pathophysiology [3].

Option 4: Sudden onset of severe nausea and vomiting. Nausea and vomiting are indeed recognized early, albeit non-specific, symptoms of DDS and can occur due to increased ICP [1, 3]. However, they are not the most critical indicators when compared to direct neurological signs. A patient can vomit from uremia or rapid fluid shifts without developing the dangerous cerebral edema that defines DDS. The presence of altered mentation with a headache provides a more definitive and critical warning of rising ICP [2].References (research sources)

- [1]Early-Onset Dialysis Disequilibrium Syndrome Presenting With Hypoxia and Subtle Neurological Signs During Initial Hemodialysis.Research articleTahir MH, Tahir F, Asghar S. (2026) · DOI: 10.7759/cureus.108587

- [2]Dialysis disequilibrium syndrome: An overview of the current neurosurgical state.Research articleGould J, Patel S, Chaurasia B. (2026) · DOI: 10.25259/sni_1287_2025

- [3]<p>Dialysis disequilibrium syndrome prevention and management</p>Research articleKirtida Mistry (2019) · DOI: 10.2147/ijnrd.s165925

- [4]Dialysis Disequilibrium Syndrome and Severe Metabolic Acidosis: A Fatal Case.Research articleRodriguez Lopez AF, Ameduite MK, Maddipati V, Coore H. (2025) · DOI: 10.7759/cureus.89369

## 임상 시나리오

Clinical Guide: Recognizing Acute Complications During Hemodialysis

When a patient on hemodialysis develops sudden chest pain and dyspnea, immediate action is required. This presentation is a red flag for rare but catastrophic complications such as air embolism or hemothorax, especially in patients with central venous catheters.

Priority Assessment & Action

- **Stop dialysis immediately** and clamp the venous line to prevent further air entry if air embolism is suspected.

- **Assess ABCs:** Evaluate airway patency, breathing effort, oxygen saturation, and circulatory status (heart rate, blood pressure).

- **Position the patient:** For suspected air embolism, place the patient in the left lateral Trendelenburg position (Durant's maneuver) to trap air in the right atrium.

- **Administer high-flow oxygen** to support oxygenation and reduce the size of air emboli via nitrogen washout.

- **Notify the provider and rapid response team** immediately; prepare for emergency chest tube insertion if hemothorax is confirmed.

Key Differential for Chest Pain/Dyspnea During Dialysis

- **Air Embolism:** Sudden onset, often with a churning murmur on auscultation. Risk factors include disconnected lines or improper priming.

- **Hemothorax:** Caused by vessel perforation from a central venous catheter. May present with unilateral decreased breath sounds and shock.

- **Acute Coronary Syndrome:** Consider in patients with cardiac history, but the temporal link to dialysis raises suspicion for procedure-related events.

- **Dialysis Membrane Reaction:** Usually presents with dyspnea, wheezing, and back pain within minutes of starting dialysis.

Nursing Pearls

- Never ignore sudden chest pain during dialysis; common complications like hypotension do not typically cause sharp, acute chest pain.

- Always inspect central line connections and catheter integrity at the start and during treatment to prevent air entry.

- Document the exact time of symptom onset, the volume of blood in the circuit, and immediate interventions performed.

## 핵심 개념

- **Air Embolism** — A rare, life-threatening complication of hemodialysis where air enters the venous system, causing chest pain, dyspnea, and cardiovascular collapse.
- **Hemothorax** — A collection of blood in the pleural cavity, often caused by central venous catheter injury to major vessels, presenting with sudden chest pain and shortness of breath.
- **Intradialytic Hypotension** — A common drop in blood pressure during hemodialysis due to rapid fluid removal, typically managed by adjusting ultrafiltration rate or administering saline.

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