Review paperDefibrillation during renal dialysis: A survey of UK practice and procedural recommendations☆
Introduction
Electrical safety during external defibrillation is important for the rescuer's safety, for effective defibrillation of the patient and avoidance of damage to equipment. Safe techniques are emphasised in current European Resuscitation Council (ERC) guidelines,1 in corresponding Advanced Life Support courses and in international standards concerned with the construction and operation of medical equipment.2, 3, 4
Electrical current predominantly takes the path of least resistance. During defibrillation it is intended that current flows from one paddle, across the thorax (and hence the heart) to the other paddle. However, if alternative routes present themselves, then current may follow them. When this occurs, accidental electrocution may result and there have been several cases of accidental electrocution during defibrillation, often associated with significant rescuer morbidity.5 Likewise, the intended current path may also be upset by the presence of other devices connected to the patient. If aberrant pathways lead to insufficient current density in the heart, then defibrillation may not be successful.
Cardiac disease accounts for the cause of death in 45% of renal dialysis patients, with 60% of these deaths due to sudden cardiac death.6 Cardiac arrest during renal dialysis is relatively common, with a reported rate of 7 per 100,000 haemodialysis sessions.7 The need for defibrillation during renal dialysis is therefore relatively common and introduces a possible aberrant pathway through the extracorporeal circuit. Defibrillation of a patient attached to renal dialysis equipment that is not defibrillation proof may risk failure to defibrillate due to current leakage thorough the dialysis circuit, risk the safety of medical staff and potentially damage the dialysis machine itself. If a patient undergoing renal dialysis requires immediate defibrillation in this circumstance, the clinician has three choices:
- (1)
Immediately disconnect the patient from the dialysis circuit and defibrillate as soon as the circuit is clear of the patient.
- (2)
Return the patient's blood volume in the extracorporeal circuit prior to disconnection of the patient from the dialysis circuit to avoid hypovolaemia and then defibrillate. This will delay defibrillation by 1–2 min.
- (3)
Immediately defibrillate with the patient while connected to the dialysis machine.
The first two options remove the risk of aberrant current pathways and associated risk to the rescuer and renal dialysis machine, but may leave the patient hypotensive or delay defibrillation, respectively. The third option enables immediate defibrillation, but is in breach of British and European safety standards.3, 4 The current ERC guidelines1 do not give specific advice as to the recommended course of action. Medical equipment may be designed to be defibrillation proof and is externally marked with a clearly identifiable symbol (Figure 1).2 Only equipment marked as defibrillation protected may be left connected to the patient during defibrillation.4
The aim of this paper is therefore to ascertain national practice in a representative group of renal dialysis units across the UK, examine the risks and safety issues and formulate recommendations for safe defibrillation of patients undergoing renal dialysis.
Section snippets
Methods
Renal dialysis units in the United Kingdom were identified using a database supplied by the National Kidney Federation. Thirty renal dialysis centres were selected to provide geographic and clinical representation across the UK. Centres were chosen to ensure representation of walk-in centres separate from a hospital site, walk-in centres on a hospital site, inpatient units in District General Hospitals and inpatient units in Teaching Hospitals.
Thirty selected renal dialysis units across the
Results
Thirty renal dialysis units were contacted by telephone. Of these, 28 were able to participate in the study:
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Addenbrookes Hospital, Cambridge. Teaching Hospital.
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Alder Hay Hospital, Liverpool. Teaching Hospital.
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Devonshire Road Hospital, Blackpool. Satellite dialysis unit.
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Churchill Hospital, Oxford. Teaching Hospital.
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Cromwell Hospital, London. Private Hospital.
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West Wing Dialysis Centre, Cardiff. Satellite dialysis unit.
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Derby City Hospital, Derby. District General Hospital.
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Glasgow Royal Infirmary,
Discussion
Defibrillation of patients undergoing renal dialysis presents safety risks to both the patient and clinical staff, and risks damage to unprotected renal dialysis machines. Although a relatively rare event, our survey shows that defibrillation is undertaken by most renal units in the UK on at least an annual basis; this includes defibrillation for all shockable rhythms which includes supraventricular arrhythmias and pulsatile ventricular tachycardias which are not classified as cardiac arrests,
Conclusion and recommendations
This survey and published literature6, 7, 10 shows that a significant number of patients are defibrillated each year whilst on dialysis, both to treat shockable rhythms causing cardiac arrest and to reverse other arrhythmias not associated with immediate cardiovascular collapse. A patient should not be defibrillated whilst attached to a dialysis system unless the system was designed with this in mind. In our survey, only one renal dialysis machine was identified as being defibrillation proof.
Conflict of interest
No author has any conflict of interest with the contents of this study.
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Cited by (8)
European Resuscitation Council Guidelines for Resuscitation 2015. Section 1. Executive summary
2015, ResuscitationCitation Excerpt :Hyperkalaemia contributes to 2–5% of deaths amongst haemodialysis patients 321 A shockable rhythm (VF/pVT) is more common in patients undergoing haemodialysis. 320,322,323 Most haemodialysis machine manufacturers recommend disconnection from the dialysis equipment prior to defibrillation.324 Cardiac arrest on board has an incidence of 1 per 5–10 million passenger flights.
European Resuscitation Council Guidelines for Resuscitation 2015. Section 4. Cardiac arrest in special circumstances
2015, ResuscitationCitation Excerpt :The safest method to deliver a shock during dialysis requires further study. Most haemodialysis machine manufacturers recommend disconnection from the dialysis equipment prior to defibrillation.474 Ensure familiarity with local dialysis equipment and check if equipment has defibrillator-proof label in accordance with the International Electrotechnical Committee (IEC) standards.
European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: Electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution
2010, ResuscitationCitation Excerpt :The safest method to deliver a shock during dialysis requires further study. Most haemodialysis machine manufacturers recommend disconnection from the dialysis equipment prior to defibrillation.18 An alternative and rapid disconnect technique for haemodialysis has been described.
In this issue
2007, ResuscitationCardiac arrest in special circumstances - Recent advances in resuscitation
2019, American Journal of TherapeuticsSummary: Chapter 1 of the European Resuscitation Council Guidelines for Resuscitation 2015
2015, Notfall und Rettungsmedizin
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A Spanish translated version of the summary of this article appears as Appendix in the final online version at 10.1016/j.resuscitation.2006.10.012.