Elsevier

Resuscitation

Volume 73, Issue 3, June 2007, Pages 347-353
Resuscitation

Review paper
Defibrillation during renal dialysis: A survey of UK practice and procedural recommendations

https://doi.org/10.1016/j.resuscitation.2006.10.012Get rights and content

Summary

Introduction

Defibrillation of patients connected to medical equipment that is not defibrillation proof risks ineffective defibrillation and harm to the operator as a result of aberrant electrical pathways taken by the defibrillation current. Many renal dialysis systems are not currently defibrillation proof. Although national and international safety standards caution against defibrillating under this circumstance, it appears to be an area of confusion that we have investigated in more detail.

Methods

Thirty renal dialysis units across the UK were invited to participate in a telephone survey of current practice from 1 October 2004 to 1 October 2005. The Medical Healthcare Regulatory Agency and renal dialysis machine manufacturers were contacted for advice, and current safety standards were reviewed.

Results

Twenty-eight renal dialysis units completed the survey. Seven (25%) units would not disconnect patients from dialysis equipment during defibrillation, collectively reporting 14 patients who had required defibrillation during dialysis. Eighteen (64.3%) units would disconnect patients from dialysis equipment during defibrillation, collectively reporting 29 patients who had required defibrillation during dialysis. No complications were identified by this survey, through the MHRA or through a literature search.

Conclusion

Defibrillation of patients while undergoing renal dialysis is common practice in the UK. Although no adverse events have been reported, this practice risks injury to the patient and clinical staff, and equipment damage if the dialysis equipment is not defibrillation proof. It is in breach of national and international safety standards and should not be practiced.

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:

  • Addenbrookes Hospital, Cambridge. Teaching Hospital.

  • Alder Hay Hospital, Liverpool. Teaching Hospital.

  • Devonshire Road Hospital, Blackpool. Satellite dialysis unit.

  • Churchill Hospital, Oxford. Teaching Hospital.

  • Cromwell Hospital, London. Private Hospital.

  • West Wing Dialysis Centre, Cardiff. Satellite dialysis unit.

  • Derby City Hospital, Derby. District General Hospital.

  • 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.

Cited by (8)

View all citing articles on Scopus

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.

View full text