complications of HD case presentation

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in view of a case presentation who has some of complications of HD and was treated promptly.

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complications of HD case presentation

  1. 1. بسم الله الرحمن الرحيم
  2. 2. Case Presentation Dr. Abrar Ali Katpar Resident Nephrology / Medicine King Khalid Hospital, Hail, KSA
  3. 3. Pt’s Profile <ul><li>Name -------------------------DOB= 10/11/1406. </li></ul><ul><li>A 23 years old Male Saudi patient from Hail. </li></ul><ul><li>Blood Group = AB+ve </li></ul><ul><li>Serology negative for HBsAg / HCV / HIV </li></ul><ul><li>This patient was referred from PHC to ER KKH for renal impairment on 14/04/1428 (the first yellow file was opened). </li></ul><ul><li>Appointment was given to OPD on 21/04/1428. </li></ul><ul><li>Through OPD he was admitted on 25/04/1428 to start early dialysis which he refused & continued conservative treatment. </li></ul><ul><li>He presented in ER with SOB + anorexia for 3 days. </li></ul><ul><li>Found to have severe metabolic acidosis + hyperkalemia & pulmonary edema on 07/02/1429. </li></ul>
  4. 4. Pt’s Profile <ul><li>He was admitted for investigations & management. </li></ul><ul><li>Found to have ESRD due to polycystic kidney disease PKD. </li></ul>
  5. 5. U/S reported
  6. 6. <ul><li>He was started urgent 1 st HD with temporary catheter in right femoral vein on 07/02/1429 time 12:05 am in ICU. </li></ul><ul><li>1 st time perm Cath. Was inserted on 12/02/1429. </li></ul><ul><li>Till Now he is on regular HD thrice a week for 4 hours a session. </li></ul><ul><li>His present access for HD is Left AVF Which is functioning well. </li></ul>
  7. 7. <ul><li>After the medical record of the patient, we would like to present this case as our routine HD patient. </li></ul>
  8. 8. Presentation of case for discussion <ul><li>His pre HD Data: </li></ul><ul><ul><li>Dry weight =47kg </li></ul></ul><ul><ul><li>B.P =129/78 </li></ul></ul><ul><ul><li>Pulse =84/ min </li></ul></ul><ul><ul><li>Temp =36.9 </li></ul></ul><ul><ul><li>RR =14/min </li></ul></ul><ul><ul><li>O2 Sat. =97% on RA </li></ul></ul><ul><li>He was prescribed HD </li></ul><ul><ul><li>Session =4 hrs. </li></ul></ul><ul><ul><li>Target wt. loss =3.5 kg </li></ul></ul><ul><ul><li>Heparin only bollus =2000iu </li></ul></ul><ul><ul><li>Dialysate = FC1+bicarb </li></ul></ul><ul><ul><li>Dialysate temp =36 C </li></ul></ul><ul><ul><li>Dialyzer = Pn5 hollow fiber </li></ul></ul><ul><ul><li>Na + =134 </li></ul></ul><ul><ul><li>Conductivity =14 </li></ul></ul><ul><ul><li>Pump =300 </li></ul></ul><ul><li>Our this patient for maintenance regular HD, </li></ul><ul><li>came ambulatory on 11/09/1429 at 8:30 am for a routine session of HD. </li></ul>
  9. 9. Investigations <ul><li>Pre HD </li></ul><ul><ul><li>CBC </li></ul></ul><ul><ul><ul><li>HB = 8.56 </li></ul></ul></ul><ul><ul><ul><li>WBC = 6.45 </li></ul></ul></ul><ul><ul><ul><li>HCT = 25.3 </li></ul></ul></ul><ul><ul><ul><li>PLT = 209 </li></ul></ul></ul><ul><ul><li>Biochemistry </li></ul></ul><ul><ul><ul><li>BUN = 10.79 </li></ul></ul></ul><ul><ul><ul><li>CREAT= 415 </li></ul></ul></ul><ul><ul><ul><li>URIC ACID = 257.1 </li></ul></ul></ul><ul><ul><ul><li>ALB = 39.91 </li></ul></ul></ul><ul><ul><ul><li>T.PROT.= 63.7 </li></ul></ul></ul><ul><ul><ul><li>AST = 21 </li></ul></ul></ul><ul><ul><ul><li>ALT = 24 </li></ul></ul></ul><ul><ul><ul><li>ALP = 507 </li></ul></ul></ul><ul><ul><ul><li>GLUC = 6.1 </li></ul></ul></ul><ul><li>Post HD </li></ul><ul><ul><li>ECG = WNL </li></ul></ul><ul><ul><li>CXR = CLEAR </li></ul></ul><ul><ul><li>Biochemistry </li></ul></ul><ul><ul><ul><li>BUN ----4.32 </li></ul></ul></ul><ul><ul><ul><li>GLUC --7.7 </li></ul></ul></ul><ul><ul><ul><li>Na+ ---144.3 </li></ul></ul></ul><ul><ul><ul><li>K+ -----3.0 </li></ul></ul></ul>
  10. 10. 12 lead ECG
  11. 11. Started HD session <ul><li>Initiated with antiseptic measure AVF pricked & dialysis started with out any problem till 3 hrs. </li></ul><ul><li>Patient was monitored as per routine every 30 minutes for </li></ul><ul><ul><li>Bp </li></ul></ul><ul><ul><li>Pulse </li></ul></ul><ul><ul><li>Arterial pressure </li></ul></ul><ul><ul><li>Venous pressure </li></ul></ul><ul><ul><li>General condition </li></ul></ul><ul><ul><li>Complains </li></ul></ul><ul><ul><li>And other parameters by programmed machine protocols. </li></ul></ul>
  12. 12. Patient presentation. Suddenly after 3 hours of HD he started complaining of:- <ul><li>Dizziness </li></ul><ul><li>Lightheadedness </li></ul><ul><li>Sweating </li></ul><ul><li>Nausea </li></ul><ul><li>Cramps and he was </li></ul><ul><li>About to collapse </li></ul><ul><li>His Vitals </li></ul><ul><li>BP = 75/40 </li></ul><ul><li>Pulse = 110/min&weak </li></ul><ul><li>Temp = 36 C </li></ul><ul><li>RR = 18/min </li></ul><ul><li>O2 Sat. = 90% on RA </li></ul>
  13. 13. Q. WHAT Is happening?
  14. 14. Quick reflexes SEVERE HYPOTENSION? <ul><li>well </li></ul><ul><li>Q. WHAT IS CAUSE OF HIS HYPOTENSION? </li></ul><ul><li>BEFORE ANSWER? </li></ul><ul><li>Let us GO through  </li></ul>
  15. 15. Complications that occur during Hemodialysis session. <ul><li>Common complications </li></ul><ul><ul><li>Hypotension </li></ul></ul><ul><ul><li>Muscle cramps </li></ul></ul><ul><ul><li>Nausea and vomiting </li></ul></ul><ul><ul><li>Headache </li></ul></ul><ul><ul><li>Chest and back pain </li></ul></ul><ul><ul><li>Febrile reactions </li></ul></ul><ul><ul><li>First-use syndromes </li></ul></ul><ul><ul><li>Pruritis </li></ul></ul><ul><li>Uncommon but serious complications </li></ul><ul><ul><li>Disequilibrium syndrome </li></ul></ul><ul><ul><li>Dialyzer reactions </li></ul></ul><ul><ul><li>Arrhythmias </li></ul></ul><ul><ul><li>Cardiac tamponade </li></ul></ul><ul><ul><li>Intracranial bleeding </li></ul></ul><ul><ul><li>Seizures </li></ul></ul><ul><ul><li>Hemolysis </li></ul></ul><ul><ul><li>Air embolism </li></ul></ul><ul><ul><li>Dialysis associated neutropenia & compliment activation. </li></ul></ul><ul><ul><li>Hypoxemia. </li></ul></ul>
  16. 16. Frequency of common complications <ul><li>Hypotension = 20 – 30 % </li></ul><ul><li>Muscle cramps = 5 – 20 % </li></ul><ul><li>Nausea & vomiting = 5 – 15 % </li></ul><ul><li>Headache = 5% </li></ul><ul><li>Chest pain = 2 – 5 % </li></ul><ul><li>Back pain = 2 – 5 % </li></ul><ul><li>Febrile reactions = <1 % </li></ul><ul><li>Itching = 5% </li></ul><ul><li>Fever and Chills = < 1 % </li></ul><ul><li>Cardiopulmonary arrest = < 1 % </li></ul>
  17. 17. Causes of Hypotension during HD <ul><li>Common causes </li></ul><ul><ul><li>1. Related to excessive decrease </li></ul></ul><ul><ul><li>in blood volume </li></ul></ul><ul><ul><ul><li>Fluctuation in U/F rates </li></ul></ul></ul><ul><ul><ul><li>High U/F rate </li></ul></ul></ul><ul><ul><ul><li>Target dry weight set too low. </li></ul></ul></ul><ul><ul><li>2. Related to lack of vasoconstriction </li></ul></ul><ul><ul><ul><li>Acetate-containing dialysis solution. </li></ul></ul></ul><ul><ul><ul><li>Relatively warm dialysis solution. </li></ul></ul></ul><ul><ul><ul><li>Food ingestion </li></ul></ul></ul><ul><ul><ul><li>Tissue ischemia </li></ul></ul></ul><ul><ul><ul><li>Autonomic neuropathy </li></ul></ul></ul><ul><ul><ul><li>Anti hypertensive medicine </li></ul></ul></ul><ul><li>3 . Related to cardiac factors </li></ul><ul><ul><li>Cardiac output unusually dependent on cardiac filling: diastolic dysfunction due to LVH, IHD, or other conditions. </li></ul></ul><ul><ul><li>Failure to increase cardiac rate </li></ul></ul><ul><ul><ul><li>Ingestion of beta blockers </li></ul></ul></ul><ul><ul><ul><li>Uremic autonomic neuropathy </li></ul></ul></ul><ul><ul><ul><li>Aging </li></ul></ul></ul><ul><ul><li>Inability to increase cardiac output for other reasons: poor myocardial contractility due to age, hypertension, atherosclerosis, myocardial calcification, valve disease, amyloidosis, etc </li></ul></ul>
  18. 18. <ul><li>Uncommon causes </li></ul><ul><ul><li>Pericardial tamponade. </li></ul></ul><ul><ul><li>Myocardial infarction. </li></ul></ul><ul><ul><li>Occult hemorrhage. </li></ul></ul><ul><ul><li>Septicemia. </li></ul></ul><ul><ul><li>Arrhythmia. </li></ul></ul><ul><ul><li>Dialyzer reaction. </li></ul></ul><ul><ul><li>Hemolysis. </li></ul></ul><ul><ul><li>Air embolism. </li></ul></ul><ul><ul><li>Infections (severe & serious). </li></ul></ul>
  19. 19. Common causes of hypotension <ul><li>Excessive or rapid decrease in the blood volume. </li></ul><ul><ul><li>Failure to use U/F controller </li></ul></ul><ul><ul><li>Large intra-dialytic weight gain or short treatment. </li></ul></ul><ul><ul><li>Excessive U/F below the pt’s “dry weight”. </li></ul></ul><ul><li>Lack of vasoconstriction. </li></ul><ul><ul><li>Use of acetate-containing dialysis solution </li></ul></ul><ul><ul><li>Dialysis pt’s are often slightly hypothermic. </li></ul></ul><ul><ul><li>Food ingestion. </li></ul></ul><ul><ul><li>Tissue ischemia. </li></ul></ul><ul><ul><li>Autonomic neuropathy. </li></ul></ul><ul><ul><li>Antihypertensive medication. </li></ul></ul>
  20. 20. Detection of hypotension <ul><li>Most patients will complain of feeling dizzy, light headedness, or nauseated when hypotension occurs. </li></ul><ul><li>Some experience muscle cramps. </li></ul><ul><li>Some times no symptoms whatsoever until the BP falls to extremely low (and dangerous ) levels. </li></ul>
  21. 21. Management of hypotension <ul><li>Fluid administration </li></ul><ul><li>Slowing the blood flow rate </li></ul><ul><ul><li>There are 2 potential reasons to lower the blood flow rate: </li></ul></ul><ul><ul><ul><li>When U/F controller is not used, slowing the blood flow rate makes it easier to limit the amount of UF. </li></ul></ul></ul><ul><ul><ul><li>At very rapid blood flow rates and at a low cardiac out put, there may be a “steal” effect by the extracorporeal circuit, with diversion of blood from systemic tissue beds. </li></ul></ul></ul>
  22. 22. Prevention of hypotension <ul><li>Use machine with U/F controller when ever possible. </li></ul><ul><li>Counsel patient to limit weight gain to < 1kg/day. </li></ul><ul><li>Do not ultra filter a patient to below dry weight. </li></ul><ul><li>Keep dialysis solution Na+ level at or above the plasma level. </li></ul><ul><li>Give daily dose of anti-hypertensive after, not before, dialysis. </li></ul><ul><li>Use Bicarb-containing dialysis solution when high blood flow rate or high-efficiency dialyzers are used. </li></ul><ul><li>In selected patients, try lowering the dialysis solution when tempreture to 34-36 oC. </li></ul><ul><li>Ensure that HCT is > 25-30% pre-dialysis. </li></ul><ul><li>Do not give food or glucose orally during dialysis to hypotensive-prone patients. </li></ul>
  23. 23. Muscle cramps <ul><li>Pathogenesis of muscle cramps during dialysis is unknown. </li></ul><ul><li>3 most important predisposing factors: </li></ul><ul><ul><li>Hypotension </li></ul></ul><ul><ul><li>The patient being below dry weight. </li></ul></ul><ul><ul><li>Use of Na+poor dialysis solution. </li></ul></ul>
  24. 24. Management of cramps <ul><li>For cramps with hypotension </li></ul><ul><ul><li>N/S 0.9% is the best on which patient responds quickly. </li></ul></ul><ul><li>In isolated cramps & acute status </li></ul><ul><ul><li>Hypertonic solutions </li></ul></ul><ul><ul><ul><li>Hypertonic saline </li></ul></ul></ul><ul><ul><ul><li>Dextrose 50%. </li></ul></ul></ul><ul><ul><ul><li>I V slowly calcium gluconate 10 to 20 ml specially in hypocalcaemic patients. </li></ul></ul></ul>
  25. 25. ANSWER is Now obvious. <ul><li>This Pt. was having Acute Severe Hypotension with muscle cramps. </li></ul><ul><li>Dizziness + Light headedness + Nausea </li></ul><ul><li>+ Sweating + & generally he was about to collapse because of sudden drop in BP. </li></ul><ul><li>Due to removal of fluid more then his dry weight as patient was young so he was tolerating up to dangerous level of low BP without any complain. </li></ul><ul><li>Due to good response of vascular system, the fluid shift from extra-vascular compartment to vascular compartment was taking place because of good vascular compliance. </li></ul>
  26. 26. Management of this case <ul><li>We managed with: </li></ul><ul><ul><li>Trendelenburg position.  </li></ul></ul><ul><ul><li>I.V bolus of NS 0.9% 200+300ml over 15 min. </li></ul></ul><ul><ul><li>Stopped U/F. </li></ul></ul><ul><ul><li>Reduce Blood Flow pump from 300 to 250 </li></ul></ul><ul><ul><li>Oxygen given 6 litters. </li></ul></ul><ul><ul><li>Hypertonic solution Dextrose 50% given. </li></ul></ul><ul><ul><li>Dialysate Na+ increased to 138. </li></ul></ul><ul><ul><li>Temperature decreased to 34.5C. </li></ul></ul><ul><ul><li>Observation vitals. </li></ul></ul><ul><ul><li>Investigations: Such as ECG + CXR + Hct+ biochemistry. </li></ul></ul>
  27. 27. Follow up <ul><li>During all above measures patient became stable after 15 minutes his vitals were with in normal limits. </li></ul><ul><li>We monitored rest of time, HD continued with altering the prescription. </li></ul><ul><li>At the end of HD he was alright & left AKU ambulatory. </li></ul><ul><li>He came again for his scheduled next HD after a day. </li></ul><ul><li>While Going Home He said  </li></ul>
  28. 28. Thank You

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