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Emergenices in Renal Failure and Dialysis Patients

Emergenices in Renal Failure and Dialysis Patients






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    Emergenices in Renal Failure and Dialysis Patients Emergenices in Renal Failure and Dialysis Patients Presentation Transcript

    • Emergencies in Renal Failure and Dialysis Patients Tintinalli chapter 93
      • ESRD: irreversible loss of renal function, accumulation of toxins and loss of internal homeostasis.
      • Uremia: clinical syndrome resulting from ESRD.
    • Epidemiology
      • 1999=89,252 new cases/424,179 patients being tx for ESRD
      • Causes: DM=#1, HTN=#2
      • Therapy: dialysis=70%
        • transplants=30%
      • ESRD deaths: 50% cardiac causes.
        • 10-25% infectious
      • Survival rates for 1,2,5 yrs= 79, 65, 34 % respectively
    • Pathophysiology of Uremia
      • Excretory Failure: causes >70 chemicals to elevate. Urea= major breakdown of proteins. Limit protein intake
      • Biosynthetic Failure: loss of hormones 1,25(OH)3 vit D3 and erythropoietin.
        • 85% of erythropoietin produced by kidney.
        • Vit. D3 deficiency= secondary hyperparathyroidism, renal bone disease.
    • Pathophysiology of Uremia
      • Regulatory Failure: over secretion of hormones , disruption of normal feedback mechanisms
    • Clinical Features of Uremia
      • Neurologic complications:
      • Subdural hematoma: 3.5% of ESRD, HTN, head trauma, bleeding dyscrasias, anticoagulants, ultrafiltration.
      • Uremic Encephalopathy: nonspecific centreal neurologic symptoms, responds to dialysis.
      • Neurologic complications:
      • Dialysis Dementia: like uremic encephalopathy but progressive and fatal, seen after 2 years on dialysis
      • Peripheral neuropathy: >50% of HD patients. “glove and stocking pattern”, improves after transplant
      • Autonomic dysfunction: common; dizzy, impotence, bowel dysfunction.
      • Cardiovascular complications: prevalence is greater in ESRD
      • d/t pre-existing conditions, uremia, toxins, high lipids, homocystine, hyperparathyroidism, dialysis related conditions
      • General population
      • CAD: 12%
      • LV hypert. 20%
      • CHF 5%
      • ESRD
      • 40%
      • 75%
      • 40%
      • Creatine protein Kinase &MB, Troponin I and T…….NOT significantly elevated in patients undergoing regular dialysis, have been shown to be specific markers in these patients.
      • HTN: 80-90% of ESRD starting dialysis. d/t volume, vasopressor effects of kidney, RAS system. Tx initially w/ volume control
      • CHF: HTN #1 cause in ESRD.
      • Uremic cardiomyopathy: dx of exclusion when other causes of CHF ruled out.
      • Pulmonary Edema: fluid overload, MI.
        • Tx w/ O2, nitrates, ACE inhib, morphine, diuretics. Can also use phlebotomy, dialysis.
      • Cardiac Tamponade: rarely w/ classic presentation of low BP, muffled sounds and JVD.
        • Echocardiography, pericardiocentisis
      • Pericarditis/ Uremic Pericarditis:
      • Uremic more common=75%
      • Fluid overload, abnl platelet function, ↑ fibrinolytic and inflammatory cell activity
      • Friction Rubs= louder, palpable, persist after metabolic abnormality resolved
      • BUN always>60 mg/dl
      • Absent EKG changes
      • Dialysis related percarditis: recurrent, most common type during dialysis. More common adhesions and fluid loculations
      • ESRD w/ pericarditis= 8%
      • Tx w/ dialysis
      • Avg survival without dialysis= 1 month
      • Hematologic Complications:
      • Anemia: low erythropoietin, blood loss from dialysis, ↓ RBC survival times
        • Normocytic, normochromic
        • Hct stabilizes @ 15-20 without tx.
        • Tx=erythropoietin
      • Bleeding diathesis: ↑ risk of GI bleed, subdural.
        • Can try tx with desmopressin
      • Immunologic deficiency: leukocyte chemotaxis and phagocytosis decreased in uremic state.
        • Dialysis does not help immune function.
      • GI complications:
      • Anorexia, nausea, vomiting=common in uremia
      • Increased GI bleeding
      • Chronic constipation
      • Ascites from portal HTN, polycystic liver ds., fluid overload.
      • Renal Bone Disease:
      • Systemic calcification; ↓ GFR=↑ serum phosphate levels.
        • Pseudogout, metastatic calcification of tissues, vessels.
        • Tx=low Ca dialysate and phosphate-binding gels
      • Hyperparathyroidism (Osteitis Fibrosa Cystica);
        • ↓ ionized Ca=↑ PTH= high bone turnover, weak bones.
        • Tx=phosphate binding gels, Vit D3 replacement, subtotal parathyroidectomy
      • Osteomalacia; defect in bone calcification
      • d/t Vit.D3 deficiency and aluminum intoxication
      • Weakened bones, muscle pains, weakness
      • Low PTH, ow to normal alkaline phosphate levels, ↑ serum aluminum
      • Tx= desferrioxamine
      • Β 2-Microglobulin amyloidosis:
      • Pts >50 yrs old, on dialysis >10 yrs
      • Amyloid deposits in GI tract, bones, joints.
      • Complications; GI perfs, bone fx’s, carpal tunnel, rotator cuff tears.
      • Pts w/ amyloidosis have ↑ mortality rates
    • Hemodialysis
      • Uses ultrafiltration and clearance to replace nephron.
      • Solute removal depends on filter pore size and concentration gradient
      • Heparin 1000-2000 units typically used
      • Sessions take @ 3-4 hrs.
    • Vascular Access Complications
      • Types of Access:
      • 1. A-V fistula
      • 2. Vascular graft: higher complication rates, shorter functional lifes.
      • 3. Tunnel-cuffed catheters; Hickman, Quinton
      • Thrombosis and Stenosis of Access:
      • Most common complication
      • Loss of bruit and thrill
      • Stenosis / thrombosis: not Emergencies= tx w/in 24 hours.
      • Vascular Access Infections:
      • 2-5% of fistulas, 10% of grafts
      • Often signs of sepsis, fever, Hypotension, ↑ WBC
      • Erythema, swelling, discharge at site often missing.
      • Staph Aureus #1, gram neg #2
      • Vanc is drug of choice, usually add Gent.
      • Hemorrhage:
      • d/t aneurysm, anastomosis rupture or over anticoagulation.
      • Direct pressure
      • Protamine 10-20 mg or 0.01 mg/unit hep.
      • Consult surgery or nephrology
      • Vascular access aneurysms:
      • Repeated punctures
      • Bulging in wall
      • Rarely rupture
      • True aneurysms very rare; 4% of fistulas
      • Vascular access pseudoaneurysm:
      • Subcutaneous extravasation of blood
      • Present w/ bleeding & infection at site
      • Vascular insufficiency: distal to access
      • “ steal syndrome”
      • Preferential shunting of blood to low pressure venous side
      • s/s exercise pain, non-healing ulcers, cool pulseless digits
      • Dx w/ doppler or angiography
      • High-output heart failure:
      • When 20% of cardiac output diverted through access
      • Branham sign: drop in HR after temporary access occlusion
      • Doppler to measure access flow rate
      • Surgical banding of access is Tx.
    • Complications During Hemodialysis
      • 1. Hypotension:
      • Most frequent, 10-20% of treatments
      • Dialysis can remove up to 2 L/hr.
      • Cardiac compensation limited d/t ↓ diastolic function common in ESRD
      • Abnormalities in vascular tone; sepsis, anit HTN meds, ↑ nitric oxide
      • Early hypotension: pre-existing hypovolemia
      • Peridialysis losses; starts HD below dry weight; d/t sepsis, GI bleed, vomiting, diarrhea, decreased salt/water intake
      • Intradialytic blood loss from tubing/dialyzer leads
      • Hypotension at end of dialysis: excessive removal, cardiac or pericardial disease.
      • Intradialytic hypotension:
      • N/V/anxiety, ortho hypotension, tachycardia, dizzy, syncope.
      • Tx.; stop HD, Trendelenburg. Salt, broth by mouth, NS 100-200 cc. IV.
      • If these fail look for other causes than excessive fluid removal
      • 2. Dialysis disequilibrium:
      • End of dialysis
      • N/V, HTN...progress to coma, seizure and death
      • d/t cerebral edema after large solute clearance in HD
      • Tx. Stop HD, administer Mannitol IV.
      • 3. Air Embolism:
      • s/s: dyspnea, chest tightness, unconscious, full cardiac arrest. Cyanosis, churning sound in heart from bubbles
      • Clamp venous blood line, place supine
      • Other Tx’s: percutaneous aspiration from R ventricle, IV steroids, full heparinization, hyperbaric O2 treatment
      • 4. Electrolyte abnormalities:
      • ↑ Ca, ↑Mg
      • N/V, HA, burning skin, weakness, lethargy HTN
      • 5. Hypoglycemia
    • Evaluation of HD Patients
      • Dialysis schedule
      • Dry weight
      • Length of dialysis
      • Inspect access site; erythema, swelling, tender, discharge.
      • Peripheral edema, HJR, JVD not always CHF
      • Murmurs; high flow d/t anemia?
    • Peritoneal Dialysis
      • Peritoneal membrane= blood-dialysate interface
      • Can be done acutely, chronically(continuous)=4 times/day, or multiple exchanges at night while sleeping.
    • Complications
      • Peritonitis #1
      • Mortality 2.5-12.5 %
      • Fever, abd pain, rebound tender
      • Dialysate fluid for cell count, Gram stain, culture
      • Staph epidermidis 40%, S. aureus 10%, Strep species 15-20%, gram neg bacteria 15-20%, anaerobic bacteria 5%, fungi 5%.
      • Empiric antibiotic therapy
      • Add to dialysate
      • Parenteral administration not needed
      • Rapid exchanges of fluid lavage to wash out inflammatory cells
      • First gen Ceph
      • Vanc if pen allergic
      • Can add Gent
      • Infections around PD catheter site:
      • Pain, erythema, swelling, discharge.
      • S. aureus, Pseudomonas aeruginosa
      • Empiric w/ first generation Ceph or Cipro
      • Outpatient therapy with f/u at CAPD center next day
      • Abdominal wall hernia
      • 10-15%
      • Highest rate of incarcerating
      • Immediate surgical repair
    • Overview Evaluating PD Patient
      • Type and frequency of dialysis
      • Date of last episode of peritonitis
      • Frequency of relapse infections
      • Baseline weight
      • Focus on abdomen and catheter tunnel
    • Questions:
      • 1. T/F Peripheral Neuropathy, “stocking and glove pattern”, is rarely seen in ESRD pts on dialysis.
      • 2. T/F ESRD patients carry the same cardiovascular risk as general population.
      • 3. T/F Troponins are commonly significantly elevated in patients on regular dialysis and cannot be trusted as cardiac marker.
      • 4. #1 cause of dialysis access site infections…
        • A. klebsiella
        • B. staph aureus
        • C. strep species
        • D. E. coli
      • 5. #1 complication during dialysis sessions is ….
        • A. hypotension
        • B. fever
        • C. CHF
        • D. cough
        • Answers: false (seen in 50%), false(inc risk), false, B, A.