• Share
  • Email
  • Embed
  • Like
  • Save
  • Private Content
Emergenices in Renal Failure and Dialysis Patients
 

Emergenices in Renal Failure and Dialysis Patients

on

  • 1,222 views

 

Statistics

Views

Total Views
1,222
Views on SlideShare
1,222
Embed Views
0

Actions

Likes
0
Downloads
71
Comments
0

0 Embeds 0

No embeds

Accessibility

Categories

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment

    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.