Emergenices in Renal Failure and Dialysis Patients

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Emergenices in Renal Failure and Dialysis Patients

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

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