Dialysis complications: Difference between revisions
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===Infection=== | ===Infection=== | ||
*Pts often p/w signs of systemic sepsis (fever, hypotension, leukocytosis) | *Pts often p/w signs of systemic [[sepsis]] ([[fever]], [[hypotension]], leukocytosis) | ||
**Classic signs of pain, erythema, swelling, d/c from infected access are often missing | **Classic signs of pain, erythema, swelling, d/c from infected access are often missing | ||
*Dialysis catheter–related bacteremia is common and potentially life-threatening | *Dialysis catheter–related bacteremia is common and potentially life-threatening | ||
**Give vancomycin 1gm IV +/- genamicin 100mg IV (if gram neg suspected) | **Give [[vancomycin]] 1gm IV +/- genamicin 100mg IV (if gram neg suspected) | ||
**Do not remove dialysis patient's access | **Do not remove dialysis patient's access | ||
*Draw peripheral and catheter blood cultures simultaneously | *Draw peripheral and catheter [[blood cultures]] simultaneously | ||
**4x higher colony count in catheter blood cx suggests catheter is source of bacteremia | **4x higher colony count in catheter blood cx suggests catheter is source of bacteremia | ||
***Even so catheter is only removed if fever persists for 2-3d after abx are started | ***Even so catheter is only removed if fever persists for 2-3d after abx are started | ||
===Hemorrhage=== | ===Hemorrhage=== | ||
*Potentially life-threatening | *Potentially life-threatening |
Revision as of 07:53, 3 March 2014
Hypotension
Background
- Most frequent complication of hemodialysis (20%-30% of tx)
- Timing of intradialytic hypotension is helpful in formulating DDX:
- Hypotension early in session usually due to preexisting hypovolemia
- Hypotension during the session is often due to blood loss (from tubing or filter leak)
- Hypotension near the end usually result of excessive ultrafiltration
- Underestimation of pt's ideal blood volume (dry weight)
- Also consider pericardial or cardiac disease
Clinical Features
- N/V
- Anxiety
- Dizziness
- Orthostatic hypotension
- Syncope
Diagnosis
- Assess:
- Volume status (US)
- Cardiac function
- Pericardial disease
- Infection
- GI bleeding
DDX
- Excessive ultrafiltration
- Predialytic volume loss
- GI losses
- Decreased oral intake
- Intradialytic volume loss
- Tube and hemodialyzer blood losses
- Postdialytic volume loss
- Vascular access blood loss
- Medication effects
- Antihypertensives
- Opiates
- Decreased vascular tone (sepsis)
- Cardiac dysfunction
- LVH, ischemia, hypoxia, arrhythmia, pericardial tamponade
- Pericardial disease
- Effusion
- Tamponade
Dialysis Disequilibrium Syndrome
- Diagnosis of exclusion (r/o SDH, CVA)
- Clinical syndrome occurring at end of dialysis
- Occurs most commonly during initial dialysis or during hypercatabolic states
- Large solute clearances -> cerebral edema
- Symptoms
- N/V, HTN; can progress to seizure, coma, death
- Treat w/ mannitol
Air Embolism
- Acute dyspnea, chest tightness, LOC, cardiac arrest
- Treat w/ 100% NRB
Vascular Access Complications
Thrombosis and Stenosis
- Most common causes of inadequate dialysis flow
- Loss of bruit and thrill over access
- Stenosis and even thrombosis are not emergencies
- Can be treated w/in 24hr by angiographic clot removal or angioplasty
- Thrombosis of vascular access can be treated w/ direct injection of alteplase 2.2mg
- This therapy should be discussed with the vascular surgeon first
Infection
- Pts often p/w signs of systemic sepsis (fever, hypotension, leukocytosis)
- Classic signs of pain, erythema, swelling, d/c from infected access are often missing
- Dialysis catheter–related bacteremia is common and potentially life-threatening
- Give vancomycin 1gm IV +/- genamicin 100mg IV (if gram neg suspected)
- Do not remove dialysis patient's access
- Draw peripheral and catheter blood cultures simultaneously
- 4x higher colony count in catheter blood cx suggests catheter is source of bacteremia
- Even so catheter is only removed if fever persists for 2-3d after abx are started
- 4x higher colony count in catheter blood cx suggests catheter is source of bacteremia
Hemorrhage
- Potentially life-threatening
- Can result from aneurysms, anastomosis rupture, or over-anticoagulation
- Control bleeding w/ pressure applied to puncture site for 5-10min; observee for 1-2hr
- Types
- Aneursym (true)
- Most are asymptomatic; rarely rupture
- Pseudoaneurysm
- Results from subcutaneous extravasation of blood from puncture sites
- Bleeding from puncture site is usually controlled by digital pressure or subq suture
- Consider vascular surgery consultation for continued bleeding or infection
- Arterial Doppler US studies can identify the aneurysm or pseudoaneurysm
- Aneursym (true)
Vascular insufficiency
- Distal extremity becomes ischemic due shunting of arterial blood to venous side
- Exercise pain, nonhealing ulcers, cool, pulseless digits
- Diagnosed by Doppler US or angiography, repaired surgically
High-output heart failure
- Occurs when >20% of cardiac output is diverted through the access
- Branham sign (drop in HR after temporary access occlusion) is diagnostic
- Doppler US can accurately measure access flow rate and establish the diagnosis
- Tx = surgical banding of the access
Peritoneal Dialysis Complications
Peritonitis
Background
- Most common complication
- Presentation no different from other causes of peritonitis
Diagnosis
- Send dialysate fluid for cell count, Gram stain, cx (if available)
- Cell count >100 w/ >50% neutrophils most c/w infection
Treatment
- Can add abx to the dialysate if possible (parenteral abx not required)
- 1st gen cephalosporin or vancomycin (if pen allergic)
Source
Tintinalli