Difference between revisions of "Dialysis complications"

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==Differential Diagnosis==
{{Dialysis complications DDX}}
{{Dialysis complications DDX}}
==Vascular Access Complications==
{{AV shunt complications DDX}}
===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
===Peritoneal Dialysis Complications===
*Pts often p/w signs of systemic [[sepsis]] ([[fever]], [[hypotension]], leukocytosis)
*[[Peritoneal dialysis-associated peritonitis]]
**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
{{ESRD Associated Skin Conditions}}
*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
**Aneursym (true)
***Most are asymptomatic; rarely rupture
***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
===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==
===[[Altered Mental Status]]===
*Most common complication
*[[Hypercalcemia]] / [[Hyperkalemia]] / [[Hyponatremia]]
*Presentation no different from other causes of peritonitis
*[[Subdural hematoma]]
*[[Dysequilibrium syndrome]] - diagnosis of exclusion made after admission
*Send dialysate fluid for cell count, Gram stain, cx (if available)
**Cell count >100 w/ >50% neutrophils most c/w infection
*Can add [[antibiotic] to the dialysate if possible (parenteral abx not required)
**1st gen [[cephalosporin]] or [[vancomycin]] (if pen allergic)

Latest revision as of 20:53, 11 February 2020