Difference between revisions of "Dialysis complications"

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{{Dialysis complications DDX}}
*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===
{{AV shunt complications DDX}}
*Orthostatic hypotension
===Peritoneal Dialysis Complications===
*[[Peritoneal dialysis-associated peritonitis]]
##Volume status (US)
##Cardiac function
##Pericardial disease
##GI bleeding
{{ESRD Associated Skin Conditions}}
#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
#Decreased vascular tone (sepsis)
#Cardiac dysfunction
##LVH, ischemia, hypoxia, arrhythmia, pericardial tamponade
#Pericardial disease
==Dialysis Disequilibrium Syndrome==
===[[Altered Mental Status]]===
*Diagnosis of exclusion (r/o SDH, CVA)
*Clinical syndrome occurring at end of dialysis
**Large solute clearances -> cerebral edema
*[[Hypercalcemia]] / [[Hyperkalemia]] / [[Hyponatremia]]
*Characterized by N/V, HTN
*[[Subdural hematoma]]
**Can progress to seizure, coma, death)
*[[Dysequilibrium syndrome]] - diagnosis of exclusion made after admission
*Occurs most commonly during initial dialysis or during hypercatabolic states
*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
*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
*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==
*Most common complication
*Presentation no different from other causes of peritonitis
*Send dialysate fluid for cell count, Gram stain, cx (if available)
**Cell count >100 w/ >50% neutrophils most c/w infection
*Can add abx 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