Difference between revisions of "Dialysis complications"

(Thrombosis and Stenosis)
Line 1: Line 1:
<h2>Hypotension</h2>
+
==Hypotension==
<h3>Background</h3>
+
===Background===
<ul><li>Most frequent complication of hemodialysis (20%-30% of tx)
+
*Most frequent complication of hemodialysis (20%-30% of tx)
</li><li>Timing of intradialytic hypotension is helpful in formulating DDX:
+
*Timing of intradialytic hypotension is helpful in formulating DDX:
<ul><li>Hypotension early in session usually due to preexisting hypovolemia
+
**Hypotension early in session usually due to preexisting hypovolemia
</li><li>Hypotension during the session is often due to blood loss (from tubing or filter leak)
+
**Hypotension during the session is often due to blood loss (from tubing or filter leak)
</li><li>Hypotension near the end usually result of excessive ultrafiltration
+
**Hypotension near the end usually result of excessive ultrafiltration
<ul><li>Underestimation of pt's ideal blood volume (dry weight)  
+
***Underestimation of pt's ideal blood volume (dry weight)  
</li><li>Also consider pericardial or cardiac disease
+
***Also consider pericardial or cardiac disease
</li></ul>
+
 
</li></ul>
+
===Clinical Features===
</li></ul>
+
*N/V
<h3>Clinical Features</h3>
+
*Anxiety
<ul><li>N/V
+
*Dizziness
</li><li>Anxiety
+
*Orthostatic hypotension
</li><li>Dizziness
+
*Syncope
</li><li>Orthostatic hypotension
+
 
</li><li>Syncope
+
===Diagnosis===
</li></ul>
+
#Assess:
<h3>Diagnosis</h3>
+
##Volume status (US)
<ol><li>Assess:
+
##Cardiac function
<ol><li>Volume status (US)
+
##Pericardial disease
</li><li>Cardiac function
+
##Infection
</li><li>Pericardial disease
+
##GI bleeding
</li><li>Infection
+
 
</li><li>GI bleeding
+
===DDX===
</li></ol>
+
#Excessive ultrafiltration
</li></ol>
+
#Predialytic volume loss
<h3>DDX</h3>
+
##GI losses
<ol><li>Excessive ultrafiltration
+
##Decreased oral intake
</li><li>Predialytic volume loss
+
#Intradialytic volume loss
<ol><li>GI losses
+
##Tube and hemodialyzer blood losses
</li><li>Decreased oral intake
+
#Postdialytic volume loss
</li></ol>
+
##Vascular access blood loss
</li><li>Intradialytic volume loss
+
#Medication effects
<ol><li>Tube and hemodialyzer blood losses
+
##Antihypertensives
</li></ol>
+
##Opiates
</li><li>Postdialytic volume loss
+
#Decreased vascular tone (sepsis)
<ol><li>Vascular access blood loss
+
#Cardiac dysfunction
</li></ol>
+
##LVH, ischemia, hypoxia, arrhythmia, pericardial tamponade
</li><li>Medication effects
+
#Pericardial disease
<ol><li>Antihypertensives
+
##Effusion
</li><li>Opiates
+
##Tamponade
</li></ol>
+
 
</li><li>Decreased vascular tone (sepsis)
+
==Dialysis Disequilibrium Syndrome==
</li><li>Cardiac dysfunction
+
*Diagnosis of exclusion (r/o SDH, CVA)
<ol><li>LVH, ischemia, hypoxia, arrhythmia, pericardial tamponade
+
*Clinical syndrome occurring at end of dialysis
</li></ol>
+
**Large solute clearances -> cerebral edema
</li><li>Pericardial disease
+
*Characterized by N/V, HTN
<ol><li>Effusion
+
**Can progress to seizure, coma, death)
</li><li>Tamponade
+
*Occurs most commonly during initial dialysis or during hypercatabolic states
</li></ol>
+
*Treat w/ mannitol
</li></ol>
+
 
<h2>Dialysis Disequilibrium Syndrome</h2>
+
==Air Embolism==
<ul><li>Diagnosis of exclusion (r/o SDH, CVA)
+
*Acute dyspnea, chest tightness, LOC, cardiac arrest
</li><li>Clinical syndrome occurring at end of dialysis
+
*Treat w/ 100% NRB
<ul><li>Large solute clearances -&gt; cerebral edema
+
 
</li></ul>
+
==Vascular Access Complications==
</li><li>Characterized by N/V, HTN
+
===Thrombosis and Stenosis===
<ul><li>Can progress to seizure, coma, death)
+
*Most common causes of inadequate dialysis flow
</li></ul>
+
**Loss of bruit and thrill over access
</li><li>Occurs most commonly during initial dialysis or during hypercatabolic states
+
*Stenosis and even thrombosis are not emergencies
</li><li>Treat w/ mannitol
+
**Can be treated w/in 24hr by angiographic clot removal or angioplasty
</li></ul>
+
**Thrombosis of vascular access can be treated w/ direct injection of alteplase 2.2mg
<h2>Air Embolism</h2>
+
***This therapy should be discussed with the vascular surgeon first
<ul><li>Acute dyspnea, chest tightness, LOC, cardiac arrest
+
 
</li><li>Treat w/ 100% NRB
+
===Vascular Access Infection===
</li></ul>
+
*Pts often p/w signs of systemic sepsis (fever, hypotension, leukocytosis)
<h2>Vascular Access Complications</h2>
+
**Classic signs of pain, erythema, swelling, d/c from infected access are often missing
<h3>Thrombosis and Stenosis</h3>
+
*Dialysis catheter–related bacteremia is common and potentially life-threatening  
<ul><li>Most common causes of inadequate dialysis flow
+
**Give vancomycin 1gm IV +/- genamicin 100mg IV (if gram neg suspected)
<ul><li>Loss of bruit and thrill over access
+
**Do not remove dialysis patient's access
</li></ul>
+
*Draw peripheral and catheter blood cultures simultaneously
</li><li>Stenosis and even thrombosis are not emergencies
+
**4x higher colony count in catheter blood cx suggests catheter is source of bacteremia
<ul><li>Can be treated w/in 24hr by angiographic clot removal or angioplasty
+
***Even so catheter is only removed if fever persists for 2-3d after abx are started
</li><li>Thrombosis of vascular access can be treated w/ direct injection of alteplase 2.2mg ***This therapy should be discussed with the vascular surgeon first
+
===Hemorrhage===
</li></ul>
+
*Potentially life-threatening
</li></ul>
+
*Can result from aneurysms, anastomosis rupture, or over-anticoagulation
<h3>Vascular Access Infection</h3>
+
*Control bleeding w/ pressure applied to puncture site for 5-10min; observee for 1-2hr  
<ul><li>Pts often p/w signs of systemic sepsis (fever, hypotension, leukocytosis)
+
*Types
<ul><li>Classic signs of pain, erythema, swelling, d/c from infected access are often missing
+
**Aneursym (true)
</li></ul>
+
***Most are asymptomatic; rarely rupture
</li><li>Dialysis catheter–related bacteremia is common and potentially life-threatening  
+
**Pseudoaneurysm
<ul><li>Give vancomycin 1gm IV +/- genamicin 100mg IV (if gram neg suspected)
+
***Results from subcutaneous extravasation of blood from puncture sites
</li><li>Do not remove dialysis patient's access
+
***Bleeding from puncture site is usually controlled by digital pressure or subq suture
</li></ul>
+
***Consider vascular surgery consultation for continued bleeding or infection
</li><li>Draw peripheral and catheter blood cultures simultaneously
+
***Arterial Doppler US studies can identify the aneurysm or pseudoaneurysm
<ul><li>4x higher colony count in catheter blood cx suggests catheter is source of bacteremia
+
===Vascular insufficiency===
<ul><li>Even so catheter is only removed if fever persists for 2-3d after abx are started
+
*Distal extremity becomes ischemic due shunting of arterial blood to venous side
</li></ul>
+
**Exercise pain, nonhealing ulcers, cool, pulseless digits
</li></ul>
+
**Diagnosed by Doppler US or angiography, repaired surgically
</li></ul>
+
===High-output heart failure===
<h3>Hemorrhage</h3>
+
*Occurs when >20% of cardiac output is diverted through the access
<ul><li>Potentially life-threatening
+
**Branham sign (drop in HR after temporary access occlusion) is diagnostic
</li><li>Can result from aneurysms, anastomosis rupture, or over-anticoagulation
+
**Doppler US can accurately measure access flow rate and establish the diagnosis **Surgical banding of the access is treatment of choice  
</li><li>Control bleeding w/ pressure applied to puncture site for 5-10min; observee for 1-2hr  
+
 
</li><li>Types
+
==Source==
<ul><li>Aneursym (true)
+
Tintinalli
<ul><li>Most are asymptomatic; rarely rupture
+
 
</li></ul>
+
[[Category:Nephro]]
</li><li>Pseudoaneurysm
 
<ul><li>Results from subcutaneous extravasation of blood from puncture sites
 
</li><li>Bleeding from puncture site is usually controlled by digital pressure or subq suture
 
</li><li>Consider vascular surgery consultation for continued bleeding or infection
 
</li><li>Arterial Doppler US studies can identify the aneurysm or pseudoaneurysm
 
</li></ul>
 
</li></ul>
 
</li></ul>
 
<h3>Vascular insufficiency</h3>
 
<ul><li>Distal extremity becomes ischemic due shunting of arterial blood to venous side
 
<ul><li>Exercise pain, nonhealing ulcers, cool, pulseless digits
 
</li><li>Diagnosed by Doppler US or angiography, repaired surgically
 
</li></ul>
 
</li></ul>
 
<h3>High-output heart failure</h3>
 
<ul><li>Occurs when &gt;20% of cardiac output is diverted through the access
 
<ul><li>Branham sign (drop in HR after temporary access occlusion) is diagnostic
 
</li><li>Doppler US can accurately measure access flow rate and establish the diagnosis **Surgical banding of the access is treatment of choice  
 
</li></ul>
 
</li></ul>
 
<h2>Source</h2>
 
<p>Tintinalli
 
</p><a _fcknotitle="true" href="Category:Nephro">Nephro</a>
 

Revision as of 00:30, 5 August 2011

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

  1. Assess:
    1. Volume status (US)
    2. Cardiac function
    3. Pericardial disease
    4. Infection
    5. GI bleeding

DDX

  1. Excessive ultrafiltration
  2. Predialytic volume loss
    1. GI losses
    2. Decreased oral intake
  3. Intradialytic volume loss
    1. Tube and hemodialyzer blood losses
  4. Postdialytic volume loss
    1. Vascular access blood loss
  5. Medication effects
    1. Antihypertensives
    2. Opiates
  6. Decreased vascular tone (sepsis)
  7. Cardiac dysfunction
    1. LVH, ischemia, hypoxia, arrhythmia, pericardial tamponade
  8. Pericardial disease
    1. Effusion
    2. Tamponade

Dialysis Disequilibrium Syndrome

  • Diagnosis of exclusion (r/o SDH, CVA)
  • Clinical syndrome occurring at end of dialysis
    • Large solute clearances -> cerebral edema
  • Characterized by N/V, HTN
    • Can progress to seizure, coma, death)
  • 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

Vascular Access 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

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

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 **Surgical banding of the access is treatment of choice

Source

Tintinalli