Difference between revisions of "Dialysis complications"

(Thrombosis and Stenosis)
(Text replacement - " dx" to " diagnosis")
 
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<h2>Hypotension</h2>
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{{Dialysis complications DDX}}
<h3>Background</h3>
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<ul><li>Most frequent complication of hemodialysis (20%-30% of tx)
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{{AV shunt complications DDX}}
</li><li>Timing of intradialytic hypotension is helpful in formulating DDX:
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<ul><li>Hypotension early in session usually due to preexisting hypovolemia
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===Peritoneal Dialysis Complications===
</li><li>Hypotension during the session is often due to blood loss (from tubing or filter leak)
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*[[Peritoneal dialysis-associated peritonitis]]
</li><li>Hypotension near the end usually result of excessive ultrafiltration
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<ul><li>Underestimation of pt's ideal blood volume (dry weight)
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===Cardiovascular===
</li><li>Also consider pericardial or cardiac disease
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*[[Cardiac tamponade]]
</li></ul>
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*[[Pericarditis]]
</li></ul>
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</li></ul>
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{{ESRD Associated Skin Conditions}}
<h3>Clinical Features</h3>
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<ul><li>N/V
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===Altered Mental Status===
</li><li>Anxiety
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*Hypotension
</li><li>Dizziness
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*[[Hypoglycemia]]
</li><li>Orthostatic hypotension
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*[[Hypercalcemia]] / [[Hyperkalemia]] / [[Hyponatremia]]
</li><li>Syncope
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*[[Subdural hematoma]]
</li></ul>
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*[[Dysequilibrium syndrome]] - diagnosis of exclusion made after admission
<h3>Diagnosis</h3>
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<ol><li>Assess:
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==References==
<ol><li>Volume status (US)
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<references/>
</li><li>Cardiac function
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</li><li>Pericardial disease
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[[Category:Renal]]
</li><li>Infection
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[[Category:Vascular]]
</li><li>GI bleeding
 
</li></ol>
 
</li></ol>
 
<h3>DDX</h3>
 
<ol><li>Excessive ultrafiltration
 
</li><li>Predialytic volume loss
 
<ol><li>GI losses
 
</li><li>Decreased oral intake
 
</li></ol>
 
</li><li>Intradialytic volume loss
 
<ol><li>Tube and hemodialyzer blood losses
 
</li></ol>
 
</li><li>Postdialytic volume loss
 
<ol><li>Vascular access blood loss
 
</li></ol>
 
</li><li>Medication effects
 
<ol><li>Antihypertensives
 
</li><li>Opiates
 
</li></ol>
 
</li><li>Decreased vascular tone (sepsis)
 
</li><li>Cardiac dysfunction
 
<ol><li>LVH, ischemia, hypoxia, arrhythmia, pericardial tamponade
 
</li></ol>
 
</li><li>Pericardial disease
 
<ol><li>Effusion
 
</li><li>Tamponade
 
</li></ol>
 
</li></ol>
 
<h2>Dialysis Disequilibrium Syndrome</h2>
 
<ul><li>Diagnosis of exclusion (r/o SDH, CVA)
 
</li><li>Clinical syndrome occurring at end of dialysis
 
<ul><li>Large solute clearances -&gt; cerebral edema
 
</li></ul>
 
</li><li>Characterized by N/V, HTN
 
<ul><li>Can progress to seizure, coma, death)
 
</li></ul>
 
</li><li>Occurs most commonly during initial dialysis or during hypercatabolic states
 
</li><li>Treat w/ mannitol
 
</li></ul>
 
<h2>Air Embolism</h2>
 
<ul><li>Acute dyspnea, chest tightness, LOC, cardiac arrest
 
</li><li>Treat w/ 100% NRB
 
</li></ul>
 
<h2>Vascular Access Complications</h2>
 
<h3>Thrombosis and Stenosis</h3>
 
<ul><li>Most common causes of inadequate dialysis flow
 
<ul><li>Loss of bruit and thrill over access
 
</li></ul>
 
</li><li>Stenosis and even thrombosis are not emergencies
 
<ul><li>Can be treated w/in 24hr by angiographic clot removal or angioplasty
 
</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
 
</li></ul>
 
</li></ul>
 
<h3>Vascular Access Infection</h3>
 
<ul><li>Pts often p/w signs of systemic sepsis (fever, hypotension, leukocytosis)
 
<ul><li>Classic signs of pain, erythema, swelling, d/c from infected access are often missing
 
</li></ul>
 
</li><li>Dialysis catheter–related bacteremia is common and potentially life-threatening
 
<ul><li>Give vancomycin 1gm IV +/- genamicin 100mg IV (if gram neg suspected)
 
</li><li>Do not remove dialysis patient's access
 
</li></ul>
 
</li><li>Draw peripheral and catheter blood cultures simultaneously
 
<ul><li>4x higher colony count in catheter blood cx suggests catheter is source of bacteremia
 
<ul><li>Even so catheter is only removed if fever persists for 2-3d after abx are started
 
</li></ul>
 
</li></ul>
 
</li></ul>
 
<h3>Hemorrhage</h3>
 
<ul><li>Potentially life-threatening
 
</li><li>Can result from aneurysms, anastomosis rupture, or over-anticoagulation
 
</li><li>Control bleeding w/ pressure applied to puncture site for 5-10min; observee for 1-2hr
 
</li><li>Types
 
<ul><li>Aneursym (true)
 
<ul><li>Most are asymptomatic; rarely rupture
 
</li></ul>
 
</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>
 

Latest revision as of 04:28, 31 July 2016