Difference between revisions of "Dialysis complications"

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==Hypotension==
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{{Dialysis complications DDX}}
===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===
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{{AV shunt complications DDX}}
*N/V
 
*Anxiety
 
*Dizziness
 
*Orthostatic hypotension
 
*Syncope
 
  
===Diagnosis===
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===Peritoneal Dialysis Complications===
#Assess:
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*[[Peritoneal dialysis-associated peritonitis]]
##Volume status (US)
 
##Cardiac function
 
##Pericardial disease
 
##Infection
 
##GI bleeding
 
  
===DDX===
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===Cardiovascular===
#Excessive ultrafiltration
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*[[Cardiac tamponade]]
#Predialytic volume loss
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*[[Pericarditis]]
##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==
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{{ESRD Associated Skin Conditions}}
*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==
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===Altered Mental Status===
*Acute dyspnea, chest tightness, LOC, cardiac arrest
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*Hypotension
*Treat w/ 100% NRB
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*[[Hypoglycemia]]
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*[[Hypercalcemia]] / [[Hyperkalemia]] / [[Hyponatremia]]
 +
*[[Subdural hematoma]]
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*[[Dysequilibrium syndrome]] - diagnosis of exclusion made after admission
  
==Vascular Access Complications==
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==References==
===Thrombosis and Stenosis===
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<references/>
*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===
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[[Category:Renal]]
*Pts often p/w signs of systemic sepsis (fever, hypotension, leukocytosis)
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[[Category:Vascular]]
**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
 
**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
 
 
 
[[Category:Nephro]]
 

Latest revision as of 04:28, 31 July 2016