Dialysis complications: Difference between revisions
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==Vascular Access Complications== | ==Vascular Access Complications== | ||
{{AV shunt complications DDX}} | |||
[[Clotting of AV fistula]] | *[[Clotting of AV fistula]] | ||
===Infection=== | ===[[Infection of AV fistula]]=== | ||
*Pts often p/w signs of systemic [[sepsis]] ([[fever]], [[hypotension]], leukocytosis) | *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 | **Classic signs of pain, erythema, swelling, d/c from infected access are often missing | ||
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***Even so catheter is only removed if fever persists for 2-3d after abx are started | ***Even so catheter is only removed if fever persists for 2-3d after abx are started | ||
===Hemorrhage=== | ===[[Hemorrhage of AV fistula]]=== | ||
*Potentially life-threatening | *Potentially life-threatening | ||
*Can result from aneurysms, anastomosis rupture, or over-anticoagulation | *Can result from aneurysms, anastomosis rupture, or over-anticoagulation | ||
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**Exercise pain, nonhealing ulcers, cool, pulseless digits | **Exercise pain, nonhealing ulcers, cool, pulseless digits | ||
**Diagnosed by Doppler US or angiography, repaired surgically | **Diagnosed by Doppler US or angiography, repaired surgically | ||
===High-output heart failure=== | |||
===[[High-output heart failure from AV fistula]]=== | |||
*Occurs when >20% of cardiac output is diverted through the access | *Occurs when >20% of cardiac output is diverted through the access | ||
**Branham sign (drop in HR after temporary access occlusion) is diagnostic | **Branham sign (drop in HR after temporary access occlusion) is diagnostic |
Revision as of 06:07, 12 December 2014
Differential Diagnosis
Dialysis Complications
- Dialysis-associated hypotension
- Dialysis disequilibrium syndrome
- Air embolism
- Missed dialysis (pulmonary edema)
Vascular Access Complications
AV Fistula Complications
- Clotting of AV fistula
- Infection of AV fistula
- Hemorrhage of AV fistula
- Vascular insufficiency from AV fistula
- AV fistula aneurysm/pseudoaneurysm
- High-output heart failure from AV fistula
- Clotting of AV fistula
Infection of AV fistula
- 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
- 4x higher colony count in catheter blood cx suggests catheter is source of bacteremia
Hemorrhage of AV fistula
- 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
- Aneursym (true)
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 from AV fistula
- 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 [[antibiotic] to the dialysate if possible (parenteral abx not required)
- 1st gen cephalosporin or vancomycin (if pen allergic)
Source
Tintinalli