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| − | + | ==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=== | |
| − | + | #Assess: | |
| − | + | ##Volume status (US) | |
| − | + | ##Cardiac function | |
| − | + | ##Pericardial disease | |
| − | + | ##Infection | |
| − | + | ##GI bleeding | |
| − | + | ||
| − | + | ===DDX=== | |
| − | + | #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 | |
| − | + | ##Antihypertensives | |
| − | + | ##Opiates | |
| − | + | #Decreased vascular tone (sepsis) | |
| − | + | #Cardiac dysfunction | |
| − | + | ##LVH, ischemia, hypoxia, arrhythmia, pericardial tamponade | |
| − | + | #Pericardial disease | |
| − | + | ##Effusion | |
| − | + | ##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 | |
| − | + | ||
| − | + | [[Category:Nephro]] | |
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Revision as of 00:30, 5 August 2011
Contents
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
- Assess:
- Volume status (US)
- Cardiac function
- Pericardial disease
- Infection
- GI bleeding
DDX
- 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
- Antihypertensives
- Opiates
- Decreased vascular tone (sepsis)
- Cardiac dysfunction
- LVH, ischemia, hypoxia, arrhythmia, pericardial tamponade
- Pericardial disease
- Effusion
- 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
- 4x higher colony count in catheter blood cx suggests catheter is source of bacteremia
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
- 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
- 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