Dialysis complications
(Redirected from Missed dialysis)
Background
- Dialysis patients are high-acuity ED patients with unique complications
- Common presentations: access problems, hypotension, electrolyte emergencies, infections
- Always check when last dialysis session was and if any were missed
Hemodialysis Complications
Dialysis Complications
- Dialysis-associated hypotension
- Dialysis disequilibrium syndrome
- Air embolism
- Missed dialysis (pulmonary edema)
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
- Thrombosed fistula/graft: absent thrill/bruit → vascular surgery referral within 24-48h
- Hemorrhage from access site: direct pressure x 10-15 min; avoid tourniquet proximal to access
- Infection: erythema, warmth, purulent drainage → blood cultures + empiric vancomycin; avoid using infected access
- Steal syndrome: hand ischemia distal to fistula (pain, pallor, cool fingers) → vascular surgery
During/Post-Dialysis
- Hypotension: most common acute complication; give NS bolus (avoid excessive fluid in volume-overloaded patient)
- Dysequilibrium syndrome: headache, N/V, AMS, seizures during/after dialysis (especially first sessions) — diagnosis of exclusion after ruling out other AMS causes
- Air embolism: rare but catastrophic; place in left lateral decubitus/Trendelenburg
- Muscle cramps: NS bolus, reduce ultrafiltration rate
Missed Dialysis
- Hyperkalemia: most immediately life-threatening — ECG, calcium, insulin/glucose, kayexalate, emergent dialysis
- Volume overload / pulmonary edema: BiPAP, nitroglycerin, furosemide (limited efficacy in anuric patients), emergent dialysis
- Uremic pericarditis: friction rub, emergent dialysis; avoid anticoagulation (hemorrhagic risk)
- Metabolic acidosis
Peritoneal Dialysis Complications
- Peritoneal dialysis-associated peritonitis: cloudy effluent, abdominal pain, fever
- Send peritoneal fluid for cell count, Gram stain, culture
- Empiric intraperitoneal antibiotics (vancomycin + ceftazidime or gentamicin)
- Catheter malposition, obstruction, leakage
- Exit site/tunnel infection: erythema, drainage at catheter site
Altered Mental Status in Dialysis Patients
- Hypotension
- Hypoglycemia
- Hypercalcemia / Hyperkalemia / Hyponatremia
- Subdural hematoma (from anticoagulation during dialysis)
- Dysequilibrium syndrome - diagnosis of exclusion made after admission
- Stroke
- Uremia (inadequate dialysis)
- Medication accumulation (renally cleared drugs)
- Sepsis
ESRD Associated Skin Conditions
- Calciphylaxis
- Nephrogenic Systemic Fibrosis (gadolinium MRI)
Cardiovascular
Evaluation
- ECG (hyperkalemia changes — peaked T waves, widened QRS)
- BMP: K, Ca, BUN, Cr, glucose
- CBC, blood cultures if febrile
- CXR: pulmonary edema, line placement
- Access exam: check thrill/bruit
Disposition
- Low threshold for admission — these are high-risk patients
- Admit: missed dialysis with hyperkalemia or volume overload, access infection, peritonitis, AMS, new arrhythmia
- Arrange emergent dialysis for: severe hyperkalemia, pulmonary edema, uremic pericarditis
- Discharge only for minor issues with ensured follow-up at dialysis center