Presentation on theme: "Emergencies in Renal Failure and Dialysis Patients"— Presentation transcript:
1 Emergencies in Renal Failure and Dialysis Patients Tintinalli chapter 93
2 ESRD: irreversible loss of renal function, accumulation of toxins and loss of internal homeostasis. Uremia: clinical syndrome resulting from ESRD.
3 Epidemiology 1999=89,252 new cases/424,179 patients being tx for ESRD Causes: DM=#1, HTN=#2Therapy: dialysis=70%transplants=30%ESRD deaths: 50% cardiac causes.10-25% infectiousSurvival rates for 1,2,5 yrs= 79, 65, 34 % respectively
4 Pathophysiology of Uremia Excretory Failure: causes >70 chemicals to elevate. Urea= major breakdown of proteins. Limit protein intakeBiosynthetic Failure: loss of hormones 1,25(OH)3 vit D3 and erythropoietin.85% of erythropoietin produced by kidney.Vit. D3 deficiency= secondary hyperparathyroidism, renal bone disease.
5 Pathophysiology of Uremia Regulatory Failure: over secretion of hormones , disruption of normal feedback mechanisms
6 Clinical Features of Uremia Neurologic complications:Subdural hematoma: 3.5% of ESRD, HTN, head trauma, bleeding dyscrasias, anticoagulants, ultrafiltration.Uremic Encephalopathy: nonspecific centreal neurologic symptoms, responds to dialysis.
7 Neurologic complications: Dialysis Dementia: like uremic encephalopathy but progressive and fatal, seen after 2 years on dialysisPeripheral neuropathy: >50% of HD patients. “glove and stocking pattern”, improves after transplantAutonomic dysfunction: common; dizzy, impotence, bowel dysfunction.
8 Cardiovascular complications: prevalence is greater in ESRD d/t pre-existing conditions, uremia, toxins, high lipids, homocystine, hyperparathyroidism, dialysis related conditions
9 General populationCAD: 12%LV hypert. 20%CHF 5%ESRD40%75%
10 Creatine protein Kinase &MB, Troponin I and T…… Creatine protein Kinase &MB, Troponin I and T…….NOT significantly elevated in patients undergoing regular dialysis, have been shown to be specific markers in these patients.
11 HTN: 80-90% of ESRD starting dialysis HTN: 80-90% of ESRD starting dialysis. d/t volume, vasopressor effects of kidney, RAS system. Tx initially w/ volume controlCHF: HTN #1 cause in ESRD.Uremic cardiomyopathy: dx of exclusion when other causes of CHF ruled out.
12 Pulmonary Edema: fluid overload, MI. Tx w/ O2, nitrates, ACE inhib, morphine, diuretics. Can also use phlebotomy, dialysis.Cardiac Tamponade: rarely w/ classic presentation of low BP, muffled sounds and JVD.Echocardiography, pericardiocentisis
13 Pericarditis/ Uremic Pericarditis: Uremic more common=75%Fluid overload, abnl platelet function, ↑ fibrinolytic and inflammatory cell activityFriction Rubs= louder, palpable, persist after metabolic abnormality resolvedBUN always>60 mg/dlAbsent EKG changes
14 Dialysis related percarditis: recurrent, most common type during dialysis. More common adhesions and fluid loculationsESRD w/ pericarditis= 8%Tx w/ dialysisAvg survival without dialysis= 1 month
15 Hematologic Complications: Anemia: low erythropoietin, blood loss from dialysis, ↓ RBC survival timesNormocytic, normochromicHct without tx.Tx=erythropoietin
16 Bleeding diathesis: ↑ risk of GI bleed, subdural. Can try tx with desmopressinImmunologic deficiency: leukocyte chemotaxis and phagocytosis decreased in uremic state.Dialysis does not help immune function.
17 GI complications:Anorexia, nausea, vomiting=common in uremiaIncreased GI bleedingChronic constipationAscites from portal HTN, polycystic liver ds., fluid overload.
18 Systemic calcification; ↓ GFR=↑ serum phosphate levels. Renal Bone Disease:Systemic calcification; ↓ GFR=↑ serum phosphate levels.Pseudogout, metastatic calcification of tissues, vessels.Tx=low Ca dialysate and phosphate-binding gels
19 Hyperparathyroidism (Osteitis Fibrosa Cystica); ↓ ionized Ca=↑ PTH= high bone turnover, weak bones.Tx=phosphate binding gels, Vit D3 replacement, subtotal parathyroidectomy
20 Osteomalacia; defect in bone calcification d/t Vit.D3 deficiency and aluminum intoxicationWeakened bones, muscle pains, weaknessLow PTH, ow to normal alkaline phosphate levels, ↑ serum aluminumTx= desferrioxamine
21 Β2-Microglobulin amyloidosis: Pts >50 yrs old, on dialysis >10 yrsAmyloid deposits in GI tract, bones, joints.Complications; GI perfs, bone fx’s, carpal tunnel, rotator cuff tears.Pts w/ amyloidosis have ↑ mortality rates
22 Hemodialysis Uses ultrafiltration and clearance to replace nephron. Solute removal depends on filter pore size and concentration gradientHeparin units typically usedSessions 3-4 hrs.
24 Thrombosis and Stenosis of Access: Most common complicationLoss of bruit and thrillStenosis / thrombosis: not Emergencies= tx w/in 24 hours.
25 Vascular Access Infections: 2-5% of fistulas, 10% of graftsOften signs of sepsis, fever, Hypotension, ↑ WBCErythema, swelling, discharge at site often missing.Staph Aureus #1, gram neg #2Vanc is drug of choice, usually add Gent.
26 Hemorrhage:d/t aneurysm, anastomosis rupture or over anticoagulation.Direct pressureProtamine mg or 0.01 mg/unit hep.Consult surgery or nephrology
27 Vascular access aneurysms: Repeated puncturesBulging in wallRarely ruptureTrue aneurysms very rare; 4% of fistulas
28 Vascular access pseudoaneurysm: Subcutaneous extravasation of bloodPresent w/ bleeding & infection at site
29 Vascular insufficiency: distal to access “steal syndrome”Preferential shunting of blood to low pressure venous sides/s exercise pain, non-healing ulcers, cool pulseless digitsDx w/ doppler or angiography
30 High-output heart failure: When 20% of cardiac output diverted through accessBranham sign: drop in HR after temporary access occlusionDoppler to measure access flow rateSurgical banding of access is Tx.
31 Complications During Hemodialysis 1. Hypotension:Most frequent, % of treatmentsDialysis can remove up to 2 L/hr.Cardiac compensation limited d/t ↓ diastolic function common in ESRDAbnormalities in vascular tone; sepsis, anit HTN meds, ↑ nitric oxide
32 Early hypotension: pre-existing hypovolemia Peridialysis losses; starts HD below dry weight; d/t sepsis, GI bleed, vomiting, diarrhea, decreased salt/water intakeIntradialytic blood loss from tubing/dialyzer leadsHypotension at end of dialysis: excessive removal, cardiac or pericardial disease.
33 Intradialytic hypotension: N/V/anxiety, ortho hypotension, tachycardia, dizzy, syncope.Tx.; stop HD, Trendelenburg. Salt, broth by mouth, NS cc. IV.If these fail look for other causes than excessive fluid removal
34 2. Dialysis disequilibrium: End of dialysisN/V, HTN...progress to coma, seizure and deathd/t cerebral edema after large solute clearance in HDTx. Stop HD, administer Mannitol IV.
35 3. Air Embolism:s/s: dyspnea, chest tightness, unconscious, full cardiac arrest. Cyanosis, churning sound in heart from bubblesClamp venous blood line, place supineOther Tx’s: percutaneous aspiration from R ventricle, IV steroids, full heparinization, hyperbaric O2 treatment
36 4. Electrolyte abnormalities: ↑ Ca, ↑MgN/V, HA, burning skin, weakness, lethargy HTN5. Hypoglycemia
37 Evaluation of HD Patients Dialysis scheduleDry weightLength of dialysisInspect access site; erythema, swelling, tender, discharge.Peripheral edema, HJR, JVD not always CHFMurmurs; high flow d/t anemia?
38 Peritoneal Dialysis Peritoneal membrane= blood-dialysate interface Can be done acutely, chronically(continuous)=4 times/day, or multiple exchanges at night while sleeping.
39 Complications Peritonitis #1 Mortality 2.5-12.5 % Fever, abd pain, rebound tenderDialysate fluid for cell count, Gram stain, cultureStaph epidermidis 40%, S. aureus 10%, Strep species 15-20%, gram neg bacteria 15-20%, anaerobic bacteria 5%, fungi 5%.
40 Empiric antibiotic therapy Add to dialysateParenteral administration not neededRapid exchanges of fluid lavage to wash out inflammatory cellsFirst gen CephVanc if pen allergicCan add Gent
41 Infections around PD catheter site: Pain, erythema, swelling, discharge.S. aureus, Pseudomonas aeruginosaEmpiric w/ first generation Ceph or CiproOutpatient therapy with f/u at CAPD center next day
42 Abdominal wall hernia10-15%Highest rate of incarceratingImmediate surgical repair
43 Overview Evaluating PD Patient Type and frequency of dialysisDate of last episode of peritonitisFrequency of relapse infectionsBaseline weightFocus on abdomen and catheter tunnel
44 Questions:1. T/F Peripheral Neuropathy, “stocking and glove pattern”, is rarely seen in ESRD pts on dialysis.2. T/F ESRD patients carry the same cardiovascular risk as general population.3. T/F Troponins are commonly significantly elevated in patients on regular dialysis and cannot be trusted as cardiac marker.
45 4. #1 cause of dialysis access site infections… A. klebsiellaB. staph aureusC. strep speciesD. E. coli
46 5. #1 complication during dialysis sessions is …. A. hypotensionB. feverC. CHFD. coughAnswers: false (seen in 50%), false(inc risk), false, B, A.