Presentation on theme: "Emergencies in Renal Failure and Dialysis Patients"— Presentation transcript:
1Emergencies in Renal Failure and Dialysis Patients Tintinalli chapter 93
2ESRD: irreversible loss of renal function, accumulation of toxins and loss of internal homeostasis. Uremia: clinical syndrome resulting from ESRD.
3Epidemiology 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
4Pathophysiology 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.
5Pathophysiology of Uremia Regulatory Failure: over secretion of hormones , disruption of normal feedback mechanisms
6Clinical 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.
7Neurologic 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.
8Cardiovascular complications: prevalence is greater in ESRD d/t pre-existing conditions, uremia, toxins, high lipids, homocystine, hyperparathyroidism, dialysis related conditions
10Creatine 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.
11HTN: 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.
12Pulmonary 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
13Pericarditis/ 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
14Dialysis 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
15Hematologic Complications: Anemia: low erythropoietin, blood loss from dialysis, ↓ RBC survival timesNormocytic, normochromicHct without tx.Tx=erythropoietin
16Bleeding 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.
17GI complications:Anorexia, nausea, vomiting=common in uremiaIncreased GI bleedingChronic constipationAscites from portal HTN, polycystic liver ds., fluid overload.
18Systemic 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
19Hyperparathyroidism (Osteitis Fibrosa Cystica); ↓ ionized Ca=↑ PTH= high bone turnover, weak bones.Tx=phosphate binding gels, Vit D3 replacement, subtotal parathyroidectomy
20Osteomalacia; 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
21Β2-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
22Hemodialysis Uses ultrafiltration and clearance to replace nephron. Solute removal depends on filter pore size and concentration gradientHeparin units typically usedSessions 3-4 hrs.
24Thrombosis and Stenosis of Access: Most common complicationLoss of bruit and thrillStenosis / thrombosis: not Emergencies= tx w/in 24 hours.
25Vascular 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.
26Hemorrhage:d/t aneurysm, anastomosis rupture or over anticoagulation.Direct pressureProtamine mg or 0.01 mg/unit hep.Consult surgery or nephrology
27Vascular access aneurysms: Repeated puncturesBulging in wallRarely ruptureTrue aneurysms very rare; 4% of fistulas
28Vascular access pseudoaneurysm: Subcutaneous extravasation of bloodPresent w/ bleeding & infection at site
29Vascular 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
30High-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.
31Complications 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
32Early 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.
33Intradialytic 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
342. 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.
353. 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
364. Electrolyte abnormalities: ↑ Ca, ↑MgN/V, HA, burning skin, weakness, lethargy HTN5. Hypoglycemia
37Evaluation 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?
38Peritoneal Dialysis Peritoneal membrane= blood-dialysate interface Can be done acutely, chronically(continuous)=4 times/day, or multiple exchanges at night while sleeping.
39Complications 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%.
40Empiric antibiotic therapy Add to dialysateParenteral administration not neededRapid exchanges of fluid lavage to wash out inflammatory cellsFirst gen CephVanc if pen allergicCan add Gent
41Infections 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
42Abdominal wall hernia10-15%Highest rate of incarceratingImmediate surgical repair
43Overview Evaluating PD Patient Type and frequency of dialysisDate of last episode of peritonitisFrequency of relapse infectionsBaseline weightFocus on abdomen and catheter tunnel
44Questions: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.
454. #1 cause of dialysis access site infections… A. klebsiellaB. staph aureusC. strep speciesD. E. coli
465. #1 complication during dialysis sessions is …. A. hypotensionB. feverC. CHFD. coughAnswers: false (seen in 50%), false(inc risk), false, B, A.