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PANTIPA TONSAWAN, M.D. July 5, 2013 First few session care.

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Presentation on theme: "PANTIPA TONSAWAN, M.D. July 5, 2013 First few session care."— Presentation transcript:

1 PANTIPA TONSAWAN, M.D. July 5, 2013 First few session care

2 Scope   Relation : ESRD, HD & death   Pre HD patient evaluation  HD prescription (initial treatment )   HD complication (Initial treatment )

3 Impact : ESRD,HD & death

4 USRDS 2012 ADR Probability of sudden cardiac death in incident dialysis patients U.S. Renal Data System, USRDS 2012 Annual Data Report Probability Month after dialysis

5 USRDS 2012 ADR Causes of death : prevalent dialysis patients, 2008–2010 Cardiac causes U.S. Renal Data System, USRDS 2012 Annual Data Report ESRD pt

6 USRDS 2012 ADR Rates of sudden cardiac death : age Period prevalent dialysis patients, age 20 & older, unadjusted. U.S. Renal Data System, USRDS 2012 Annual Data Report

7 USRDS 2012 ADR Rates of sudden cardiac death prevalent dialysis patients, by primary diagnosis U.S. Renal Data System, USRDS 2012 Annual Data Report Death /1000 patient years

8 USRDS 2012 ADR Rates of sudden cardiac death following initiation of treatment in incident HD patients 0-90 days : 1/10 U.S. Renal Data System, USRDS 2012 Annual Data Report Death /1000 patient years

9 Caution !!! : sudden cardiac death  RRT : Hemodialysis  Aging : Exp > 65 yrs…>75 yrs  Underlying : DM, HT  Duration initial treatment : 0-90 days

10 Patient evaluation

11 Pre HD Evaluation Patient information Vascular access Hemodialysis prescription

12 Patient information 1.History taking  Indication & complication Acute or chronic HD, hyper K, volume↑  Underlying disease…DM, HT, IHD Active problem..GI Bleed, MI, stroke  Hemodynamic status Arrhythmia, BP  Medication Anti HT, anti coagulant

13 Patient information 2.Laboratory data  CBC : Hb/HCT, Platelet…..risk bleeding  BUN/Cr : High BUN…..Risk ….DDS  Electrolyte : Select : Dialysate solution component  Serology: HBV, HCV, HIV…..isolated

14 Vascular access : initial use Arteriovenous fislula Arteriovenous graft HD catheter Prepare : 3-6 mo ….. Maturation Prepare : 3-6 wk : at least 2 wk after Surgery immediately use..complication ? Prompt ? Infection ? Exit site, redness, warm

15 Hemodialysis prescription

16 Order HD prescription (initial treatment ) Session length : Perform HD 2 hrs BFR : 200 ml/min Dialyzer: Low flux Dialysate solution composition: Na …, K…., HCO3 …, Ca…, Mg…, Dextrose….. DFR : 500 ml/min Dialysis solution temp. : 36 o c Fluid removal order: remove … Lite Anti-coagulant : heparinloading..,maintenance … ( หรือ non-heparin ตามความเหมาะสม ) 50 % glucose ml intra HD ( พิจารณาตามความเหมาะสมของผู้ป่วยแต่ละราย ) Daugirdas JT. Acute & Chronic hemodialysis prescription; Handbook of dialysis 2007

17 HD prescription (initial treatment ) Daugirdas JT. Acute & Chronic hemodialysis prescription; Handbook of dialysis 2007   Time : initial 2 hr… ↑ 30 min q HD ……until 4 hr   BFR : initial ml/min …↑ 30 min q HD ……until ml/min   Dialyzer : initial low flux, low SA …. (AIM ….Kt/V , URR 40 %)   DFR : 500 ml/min … 800ml/min (high BFR)

18 HD prescription (initial treatment ) Daugirdas JT. Acute & Chronic hemodialysis prescription; Handbook of dialysis 2007   Dialysate composition :   Temp. : low temp prevent Hypotension 36.5 C   UF : < 1 L /hr, ….if need…sequential HD NaKCaHCO3 Acute1452, 3, Chronic ,   Hypertonic solution : 50 % glucose ….DDS   Anticoagulant : depend on patient. condition

19 Hemodialysis complications

20 Dialysis disequilibrium syndrome  Acute neurological complication  Consequence of rapid HD …osmotic gradient brain Vs plasma caused.. cerebral edema Risk factor 1 st session hemodialysis Extreme age : child or aging High BUN level: > 125 mg/dl CNS disorder (stroke, tumor, dementia,hypo Na), head injury (subdural hematoma) …. Seminars in Dialysis—Vol 20, No pp. 493–498 Pediatr Nephrol (2012) 27:2205–2211

21 Dialysis disequilibrium syndrome I Urea CF : brain ICF ICF : bra in IVFECF Brain Urea H20 H2O Urea↑ High Osm HD Urea Cerebral edema Reverse osmotic shift Urea slow

22 Dialysis disequilibrium syndrome Diagnosis Treatment Clinical : fatigue, mild headache, nausea, vomiting, disturbed consciousness, convulsions… coma. Common mild..Self limited, fatal.. if severe Clinical diagnosis (during HD, after HD) + risk factor Exclusion other condition Symptomatic treatment/ hypertonic solution/ + stop HD Seminars in Dialysis—Vol 20, No pp. 493–498

23 Prevention Dialysis disequilibrium syndrome Most important Dialysis time (2 hours) Blood flow rate 200 ml/min Less efficient (small) dialyzer A goal URR : 0.4–0.45 or diffusive Kt/V of 0.6–0.7 Hypertonic solution Seminars in Dialysis—Vol 20, No pp. 493–498

24 Cardiac arrhythmia, Ischemia, sudden death  DIALYSIS-INDUCED MYOCARDIAL STUNNING  Echocardiogram - Pre HD …normal - During HD …. RWMA abnormality - Post HD 30 min …normal  Positron emission tomography : Measure..MBF dialysis ….. HD precipitates reductions MBF CAG …..normal Effects of hemodialysis on cardiac function ;Kidney International (2009) 76, 371–375 Clin J Am Soc Nephrol 2008; 3: 19–26. Semin Dial 2007; 20: 220–228

25 Cardiac arrhythmia, Ischemia, sudden death  DIALYSIS-INDUCED CARDIAC ISCHEMIA Myocardial stunning : Occur ….60 % Related to UF (total/rate ) & HD instability Effects of hemodialysis on cardiac function ;Kidney International (2009) 76, 371–375 High mortality PET Long term

26 Intradialytic hypotension Initial treatment : associated cause High UF rate : limit time Trial & error : set DW High dose : anti HT Nutrition status : malnutrition …low plasma refilling  Treatment  Sequential HD   Limit IDWG < 1 kg/day   Decrease anti HT ….decrease DW  A  Avoid : eating during HD  low Temp.

27 Dialyzer reaction  Full brown, Severe reaction  Common : 5 min after HD…but delayed 30 min  Cause : ETO oxide, AN 69 reaction, contaminated dialysis solution, reuse Type A : anaphylactic type Management : Safest to stop dailysis, without returning blood Cardiorespiratory support Prevention : proper rinsing, y-irradiated or stream- sterilized dialyzer First use syndrome Type B :non-specific

28 Dialyzer reaction  Mild symptoms : chest pain, back pain  Onset min after HD  Cause : unknown Management : Supportive care Differential diagnosis : coronary artery disease

29 USRDS 2012 ADR Post HD care Complication Next session HD

30 Summary   Cardiovascular : common cause of death HD patient   Risk : aging, DM, HT, HD 0-90 day   Pre HD patient evaluation: important …Recognized risk of HD complication   Appropriate HD prescription …reduce & prevent HD complication   Prompt to treatment of complication : if HD… started


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