medical emergencies in dialysis patients · dialysis disequilibrium syndrome venous air embolism...

Excellent care with compassion

Medical Emergencies in Dialysis Patients

John Anderton

Consultant Renal Physician

Lancashire Teaching Hospitals NHS Foundation Trust


• A Flavour of Dialysis patients

• Emergencies in HD patients

• Emergencies in PD patients

Talk Plan


Maintenance Dialysis Patients


https://www.renalreg.org/


Treatment Modality by Age


Cardiovascular disease mortality in the

general population and in dialysis patients

(from Foley et al. Am J Kidney Dis 1998; 32 [Suppl 3])


Who do we take onto Dialysis?

• Very few absolute contraindications

• Decision-making by MDT

• Conservative care may be the right choice for some


Overview of Service - Staff

John Speed’s 1610 Map of Lancashire

23 Doctors

100 Nurses


Overview of Service : 1100+ RRT Patients

64

98

73

74 60

115

517 Centre HD

60 PD

34 Home HD

527 Transplant

33

15% on home

dialysis

therapy


Clinical Cases


1. You are called to Chorley Dialysis Unit at 11.00pm

Mr Smith is 72 yo with hypertensive nephropathy and COPD

He dropped his BP 30 mins into HD and is now rigoring

His fistula failed 4 weeks ago and he now has tunnelled neck line.

Temp 37.9

BP 90/60

Saturation 98%

What is the most likely septic focus?

What are the best tests?

What treatment are you planning?


Well…. it could be the line (RR S. aureus bacteraemia line vs. AVF = 3.5)

But - catheter-associated bacteraemia less common than previously

• NHS-wide strategies to reduce MRSA etc

• Antiseptic or antibiotic line locks - we use Taurolock

• Antiseptic exit site patches – we use Biopatch

• Most HD lines are tunnelled


Tunnelled central venous catheter

Don’t be falsely reassured

by a clean exit site


1. You are called to Chorley Dialysis Unit at 11.00pm

Mr Smith is 72 yo with hypertensive nephropathy and COPD

He dropped his BP 30 mins into HD and is now rigoring

His fistula failed 4 weeks ago and he has a new tunnelled neck line.

Temp 37.9

BP 90/60

Saturation 98%

cue towards this being line infection

HD has cooling effect so fever may be masked

Full septic screen

Line and ‘peripheral’ cultures if possible – NB anticoagulated; don’t handle line

ECG

May need fluids

Empirical antibiotics to cover likely organisms


Antibiotics with useful Pharmacokinetics in ESRD

• Vancomycin

• Gentamicin (2.5mg/kg max)

• Cefuroxime

• Ceftazidime

• Meropenem


2. You are called to Wigan Dialysis Unit at 10.00pm

Mr Brown is 75 yo with diabetic nephropathy. He’s been on HD for 10 years.

The staff are worried about a swollen fistula arm and prolonged bleeding from

his needle sites.

Possible explanations –

A ‘blow’ – ie haematoma

Cellulitis

Venous hypertension


Venous Hypertension


Lines

Early procedural

Infection

Poor flow

Venous stenosis

Thrombosis

Fistulae

Early procedural

Infection

Steal Syndrome

Rupture

Nerve compression

Heart failure

‘Cosmetic’

Access Complications


3. The Duty Biochemist rings you at 11.00pm with a blood

result from Mrs D, a maintenance HD patient who

attended for dialysis earlier that afternoon.

Na 136

K 2.3

Urea 18.3

Creatinine 425

What action will you take?


The Haemodialysis Blood Circuit

[K] often 1 or 2 mmol/L


3. The Duty Biochemist rings you at 11.00pm with a blood

result from Mrs D, a maintenance HD patient who

attended for dialysis earlier that afternoon.

Na 136

K 2.3

Urea 18.3

Creatinine 425

What action will you take? – not this!


4. You are StR at Preston. You are called to ED on Sunday 4.00am

Mrs Brown is a 55 yo maintenance HD patient with Reflux Nephropathy.

She has been on HD for 3 years.

She has had a lot of family stress and has missed her last 2 scheduled

sessions.

She’s very breathless.

Temp 36.9

BP 168/102

Saturation 90% on air

Resp Rate 29

What is the most likely explanation for her symptoms?

What treatment will you give?


iv Nitrate

Oxygen

Opiates

iv diuretic in this case unlikely to

help - if you do try use (eg) Furosemide

250mg over 30 min

Would this change your plan?


5. Other HD Emergencies you may have heard of:

Dialysis Disequilibrium Syndrome

Venous Air Embolism

Haemolysis

Allergic Reactions

Venous Needle Dislodgement




Venous Air Embolism

Haemolysis

Allergic Reactions


Generally first HD session in

advanced uraemia

Mild: headache

Severe: coma/seizures

Usually can be anticipated and

prevented




Venous Air Embolism

Haemolysis

Allergic Reactions


Exceedingly rare with modern

HD machines

May occur with split line, or

when putting on or taking off

HD




Venous Air Embolism

Haemolysis

Allergic Reactions


Kinked/faulty blood tubing

Single-needle high flow HD

Dialysate contamination – eg

chloramine




Venous Air Embolism

Haemolysis

Allergic Reactions


(Membranes)

(Sterilising agents)

Heparin

iv Iron

Blood products




Venous Air Embolism

Haemolysis

Allergic Reactions


Flow may be >1.5L/min


6. You are called to ED at Stockport

Mrs Khan 68 yo with diabetic nephropathy on peritoneal dialysis

2 days of abdo pain, and now diarrhoea

Temp 37.8

BP 95/50

Dry mucous membranes

Diffusely tender abdo

Surgical Reg: not interested ‘busy in theatre’

What are the possible diagnoses?

What are the best tests?

What treatment are you planning?


∆∆ PD Peritonitis

+

All the causes of abdo pain anyone else might get

Ix PD fluid for microscopy and culture - but only by someone trained

Blood culture

Inflammatory markers

Biochemistry/FBC

Amylase

AXR or ?CT

Rx Liaise with your Renal Unit


Lanthanum Carbonate (Sevelamer)


Overnight Automated Peritoneal Dialysis (APD)

Baxter HomeChoice


Treatment - if PD peritonitis confirmed/likely

• Continue PD - may modify regime in view of volume status

• ip/po antibiotics if well – eg ciprofloxacin and vancomycin

• iv antibiotics if unwell

• iv fluid/antiemetic

Often patients are not unwell

Skin contaminants

Cloudy bag acts as ‘early warning system’

Can be managed as outpatient


Standard CAPD Fluid Constituents

• 1.36 % Dextrose

• NaCl

• Lactate

• Mg Ca (Dianeal)

Other solutions

• 2.27%, 3.86% Dextrose

• Icodextrin (Extraneal)

• 1.1% amino acids (Nutrineal)

• Bicarbonate Buffered Solutions (Physioneal)


A word on Troponin…


Circulation. 2005;112:3088-3096


Questions?

[email protected]

medical emergencies in dialysis patients · dialysis disequilibrium syndrome venous air embolism...

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