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| ==Hypotension==
| | {{Dialysis complications DDX}} |
| ===Background===
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| #Most frequent complication of hemodialysis, occurring during 20% to 30% of treatments
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| #Timing of intradialytic hypotension is helpful in formulating DDX:
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| ##Hypotension early in session usually due to preexisting hypovolemia
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| ##Hypotension during the session is often due to blood loss (from tubing or filter leak)
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| ##Hypotension near the end usually result of excessive ultrafiltration
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| ###Underestimation of pt's ideal blood volume (dry weight)
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| ###Also consider pericardial or cardiac disease
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| ===Clinical Features===
| | {{AV shunt complications DDX}} |
| #N/V
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| #Anxiety
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| #Dizziness
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| #Orthostatic hypotension
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| #Syncope
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| ===Diagnosis=== | | ===Peritoneal Dialysis Complications=== |
| #Assess:
| | *[[Peritoneal dialysis-associated peritonitis]] |
| ##Volume status (US)
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| ##Cardiac function
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| ##Pericardial disease
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| ##Infection
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| ##GI bleeding
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| ===DDX===
| | {{ESRD Associated Skin Conditions}} |
| #Excessive ultrafiltration
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| #Predialytic volume loss
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| ##GI losses
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| ##Decreased oral intake
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| #Intradialytic volume loss
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| ##Tube and hemodialyzer blood losses
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| #Postdialytic volume loss
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| ##Vascular access blood loss
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| #Medication effects
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| ##Antihypertensives
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| ##Opiates
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| #Decreased vascular tone (sepsis)
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| #Cardiac dysfunction
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| ##LVH, ischemia, hypoxia, arrhythmia, pericardial tamponade
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| #Pericardial disease
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| ##Effusion
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| ##Tamponade
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| ==Dialysis Disequilibrium Syndrome== | | ===[[Altered Mental Status]]=== |
| ###Clinical syndrome occurring at end of dialysis
| | *[[Hypotension]] |
| ###Characterized by N/V, HTN (can progress to seizure, coma, death)
| | *[[Hypoglycemia]] |
| ###Large solute clearances -> cerebral edema
| | *[[Hypercalcemia]] / [[Hyperkalemia]] / [[Hyponatremia]] |
| ####Occurs most commonly during initial dialysis or during hypercatabolic states
| | *[[Subdural hematoma]] |
| ###Treatment
| | *[[Dysequilibrium syndrome]] - diagnosis of exclusion made after admission |
| ####Mannitol
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| ==Air Embolism== | | ==References== |
| ###Acute dyspnea, chest tightness, LOC, cardiac arrest
| | <references/> |
| ###Treatment
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| ####100% NRB
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| ==Vascular Access Complications==
| | [[Category:Renal]] |
| ===Thrombosis and Stenosis===
| | [[Category:Vascular]] |
| #Most common causes of inadequate dialysis flow
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| ##Loss of bruit and thrill over access
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| #Stenosis and even thrombosis are not emergencies
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| ##Can be treated w/in 24hr by angiographic clot removal or angioplasty
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| ##Thrombosis of vascular access can be treated w/ direct injection of alteplase 2.2mg ###This therapy should be discussed with the vascular surgeon first
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| ===Vascular Access Infection===
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| #Pts often p/w signs of systemic sepsis (fever, hypotension, leukocytosis)
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| ##Classic signs of pain, erythema, swelling, d/c from infected access are often missing
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| #Dialysis catheter–related bacteremia is common and potentially life-threatening
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| ##Give vancomycin 1gm IV +/- genamicin 100mg IV (if gram neg suspected)
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| ##Do not remove dialysis patient's access
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| #Draw peripheral and catheter blood cultures simultaneously
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| ##4x higher colony count in catheter blood cx suggests catheter is source of bacteremia
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| ###Even so catheter is only removed if fever persists for 2-3d after abx are started
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| ===Hemorrhage===
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| #Potentially life-threatening
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| #Can result from aneurysms, anastomosis rupture, or over-anticoagulation
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| #Control bleeding w/ pressure applied to puncture site for 5-10min; observee for 1-2hr
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| #Types
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| ##Aneursym (true)
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| ###Most are asymptomatic; rarely rupture
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| ##Pseudoaneurysm
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| ###Result from subcutaneous extravasation of blood from puncture sites
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| ###Bleeding from puncture site is usually controlled by digital pressure or subq suture
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| ###Consider vascular surgery consultation for continued bleeding or infection
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| ###Arterial Doppler US studies can identify the aneurysm or pseudoaneurysm
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| ===Vascular insufficiency===
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| #Distal extremity becomes ischemic due shunting of arterial blood to venous side
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| ##Exercise pain, nonhealing ulcers, cool, pulseless digits
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| ##Diagnosed by Doppler US or angiography, repaired surgically
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| ===High-output heart failure===
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| #Occurs when >20% of cardiac output is diverted through the access
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| ##Branham sign (drop in HR after temporary access occlusion) is diagnostic
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| ##Doppler US can accurately measure access flow rate and establish the diagnosis ##Surgical banding of the access is treatment of choice
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| ==Source==
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| Tintinalli
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| [[Category:Nephro]] | |
