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| <h2>Hypotension</h2>
| | {{Dialysis complications DDX}} |
| <h3>Background</h3>
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| <ul><li>Most frequent complication of hemodialysis (20%-30% of tx)
| | {{AV shunt complications DDX}} |
| </li><li>Timing of intradialytic hypotension is helpful in formulating DDX:
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| <ul><li>Hypotension early in session usually due to preexisting hypovolemia
| | ===Peritoneal Dialysis Complications=== |
| </li><li>Hypotension during the session is often due to blood loss (from tubing or filter leak)
| | *[[Peritoneal dialysis-associated peritonitis]] |
| </li><li>Hypotension near the end usually result of excessive ultrafiltration
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| <ul><li>Underestimation of pt's ideal blood volume (dry weight)
| | {{ESRD Associated Skin Conditions}} |
| </li><li>Also consider pericardial or cardiac disease
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| </li></ul>
| | ===[[Altered Mental Status]]=== |
| </li></ul>
| | *[[Hypotension]] |
| </li></ul>
| | *[[Hypoglycemia]] |
| <h3>Clinical Features</h3>
| | *[[Hypercalcemia]] / [[Hyperkalemia]] / [[Hyponatremia]] |
| <ul><li>N/V
| | *[[Subdural hematoma]] |
| </li><li>Anxiety
| | *[[Dysequilibrium syndrome]] - diagnosis of exclusion made after admission |
| </li><li>Dizziness
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| </li><li>Orthostatic hypotension
| | ==References== |
| </li><li>Syncope
| | <references/> |
| </li></ul>
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| <h3>Diagnosis</h3>
| | [[Category:Renal]] |
| <ol><li>Assess:
| | [[Category:Vascular]] |
| <ol><li>Volume status (US)
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| </li><li>Cardiac function
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| </li><li>Pericardial disease
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| </li><li>Infection
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| </li><li>GI bleeding
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| </li></ol>
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| </li></ol>
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| <h3>DDX</h3>
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| <ol><li>Excessive ultrafiltration
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| </li><li>Predialytic volume loss
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| <ol><li>GI losses
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| </li><li>Decreased oral intake
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| </li></ol>
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| </li><li>Intradialytic volume loss
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| <ol><li>Tube and hemodialyzer blood losses
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| </li></ol>
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| </li><li>Postdialytic volume loss
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| <ol><li>Vascular access blood loss
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| </li></ol>
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| </li><li>Medication effects
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| <ol><li>Antihypertensives
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| </li><li>Opiates
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| </li></ol>
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| </li><li>Decreased vascular tone (sepsis)
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| </li><li>Cardiac dysfunction
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| <ol><li>LVH, ischemia, hypoxia, arrhythmia, pericardial tamponade
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| </li></ol>
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| </li><li>Pericardial disease
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| <ol><li>Effusion
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| </li><li>Tamponade
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| </li></ol>
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| </li></ol>
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| <h2>Dialysis Disequilibrium Syndrome</h2>
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| <ul><li>Diagnosis of exclusion (r/o SDH, CVA)
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| </li><li>Clinical syndrome occurring at end of dialysis
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| <ul><li>Large solute clearances -> cerebral edema
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| </li></ul>
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| </li><li>Characterized by N/V, HTN
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| <ul><li>Can progress to seizure, coma, death)
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| </li></ul>
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| </li><li>Occurs most commonly during initial dialysis or during hypercatabolic states
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| </li><li>Treat w/ mannitol
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| </li></ul>
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| <h2>Air Embolism</h2>
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| <ul><li>Acute dyspnea, chest tightness, LOC, cardiac arrest
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| </li><li>Treat w/ 100% NRB
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| </li></ul>
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| <h2>Vascular Access Complications</h2>
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| <h3>Thrombosis and Stenosis</h3>
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| <ul><li>Most common causes of inadequate dialysis flow
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| <ul><li>Loss of bruit and thrill over access
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| </li></ul>
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| </li><li>Stenosis and even thrombosis are not emergencies
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| <ul><li>Can be treated w/in 24hr by angiographic clot removal or angioplasty
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| </li><li>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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| </li></ul>
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| </li></ul>
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| <h3>Vascular Access Infection</h3>
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| <ul><li>Pts often p/w signs of systemic sepsis (fever, hypotension, leukocytosis)
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| <ul><li>Classic signs of pain, erythema, swelling, d/c from infected access are often missing
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| </li></ul>
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| </li><li>Dialysis catheter–related bacteremia is common and potentially life-threatening
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| <ul><li>Give vancomycin 1gm IV +/- genamicin 100mg IV (if gram neg suspected)
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| </li><li>Do not remove dialysis patient's access
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| </li></ul>
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| </li><li>Draw peripheral and catheter blood cultures simultaneously
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| <ul><li>4x higher colony count in catheter blood cx suggests catheter is source of bacteremia
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| <ul><li>Even so catheter is only removed if fever persists for 2-3d after abx are started
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| </li></ul>
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| </li></ul>
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| </li></ul>
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| <h3>Hemorrhage</h3>
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| <ul><li>Potentially life-threatening
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| </li><li>Can result from aneurysms, anastomosis rupture, or over-anticoagulation
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| </li><li>Control bleeding w/ pressure applied to puncture site for 5-10min; observee for 1-2hr
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| </li><li>Types
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| <ul><li>Aneursym (true)
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| <ul><li>Most are asymptomatic; rarely rupture
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| </li></ul>
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| </li><li>Pseudoaneurysm
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| <ul><li>Results from subcutaneous extravasation of blood from puncture sites
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| </li><li>Bleeding from puncture site is usually controlled by digital pressure or subq suture
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| </li><li>Consider vascular surgery consultation for continued bleeding or infection
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| </li><li>Arterial Doppler US studies can identify the aneurysm or pseudoaneurysm
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| </li></ul>
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| </li></ul>
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| </li></ul>
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| <h3>Vascular insufficiency</h3>
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| <ul><li>Distal extremity becomes ischemic due shunting of arterial blood to venous side
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| <ul><li>Exercise pain, nonhealing ulcers, cool, pulseless digits
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| </li><li>Diagnosed by Doppler US or angiography, repaired surgically
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| </li></ul>
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| </li></ul>
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| <h3>High-output heart failure</h3>
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| <ul><li>Occurs when >20% of cardiac output is diverted through the access
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| <ul><li>Branham sign (drop in HR after temporary access occlusion) is diagnostic
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| </li><li>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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| </li></ul>
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| </li></ul> | |
| <h2>Source</h2>
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| <p>Tintinalli
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| </p><a _fcknotitle="true" href="Category:Nephro">Nephro</a>
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