Medical Emergencies in Dialysis Patients

Transcription

1 Medical Emergencies in Dialysis Patients John Anderton Consultant Renal Physician Lancashire Teaching Hospitals NHS Foundation Trust

2 Talk Plan A Flavour of Dialysis patients Emergencies in HD patients Emergencies in PD patients

3 Maintenance Dialysis Patients

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6 Treatment Modality by Age

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10 Cardiovascular disease mortality in the general population and in dialysis patients (from Foley et al. Am J Kidney Dis 1998; 32 [Suppl 3])

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12 Who do we take onto Dialysis? Very few absolute contraindications Decision-making by MDT Conservative care may be the right choice for some

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14 Overview of Service - Staff 23 Doctors 100 Nurses John Speed s 1610 Map of Lancashire

15 Overview of Service : RRT Patients Centre HD 60 PD Home HD 527 Transplant 73 15% on home dialysis therapy

16 Clinical Cases

17 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?

18 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

19 Tunnelled central venous catheter Don t be falsely reassured by a clean exit site

20 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

21 Antibiotics with useful Pharmacokinetics in ESRD Vancomycin Gentamicin (2.5mg/kg max) Cefuroxime Ceftazidime Meropenem

22 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

23 Venous Hypertension

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27 Access Complications Lines Early procedural Infection Poor flow Venous stenosis Thrombosis Fistulae Early procedural Infection Steal Syndrome Rupture Nerve compression Heart failure Cosmetic

28 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?

29 The Haemodialysis Blood Circuit [K] often 1 or 2 mmol/l

30 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!

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32 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?

33 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?

34 5. Other HD Emergencies you may have heard of: Dialysis Disequilibrium Syndrome Venous Air Embolism Haemolysis Allergic Reactions Venous Needle Dislodgement

35 5. Other HD Emergencies you may have heard of: Dialysis Disequilibrium Syndrome Venous Air Embolism Haemolysis Allergic Reactions Venous Needle Dislodgement Generally first HD session in advanced uraemia Mild: headache Severe: coma/seizures Usually can be anticipated and prevented

36 5. Other HD Emergencies you may have heard of: Dialysis Disequilibrium Syndrome Exceedingly rare with modern HD machines Venous Air Embolism Haemolysis Allergic Reactions Venous Needle Dislodgement May occur with split line, or when putting on or taking off HD

37 5. Other HD Emergencies you may have heard of: Dialysis Disequilibrium Syndrome Venous Air Embolism Haemolysis Allergic Reactions Kinked/faulty blood tubing Single-needle high flow HD Dialysate contamination eg chloramine Venous Needle Dislodgement

38 5. Other HD Emergencies you may have heard of: Dialysis Disequilibrium Syndrome Venous Air Embolism Haemolysis Allergic Reactions Venous Needle Dislodgement (Membranes) (Sterilising agents) Heparin iv Iron Blood products

39 5. Other HD Emergencies you may have heard of: Dialysis Disequilibrium Syndrome Venous Air Embolism Haemolysis Allergic Reactions Venous Needle Dislodgement Flow may be >1.5L/min

40 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?

41 PD Peritonitis + All the causes of abdo pain anyone else might get Ix Rx PD fluid for microscopy and culture - but only by someone trained Blood culture Inflammatory markers Biochemistry/FBC Amylase AXR or?ct Liaise with your Renal Unit

42 Lanthanum Carbonate (Sevelamer)

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44 Overnight Automated Peritoneal Dialysis (APD) Baxter HomeChoice

45 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

46 Standard CAPD Fluid Constituents 1.36 % Dextrose NaCl Lactate Mg Ca (Dianeal) Other solutions 2.27%, 3.86% Dextrose Icodextrin 1.1% amino acids Bicarbonate Buffered Solutions (Extraneal) (Nutrineal) (Physioneal)

47 A word on Troponin

48 Circulation. 2005;112:

49 Questions?