Dialysis Related Emergencies Susan B. Promes, MD, FACEP Professor and Vice Chair for Education Department of Emergency Medicine University of California San Francisco Objectives Discuss management strategies of life threatening emergencies in renal failure patients Identify pitfalls that may be encountered when dealing with this patient population Statistics More than 500,000 Americans have kidney failure (KF) and need dialysis or a transplant African Americans 4x more likely and Latinos 2x more likely to develop kidney failure 25% of the Medicare spending Annual cost per person approx $20K ++ Morbidity and Mortality 5 year survival rate = 35% 2005 lifespan 20-24 yo: 14.2 years 40-44 yo: 8.1 years 60-64 yo: 4.5 years Mortality doubled if patient dialyzes less than 4 hrs/wk 1
What KF patients die from? Cardiovascular disease 50% of all deaths Highly linked to diabetes Infection 15-20% of all deaths Primarily catheter related The ED Evaluation History Reason for ESRD, last dialysis, dry weight, non-compliance, medication changes Physical Exam Vitals Access Other evaluating tools CBC, chemistries, electrolyte, urinalysis Blood Cx - line site and peripheral Imaging studies Contact nephrologist CC: I have chest pain CAD is the primary cause of death in ESRD pts Multiple etiologies of chest pain Cardiovascular Pulmonary Gastrointestinal Musculoskeletal Miscellaneous Cardiac Complaints: ACS Acute coronary syndrome Highly symptomatic Enzymes: normal range vs patterns A frankly positive troponin I is abnormal! Treatment Conventional MONA Fibrinolytics Consider transfusions with hgb<10 2
Pericarditis Pericarditis Sx: positional chest pain, fever, malaise PE: friction rub, HR, fever Lab: BUN>60 ECG: varies Dx: echo Tx: stable vs unstable Aggressive heparin free dialysis Careful volume control Pericardiocentesis Pericardial Effusion CC: SOB Dyspnea Non-cardiac vs cardiac etiology Primary Cause of Dyspnea CHF 83% mortality in 3 years Risk Factors: age, HTN, anemia, CAD and systolic dysfunction 3
Dyspnea Pulmonary Edema Emergent dialysis! Conventional treatment Nitrates, opiates Diuretics: Furosemide Calcium channel blockers Nitroprusside Select cases CPAP, phlebotomy, sorbitol Nicholadoni-Branham s sign Identifies cardiac failure secondary to fistula problem Temporary occlusion of fistula causes decreased HR Rx: surgical revision CC: The thrill is gone Dialysis lifeline 3 types: Graft Fistula Double lumen catheter IJ is preferable 3 problems: Hemorrhage Thrombosis Infection Access Site Hemorrhage Background - ESRD Thrombocytopenia (transient) Uremia induced platelet dysfunction Aneurysms or pseudoaneurysm Heparin rebound Complications rupture compartment syndrome 4
Vascular Access Hemorrhage Treatment of Hemorrhage Direct Pressure Document a thrill after your pressure! Decrease the motion of the arm Observe for up to 2 hours Protamine DDAVP FFP or cryoprecipitate Cryoprecipitate has less volume Vascular Surgery Consultation Access Thrombosis Thrombus Sx: not working, pain, swelling or edema CHF Two Etiologies: Extrinsic and Intrinsic thrombosis Primary complication of catheters Main cause of catheter loss Dx: US, angiography,venography 5
Treatment of Thrombosis Forceful agitation 10 cc syringe Intraluminal lytic tpa Anti-coagulation - long term Catheter replacement over wire Catheter removal Vascular surgery CC: I don t feel well ESRD = rates of infections Uremic toxins Dialysis removes important mediators Catheter related vs systemic Access related has mortality rates Sx: vague to pus from my catheter VERY high index of suspicion 1/3 patients have no fever Show me the money #1 cause of infection = catheter Type of catheter Metastatic infection Anatomic site Risk factors: time, previous hx, surgery, DM Dx: blood cultures Tx: Abx Gram + (vancomycin) Gram (gentamycin) +/- catheter removal Non-catheter Sources of Infections Pneumonia Fluid fluctuations C. difficile colitis Cellulitis MRSA, catheters Endocarditis indwelling catheters and access UTI Residual urine Pyrogen reaction 6
Antibiotics for Systemic Infections Tx: broad spectrum abx Piperacillin/Tazobactam (zosyn) Ticarcillin/clavulanate (timentin) Imipenem Specifics Gram +: vancomycin Remember pseudomonas CC: I feel weak and dizzy Hyperkalemia #1 cause of cardiac arrest in ESRD pts Relatively uncommon in compliant pts Dietary indiscretion, inadequate dialysis, GIB rhabdomyolysis Medications Potentiated by metabolic acidosis Acute K+ > 7.0 meq/l = life threatening Weakness = most common sx Treat (regardless of ECG) with K+ > 6.5 meq/l and weakness ECG appearance of K+ Treatment for hyperkalemia ECG #1 Peaked T waves - V2, V3, V4, II and III QRS widening PR lengthening P wave disappears Sine wave ECG #2 bradycardia RIP K = 6-7 K = 7-8 K = 6-9 K = 8-10 K > 10 Stabilization of myocytes Calcium IV Redistribution of K+ NaHCO 3 Insulin/glucose Albuterol nebulizer Extraction Kayexalate Furosemide Dialysis! 7
CC I still feel weak Other electrolyte disturbances Phosphorous Calcium > 15 meq/dl ECG - shortened QT Calcitonin, IV fluids Magnesium Mixed gap metabolic acidosis Anion and non anion gaps Cardiac Arrest OK to use vascular access site Usual normal ACLS drugs except Procainamide same loading dose but decrease infusion by 1/3 to 1/2 Think electrolyte abnormality and cardiac tamponade CC: I have abdominal pain Peritoneal Dialysis 1926 1968 10% of dialysis patients in the US Slow rates of solute and volume removal Careful selection of candidates Peritoneal Dialysis: Peritonitis Peritonitis Most common and serious infection of PD Symptoms Abdominal pain - 80% Fever - 57% Nausea - 31% Diarrhea - 7% Cloudy dialysate -? 8
Peritoneal Dialysis Peritonitis Diagnosis Dialysate - culture is gold standard >100 wbc/mm 3 with >50% PMN Organisms Skin contaminants > GNR > sterile > fungal Treatment Rapid exchanges Intra-abdominal antibiotics Vancomycin or cephalosporins Home therapy CC: The patient is seizing Neurological abnormalities are common AMS Metabolic, drug induced, hypoxic, dialysis disequilibrium syndrome Seizures Metabolic, drug induced, hypoxic CVA Encephalopathy Uremic and hypertensive Intracranial hemorrhage 3% - subdurals Seizures Common problem with multiple etiologies: Uremic encephalopathy HTN encephalopathy Dialysis disequilibrium syndrome Drugs - sulfonylureas, acyclovir, star fruit Intracranial hemorrhage Electrolyte disturbances Alcohol withdrawal Treatment of seizures Traditional therapy works well Benzodiazipine of choice Phenytoin 8-12 mg/kg, slow IV Therapeutic level is 1/2 of normal Phenobarbital Until seizure stops up to 20 mg/kg 9
The CT scan and ESRD Patients that need CT scans should get CT scans Consider using the non-ionic contrasts If intrinsic renal function left Consider Bicarbonate infusion - 3 amps HCO 3 in 1L D 5 3ml/kg/hr for 1 hour 1ml/kg/hr for 6 hours Take Home Points Patients generally have multiple comorbidities Cardiac arrest Think electrolytes & tamponade Hemorrhage treat aggressively if direct pressure does not work Pulmonary Edema - IV Lasix drip ECG is not a sensitive indicator of K+ Catheter and fever - don t pull the catheter Peritonitis > 100 wbc/mm 3 10