Emergencies in Hemodialysis Jeff Kaufhold, MD FACP Nephrology Associates 2007

Seizures Long term dialysis pt develops seizure near end of dialysis session. No head injury or intracranial abnormality. After dialysis stopped, pt returns to baseline. Calcium mag, K levels all normal. Differential?

Seizures Hypotension, especially in a pt with hx of stroke. Electrolyte abnormalities from dialysate (but these should persist after Tx) Alkalosis with change in ionized Calcium Reglan also associated. Hypoxia, due to decreased resp drive.

Hyperkalemia Pt who normally watches diet and comes to her treatments has weakness and presents to ER. K is 7.2. Gets tx at hospital and K normalizes. She returns the next week with similar findings. Why is her K suddenly a problem?

Hyperkalemia First thing to consider is her ACCESS. If her AVF is developing a stenosis, she may not be receiving adequate clearance. Any new meds? Hungry bone syndrome, after parathyroidectomy is also a known cause.

Malignant Hypertension 37 y.o. male with severe htn and ESRD presents with mental status changes, dysarthria, and BP of 250/170 Treated with Nipride to target BP of 200/100 2 days later, he develops agitation, tachycardia, hypotension. Anion Gap is increased.

Malignant Hypertension Cyanide Toxicity Thiocyanate toxicity presents the same. To avoid this you can: Get them off Nipride ASAP, by immediately resuming outpt oral meds (I like q6h procardia XL) Use another agent, such as Nitroglycerine, Labetolol drip. Expensive option is Corlepam.

Shortness of Breath, CP 56 y.o. male complains of SOB and SSCP minutes after starting treatment. No hx of heart disease. Tachy, hypotensive, Desats. What to look for?

SOB and CP Infusions: IV iron, Antibiotics, IDPN First Use phenomenon Reaction to ETO sterilant (kidney was not rinsed sufficiently) Bioincompatible kidney PAN kidney in ACE treated pt. Surreptitious hemorrhage Pericardial effusion (may not have RV collapse if echo done off dialysis)

Widespread Problems Multiple patients begin complaining of abdominal pain, SOB, and hypo OR hypertension during treatment. Patients labwork cannot be run due to interference from Hemolysis.

Hemolysis Consider chloramine release from water treatment system. Consider tubing problem (narrow lumen can cause hemolysis). Consider sterilant problem/ inadequate rinsing of reused kidneys.