Dialysis Emergencies Joe Lally February 2018

Objectives Understand etiologies of the hypotensive dialysis patient. Understand presentation and treatment of hyperkalemia Presentation and treatment of Vascular access complications Etiologies of chest pain, dyspnea and altered mental status in dialysis patient

Tunneled Catheter

Graft

Fistula

Access Complications Infection Stenosis and Thrombosis Bleeding Tunneled Catheter > Graft > Fistula Classic localized signs may be absent Bacteremia is common Higher risk of endocarditis, osteomyelitis, septic arthritis, epidural abscess … Stenosis and Thrombosis Unable to acces; loss of thrill Urgent: angio guided clot retrieval vs angioplasty vs directed tPA Bleeding Direct pressure, gel-foam/quick clot/thrombin…..tourniquet

Yes No

Monday morning Arrival Weakness. Syncope “Too weak to go to dialysis this morning” No chest pain or dyspnea T 37, HR 70, BP 100/60, RR 18, 99%

Increasingly less responsive HR 30, BP 90/50

Cardiac Arrest! Hyperkalemia! Symptoms: neuromuscular and cardiac Disrupts cardiac membrane Cardiac instability and ECG findings may rapidly progress Diagnosis: Can’t wait for lab! Clinical findings, ECG Treatment: low threshold Stabilize cardiac membranes: CALCIUM Temporalizing measures: shift potassium Remove: dialysis

Hypotension in the Dialysis Patient Hemorrhage: get control Hyperkalemia: clinical suspicion; low threshold to treat 911 call probably not from dialysis center Sepsis: higher risk for all sources Cardiac Tamponade ESRD/Uremia risk for developing pericardial effusion Hypotension without source?—bedside US

Dispatched to Dialysis Center for hypotension Arrival Pale, clammy patient T 37, HR 70, BP 75/40, RR 18, 100%

Need more history Exam Did they miss any recent dialysis sessions? How much dialysis did they get today? What’s their dry weight? Did they come in over or under If under, why? Recent illness? Was the patient hypovolemic to start with? Exam Are they dry? Crackles? Edema?

Dialysis Hypotension Syndrome Secondary to fluid shifts: multifactorial Patient dependent factors Comorbidities; ability to compensate. Contribution of drugs Treat the patient, not the number Wait for body to compensate, small fluid bolus

Chest pain ACS Uremic pericarditis ESRD independent risk factor for CAD 50 % of deaths in ESRD patients Uremic pericarditis MC during severe uremic periods Lacks typical ECG findings

Dyspnea Sub-Acute Cardio-Renal Syndrome Underlying CHF Volume overload Uremic cardiomyopathy Volume overload Gradual. Typical symptoms. Cardio-Renal Syndrome Direct relationship

Dispatched to home for SOB Severe distress Increase WOB, diaphoresis HR 140, BP 220/115, RR 30, 82% Hx of HTN, DM, CAD (stent one year ago) Reported mild chest discomfort earlier in day Abrupt respiratory distress prior to 911 call

What’s happening and what next? Exam Diaphoretic + Crackles bilaterally No peripheral edema What’s happening and what next?

Acute Flash Pulmonary Edema Not unique to ESRD Not related to systemic volume overload Not unique to ESRD Ischemia Arrhythmia Sudden decreased in LV function Loss of forward flow Flash pulmonary edema Sympathetic/Cathecolamine surge Markedly elevated BP, diaphoresis, DISTRESS

Treatment Decreased preload Decreased WOB NITRO: SL BIPAP 400 mcg/tab Will also decrease afterload by decreasing BP/SVR Decreased WOB BIPAP Will also redistribute some fluid out of alveoli

Altered Mental Status Hypoglycemia? ICH Much more common Poorly controlled HTN, bleeding dyscrasia SDH 10x more likely in this population. Look/ask for signs of subtle remote trauma Dialysis disequilibrium syndrome Rapid osmotic shifts during dialysis; cerebral edema HA, nausea, blurred vision, seizure Treatment: stop dialysis and wait. Supportive Uremic encephalopathy Accumulation of renally cleared toxins. Abrupt changes: ARF, missed dialysis. Treatment--dialysis