Wendy DeMartino, MD PGY-2 Renal Failure Wendy DeMartino, MD PGY-2

Objectives Anatomy Function Acute Renal Failure (ARF) Causes Symptoms Management Chronic Renal Failure (CRF) Dialysis

Anatomy 2 Kidneys 2 Ureters Bladder Urethra

What do the kidneys do??

Kidney Function Detoxify blood Increase calcium absorption calcitriol Stimulate RBC production erythropoietin Regulate blood pressure and electrolyte balance renin

Classifications Acute versus chronic Pre-renal, renal, post-renal Anuric, oliguric, polyuric

Acute Versus Chronic Acute Chronic sudden onset rapid reduction in urine output Usually reversible Tubular cell death and regeneration Chronic Progressive Not reversible Nephron loss 75% of function can be lost before its noticeable

Acute Renal Failure Pre-renal = 55% Renal parenchymal (intrinsic)= 40% Post-renal = 5-15%

Causes of ARF Pre-renal = Intrinsic Post-renal = vomiting, diarrhea, poor fluid intake, fever, use of diuretics, and heart failure cardiac failure, liver dysfunction, or septic shock Intrinsic Interstitial nephritis, acute glomerulonephritis, tubular necrosis, ischemia, toxins Post-renal = prostatic hypertrophy, cancer of the prostate or cervix, or retroperitoneal disorders neurogenic bladder bilateral renal calculi, papillary necrosis, coagulated blood, bladder carcinoma, and fungus

Symptoms of ARF Decrease urine output (70%) Edema, esp. lower extremity Mental changes Heart failure Nausea, vomiting Pruritus Anemia Tachypenic Cool, pale, moist skin

Diagnosis of Renal Failure Not A Field Diagnosis

Acute Renal Failure Management Make/think about the diagnosis Treat life threatening conditions Identify the cause if possible Hypovolemia Toxic agents (drugs, myoglobin) Obstruction Treat reversible elements Hydrate Remove drug Relieve obstruction

ARF: Life Threatening Conditions Hyperkalemia Volume overload Vascular access

Hyperkalemia Symptoms EKG? Weakness Lethargy Muscle cramps Paresthesias Hypoactive DTRs Dysrhythmias

Hyperkalemia & EKG K > 5.5 -6 Tall, peaked T’s Wide QRS Prolong PR Diminished P Prolonged QT QRS-T merge – sine wave

Hyperkalemia Treatment Calcium gluconate (carbonate) Sodium Bicarbonate Insulin/glucose Kayexalate Lasix Albuterol Hemodialysis

Chronic Renal Failure 150–200 cases per million people = new cases each year Chronic renal failure and ESRD affect more than 2 out of 1,000 people in the U.S Mortality = 20%

Chronic Renal Failure Causes Diabetic Nephropathy Hypertension Glomerulonephritis HIV nephropathy Reflux nephropathy in children Polycystic kidney disease Kidney infections & obstructions

CRF Symptoms Malaise Weakness Fatigue Neuropathy CHF Anorexia Nausea Vomiting Seizure Constipation Peptic ulceration Diverticulosis Anemia Pruritus Jaundice Abnormal hemostasis

Acute Problems in CRF Relating to underlying disease Relating to ESRD Dialysis related problems

Problems Related to ESRD Metabolic – K/Ca Volume overload Anemia, platelet disorder, GI bleed HTN, pericarditis Peripheral neuropathy, dialysis dementia Abnormal immune function

Dialysis ½ of patients with CRF eventually require dialysis Diffuse harmful waste out of body Control BP Keep safe level of chemicals in body 2 types Hemodialysis Peritoneal dialysis

Hemodialysis 3-4 times a week Takes 2-4 hours Machine filters blood and returns it to body

Types of Access Temporary site AV fistula AV graft Surgeon constructs by combining an artery and a vein 3 to 6 months to mature AV graft Man-made tube inserted by a surgeon to connect artery and vein 2 to 6 weeks to mature

Temporary Catheter

AV Fistula & Graft

What This Means For You No BP on same arm as fistula Protect arm from injury Control obvious hemorrhage Bleeding will be arterial Maintain direct pressure No IV on same arm as fistula A thrill will be felt – this is normal

Access Problems AV graft thrombosis AV fistula or graft bleeding AV graft infection Steal Phenomenon Early post-op Ischemic distally Apply small amount of pressure to reverse symptoms

Peritoneal Dialysis Abdominal lining filters blood 3 types Continuous ambulatory Continuous cyclical Intermittent

EMS Considerations Make sure the dressing remains intact Do not push or pull on the catheter Do not disconnect any of the catheters Always transport the patient and bags/catheters as one piece Never inject anything into catheter

Dialysis Related Problems Lightheaded –give fluids Hypotension Dysrhythmias Disequilibration Syndrome At end of early sessions Confusion, tremor, seizure Due to decrease concentration of blood versus brain leading to cerebral edema

Questions?

1. The normal urinary system consists of: two kidneys, two ureters, one urethra two kidneys, one ureter, one bladder, one urethra one kidney, two ureters, one bladder, one urethra two kidneys, two ureters, one bladder, one urethra D

2. The basic, functional unit of the kidney that acts to mechanically filter fluids, wastes and electrolytes is called: C Ureter Bladder Nephron Trigone

3. You receive a 911 call to respond to a local residence for a report of an elderly male who is unconscious.  Upon arrival you find a 68 year old female patient who is unconscious with snoring respirations.  Your partner opens the airway and the patient begins breathing at a rate of 44 breaths per minute.  Patients daughter states her mother has ESRD and has decided she wants to die.  Patient has not had dialysis treatment for 3 weeks.  After quick assessment of ABCs what is your first priority in treating this patient? B Oxygen 15 LPM/NRBM, rapid transport Oxygen 15 LPM/NRBM, check blood glucose, rapid transport Have the patient’s daughter sign refusal and call in to medical control

4. You are dispatched for “Man light headed and bleeding from a shunt 4. You are dispatched for “Man light headed and bleeding from a shunt.”  Upon arrival you find a 38 year old male with a recent history of ARF and receives dialysis 3 times a week.  Today he was changing his shirt.  The Permcath in the right side of his chest became caught in a button hole and the red port of the catheter was sheared off.  Which of the following treatments are appropriate? C Quickly check blood pressure then clamp catheter, and then perform primary assessment. Wrap a paper towel around catheter to soak up excess blood, apply oxygen 15 LPM/NRBM Immediately clamp catheter close to skin level, place patient on his left side with head low and feet high, primary assessment, oxygen 15LPM/NRBM

5. 911 dispatch pages your department for a 72 year old female with high fever, needs to be transported to emergency room for evaluation.  Upon arrival you find an elderly female who is confused with hot dry skin and a respiratory rate of 40 BPM.  Her blood pressure is 80/40 with a pulse of 120.  The patient has a history of CRF and is on peritoneal dialysis.  You note a large tube coming from her abdomen that is connected to other tubes and large empty bags.  Patient’s daughter states that it is time to “drain mom’s dialysis water.”  Based upon your knowledge of peritoneal dialysis which of the following is an appropriate response?

5 (cont). Appropriate response? Allow the patient’s daughter to unclamp the drain tube, package the patient without disconnecting any tubes and transport the patient and all dialysis tubing intact. Inform the patient’s daughter that you are not allowed to transport anyone on peritoneal dialysis, disconnect the tubes from the abdominal catheter, cover catheter with a plastic bag and transport. Call Med Flight to transport patient. Tell the patient’s daughter to disconnect all excess tubing and transport. A

6. Renal failure often occurs in trauma patients who have had sustained hypotension because: Blood pressure has no effect on kidney function. Low blood pressure causes damage to the ureter preventing urine from draining into the bladder. Low blood pressure prevents adequate blood flow through kidneys causing kidney tissue damage. Low blood pressure stimulates arteries to dilate causing an increase in the amount of blood flow through the kidneys.

7. You arrive on scene for a dialysis patient with a history of kidney failure complaining of shortness of breath.  You notice the right arm has large bulging veins.  When taking a blood pressure which of the following answers best describes appropriate actions: A Take blood pressure and pulse in the left arm. Take blood pressure in the right arm. Take pulse in the right arm, blood pressure measurement is not necessary in dialysis patients. Call for Med Flight. ALS ambulance agencies cannot transport patients with an AV shunt.

8. You are transporting an unconscious dialysis patient to the hospital.  The arm with is AV shunt was left dangling over the cot.  When loading in the ambulance the arm banged against the wall of the rig.  During transport you notice that there is a large hematoma over one of the veins of the arm.  The hematoma is growing quickly.  What is the most appropriate action: C Ignore it, pulsating masses in patients with AV shunts is normal. Wrap a blood pressure cuff around the arm proximal to the injury and inflate to 20mmHG higher than SBP. Immediately apply direct pressure over the site and maintain pressure during transport. Have your partner radio ahead to the receiving hospital to notify of condition. Call insurance company to make sure liability insurance premiums have been paid.

9. Which of the following could potentially cause renal failure: Hypovolemic shock Chemical exposure Obstruction by kidney stone All of these D

References http://www.umm.edu/ency/article/000471.htm http://www.fpnotebook.com/REN38.htm http://www.paems.org/eWebquiz/renal%20failure/Dialysis%20CEU.pdf http://www.loyolaems.com/sop/4med.htm#med8 http://www.chpnet.org/BIEM_Res/lectures.asp http://www.emedicine.com/emerg/topic501.htm  http://g.msn.com/9SE/1?http://www.irishhealth.com/index.html?level=4&id=538&&DI=293&IG=6f0f1fd0f6854d928d14d6e96915e742&POS=22&CM=IMG&CE=22&CS=AWP&SR=22 http://http://www.medonline.com.br/med_ed/med1/iranejm.htm www.auburn.edu/~deruija/renal_part3/sld001.htm file:///C:/Documents%20and%20Settings/Wendy/Local%20Settings/Temporary%20Internet%20Files/Content.IE5/FBZ7VWDX/12.03.03-DrSturmann-Acute%26ChronicRenalFailure%5B1%5D.ppt#256,1,RENAL FAILURE file:///C:/Documents%20and%20Settings/Wendy/Local%20Settings/Temporary%20Internet%20Files/Content.IE5/AQVFLSNN/CHRONICRENALFAILUREANDHEMODIALYSIS%5B1%5D.ppt#311,2,CHRONIC RENAL FAILURE