1. Dialysis Emergencies
Joe Lally
February 2018

2. 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

7. Tunneled Catheter

8. Graft

9. Fistula

10. 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

11. Yes No

12. 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%

14. Increasingly less responsive
HR 30, BP 90/50

18. 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

20. 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

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

23. 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?

24. 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

25. 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

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

28. 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

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

30. 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

32. 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

33. 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