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Subject: Dialysis Complications, Emergency Medicine
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Vascular access related (infection, bleeding)
Nonvascular access related (hypotension, hyperkalemia)
Peritoneal (abdominal pain, infection)
Vascular access related:
Infections (largely access related or peritonitis) are a major cause of death in dialysis patients.
Often caused by Staphylococcus aureus
Can present with signs of localized infection or systemic sepsis
Can also present with minimal findings
Thrombosis or stenosis:
Often presents with loss of bruit or thrill over access site
Must be addressed quickly (within 24 hr) to avoid loss of access site
Can be life-threatening
Nonvascular access related:
Most common complication of hemodialysis
After dialysis: Often owing to acute decrease in circulating blood volume
During dialysis: Hypovolemia (more commonly) or onset of cardiac tamponade owing to compensated effusion suddenly becoming symptomatic after correction of volume overload
MI, sepsis, dysrhythmias, hypoxia
Hemorrhage secondary to anticoagulation, platelet dysfunction of renal failure
Shortness of breath:
Development of dyspnea during dialysis owing to tamponade, pericardial effusion, hemorrhage, anaphylaxis, pulmonary embolism, air embolism
Dialysis patients are often at high risk for having atherosclerotic disease
Dialysis is an acute physiologic stressor with transient hypotension and hypoxemia that increases myocardial oxygen demand.
Pericarditis, pulmonary embolism
Neurologic dysfunction: Disequilibrium syndrome:
Rapid decrease in serum osmolality during dialysis leaves brain in comparatively hyperosmolar state.
Owing to contamination of peritoneal dialysate or tubing during exchange
S. aureus or Staphylococcus epidermidis (70%)
Perforated viscus with abdominal pain that can be severe, fever, brown or fecal material in effluent, or localized tenderness
Fibrinous blockage of catheter resulting from infection or inflammation
Bleeding from puncture sites
Loss of bruit in graft
Local infection, cellulitis, fever
Decreased sensation and strength distal to access
New or increasing size mass adjacent to access site
Hypotension before, during, or after procedure
Neurologic symptoms (disequilibrium syndrome):
Cloudy dialysis effluent
Nausea and vomiting
Exudates or inflammation at insertion site of Tenckhoff catheter
Careful physical exam:
Complete set of vital signs including auscultated BP, pulse, respiratory rate, accurate temperature, and pulse oximetry
Careful physical exam for occult infectious sources (odontogenic, perirectal abscess)
Auscultation of lungs for evidence of infection (rhonchi) or volume overload (rales)
Search for other evidence of volume overload (edema)
Careful cardiac exam including listening for murmurs or rubs
EKG: Look for signs of electrolyte balance or conduction disturbances.
Blood and wound cultures
Cell count, Gram stain, culture of peritoneal fluid
CBC to evaluate anemia and platelet count
Chest pain or shortness of breath:
EKG, cardiac enzymes (if appropriate, based on history)
Neurologic dysfunction: CT of brain for intracranial hemorrhage
Glucose, electrolytes, BUN, and creatinine
ECG for suspected:
US of access for possible clotted graft or fistula
ECHO to assess for pericardial effusion/tamponade
Peritoneal cathergram for blockages
CT scan for pulmonary embolism:
Dialysis patients are at risk for both bleeding and clotting problems.
Problematic in renal insufficiency owing to contrast dye load:
Can be done in renal failure, but contrast is then a fluid bolus and may need to be dialyzed off
Communicate contrast load to renal team, as dialysis may need to occur for longer-than-normal duration.
Cardiogenic shock, acute MI, tamponade, primary dysrhythmias
Electrolyte abnormalities leading to dysrhythmias (hyperkalemia and hypokalemia)
Embolism: Air or pulmonary
Vascular instability: Autonomic neuropathy, drug related, dialysate related
Hyperglycemia or hypoglycemia
Hypernatremia or hyponatremia
Meningitis or abscess
Acute abdominal process: Appendicitis, cholecystitis
Do not perform IV access and BP measurement in extremity with functioning AV graft or fistula.
Run IV fluids slowly and keep to min., if possible.
Administer furosemide in pulmonary edema (anuric patients: Use high doses ≤200 mg).
Check airway, breathing, and circulation.
Firm pressure to site(s)
Do not totally occlude access; may cause clotting.
Will likely need pressure applied for at least 5–10 min to stop even minor bleeding
Document presence or absence of thrill after pressure was applied.
Search for underlying cause.
Preload and afterload reduction with nitrites and ACE inhibitors.
Attempt diuresis if fluid overload is suspected cause.
Arrange for dialysis.
Administer IV calcium, bicarbonate, insulin, and glucose when appropriate (see “Hyperkalemia”).
Monitor cardiac rhythm.
Administer ion-exchange resin (Kayexalate).
Administer naloxone, thiamine, dextrose (or Accu-Chek) for altered mental status.
Control seizures with benzodiazepines.
Initiate antistaphylococcal IV antibiotics.
Vascular surgery consult
Administer IV fluids and blood products.
Treat hypercalcemia or hypermagnesemia with saline infusion if tolerated (dilution).
Diuresis with furosemide after preload and afterload reduction (nitroglycerin, enalapril)
Attempt diuresis with nitrites and furosemide.
Pericardial effusion or tamponade:
Emergent pericardiocentesis may be necessary in unstable patient.
Thrombolytics or angioplasty if patient is appropriate candidate
Nitrates to decrease myocardial workload
Rule out other causes of altered mental status.
Generally resolves over time
Peritonitis: IV or intraperitoneal antibiotics
Culture catheter or tunnel infection, visible exudates:
Oral antibiotics (antistaphylococcal)
If recurrent or tunnel, may need to be unroofed
Meticulous site care
Calcium gluconate: 1 g slowly IV (cardioprotective in hyperkalemia with widened QRS complex)
Cefazolin: 1 g IV or IM followed by 250 mg/2 L bag for 10 days (peritonitis)
Captopril: 25 mg sublingually
Dextrose D50W: 1 amp: 50 mL or 25 g (peds: dextrose D25W: 2–4 mL/kg)IV
Dopamine: 2–20 μg/kg/min IV
Enalapril: 1.25 mg IV
Furosemide: 20–100 mg IV (may require doses of ≥30 mg to effect diuresis in chronic renal failure)
Insulin: 5–10 U regular insulin IV (with D50 for hyperkalemia)
Naloxone (Narcan): 2 mg (peds: 0.1 mg/kg) IV or IM initial dose
Nitroglycerin: 0.4 mg sublingually; 5–20 μg/min IV
Sodium bicarbonate: 1 mEq/kg up to 50–100 mEq IV PRN
Sodium polystyrene sulfonate (Kayexalate): 1 g/kg up to 15–60 g PO or 30–50 g retention enema q6h PRN (for hyperkalemia)
Thiamine (vitamin B1): 100 mg (peds: 50 mg) IV or IM
Tobramycin: 1.7 mg/kg IV or IM followed by 10 mg/2 L bag for 10 days (peritonitis)
Vancomycin: 1 g IV or IM followed by 50 mg/2 L bag for 10 days (peritonitis)
Peritonitis with toxic or systemic symptoms
Peritonitis without toxic or systemic symptoms
Non–life-threatening electrolyte disturbances
Inability to provide self-care for continuous ambulatory peritoneal dialysis with antibiotics
Mild infections of access site
Same-day surgery for some thrombectomy procedures
Hemostasis at puncture sites
Consider cardiac tamponade in dialysis patients, even when they don't exhibit classic symptoms.
Always consider hyperkalemia in dialysis patients.
Infections can have very subtle presentations in dialysis patients and are a common cause of morbidity and mortality
Early vascular surgery consultation is important for patients with clotted or ruptured access sites
Feldman HI, Held PJ, Hutchinson JT, et al. Hemodialysis vascular access morbidity in the United States. Kidney Int. 1993;43(5):1091–1096.
Khan IH, Catto GR. Long-term complications of dialysis: Infection. Kidney Int Suppl. 1993;41:S143–S148.
Zink JN, Netzley R, Erzurum V, et al. Complications of endovascular grafts in the treatment of pseudoaneurysms and stenoses in arteriovenous access. J Vasc Surg. 2013;57:144–148.
Padberg FT Jr, Calligaro KD, Sidawy AN. Complications of arteriovenous hemodialysis access: Recognition and management. J Vasc Surg. 2008;48:55S–80S.
996.1 Mechanical complication of other vascular device, implant, and graft
996.62 Infection and inflammatory reaction due to other vascular device, implant, and graft
999.9 Other and unspecified complications of medical care, not elsewhere classified
996.68 Infection and inflammatory reaction due to peritoneal dialysis catheter
996.56 Mechanical complication due to peritoneal dialysis catheter
T80.29XA Infct fol oth infusion, transfuse and theraputc inject, init
T80.90XA Unsp comp following infusion and therapeutic injection, init
T82.9XXA Unspecified complication of cardiac and vascular prosthetic device, implant and graft, initial encounter
T82.7XXA Infect/inflm react d/t oth cardi/vasc dev/implnt/grft, init
T82.818A Embolism of vascular prosthetic devices, implants and grafts, initial encounter
T82.828A Fibrosis of vascular prosthetic devices, implants and grafts, initial encounter
T82.868A Thrombosis of vascular prosth dev/grft, init
19765000 Complication of dialysis (disorder)
85223007 Complication of hemodialysis (disorder)
33461007 Complication of peritoneal dialysis (disorder)
430332005 Infection of arteriovenous graft for hemodialysis (disorder)
17778006 Mechanical complication of dialysis catheter (disorder)
430958003 Infection of peritoneal dialysis catheter (disorder)
473034005 Complication associated with dialysis catheter (disorder)