Dialysis Complications, Emergency Medicine

Christopher B. Colwell Reviewed 06/2017
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Subject: Dialysis Complications, Emergency Medicine

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Basics

Description

Dialysis complications may be: 
  • Vascular access related (infection, bleeding)

  • Nonvascular access related (hypotension, hyperkalemia)

  • Peritoneal (abdominal pain, infection)

Etiology

  • Vascular access related:

    • Infections:

      • 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

    • Bleeding:

      • Can be life-threatening

      • Aneurysm

  • Nonvascular access related:

    • Hypotension:

      • 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:

      • Volume overload

      • Development of dyspnea during dialysis owing to tamponade, pericardial effusion, hemorrhage, anaphylaxis, pulmonary embolism, air embolism

    • Chest pain:

      • Ischemic:

        • 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.

      • Pleuritic:

        • Pericarditis, pulmonary embolism

    • Neurologic dysfunction: Disequilibrium syndrome:

      • Rapid decrease in serum osmolality during dialysis leaves brain in comparatively hyperosmolar state.

  • Peritoneal:

    • Peritonitis:

      • 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

Diagnosis

Signs and Symptoms

  • Vascular access related:

    • 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

  • Nonvascular access related:

    • Hypotension before, during, or after procedure

    • Palpitations

    • Syncope

    • Chest pain:

      • Ischemic

      • Pleuritic

    • Hemorrhage:

      • GI

      • Pleural

      • Retroperitoneal

    • Shortness of breath:

    • Neurologic symptoms (disequilibrium syndrome):

      • Headache

      • Malaise

      • Seizures

      • Coma

  • Peritoneal:

    • Abdominal pain

    • Cloudy dialysis effluent

    • Nausea and vomiting

    • Exudates or inflammation at insertion site of Tenckhoff catheter

Essential Workup

  • 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.

  • Infection:

    • Blood and wound cultures

    • Cell count, Gram stain, culture of peritoneal fluid

  • Bleeding:

    • CBC to evaluate anemia and platelet count

    • Coagulation studies

  • Chest pain or shortness of breath:

    • Chest radiograph

    • ABG

    • EKG, cardiac enzymes (if appropriate, based on history)

  • Neurologic dysfunction: CT of brain for intracranial hemorrhage

Diagnosis Tests & Interpretation

Lab

  • Glucose, electrolytes, BUN, and creatinine

  • CBC

Imaging

  • ECG for suspected:

    • Hyperkalemia

    • Pericarditis

    • Effusion

    • Tamponade

  • 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.

Differential Diagnosis

  • Hypotension:

    • Sepsis

    • Cardiogenic shock, acute MI, tamponade, primary dysrhythmias

    • Electrolyte abnormalities leading to dysrhythmias (hyperkalemia and hypokalemia)

    • Embolism: Air or pulmonary

    • Hypovolemia

    • Vascular instability: Autonomic neuropathy, drug related, dialysate related

  • Neurologic complications:

    • Cerebrovascular accident

    • Disequilibrium syndrome

    • Hyperglycemia or hypoglycemia

    • Hypernatremia or hyponatremia

    • Hypoxemia

    • Intracranial bleed

    • Meningitis or abscess

    • Uremia

  • Peritoneal complications:

    • Peritonitis

    • Hernia incarceration

    • Perforated viscus

    • Acute abdominal process: Appendicitis, cholecystitis

Treatment

Pre-Hospital

  • 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).

Initial Stabilization/Therapy

  • Check airway, breathing, and circulation.

  • Vascular access related:

    • Bleeding:

      • 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.

      • Apply Gelfoam.

  • Nonvascular access related:

    • Hypotension:

      • Search for underlying cause.

      • Vasopressors, fluids

    • Shortness of breath:

      • Preload and afterload reduction with nitrites and ACE inhibitors.

      • Attempt diuresis if fluid overload is suspected cause.

      • Arrange for dialysis.

    • Hyperkalemia:

      • Administer IV calcium, bicarbonate, insulin, and glucose when appropriate (see “Hyperkalemia”).

      • Monitor cardiac rhythm.

      • Administer ion-exchange resin (Kayexalate).

      • Arrange for dialysis.

    • Neurologic complications:

      • Administer naloxone, thiamine, dextrose (or Accu-Chek) for altered mental status.

      • Control seizures with benzodiazepines.

Ed Treatment/Procedures

  • Vascular access related:

    • Infection:

      • Initiate antistaphylococcal IV antibiotics.

    • Clotted access:

      • Analgesia

      • Warm compresses

      • Vascular surgery consult

    • Hemorrhage:

      • Control bleeding.

      • Correct coagulopathies.

      • Administer IV fluids and blood products.

  • Nonvascular access related:

    • Electrolyte imbalances:

      • Treat hypercalcemia or hypermagnesemia with saline infusion if tolerated (dilution).

      • Diuresis with furosemide after preload and afterload reduction (nitroglycerin, enalapril)

      • Arrange for dialysis.

    • Volume overload:

      • Attempt diuresis with nitrites and furosemide.

      • Arrange for dialysis.

    • Pericardial effusion or tamponade:

      • Emergent pericardiocentesis may be necessary in unstable patient.

      • Arrange for dialysis.

    • Acute MI:

      • Thrombolytics or angioplasty if patient is appropriate candidate

      • Nitrates to decrease myocardial workload

    • Disequilibrium syndrome:

      • Rule out other causes of altered mental status.

      • Generally resolves over time

  • Peritoneal:

    • 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

    • Perforated viscous:

      • IV antibiotics

      • Surgical consultation

Medication

  • 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)

Follow-Up

Disposition

Admission Criteria

  • ICU admission:

    • Severe hyperkalemia

    • Pulmonary edema

    • Volume overload

    • Persistent hypotension

    • Uncontrolled seizures

    • Acute MI

    • Cardiovascular accident

    • Pericarditis

    • Sepsis

    • Peritonitis with toxic or systemic symptoms

  • Regular admission:

    • Fever

    • Vomiting

    • Peritonitis without toxic or systemic symptoms

    • Non–life-threatening electrolyte disturbances

    • Inability to provide self-care for continuous ambulatory peritoneal dialysis with antibiotics

Discharge Criteria

  • Mild infections of access site

  • Same-day surgery for some thrombectomy procedures

  • Hemostasis at puncture sites

Followup Recommendations

Most patients on dialysis are followed closely by their nephrologists. 

Pearls and Pitfalls

  • 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

Additional Reading

  • 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.

See Also (Topic, Algorithm, Electronic Media Element)

  • Renal Failure

  • Hyperkalemia

Codes

ICD9

  • 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

ICD10

  • 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

SNOMED

  • 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)

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