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dialysis_patient

the dialysis patient in the ED

introduction

  • the dialysis patient presents unique complexities to ED staff and early discussion with a renal team is advisable.
  • many peripheral hospitals have satellite outpatient dialysis services managed by a parent renal unit in a tertiary hospital, although dialysis is limited to routine dialysis and not to manage severe acute hyperkalaemia.
  • as a general rule, patients from these services who develop significant medical issues and present to the ED, should have their care discussed with their parent renal unit, in the first instance rather than a local renal unit.
  • if dialysis patients require admission to hospital, at most hospitals including WH, the patient should be admitted under the renal unit irrespective of their presenting complaint

the patient who missed their dialysis session

  • these patients are at significant risk of both:
  • this risk increases with length of delay and if the delay has been more than 24hrs, the renal registrar should be contacted ASAP and the patient should have an urgent ECG and U&E on arrival, and if ECG changes or hyperkalaemia, moved to a monitored cubicle urgently and iv access gained (but not via the fistula)
  • if mod-severe ECG changes of hyperkalaemia, the patient should have Rx started ASAP whilst awaiting emergent dialysis
    • start iv 50% glucose 50ml with 10-20 units actrapid insulin over 1hr
    • consider iv 1g calcium gluconate 10% 10ml over 3-5min if severe ECG changes
  • immediate dialysis in a cardiac monitored area (ICU or ED) is preferable to driving K into cells as this then reduces the effectiveness of dialysis in removing K+ resulting in rebound hyperkalaemia after dialysis
    • if K > 7mM or wide QRS or loss of P waves, it is probably worth starting insulin/dextrose whilst awaiting dialysis, particularly if there is delay

medical emergencies post-dialysis

post-dialysis hyperkalaemia

  • see above

hypotension

  • dialysis removes body fluid reducing effective circulating fluid volume and risks hypotension if rate of removal exceeds the person's ability to compensate
  • most patients have a 10ml/kg/hour maximum hourly ultrafiltration rate during haemodialysis although renal doctor may vary this
  • daily doses of antihypertensive medication should be given after, and not before, dialysis treatment unless otherwise instructed
  • hypotensive prone patients should not be given food during dialysis

Mx of presumed haemodialysis-induced hypotension

  • turn off ultrafiltration
  • Trendelenberg position
  • 100-200mL iv N Saline bolus, repeat as needed to max. 500mL
  • if BP still low, cease dialysis, search for other causes of hypotension
  • if BP acceptable, recommence UFR, reassess patient’s dry weight

dialyser reactions

Type A – anaphylactoid response

  • more likely to occur in patients with a history of atopy and/or eosinophilia
  • may occur within the first 30 minutes of dialysis
  • cease dialysis
  • clamp blood lines
  • discard dialyser and blood lines without returning blood to patient
  • consider antihistamines, steroids, adrenaline as per Anaphylaxis

Type B - non-specific response

  • less well understood and are suggested to be caused by complement activation
  • usually present as chest/back pain within 20-40min of starting dialysis
  • exclude other causes of chest pain
  • can usually continue dialysis

air embolism

  • in seated patients, may present as:
    • stroke
    • convulsions
    • loss of consciousness
  • in recumbent patients, may present as:
    • chest tightness, cough, SOB
    • weakness
    • arrhythmias
    • cardiac arrest

Mx of presumed air embolism

  • turn blood pump off, do not return blood
  • clamp lines
  • position patient on left side, head down (Trendelenberg position) to trap air in the right ventricle of the heart
  • 100% oxygen
  • resuscitation as needed
  • determine site of air entry
  • take dialysis machine out of service for maintenance

haemolysis

  • acute haemolysis during dialysis may be a medical emergency due to sudden severe hyperkalaemia and anaemia
  • note that delayed haemolysis of injured red blood cells may continue for some time after the dialysis session has been terminated
  • may present as:
    • back pain/ chest pain/ dyspnoea
    • tightness in chest and/or pain in fistula arm
    • blood leaving the dialyser is translucent and doesn’t clot (cherry red or port wine colour)
    • dramatic deepening of skin pigmentation
    • marked fall in haemoglobin
    • weakness
    • cardiac arrest

Mx of acute haemolysis

  • stop blood pump and clamp venous and arterial lines
  • do not return blood to the patient - haemolysed blood has a very potassium content
  • disconnect patient from dialysis machine
  • resuscitation as needed
  • cardiac monitor and ECG, be prepared to Rx hyperkalaemia
  • take urgent bloods for U&E, FBE, haptoglobin, LDH, bilirubin and AST
  • collect dialysate sample for assessment of contaminants
  • dialysis machine must be taken out of service
  • batch numbers of the fistula needles, blood lines and dialyser must be recorded and communicated to the dialysis consumables provider
  • water contaminants will affect all patients, thus every patient undergoing dialysis at the same time in the unit should be reviewed for signs of haemolysis including the collection of an urgent FBE specimen

dialysis disequilibrium syndrome

dialysis_patient.txt · Last modified: 2019/04/05 08:34 (external edit)