Dialysis

Dialysis Dialysis (Intern’s Guide to Eckel)(Intern’s Guide to Eckel)

Intern Boot Camp Intern Boot Camp

7/6/20107/6/2010

Why the boot camp lecture?Why the boot camp lecture?

Most do not get ample exposure to Most do not get ample exposure to patients on hemodialysis during medical patients on hemodialysis during medical schoolschool

Patients on hemodialysis have a different Patients on hemodialysis have a different set of medical problems that are unique to set of medical problems that are unique to them. them.

We’ll try to make this short and simple. We’ll try to make this short and simple.

ObjectivesObjectives

- Types of Dialysis- Types of Dialysis - Access- Access - Acute Indications for Dialysis- Acute Indications for Dialysis - What do I need to know to survive Eckel- What do I need to know to survive Eckel - Cases of common admissions and - Cases of common admissions and

overnight issuesovernight issues

Types of Dialysis That You Should Types of Dialysis That You Should Be Aware ofBe Aware of

1. Hemodialysis1. Hemodialysis 2. Peritoneal dialysis – just be aware of it’s 2. Peritoneal dialysis – just be aware of it’s

existence existence 3. CVVH / CVVHD / CVVHDF – mostly 3. CVVH / CVVHD / CVVHDF – mostly

seen in the ICU setting and can be seen in the ICU setting and can be grouped into one entity grouped into one entity

HemodialysisHemodialysis Hemodialysis -Dialysis works on the principles of the Hemodialysis -Dialysis works on the principles of the

diffusiondiffusion of solutes and of solutes and ultrafiltrationultrafiltration of fluid across a of fluid across a semi-permeable membranesemi-permeable membrane. .

Hemodialysis removes wastes and water by circulating Hemodialysis removes wastes and water by circulating blood outside the body through an external filter that blood outside the body through an external filter that contains a semipermeable membrane. The blood flows contains a semipermeable membrane. The blood flows in one direction and the dialysate flows in the opposite. in one direction and the dialysate flows in the opposite. This maximizes the concentration gradient of solutes This maximizes the concentration gradient of solutes between the blood and dialysatebetween the blood and dialysate

Ultrafiltration occurs by increasing the hydrostatic Ultrafiltration occurs by increasing the hydrostatic pressure across the dialyzer membrane. This usually is pressure across the dialyzer membrane. This usually is done by applying a negative pressure to the dialysate done by applying a negative pressure to the dialysate compartment of the dialyzer. This pressure gradient compartment of the dialyzer. This pressure gradient causes water and dissolved solutes to move from blood causes water and dissolved solutes to move from blood to dialysate, and allows the removal of several liters of to dialysate, and allows the removal of several liters of fluidfluid

Source - Wikipedia

Peritoneal DialysisPeritoneal Dialysis

Peritoneal dialysis - uses the same principles as before however Peritoneal dialysis - uses the same principles as before however rather than extracorpeal membranes, uses patients own peritoneal rather than extracorpeal membranes, uses patients own peritoneal membrane to move solutes across. Place dialysate bath into membrane to move solutes across. Place dialysate bath into patient’s abdomen. May have a few patients on this on the Eckel patient’s abdomen. May have a few patients on this on the Eckel serviceservice

CVVH / CVVHD / CVVHDFCVVH / CVVHD / CVVHDFWHY SO MANY ACRONYMS????WHY SO MANY ACRONYMS????

Continuous veno veno hemofiltration, continuous veno veno hemodialysis, Continuous veno veno hemofiltration, continuous veno veno hemodialysis, Continuous veno veno hemodiafiltrationContinuous veno veno hemodiafiltration

You’ll see this in the ICU setting in patients who have acute renal failure and You’ll see this in the ICU setting in patients who have acute renal failure and volume overload. This basically allows for fluid removal through volume overload. This basically allows for fluid removal through ultrafiltration and convection (high to low pressure system) as well as ultrafiltration and convection (high to low pressure system) as well as dialysis for solute removal in patient’s who may not be able to tolerate dialysis for solute removal in patient’s who may not be able to tolerate intermittent dialysis. Allows for less drastic fluid shifts and hypotension. intermittent dialysis. Allows for less drastic fluid shifts and hypotension. Goes on for 24 hours a day. Do to the high volume of ultrafiltrate that is Goes on for 24 hours a day. Do to the high volume of ultrafiltrate that is produced, know that fluid replacement is needed to to restore ideal fluid produced, know that fluid replacement is needed to to restore ideal fluid balance. balance.

You can either just have You can either just have - hemofiltration (no dialysate, replacement fluid, moderate solute removal and hemofiltration (no dialysate, replacement fluid, moderate solute removal and

large fluid removal) large fluid removal) - hemodialysis (dialysate, no replacement fluid, large solute removal, less hemodialysis (dialysate, no replacement fluid, large solute removal, less

fluid removal fluid removal - combination of both with dialysate and replacement fluidcombination of both with dialysate and replacement fluid

An Attempted diagram to Make you An Attempted diagram to Make you UnderstandUnderstand

Replacement Fluid

Dialysate

Hemofilter

From the Patient

To The Patient

Fluid Pump

Blood Pump

Ultrafiltrate Pump

Dialysate Pump

Air Detector

One slide on access. One slide on access.

This includes AV fistulas, grafts, temporary lines or permanent central access This includes AV fistulas, grafts, temporary lines or permanent central access lines that are tunneled. lines that are tunneled.

Fistulas are the preferred access type but take 3-6 months to mature. Grafts Fistulas are the preferred access type but take 3-6 months to mature. Grafts are used when you don’t have good veins/arteries next to each other and are used when you don’t have good veins/arteries next to each other and they don’t take as long after insertion to use. Complications of these include they don’t take as long after insertion to use. Complications of these include thrombosis, infections and aneurisms, and outlet obstruction. thrombosis, infections and aneurisms, and outlet obstruction.

Lines are common with our patients in the hospital because the most common Lines are common with our patients in the hospital because the most common admission on the eckel service is line infection or probable line infection. admission on the eckel service is line infection or probable line infection.

KNOW THEIR ACCESS. KNOW THEIR ACCESS.

FYI – When you try to order a picc line on a patient who is on dialysis, the FYI – When you try to order a picc line on a patient who is on dialysis, the picc line nurse will likely say no and that you need nephrology approval. picc line nurse will likely say no and that you need nephrology approval. This is because picc lines use potential areas for future access so we prefer This is because picc lines use potential areas for future access so we prefer not putting them in. If access is really needed for a long period of time, you not putting them in. If access is really needed for a long period of time, you can order a tunneled picc line to be put in by IR. can order a tunneled picc line to be put in by IR.

Eckel Admissions – Must KnowEckel Admissions – Must Know

Mr/Ms ________ is a ____ y/o with a hx of esrd or not (CKD stage __) 2/2 ______ on Mr/Ms ________ is a ____ y/o with a hx of esrd or not (CKD stage __) 2/2 ______ on hemodialysis _______via ______ at __________ hemodialysis _______via ______ at __________

- also know dry weight- also know dry weight - inter-dialysis weight gains- inter-dialysis weight gains - last dialysis session- last dialysis session - full session or not- full session or not - their nephrologist’s name - their nephrologist’s name - nutritional status- nutritional status - code status- code status

Gold Star - If their admission pertains to missed dialysis session, hypotension during Gold Star - If their admission pertains to missed dialysis session, hypotension during dialysis, anything to do with dialysis, you can get the flow sheets from the dialysis dialysis, anything to do with dialysis, you can get the flow sheets from the dialysis center by calling them. They will fax that last few sessions to you and will document center by calling them. They will fax that last few sessions to you and will document vitals and bp during session, febrile or not, medications that were given during vitals and bp during session, febrile or not, medications that were given during dialysis. dialysis.

Know if they get any medications during dialysis such as antibiotics, epogen etc. Know if they get any medications during dialysis such as antibiotics, epogen etc.

Now this is getting good. What else? Now this is getting good. What else? Give me more, give me more!!Give me more, give me more!!

- Dosing of meds - always check renal dosing on medications or HD - Dosing of meds - always check renal dosing on medications or HD dosing. These are not the same as what you usually have to dosing. These are not the same as what you usually have to prescribe. This is important because HD patients do not clear meds prescribe. This is important because HD patients do not clear meds the same way as others might, must check dosing of medications. the same way as others might, must check dosing of medications.

- ABX dosing - many abx are given as loading doses and then - ABX dosing - many abx are given as loading doses and then dosed after dialysis. Remember common ones such as vanc and dosed after dialysis. Remember common ones such as vanc and gent which are given as loading doses and then dosed during/after gent which are given as loading doses and then dosed during/after dialysis depending on vanc or gent levels. (Vanc dosing is usually dialysis depending on vanc or gent levels. (Vanc dosing is usually 20 mg/kg loading and then 500 mg after dialysis, gent is 1.5 - 2 20 mg/kg loading and then 500 mg after dialysis, gent is 1.5 - 2 mg/kg loading dose, then 1 mg/kg maintenance)mg/kg loading dose, then 1 mg/kg maintenance)

- Medications not to give to HD patients - fleet enemas, mri gad, - Medications not to give to HD patients - fleet enemas, mri gad, magnesium and phosphate, morphine! magnesium and phosphate, morphine!

CHECK DOSING, CHECK DOSING, CHECK DOSINGCHECK DOSING, CHECK DOSING, CHECK DOSING

Case 1Case 1 62 y/o female with pmh of esrd (not initiated on 62 y/o female with pmh of esrd (not initiated on

dialysis yet who is on the transplant list, dialysis yet who is on the transplant list, (baseline creatinine 7) htn, dm presents from an (baseline creatinine 7) htn, dm presents from an osh with complaints of chest pain x 5 days, osh with complaints of chest pain x 5 days, generalized fatigue and malaise. Patient on generalized fatigue and malaise. Patient on arrival to UH MICU was unstable with arrival to UH MICU was unstable with temperature of 39.0, tachycardia into 140’s, temperature of 39.0, tachycardia into 140’s, blood pressure into systolics of 70’s, with blood pressure into systolics of 70’s, with respirations 24. On exam, patient is alert and respirations 24. On exam, patient is alert and oriented, conversive, has flat neck veins, slightly oriented, conversive, has flat neck veins, slightly decreased breath sounds over left base, cv decreased breath sounds over left base, cv exam remarkable for tachycardia and no exam remarkable for tachycardia and no pericardial rub, no abdominal pain, trace pedal pericardial rub, no abdominal pain, trace pedal edema, foley catheter with dark urine. edema, foley catheter with dark urine.

Laboratory evaluation as below. Laboratory evaluation as below. 131 / 104 / 126 / 131 / 104 / 126 / --------------------- < 117 --------------------- < 117

WBC 10, HGB/ HCT 11.4 / 35.9, PLT 195WBC 10, HGB/ HCT 11.4 / 35.9, PLT 195 5.5 / 7 / 10.9 5.5 / 7 / 10.9 What more would you like? What more would you like? - if you asked for a blood gas, ph was 7.07if you asked for a blood gas, ph was 7.07- Coagulation panel showed inr of 10.2 as patient was on coumadinCoagulation panel showed inr of 10.2 as patient was on coumadin

What abnormalities do you see on hx, exam, and labs? What abnormalities do you see on hx, exam, and labs? - Decreased breath sounds suggesting possible pna- Decreased breath sounds suggesting possible pna- Vitals signsVitals signs- Anion Gap Metabolic Acidosis (as well as a non anion gap metabolic Anion Gap Metabolic Acidosis (as well as a non anion gap metabolic

acidosis)acidosis)- Upper limit of normal potassiumUpper limit of normal potassium- Acute on Chronic Renal FailureAcute on Chronic Renal Failure- Hyponatremia (likely hypovolemic hyponatremia)Hyponatremia (likely hypovolemic hyponatremia)- UremiaUremia

Does this patient need Dialysis?Does this patient need Dialysis?

ACUTE INDICATIONS FOR ACUTE INDICATIONS FOR DIALYSISDIALYSIS

Creatinine level is not an indication for dialysis Creatinine level is not an indication for dialysis Remember your vowels Remember your vowels - A – Acidosis (metabolic acidosis)- A – Acidosis (metabolic acidosis) - E - Electrolyte Abnormalities (hyperkalemia)- E - Electrolyte Abnormalities (hyperkalemia) - I - Ingestants/Toxins (lithium)- I - Ingestants/Toxins (lithium) - O – Overload (volume overload causing respiratory - O – Overload (volume overload causing respiratory

distress)distress) - U – uremia (systemic effects – uremic encephalopathy, - U – uremia (systemic effects – uremic encephalopathy,

uremic pericarditis)uremic pericarditis)

Case 2Case 2 Patient is a 42 y/o female with esrd 2/2 lupus nephritis Patient is a 42 y/o female with esrd 2/2 lupus nephritis

on HD mwf via left radial av fistula who presents to ED on HD mwf via left radial av fistula who presents to ED with compalints of muscle cramps. Vitals signs are with compalints of muscle cramps. Vitals signs are

T 36.3 / hr 97 / bp 109/68 / r 20 T 36.3 / hr 97 / bp 109/68 / r 20 Exam is significant for 1+ edema b/l in lower extremities. Exam is significant for 1+ edema b/l in lower extremities. Laboratory evaluation shows a renal function panel as Laboratory evaluation shows a renal function panel as

below. below. 132 / 109 / 36 132 / 109 / 36 -------------------- 142-------------------- 142 6.3 / 22 / 7.36.3 / 22 / 7.3

- What is your next step?- What is your next step?

Common AdmissionsCommon Admissions

HYPERKALEMIA HYPERKALEMIA Questions to ask Questions to ask - did they miss a dialysis session- did they miss a dialysis session - was their dialysis session cut short - inadequate - was their dialysis session cut short - inadequate

dialysis sessiondialysis session - did they eat an extra banana for breakfast - dietary - did they eat an extra banana for breakfast - dietary

indiscretionindiscretion - any new medications - any new medications

Follow C a BIG K Drop (Calcium, B-agonist/Bicarbonate, Follow C a BIG K Drop (Calcium, B-agonist/Bicarbonate, Insulin, Glucose, Kayexalate, Dialysis) Insulin, Glucose, Kayexalate, Dialysis)

Case 3Case 3

Mr. Jackson is a 55 y/o female with esrd 2/2 Mr. Jackson is a 55 y/o female with esrd 2/2 hypertensive nephrosclerosis on hd t/t/s via right hypertensive nephrosclerosis on hd t/t/s via right tunneled ij line who presents from his HD tunneled ij line who presents from his HD session with hypotension. Patient’s session was session with hypotension. Patient’s session was cut short 2/2 to blood pressure systolic drop into cut short 2/2 to blood pressure systolic drop into 70 systolic. Currently patient is without 70 systolic. Currently patient is without complaints. complaints.

- What are the different causes of hypotension What are the different causes of hypotension during dialysis?during dialysis?

Case 3 ContinuedCase 3 Continued

HYPOTENSION during dialysisHYPOTENSION during dialysis - too rapid or excessive fluid removal - too rapid or excessive fluid removal

removalremoval - acetate in dialysate- acetate in dialysate - heat-related vasodilation- heat-related vasodilation - underlying conditions (eg, autonomic - underlying conditions (eg, autonomic

neuropathy, myocardial ischemia, neuropathy, myocardial ischemia, arrhythmias)arrhythmias)

- sepsis- sepsis

Case 3 continuedCase 3 continuedMr. Jackson was admitted to the hospital for low Mr. Jackson was admitted to the hospital for low

blood pressures. Overnight, Odessa the blood pressures. Overnight, Odessa the secretary on LK40 calls you stating the nurse secretary on LK40 calls you stating the nurse just took his temperature and it is 38.4. just took his temperature and it is 38.4.

You look at your signout and realize you don’t You look at your signout and realize you don’t have a signout on Mr. Jackson. Now what? have a signout on Mr. Jackson. Now what?

You now head over to LK40 to read the admission You now head over to LK40 to read the admission note which states that the patient was admitted note which states that the patient was admitted for hypotension during dialysis, is usually for hypotension during dialysis, is usually hypertensive and now has spiked a temperature. hypertensive and now has spiked a temperature. Patient had a temperature during dialysis of Patient had a temperature during dialysis of 38.0 based on dialysis flowsheets in the chart. 38.0 based on dialysis flowsheets in the chart. What are you thinking?What are you thinking?

- Could this patient be septic?Could this patient be septic?- Next steps?Next steps?

Case 3 ContinuedCase 3 Continued

You go an examine the patient and notice You go an examine the patient and notice vital signs of 38.3 / 110 / 90/60 / 22vital signs of 38.3 / 110 / 90/60 / 22

On exam of the right tunneled ij, you On exam of the right tunneled ij, you noticed some erythema and tenderness at noticed some erythema and tenderness at the line site, no active drainage from the the line site, no active drainage from the catheter site? catheter site?

Now what? Now what? Labs? Labs? Meds?Meds?

Things that go bump in the Things that go bump in the night……night……

FEVER FEVER - common things common (pneumonia, uti - common things common (pneumonia, uti

(make sure they are not anuric), line infections, (make sure they are not anuric), line infections, diarrhea, osteomyelitisdiarrhea, osteomyelitis

- Line infection – Make sure you look at the line - - Line infection – Make sure you look at the line - exit site infection, tunnel infection, catheter exit site infection, tunnel infection, catheter related bacteremia. related bacteremia.

Treatment options include catheter removal, Treatment options include catheter removal, change catheter over guide wire, antibiotic locks change catheter over guide wire, antibiotic locks and catheter salvage. This depends on the and catheter salvage. This depends on the speciation of the organism. speciation of the organism.


SHORTNESS OF BREATHSHORTNESS OF BREATHQuestions to askQuestions to ask - did they miss a dialysis session- did they miss a dialysis session - was their dialysis session cut short - inadequate - was their dialysis session cut short - inadequate

dialysis sessiondialysis session If they make urine, you can give trial of diuretic (high If they make urine, you can give trial of diuretic (high

dose lasix or bumex if blood pressure allows)dose lasix or bumex if blood pressure allows) If they don’t make urine, will they make it to their next If they don’t make urine, will they make it to their next

dialysis sessiondialysis session - remember those things that pertain to all patients – PE, - remember those things that pertain to all patients – PE,

pleural effusions, pna, pericardial effusions (htn pleural effusions, pna, pericardial effusions (htn medications)medications)


Hypertension – Stuck between a rock and a hard place. Hypertension – Stuck between a rock and a hard place.

- Treat the hypertension with prn antihypertensives, Treat the hypertension with prn antihypertensives, increasing the next doses of medications that are increasing the next doses of medications that are already given. already given.

- Do not want the patient to go into hypertensive Do not want the patient to go into hypertensive emergency and flash pulmonary edema however the emergency and flash pulmonary edema however the patient needs adequate blood pressure for perfusion patient needs adequate blood pressure for perfusion (normal at higher blood pressures, need to perfuse (normal at higher blood pressures, need to perfuse access site as well as need adequate blood pressure for access site as well as need adequate blood pressure for next dialysis session.)next dialysis session.)


Bleeding Post DialysisBleeding Post Dialysis- Not much you can do about this as most Not much you can do about this as most

ESRD patients have thrombocytopenia ESRD patients have thrombocytopenia and platelet dysfunction. and platelet dysfunction.

- PRESSURE, PRESSURE, PRESSUREPRESSURE, PRESSURE, PRESSURE- In the ICU setting, can consider DDAVP In the ICU setting, can consider DDAVP

however not used very often. however not used very often.


Low Blood Counts Low Blood Counts - You will likely get called on a patient’s morning - You will likely get called on a patient’s morning

CBC by a nurse. This is likely not acute and if it CBC by a nurse. This is likely not acute and if it is, pay attention to next week’s boot camp is, pay attention to next week’s boot camp lecture by Dr. Tannous on GI bleed. lecture by Dr. Tannous on GI bleed.

- Remember in most cases, DO NOT give blood Remember in most cases, DO NOT give blood overnight. Give blood with dialysis. (general rule, overnight. Give blood with dialysis. (general rule, give abx during or after dialysis, give blood give abx during or after dialysis, give blood during or after dialysis, get labs during or after during or after dialysis, get labs during or after dialysis. dialysis.

Questions?Questions?

RememberRemember- ALWAYS GO ASSESS THE PATIENTALWAYS GO ASSESS THE PATIENT- YOU ARE NEVER ALONE, IF YOU NEED YOU ARE NEVER ALONE, IF YOU NEED

HELP, CALL YOUR SENIORHELP, CALL YOUR SENIOR

THE ENDTHE END

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