Transcript
Chronic hemodialysisChronic hemodialysisChronic hemodialysisChronic hemodialysis
Acute HemodialysisAcute HemodialysisAcute HemodialysisAcute Hemodialysis
Treatment of poisoningTreatment of poisoningTreatment of poisoningTreatment of poisoning
ConvectionNa
KPo4
BUN
Cr
DialysisNa
yK
BUN
Po4
Cr
Complications of Central Vein pCanulation
InsertionInsertionInsertion Insertion ComplicationsComplicationsComplicationsComplicationsInfectionInfectionCatheter ThrombosisCatheter ThrombosisCentral Vein StenosisCentral Vein Stenosis
Remove catheter ifRemove catheter if::F /F / i if b i i ii if b i i iFever +/Fever +/-- rigor, if no obvious origin rigor, if no obvious origin for infectionfor infectionExit site drainage (+/Exit site drainage (+/-- systemic systemic
i )i )signs)signs)>> 7272 hours in the femoral cathetershours in the femoral catheters> > 72 72 hours in the femoral catheters hours in the femoral catheters (except in ICU patients) (except in ICU patients) Insert ional complications (arterial Insert ional complications (arterial puncture,…)puncture,…)puncture,…)puncture,…)Thrombosis and malfunctionsThrombosis and malfunctions
Vascular Access Complications:Vascular Access Complications:Vascular Access Complications:Vascular Access Complications:
Most commonMost commonMost commonMost common P blP blMost commonMost commonMost commonMost common Problems Problems Most harmfulMost harmfulMost harmfulMost harmful In In
DialysisDialysisMost cost burdenMost cost burdenMost cost burdenMost cost burden
yPatients
yPatients
Hand Ischemia Hand Ischemia (Steal (Steal Hand Ischemia Hand Ischemia (Steal (Steal Phenomena): Phenomena): Phenomena): Phenomena):
Arterial insufficiencyArterial insufficiencyArterial insufficiencyArterial insufficiency
Venous hypertensionVenous hypertensionVenous hypertensionVenous hypertension
Hand Ischemia (Steal Hand Ischemia (Steal Phenomena):Phenomena): Arterial insufficiency:Arterial insufficiency:Phenomena):Phenomena): Arterial insufficiency:Arterial insufficiency:Is more common in grafting of large Is more common in grafting of large
l d l ti (DM SLE)l d l ti (DM SLE)vessels and vasculopaties (DM, SLE)vessels and vasculopaties (DM, SLE)
Allen testAllen test
Hand Hand Ischemia Ischemia (Steal (Steal Phenomena)Phenomena)Phenomena):Phenomena):Venous Venous h t ih t ihypertensionhypertension(Sore(Sore--Thumb Thumb S )S )Sy)Sy)
Predisposing factors to Predisposing factors to aneurysm &pseudoaneurysm:aneurysm &pseudoaneurysm:
Repeated puncture siteRepeated puncture siteInfectionInfectionS b t bl diS b t bl diSubcutaneous bleedingSubcutaneous bleedingStenosis in proximal veinStenosis in proximal veinStenosis in proximal veinStenosis in proximal vein
Insufficient Blood Flow From AInsufficient Blood Flow From A--V Fistula During DialysisV Fistula During Dialysis
Hypotension, Muscle cramp, Low Sodium
Complications related to Dialysate (1)
ON yp , p,
Hemolysis, Dysequilibrium SY
Thirst,Interdialysis weight gainHigh Sodium
OSI
TIO
Cardiac Arrhythmia, Hypertension Low Potassium
OM
PO
Cardiac Arrhythmia High Potassium
Mild Hypotension, HPT, Twitching, Low CalciumTE C
O
Mild Hypotension, HPT, Twitching, tetany, Petechia
Low Calcium
Hypertension, Arrhythmia, tissue High CalciumOLY
T
calcification, hard water Sy
HPT Low magnesiumEC
TRO
magnesiumOsteoprosis and osteomalacia,Nausea, Blurred vision, weakness, hypotension
High MagnesiumEL
E
Complications related to Dialysate (2)E T
COSE
NT
ENT
HypoglycemiaNo
GLU
CCO
N Hypoglycemia( Rare)
No glucose
Hypotension, Arrhythmia, Headache, Hypoventilation,
H i H i
Acetate
uffe
r Hypocapnia, Hypoxia
Bu Metabolic Alkalosis, Bacterial overgrowthBicarbonate
Complications related to Dialysate (3)
LOWE
Hypothermia, Chills
LOWAT
URE Chills
PERA
T
S ti WHIGH
TEM
PE Sweating, Warmness, Hypotension,
Hyperventilation
HIGH
TE Hyperventilation, Tachycardia,Vomitting,
Hemolysis and yHyperkalemia
Complications related to Dialysate (4)
NHemolysis and hyperkalemia, Hyrogen Peroxide,
ATIO
Ny yp ,
Methemoglobinemia resulting cyanosis, Bownish
discoloration of venous blood
y g ,Formaldehyde, Hypochlorite,
Chloramine Nitrate
TAM
INA discoloration of venous blood,
fatigue, malaise, Coma Chloramine, Nitrate,
Copper
CONT
A
EARLY: nausea, vomitting, pruritis headache Syncope
Floride
SATE
C pruritis, headache, Syncope, bach and abdominal pain,
diarrhea, arrhythmia
DIAL
YS
LATER: Symptoms related to precipitation of calciumD precipitation of calcium,
respiratory failure, hypotension, seizure, coma
Complications related to Dialysate (5)
NAT
ION
Fever, Hypotension, Shock Malnutrition
TAM
INA Shock, Malnutrition,
Arthropathies, Amyloidosis Liver
CONT
A Amyloidosis, Liver failure (microcystins
fromMicroorganisms and Pyrogens
SATE
C from Cyanobacteria)
and Pyrogens
DIAL
YSD
Factors Resulting in a Reduction of the prescribed Dose of Hemodialysis Delivered (1)y ( )
1) Compromised urea clearance– Access recirculation
I d t bl d fl f th l– Inadequate blood flow from the vascular access– Inaccurate estimation of dialyzer performance– Inadequate dialyzer perocessing related to inadequateInadequate dialyzer perocessing related to inadequate
quality control of reuse– Blood pump/ dialysate flow calibration errors
Di l l tti d i di l i ( hi h d– Dialyzer clotting during dialysis ( which reduces effective dialyzer surface area )
– Errors in prescribed blood and dialysate flow rate due to p yvariablility in blood pump tubing
– Dialysate flow that is inappropriately set too low– Dialysate flow miscalibration– Dialysate flow miscalibration– Dialyzer reuse
Factors Resulting in a Reduction of the prescribed Dose of Hemodialysis Delivered (2)
2) Reductions in treatment time
y ( )
)– Inaccurate assessment of effective time (e.g. Use of clock)– Incorrect assumption of continuous treatment time
di i i f h di l i h i– Premature discontinuation of hemodialysis to honor patientrequest / adherence
– Premature discontinuation of hemodialysis for staff or unitPremature discontinuation of hemodialysis for staff or unit convenience, e.g. ,due to scheduling conflicts
– Delayed in starting dialysis session due to patient tardinessi k ff di l i– Wrong patient taken off dialysis
– Time on dialysis calculated incorrectlyTime read incorrectly for initiation or completion of– Time read incorrectly for initiation or completion of hemodialysis
Factors Resulting in a Reduction of the prescribed Dose of Hemodialysis Delivered (3)
3) Laboratory or blood sampling errors
y ( )
) y p g– Dilution of predialysis BUN blood sample with saline– Drawing predialysis BUN blood sample after the start ofDrawing predialysis BUN blood sample after the start of
dialysis– Laboratory error due to calibration or equipment problemsy q p p– Drawing post dialysis BUN blood sample before the end of
dialysisy– Drawing post dialysis BUN blood sample before 5 minutes
after dialysis– Laboratory error in the BUN measurement
C li ti D i HD Complications During HD hypotension (20%-30% of dialyses),cramps (5%-20%),p ( )nausea and vomiting (5%-15%), headache (5%),( %),chest pain (2%-5%),back pain (2%-5%)back pain (2% 5%),itching (5%),and fever and chills (<1%)and fever and chills (<1%).
Is the most frequent problem in chronic HDHypotension During HD
Is the most frequent problem in chronic HD patients ( it occurs in 20-50% of patients).Incidence of hypotension during HD has not been declined in the recent past 20pyears. Because acceptance of more older and more severe ill patients in HD andand more severe ill patients in HD and shorter times HD .I t di l i h t i t ib t tIntra-dialysis hypotension contributes to overall patients morbidity, limits fluid removal during dialysis and increases the need for nursing interventions.
R id fl id l ( h i l bili )
Etiology Of Hypotension During HD (1)Rapid fluid removal (more than patient tolerability).Underestimation of dry weight.Rapid reduction of plasma osmolality.Autonomic neuropathy.Diminished cardiac reserve.Use of acetate rather than bicarbonate as the dialyset buffer.Intake of antihypertensive drugs prior of dialysis.Use of low sodium concentration in dialyset.
Etiology Of Hypotension During HD (2)
Ingestion of meals during or just before di l idialysis.
Arrhythmia or severe pericardial effusion.Arrhythmia or severe pericardial effusion.
Inflammatory reaction to dialysis membrane.
Release of NO during HD.
Rare causes such as sepsis, air embolism, hemolysis, bleedinghemolysis, bleeding.
Release of adenosine.
Ischemia ATP breakdown
Decreased CO
Adenosine release
Vasodilatation
Prevention 0f Hypotension During HD (1)
Exclude cardiac causes and treat it.Avoid eating during HD.g gWithhold antihypertensive agents on the day of HDof HD.Reassess of dry weight.Correction of anemia with Erythropoietin. Intra-dialysis Dubotamine infusion.Intra dialysis Dubotamine infusion.Pre dialysis Midodrine (an alpha 1 agonist) or Sertraline (Serotonin reuptake blocker)or Sertraline (Serotonin reuptake blocker).
Prevention Of Hypotension During HD (2)
Cool temperature dialysis.Change of acetate dialysis to bicarbonateChange of acetate dialysis to bicarbonate dialysis.Adj t di l t di d ++Adjust dialyset sodium and ca++.Sodium modeling ( sodium ramping).g ( p g)Sequential UF.C t t UF # UF d liConstant UF # UF modeling.Caffeine as an adenosine receptor pblocker.
Muscle cramp During HD
waterwater
pre exercise post exercise
8090
10096.3UTi
50607080
84.4P<0.0005P<0.0005
10203040
44.949.6
42.3
45.8
8.4 8.93 2 1 6.9 8.2
P<0.05 P<0.0005P<0.005
010
symp
affec
well b
functi
objec
Subje
3 2.1
mptoms scoreect score
ll being
ctional disabiljective qualitybjective qualit
Changes in quality of life pre and post exercise during dialysis e bility
ty ity
1.13 1.1** ** * *
0.810.92
1.01
1
1.2
0 6
0.8
0.4
0.6
0
0.2
pre exercise
1 month lat
2 months la
3 months la
4 months la*p<0 05
KT/V increased after exercise during dialysisse ater
later
later
later*p<0.05**p<0.005
2 22.33 2.38 2.46*
**
1.85
2.2
2
2.5
1.5
2
0 5
1
0
0.5
/k /d pre exercise
1 month lat
2 months la
3 months la
4 months la*p<0 025
gr/kg/day
nPCR is increased after exercise during dialysisse ater
later
later
later*p<0.025**p<0.01
Hypertension during HD
Consequences of hypertension in DialysisConsequences of hypertension in DialysisCardiovascular DiseasesCardiovascular Diseases
LVH& CHF& IHD LVH& CHF& IHD M li & NM li & N li li Malignant& NonMalignant& Non--malignant malignant hypertension hypertension SS k (i h i h h i ) k (i h i h h i ) SStroke (ischaemic, haemorrhagic) troke (ischaemic, haemorrhagic) Vessel wall remodellingVessel wall remodelling(h h /h l i f i i & (h h /h l i f i i & (hypertrophy/hyperplasia of intima& (hypertrophy/hyperplasia of intima& media)media)Al d li f l i iAl d li f l i iAltered compliance of elastic arteriesAltered compliance of elastic arteriesEndothelial cell dysfunction?Endothelial cell dysfunction?
Causes of poor BP control in HD patients
Physician errorsP ti t liPatients non complianceInadequate UFqInadequate dialysisI d t tih t i dInadequate antihypertensive drugUnderlying secondary hypertensiony g y ypLack of a clear guideline for therapy
Am J Kidney Dis. [suppl 3], s120-s141; 1998
Mechanisms of Hypertension in CRF:
Expansion of ECF volume RAA system stimulationyIncreased sympathetic activityEndogenous digitalis-like factorg gProstaglandin/BradykininsAlteration of NO/endothelin/Increased body weightIncreased PTH and intracellular CaCalcification of arterial treePreexisting essential hypertensiong ypRVD and RAS
Hypertension during dialysis:Hypertension during dialysis:
Intermittent hypertension ypin the last hours of dialysisy
Treatment: Treatment:
Sub Lingual Therapy of Hypertensive Emergencies during dialysis:Emergencies during dialysis:
90%83%90%
ff ti83%
70%
80%effctiveness
complications
50%
60%
30%
40%
0%
14% 11%
0%10%
20%
0% 0%0%
Captopril Nifedipine PrazocinNephron; Nephron; 6565: : 284284--287287, , 19931993
Dialysis Disequilibrium Syndrome:Dialysis Disequilibrium Syndrome:
nausea and vomiting, restlessness, headaches, and fatigue during HD or in the immediate postdialysis period
Decreased urea concentration very fast
Arrhythmia and Angina during HD Arrhythmia and Angina during HD
Special attention to hypokalemia and digoxin
Hypoglycemia during hemodialysis Hypoglycemia during hemodialysis
Insulin dose should be reduced in the dialysis days
Hemorrhage during hemodialysis Hemorrhage during hemodialysis
Blood membrane interactionsBlood membrane interactions
Complications of CRRT (1)
:Technical Complications
1) Vascular access malfunction
2) Bl d fl d ti & l tti2) Blood flow reduction & clotting
3) Line disconnection3) Line disconnection
4) Air embolism
5) Fluid& Electrolyte disorders
6) Loss off filter efficacy
Complications of CRRT (2)
Cli i l C li ti :Clinical Complications1) Bleeding1) Bleeding
2) Thrombosis
3) Infection& Sepsis
4) Biocompatibility& Allergic reactions
5) Hypothermia5) Hypothermia
6) Nutrient loss6) ut e t oss
7) Inadequate blood purification
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