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Dialysis Complications, Emergency Medicine

Basics

Description

- 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

- 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: - Hemorrhage: - 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

- EKG: Look for signs of electrolyte balance or conduction disturbances. - Infection: - Blood and wound cultures - Cell count, Gram stain, culture of peritoneal fluid

- Peritoneal complications: - Peritonitis - Hernia incarceration - Perforated viscus - Acute abdominal process: Appendicitis, cholecystitis

- Clotted access: - Analgesia - Warm compresses - Vascular surgery consult

- Acute MI: - Thrombolytics or angioplasty if patient is appropriate candidate - Nitrates to decrease myocardial workload

- 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

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 aureusCan present with signs of localized infection or systemic sepsisCan also present with minimal findingsThrombosis or stenosis:Often presents with loss of bruit or thrill over access siteMust be addressed quickly (within 24 hr) to avoid loss of access siteBleeding:Can be life-threateningAneurysm
  • Nonvascular access related:Hypotension:Most common complication of hemodialysisAfter dialysis: Often owing to acute decrease in circulating blood volumeDuring dialysis: Hypovolemia (more commonly) or onset of cardiac tamponade owing to compensated effusion suddenly becoming symptomatic after correction of volume overloadMI, sepsis, dysrhythmias, hypoxiaHemorrhage secondary to anticoagulation, platelet dysfunction of renal failureShortness of breath:Volume overloadDevelopment of dyspnea during dialysis owing to tamponade, pericardial effusion, hemorrhage, anaphylaxis, pulmonary embolism, air embolismChest pain:Ischemic:Dialysis patients are often at high risk for having atherosclerotic diseaseDialysis is an acute physiologic stressor with transient hypotension and hypoxemia that increases myocardial oxygen demand.Pleuritic:Pericarditis, pulmonary embolismNeurologic 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 exchangeS. aureus or Staphylococcus epidermidis (70%)Perforated viscus with abdominal pain that can be severe, fever, brown or fecal material in effluent, or localized tendernessFibrinous blockage of catheter resulting from infection or inflammation

Diagnosis

Signs and Symptoms

  • Vascular access related:Bleeding from puncture sitesLoss of bruit in graftLocal infection, cellulitis, feverDecreased sensation and strength distal to accessNew or increasing size mass adjacent to access site
  • Nonvascular access related:Hypotension before, during, or after procedurePalpitationsSyncopeChest pain:Hemorrhage:Shortness of breath:Neurologic symptoms (disequilibrium syndrome):HeadacheMalaiseSeizuresComa
  • Peritoneal:Abdominal painCloudy dialysis effluentNausea and vomitingExudates 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 oximetryCareful 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 culturesCell count, Gram stain, culture of peritoneal fluid
  • Bleeding:CBC to evaluate anemia and platelet countCoagulation studies
  • Chest pain or shortness of breath:Chest radiographABGEKG, 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:HyperkalemiaPericarditisEffusionTamponade
  • US of access for possible clotted graft or fistulaECHO 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 offCommunicate contrast load to renal team, as dialysis may need to occur for longer-than-normal duration.

Differential Diagnosis

  • Hypotension:SepsisCardiogenic shock, acute MI, tamponade, primary dysrhythmiasElectrolyte abnormalities leading to dysrhythmias (hyperkalemia and hypokalemia)Embolism: Air or pulmonaryHypovolemiaVascular instability: Autonomic neuropathy, drug related, dialysate related
  • Neurologic complications:Cerebrovascular accidentDisequilibrium syndromeHyperglycemia or hypoglycemiaHypernatremia or hyponatremiaHypoxemiaIntracranial bleedMeningitis or abscessUremia
  • Peritoneal complications:PeritonitisHernia incarcerationPerforated viscusAcute 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 ā¤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 bleedingDocument presence or absence of thrill after pressure was applied.Apply Gelfoam.
  • Nonvascular access related:Hypotension:Search for underlying cause.Vasopressors, fluidsShortness 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:AnalgesiaWarm compressesVascular surgery consultHemorrhage: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 candidateNitrates to decrease myocardial workloadDisequilibrium syndrome:Rule out other causes of altered mental status.Generally resolves over time
  • Peritoneal:Peritonitis: IV or intraperitoneal antibioticsCulture catheter or tunnel infection, visible exudates:Oral antibiotics (antistaphylococcal)If recurrent or tunnel, may need to be unroofedMeticulous site carePerforated viscous:IV antibioticsSurgical 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 Ī¼g/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 Ī¼g/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 hyperkalemiaPulmonary edemaVolume overloadPersistent hypotensionUncontrolled seizuresAcute MICardiovascular accidentPericarditisSepsisPeritonitis with toxic or systemic symptoms
  • Regular admission:FeverVomitingPeritonitis without toxic or systemic symptomsNon-life-threatening electrolyte disturbancesInability 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 dont 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)