2155 (ic17) RRT Flashcards
What are the 3 ways that waste is removed in dialysis?
Diffusion
Ultrafiltration
Convection
Typical schedule of HD
4hours, 3 times a week
3 types of AV access
AV fistula
AV graft
Venous catheter
+ and - of AV fistula
Gold standard
Connecting artery to vein
Advantages
Longest survival (AV fistula can last very long)
Lowest complication rates
Disadvantages
Requires >2 months to mature
Difficult in patients with very small veins eg. elderly, diabetes, peripheral vascular disease
+ and - for av graft
Using synthetic graft
Only takes 2-3 weeks
Shorter survival, higher rates of complications
+ and - for venous catheter
Only a temporary access, when permanent access is not ready yet
For children, DM, severe PVD, obese, failed AVF or AVG attempts
For emergency dialysis
Disadvantages:
Short lifespan (weeks-months)
Prone to complications and clotting
Low blood flow - compromise dialysis adequacy
Proper cleaning and care required
Goal URR
> 65%
Goal Kt/V for HD
1.4
Goal Kt/V for PD
1.7
Why is PD less efficient than HD?
Blood is not in direct contact with peritoneal membrane → metabolic waste must travel some distance to peritoneal cavity
Cannot regulate blood flow to surface of peritoneal membrane
No countercurrent blood flow and dialysate
Suitability of PD patients
For hemodynamically unstable pts
With significant residual kidney function
No abdominal surgery in the past
Motivated, adherent to therapy
Be able to store dialysate fluid at home
Good hygiene, prevent infection
When should non diabetics and diabetics start dialysis?
Non diabetics: GFR < 15
Diabetics: GFR < 20
Higher for diabetics as if diabetes causes CKD, progression to CKD will happen faster
What are 2 most common complications during HD?
Hypotension (most common)
Due to excessive fluid removal
Advise patient to take BP meds after dialysis
Avoid heavy meals
Eat too much → splanchnic dilation, blood travels to gut and cause hypotension
Can decrease dialysate temperature
Lower temperature causes vasoconstriction → increase BP
Cramps
Caused by electrolyte imbalance
How to manage hypotension during HD?
Place patient in trendelenburg position
Reduce rate or turn off ultrafiltration → water not removed
Administer 100 - 200ml bolus of IV normal saline
Increase dialysate Na conc
Switch to bicarbonate buffered dialysate (instead of lactate dialysate which causes vasodilation)
Set dry weight accurately
Lower dialysate temp
Give Midodrine (a1 adrenergic agonist)
Cause vasoconstriction
Contraindicated with CV conditions
Correct anaemia
Administer O2
Avoid food before/during HD
Non pharm ways of catheter thrombosis (3 pts)
Force saline through (push clot out)
Mechanically remove clot
Remove catheter
Pharm ways of thrombosis
Alteplase, Urokinase, Reteplase
Symptoms during CRBSI
Fever, chills, high WBC count
What are the 2 types of CRBSI?
Exit site and Catheter related bacteremia
Treatment for exit site infection
Treat with topical antibiotics (mupirocin ointment) or IV (gram positive)
Treatment for Catheter related Bacteremia
Adopt empiric therapy
Start with gram positive (+) eg. Cefazolin, Vancomycin, and (-) antibiotic coverage
(asymptomatic) Culture specific Antibiotics for 3 weeks
(symptomatic > 36hrs) Remove catheter
Do not place fistula, graft until blood culture performed after stopping antibiotics and negative for 48 hours
Staph Aureus (Gram positive (+)) eg. MSSA (Methicillin Sensitive S.Aureus)
Use Cefazolin
MRSA (Methicillin Resistant S.Aureus)
Vancomycin
Gram negative (-) coverage
Gentamicin, Ceftazidime
BP goal for dialysis patients w hypertension
140/90 for predialysis
130/80 post dialysis
What are some medical complications of peritoneal dialysis?
Fluid overload
Increase ultrafiltration, diuretics if have kidney function
Electrolyte abnormalities eg. Hyperkalemia (cos PD solution does not contain K)
Malnutrition
During PD, patients lose more amino acids → increase protein intake
Increased glucose load (if dialysate contains dextrose)
Exacerbate DM
Can administer intraperitoneal insulin or increase subcutaneous insulin
Fibrin formation
Causes drainage bag to look cloudy
Cause outflow obstruction
Administer IP heparin
Antibiotics for peritonitis
Gram (+): Cefazolin, Vancomycin
Gram (-): Gentamicin
(+) and (-): Cefepime
Other conditions to treat during peritonitis?
Treat Hypokalaemia
Dont use H2RA
Treat GI problems eg. constipation
Do Antifungal prophylaxis eg. oral Nystatin or Fluconazole
What should we do during fungal peritonitis
Remove catheter immediately
