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55 > CKD - RRT > Flashcards

CKD - RRT Flashcards

1
Q

what to watch out for to see if need acute/emergency dialysis

A
  • Acid base imbalance
  • Electrolyte imbalance
  • Intoxication (drug overdose)
  • Overload (fluid)
  • Uremia
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2
Q

Places for HD access

A
  • AV fistula (best one) –> longest survival, lowest complication but take 2 wweks to set up
  • AV graft –> synthetic graft
  • Venous catheter –> for AKI and emergenct/ short term access, highest risk of complications (cleaning and care is required)
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3
Q

Goals of hemodialysis

A
  • removal of waste
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4
Q

SE of HD

A
  • Hypotension
  • N/V, headache
  • Pruritis
  • Fever / chills (infection!!)
  • cramps
  • loss of conciousness
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5
Q

causes of hypotension in HD

A
  • hypovolemia (lack of fluids)
  • excessive ultrafiltration
  • anti HTN meds
  • target dry weight is too low
  • Diastolic , autonomic dysfunction
  • Low Na and Ca in dialysate
  • Meal (blood flow to gut)
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6
Q

Management of intradialytic hypotension

A
  • administer fluids for hypovolemia
  • turn off ultrafiltration
  • decrease temp to 35 -36 to cause vasoconstriction
  • put in trendelburg position
  • reduce vasodilation: use bicarbonate buffered dialysate, use midocrine (alpha 1 agonist)

administer O2 if pt has anemia

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7
Q

Causes of cramps due to HD

A
  • IDH and muscle hypoperfusion
  • electrolyte/acid base imbalance
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8
Q

Management of cramps

A
  • correct volume contraction/electrolyte imbalance
  • massage
  • vit E
  • muscle relaxants
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9
Q

Management of catheter related thrombosis (CRT) in HD

A
  • forced saline flush
  • catheter removal / exchange over guide wire
  • Pharmacological (Intraluminal thrombolytics): Alteplase (r-tPA), Urokinase, Reteplase

  • Risk in decreasing order: Catheters > grafts > fistulas
  • Intrinsic (inside lumen) VS extrinsic (outside lumen)
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10
Q

Presentation of Catheter-related blood stream infection (CRBSI) in HD

A
  • Fever, chills, rigors, elevated WBC count
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11
Q

risk factors for bacteremia from CRBSI

A
  • DM
  • immunosuppressed
  • history of catheter infections
  • S.aureus in nasal carriage
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12
Q

How to treat catheter-related bacteremia

A
  1. empiric therapy
  2. take a culture
  3. streamline therapy –>ABx for min 3 weeks
    - if >36h/unstable: remove catheter

Do not place permanent access until blood cultures (performed after stopping Abx) have been -ve for 48h

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13
Q

What antibiotics are used in CRBSI

what bacteria use what antibiotic

A
  • MSSA (methicillin-susceptible S. aureus) –> cefazolin
  • MRSA (methicillin-resistant S.aureus) –> vancomycin. Can be used when pt has past history of catheter infections
  • Gram -ve : gentamicin (nephrotoxic but pt id on HD so issok) or ceftazidime (3rd gen cephalosporin)

vancomycin for MRSA: can be used when pt has past history of catheter infections

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14
Q

Whats Abx lock therapty

and function and how to do it

A
  • function: to salvage catheter
  • instil catheter lumen with Abx solution at the end of dialysis
  • Solution is withdrawn before next HD and this process is repeated after every HD.
  • Abx solution usually mixed with heparin or NS to fill catheter lumen (2-5ml)
  • Usually used in combi with systemic Abx for 7-14 days
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15
Q

How to manage HTN in HD

A
  • Between dialysis session, excess fluid accumulation , fluid restriction (800ml), Na restriction.
  • increase dialysis ultrafiltration/ length / frequency
  • ACE/ARB, DHP CCB can be restarted
    • Anti HTN drugs taken at night to reduce nocturnal surge of BP and minimise IDH.
  • Some drugs are not dialysed out so consider dose adjustment

  • can take anti htn med on non dialysis days to prevent hypotension
  • Diuretics only if they have sufficient urine output (~250ml)
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16
Q

who are PD suitable for:

A
  • hemodynamically unstable. These pts have lower BP or weaker cardiac function who cannot tolerate HD
  • with significant residual kidney function
  • ambulant and disciplined to self care, practise proper hygiene
  • must not have major abdominal surgeries in the past
17
Q

Complications of PD

A
  • Kinking of cathter
  • inflow/outflow obstruction
  • impacted stools
  • Peritonitis (infection!!)
  • Fluid overload
  • electrolyte abnormalities (esp hypokalemia)
  • Malnutrition
  • ## High glucose load

Hypokaelmia: PD dialysate no K, PD is done multiple times a day, dextrose can stimulate insulin pdtn –> K shift from ECF to ICF

18
Q

Clinical presentation of Peritonitis

and lab abnormalities

A
  • Elevated dialysate WBC >100/mm3 + >50% neutrophils
  • Abdominal pain, cloudy effluent, fever, N/V, chills

  • Gram +ve due to involvement of skin. However, sterile culture peritonitis can occur
  • Can be gram -ve since peritoneum is near the GIT which is full of gram -ve bacteria
19
Q

How to prevent Peritonitis

A
  • Systemic prophylactic Abx given immediately before catheter placement: cefazolin, vancomycin, gentamicin.
    • Use antifungal prophylaxis during Abx therapy (Nystatin PO 500,000 units QDS or Fluconazole 200mg q48h)
  • Avoid/treat hypokalemia
  • Avoid/limit use of H2RAs -> GIT decreased ability to kill bacteria
  • Avoid/treat GI problems e.g. constipation
20
Q

How to treat Peritonitis

A
  • IP Abx
  • Empiric therapy: Cefazolin, vancomycin, gentamicin, ceftazidime (gram -ve), cefepime (!! 4th gen cephalosporin is both gram +&-)
  • IP AG -> intermittent dose recommended to avoid risk of ototoxicity
  • Donot put AG and penicillin in the same bag
  • If no improvement in 5 days remove catheter, initiate HD, IV ABx for 2 weeks

allow Abx to dwell for at least 6h

21
Q

How to treat fungal peritonitis

A
  • Remove catheter immediately
  • Treatment: azoles (fluconazole), echinocandins (caspofungin), amphotericin B
22
Q

Catheter related infection (CRI) in PD

types, causes, risk factors

A
  • exit-site and tunnel infection
  • mostly caused by S. aureus
  • risk: DM, immunosuppress, nasal carriers of S. aureus

  • Frequency of exit site infection ~every 24-48 months
23
Q

Clinical presentation of CRI in PD

A

Purulent discharge (most likely exit site), erythema (at exit site), fever, chills

24
Q

Prevention and treatment of CRI in PD

A
  • Prophylactic Abx (e.g. nasal Abx for nasal carriers of S.aureus) before catheter insertion
  • Leave exit site dressing intact for 7 days after catheter insertion
  • Train and educate pts and caregivers on care of exit site
  • treatment: oral Abx
25
Q
A

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