HD Flashcards
1
Q
indication of starting RRT?
A
intractable FO / HT refractory hyperK refractory acidosis refractory anaemia unexplained functional decline weight loss or nutritional status deterioration
urgent: neuropathy, encephalopathy, pericarditis, pleuritis, bleeding tendency
2
Q
benefit of early start RRT?
A
IDEAL: 9ml vs 7ml no change in QOL or survival
3
Q
What is extraction ratio?
A
(inlet - outlet)/ inlet urea concentration
4
Q
What is clearance?
A
volumn of blood cleared of solute in certain period of time
5
Q
relationship of extraction ratio and clearance?
A
extraction ratio x Qb = clearance
but higher Qb has lower ER
6
Q
What is K0A
A
mass transfer area coefficient, clearance at maximal Qb and Qd
depends on area and membrane permeability
as dialyzer clearance
<500ml/min low, >800ml/min high
7
Q
What is flux
A
Kuf water permeability, to measure ability to remove large molecule
high flux >20ml/hr, low flux < 8
8
Q
how to measure spkT/V
A
stop UFR
slow Qb to 100ml/min, wait 30s
or stop Qd and wait 3min
9
Q
what is cardiopulmonary recirculation
A
blood from outlet returns to inlet through heart and lung without going through capillary bed again
usually 5 - 10% less efficient
10
Q
what is ekT/V
A
measure post dialysis urea 30min after RRT after urea rebound to calculate kT/V
11
Q
how to measure residual Kru
A
urine vol x urine urea / serum urea x (24hr x 60min)
12
Q
what is stdkT/V
A
to normalize kT/V so not dependent on number of treatment used
13
Q
target spkT/V?
A
3x HD: min 1.2 target 1.4
2x HD: min 1.8 target 2.0
14
Q
ultrapure dialysis solution requirement?
A
bacteria < 0.1 cfu / ml
endotoxin < 0.03 eu/ml
15
Q
aluminium toxicity symptom?
A
EPO refractory anaemia, dialysis encephalopathy syndrome, bone disease
16
Q
aluminium source in HD patient?
A
from aluminium pipe
17
Q
chloramine toxicity symptoms?
A
hemolysis
18
Q
source of chloramine
A
in water as bacterstatic, increase if depleted carbon bed
19
Q
fluoride toxicity symptoms?
A
puruitis, VF, nausea
20
Q
fluoride source in HD?
A
depleted deionizer
21
Q
standard HD dialyzate composition?
A
Na 135 - 145 K 2 HCO3 26 - 36 Ca 1.25 - 1.75 Mg 0.25 - 0.375 glycose 5.5 acetate 3 - 8
22
Q
preparation for AVF?
A
preserve arm veins avoid CVC / IV drip / PPM
Hx: DM / PVD, CHF
P/E palpate pulse, bil arm BP, allen test, edema / collateral vein / size discrepency
Imaging: USG doppler:
- minimal vein 2.5mm, minimal arterial size 1.5mm, arterial / vein dilatation test, mapping
venogram / arteriogram if indicated
23
Q
AVF sites?
A
conventional:
- snuffbox
- radiocephalic
- ulnar-basilic
- brachiocephalic
transposed:
- forearm cephalic to proximal radial / brachial
- forarm basilic to radial / brachial
24
Q
how to assess AVF ready to use?
A
rule of six: 6 weeks maturation 600ml/min flow < 6mm away from skin surface > 6mm in diameter 6cm length
25
AVG site?
radio-basilic (straight)
brachial basilic (loop)
brachial axillary
26
A and V needle position?
inlet: distal, 3cm from anastomotic site, point downstream
outlet: proximal, 5cm (or ?2.5cm) away from inlet, point downstream
27
buttonhole technique pros and cons?
increase infection and does not prolong AVF survival
28
how long to press after cannulation AVF?
```
10min
prolonged bleeding (>20min) suggest outflow stenosis
```
29
complications of CVC insertion?
```
arterial puncture
pneumothorax / hemothorax
arrhythmia, perforation of cardiac chamber, tamponade
air embolism
retroperitoneal hematoma
```
Watch out if chest pain / SOB / hypotension after starting HD
delayed complications:
thrombosis, infection, central vein stenosis, AVF
injury to brachial plexus, recurrent laryngeal nerve
30
care of CVC?
sock catheter hub and connectors in antiseptic x 5min (chlorhexidine >0.5% better than povidone iodine), dried then disconnect
scrubbed with chlorhexidine and covered with dry dressing
avoid bathing
1000 - 5000 unit/ml heparin priming
flush with heparinizaed saline (100unit/ml) before use
vancomyin / gentamycin lock controversal
ES mupirocin ointment reduced CRBSI and cath survival but increase resistance
31
AVF stenosis features?
P/E: pulse augmentation fail: inflow stenosis
arm elevation fail to collapse: outflow stenosis
occluding access between A and V needle, if AP / VP worsen will suggest inflow / outflow stenosis
HD: increase recirculation > 10%, prolonged bleeding, high AP / VP > 120mmHg if 15G or 150mmHg if 16G
saline dilution
doppler, < 600ml/min for AVF, < 1000ml/min for AVG
intra access pressure: A limb > 75% MAP, V limb > 50% MAP
32
AVF stenosis Tx?
angioplasty if > 50%, +/- stenting (more in AVG)
33
AVF thrombosis Px?
DAPT ? warfarin
34
AVF steal feature?
cold, weakness, numbness extremities
35
AVF with numbness ddx?
CTS, VPD, neuropathy
36
AVF steal Tx?
DRIL, banding
37
AVF pseudoaneurysm s/s?
thin / shinny skin, prolnoged bleeding, ulcer, increasing size suggest impending rupture
38
AVF pseudoaneurysm Tx?
stenting / surgery
39
AVF infection Tx?
Abx x 6 weeks, remove if embolic
40
AVG infection Px and Tx?
prophylactic Abx if dental, genitourinary OT
cover both SA and GNB
remove AFG if within 30 days of placement
41
CHF with AVF ddx
anaemia, minoxidil / hydralazine without BB use
42
CVC MSSA ESI Tx?
```
topical mupirocin / oral Abx
nasal decolonization (IN mupirocin bd each nostril x 5 days)
```
43
indication for CVC removal in ESI?
tunnel tract collection, persistant / recurrance ESI, systemic sign, blood C/ST +ve
44
CRBSI Tx?
empirical Abx (vancomycin 20mg/kg then 500mg post each HD) / cefazolin 20mg/kg post HD + gentamycin 1mg/kg post HD / fortum 1g post HD)
with antibiotics lock (vancomycin 2.5mg/ml or gentamycin 1mg/ml) mix with 5000 unit/ml heparin
if C/ST -ve: stop antibiotics
if bacteremia / fungemia clears:
- CnS: 2wks abx or guidewire exchange
- GNB: 2wks abx or guidewire exchange
- SA: 3 wks abx + CVC removal if TEE -ve
- Candida: 2 weeks abx + CVC removal
- PA: 3wks abx + CVC removal
if bacteremia persists:
- CVC removal + rule out mestatic infection (IE, OM, epidural abscess, septic arthritis) + 4 - 6wks Abx
guidewire exchange only if s/s CRBSI clears and not SA / PA / candida
45
indication for removal in CRBSI?
septic emboli, septic shock, tunnel tract infection
46
CVC poor flow causes and Ix and Tx?
early dysfunction:
kinking, edema compressing on catheter (resolve in 24hr), malposition, improper tip, neck position, intracatheter thrombosis
Ix: CXR
Tx: try alteplase 1mg/ml x 2mg +/- filling NS and dwell x 30 - 60min, or try infusion 1mg / lumen / hour
late dysfunction:
fibrin sleeve, mural thrombus: treat by balloon angioplasty to tunnel
47
Central vein stenosis s/s and Ix and Tx?
limb / neck / face edema, neck collaterals, high VP, prolonged bleeding
Ix by angiogram
Tx by angioplasty, stenting, bypass, AVF ligation
48
Acute HD URR target / kT/V target and how?
URR 40% esp if urea > 44
BFR 200ml/min, 2 hour Tx time, relatively low efficiency (500 - 600) dialyzer
then aim kT/V > 1.3, assume 3x / week HD
49
acute HD dialyzate HCO3 setting?
if respi alkalosis / acidosis: aim normal pH with low or high HCO3
if acidosis < 10 HCO3: use HCO3 20-25 to avoid hypoCa, acidification of CSF and lactic acidosis
also consider HCO3 4 from acetate
50
acute HD dialyzate Na setting?
If Na > 130: aim dNa 140-145, dNA - sNa < 10
If Na < 130:
use CVVH, or correct hypoNa first
or use 100ml/min BFR, lowest dNa setting, HD x 1-2hours
if hyperNa: dNA - sNA < 5 to avoid cerebral edema / spasm,
51
acute HD dialyzate K setting?
most 2, 2.5 or 3.5 if prone to arrhythmia / on digitalis
52
acute HD dialyzate Ca setting
1.25, though 1.5 might have less hypotension
53
acute HD dialyzate Mg setting?
0.375, 0.25 more IDH
54
hypoMg in HD causes?
TPN, malnorish, PPI, diuretics
55
acute HD dextrose setting?
5.5, higher 11 has less K removing effect
56
acute HD PO4 setting?
1.3 if hypoPO4 as can cause respi arrest
| or correct PO4 first
57
acute HD UFR aim?
10ml/kg/h
58
cause of inflow sucking and Mgt
CVC: tip malposition, fibrin plug
- move neck, AV exchange, urokinase lock, stripping
```
AVF: improper A needle position
low BP
AVF vessel spasm
inflow stenosis
A needle clotting
A line kinking
access collapse
needle too small
- redue BFR, check BP, A needle manipulation, evaluate for inflow stenosis
```
59
cause of high VP
small V needle
clotting venous bloodline filter
outflow stenosis
improper needle prosition
60
ekT/v target ?
usually 0.15 lower than spkT/V
61
stdkT/V target?
2.1
62
suboptimal kT/V cause and Tx?
poor access
large patient
interruption of HD session
63
high flux vs low flux benefit?
HEMO: no survival benefit
but if on longer dialysis > 3.7 years survival better, also less CV mortality
European MPO same
64
chronic HD K setting?
2, 3 unless pre HD hypoK or on digitialis, 1 is associated with cardiac arrest
65
optimal total cholesterol level?
5.2-6.5
66
IDH causes?
```
volume related:
- DW too low
- high IDWG
- short dialyzate time
vasoconstriction:
- Anti HT
- autonomic dysfunction
- aneamia
- eating during HD
- dialyzate temp too high
cardiac
- diastolic dyfunction
- tamponade
- MI
Others
- septicaemia
- hemolysis
- hemorrhage
- air embolism
- dialyzer reaction
```
67
IDH Drug Px:
midodrine (alpha agonist) before HD (CI if IHD)
sertraline (SSRI)
fludrocortisone if low aldo
68
type of dialyzer reaction, sym and cause and tx?
type A: IgE related
sym: fever, rash, SOB, abdo pain, diarrhea, cough, running nose
cause: ethylene oxide, AN69 + ACEI, endotoxin / bacteria, heparin, unsubstituded cellulose membrane
type B: complement related
sym: chest pain, back pain
cause: non biocompatible dialyzer membrane
Tx: stop HD, clamp line, H2R / steroid / adrenaline
69
sym and cause and Tx of hemolysis in HD?
sym: SOB, chest pain, back pain, pot wine blood in venous line
mechanical: tube kinking, small needle under high BFR
dialyzate related:
- too hot
- hypotonic due to insufficient substrate
- chloramine contamination
- copper / zinc / formaldehyde, bleach, fluoride, nitrate, H2O2
Tx: stop HD, clamp line, treat hyperK, anaemia, test dialyzate water
70
air embolism sym and cause in HD?
sym: LOC, convulsion, chest pain, SOB, arrhythmia, foam in venous bloodline
cause: disconnected tubing with v negative AP
Tx: clamp bloodline, lean on left side with head down
71
dysequilibrium sym and Tx and Px?
sym: headache, confusion, convulsion
Tx: reduce BFR or stop HD, ? hypertonic saline / manniotol
Px: URR 40% if urea high, dialyzate Na not lower than serum Na > 3
72
muscle clamp in HD ddx and Tx?
```
ddx:
- vasoconstriction of vessel to muscle
- hypoCa
- hypoK
Tx:
- hypertonic saline / D10, massage, nifedipine
Px:
- stretching, increase dialyzate Na, high dialyzate Mg .5, carnitine, oxazepam, Vit E, NOT quinine
```
73
nausea in HD ddx?
dysequilibrium, dialyzer reaction, IDH, gastroparesis
74
itchiness in HD ddx?
high CaPOt production, PTH high, inadequete kT/V, dialyzer reaction
75
uremic puruitis Tx?
adequete kT/V, CaPO4 control
ointment, gabapentin (300mg daily), UVB, charcoal 6g/d, Nalfurafine (K opioid agonist), Naltrexone (mu opioid antagonist), FK ointment, acupuncture
76
RF for HD clotting
low BFR, high Hct, high UFR, access recirculation, blood / lipid infusion, drip chamber
77
signs of HD clotting
dark blood, black streak in dialuzer, foaming in drip chamber, rapid filling of transducer monitor with blood, teetering (blood in venous line fall back into line segment), clot at inflow dialyzer header
high AP / VP
dialyzer clotted fiber (< 10% grade 1, < 50% grade 2, > 50% grade 3)
78
agent for anticoagulation in HD?
unfractionated / LMWH, trisodium citrate, direct thrombin inhibitors (argatroban), heparinoid (fondaparinux), prostanoid, nafamostat maleate (synthetic serine protease inhibitor)
79
heparin S/E?
bleeding, thrombocytopenia (HIT1: time and dose dependent, HIT2: formation of heparin plt factor 4 Ab), allergy, alopecia, osteoporosis, hyperlipidemia, hypoaldosteronism
80
how to monitor anticoagulation in HD?
APTT (unfractionated)
whole blood partial thromboplastin time (WBPTT): blood + thrombofax to accelerate clot, for unfractionated
activated clotting time: blood + siliceous earth, for unfractionated
activated factor Xa: for LMWH
activated ACT factor Xa
81
alternative method if bleeding risk high in HD?
```
heparin free / heparin rinse
heparin coated dialyzer
high BFR and low UFR
smaller area dialyzer
citrate containing dialyzate
```
82
SLED vs HD?
BFR 200, DFR 100 - 300
83
indication of CRRT than IHD?
hemodynamic unstability
grossly abnormal biochemistry
large amount of fluid removal (ARDS, APO)
head injury, high ICP
84
C HD typical BFR and DFR?
BFR = >3x DFR, ~ 150
| DFR 20-25ml/kg/h
85
what is filtration fraction?
UFR / BFR x (1 - hct)
86
target of fitration fraction in HF?
< 25%
87
how to maintain fitration fraction?
increase BFR, reduce UFR
| predilution mode
88
CRRT dialyzate setting?
```
Na 140 (unless trisodium citrate use)
K 0, 2, 4 to avoid arrhythmia
PO4 0 or 1.3
Ca 1.5 - 1.75 (0 if RCA use + Ca infusion)
Mg 0.5
glucose 5.5
room temperature
```
89
target of CRRT?
20-25ml/kg/h
| aim average urea 16
90
SLED target?
weekly kT/V 3.9
91
citrate toxicity sign?
HAGMA, Total Ca / ionized Ca > 2.5
92
home HD setting?
```
buttonhole technique
alt day HD
Duration 6 - 10 hours
high flux dialyzer
Qb 200 - 300
Qd 100 - 300
Na 135 - 140
K 2
HCO3 28 - 33
PO4 0.32
Ca 1.5
```
93
Effect of frequent NHD?
FHN Nocturnal trial: loss of RKF higher if more than 4.5x / week total time > 28 hours
better survival, BP and PO4 control, less LVH
94
contraindication to NHHD?
patient factor: uncompliance, psychiatric issue
comorbid: seizure, hypoglycemia, IDH
access problem
home environment
95
predilution and post dilution HDF pros and cons?
predilution: allow lower BFR, reduce fouling, but reduce solute clearance, increase substitution fluid use
post dilution: high solute clearance, use less substituion fluid, but increase clotting and fouling
96
HDF setting?
access with BFR 350 - 400
dizlyaer high flux > 50ml/hr, high sieving coefficient B2M > 0.6, high SA 1.6-1.8m2
Ultrapure dialyzate (with 2 RO)
UFV 20 - 24L (post dilution), x2 (pre dilution), x1.3 (mixed)
Na, K, Ca, Mg, HCO3 same as HD
heparin anticoagulation given at venous port
97
clinical benefit of HDF?
```
less IDH
might preserve RKF
lower CRP
no effect on anaemia, nutrition
reduce B2M amyloidosis and CTS
CONTRAST: 21L UFV no survival benefit
ESHOL: 23-24L UFV improve overall survival
```
98
how to estimate plasma volume?
40ml/kg
| 0.07 x BW x (1 - Hct)
99
indication of FFP as replacement fluid?
TTP / HUS
high bleeding risk
low pretreatment fibrinogen level
multiple closely space treatment
100
complication of plasmaphoresis?
vascular acess: hematoma, pneumothorax, retroperitoneal bleed, local infection
procedure: hypotension, coagulopathy, edema, hypersensitivity, hypoK, hypoCa
anticoagulation: bleeding
replacement fluid: anaphylaxis (FFP)
101
pre-caution of TPE?
stop ACEI 1-2days before TPE
| IVIG 100 - 400mg/kg if infection
102
TPE setting for Anti GBM?
1.5-2 PV x 2 weeks or until Anti GBM -ve and lung hemorrhage subsides
FFP replacement if hemorrhage
103
TPE setting for TTP?
1 PV daily till plt and LDH normalize / 7 - 10 days,
| full FFP replacement
104
TPE setting for ANCA?
MEPEX: 60ml/kg replacement daily till hemorrhage subside, then alt day for total 2 weeks
105
TPE indication and setting for SLE?
life threatening SLE: crescentic LN, lung hemorrhage, cerebral lupus, catastrophic APS
1-1.5PV x 7
106
TPE setting for recurrent FSGS
1-1.5PV x 5
107
acute confusion in HD patient?
```
Bleeding: ICH
Infraction: CVA, air embolism
Metabolic cause: hypogly, hyponatremia, hypercalcemia, dysequilibrium
Hypotension: high UF, arrhythmia, MI
Infection: CNS
Hypertensive encephalopathy
Anaphylaxis: dialyzer reaction
Aluminium toxicity
Drug: antibiotics, antiviral, opiates, anticonvulsant
```
