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Nefrologia PT > Hemodialysis > Flashcards

Hemodialysis Flashcards

1
Q

most appropriate referral to nephrology

A

stage 3b or 4

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2
Q

rule of 6 in AVF

A

at least 6 mm in diameter
at least 6 cm of overall needle accessible length
no more than 6 cm below the surface

Rule of 6’s 6 weeks after the AV fistula has been placed, the fistula should: • Be able to support a blood flow of 600 ml/min • Be at a maximum of 6mm from the surface • Have a diameter greater than 6 mm

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3
Q

advantage of end ro side appeoach

A

avoidance of venous htn

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4
Q

ideal hd access

A

high prrimary patency rate
instant usability
long survival
low thrombosis rate
low infection rate
high blood flow rate
patient comfort
bathing/hygiene
minimize needles
minimal cosmetic effect

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5
Q

duration of lack of change on physical examination prognostic of nonmaturation

A

4 to 6 weeks

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6
Q

most impt monitoring technique

A

good pe of av shunt

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7
Q

acess placement

A

gfr < 20

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8
Q

factors influencing effective clearance: small molecules

A

Small FATmembrane
flow (blood/dialysate)
area (membrane surface)
Time (treatment time)
membrane permeability

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9
Q

most impt intrinsic physical feature governing removal

A

size of molecule

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10
Q

guards against excessive suction on the vascular access

A

arterial pressure
normal: -20 to 80

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11
Q

gauges resistance to blood return

A

venous pressure
+ 50 to + 200

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12
Q

affect solute clearance of a hemodialyzer

A

Increase clearance
- porosity, surface area, hydrophilicity, blood/dialysate flow

decrease clearance
- thickness, molecular weight/size, lipid solubility, protein binding, unstirred layer

varies
-membrane charge

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13
Q

degree to which membrane activates blood components

A

biocompatibility

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14
Q

min accetable internal fiber diameter

A

180 mcm

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15
Q

target aluminum level in water

A

< 10 mg/L
osteomalaciac microcytic anemia, encephalopatjy

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16
Q

direct exposure to this causes hemolysis and methemoglobinemua

A

chloramine

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17
Q

cardiac arrhythmia and acute death

A

Fluoride

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18
Q

Hard water syndrome - nausea vomiting weakness flushing labile bp

A

Excess ca and Mg

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19
Q

target temp of water

A

77F-100F

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20
Q

quality of dialysis water

A

lower maximal level of 100 cfu/ml bacteria and a max concn of less than 0.25 eu/ml for endotoxin

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21
Q

action levels

A

25 cfu
0.125 eu/ml

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22
Q

ultra pure dialysate

A

bacterial count of less than 0.1 cfu/ml
endotoxin less than 0.03 eu/ml

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23
Q

monitoring of water quality

A

monthly

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24
Q

post bun sampling

A

slowing the blood pump to 100 ml/min for 15s, stopping the dialysate flow for 3 mins, drawing sample from dialysate inflow port

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25
Q

clinical conditions with no anticoagulation or reginal anticoagulation

A

actively bleeding
significant risk for bleeding
major thrombi static defect
major sx within 7 fays
intracranial sx 14 days
biopsy of visceral organs with 72h
pericarditis

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26
Q

Low dose heparin clinical conditions

A

Major sx beyond 7 days
biopsy if visceral organs beyond 72h
minor sx 8h prior
minor sx within 72h

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27
Q

either low dose or no anticoagulation

A

major sx 8h prior

28
Q

to prevent clotting

A

rinse circuit with heparinized saline
less thrombogenic dialyzer
flush the circuit with 100 to 200 ml 0.9% Nacl every 30 mins
avoid blood or platelet transfusion through circuit
high blood flow rate
limit uf

29
Q

Mg for persistent intradialytic hypotension

A

Higher dialysate Mg

30
Q

Adynamic bone disease

A

lower dialysate Mg

31
Q

major complication of bicarbonate dialysate

A

bacterial contamination and precipitation of Ca and Mg salts

32
Q

surrogate marker for cardiovascular disease in hd

A

carotid intimal thickness

33
Q

reduce plasma isoprostanes and isofurans, markers of oxidative stress and endothelia function

A

coenzyme q10

34
Q

surrogates of overall bp status

A

prehd and post hd bp

35
Q

htn meds removed poorly with hd

A

losartan, fosinopril, ramipril, carvedilol, bisoprolol, propranolol

36
Q

when can false positive hbsag occur

A

3 weeks

37
Q

decrease in sbp 20 mmhg or more or a decrease in map of 10 mmhg with clinical events

pas <90

A

hypotension arterial interdialitica

maior mortalidade, maior atordoamento cardiaco,

aumento do risco de trombose da fav

causas de hid:

peso seco baixo, uf muito alta, tempo muito curto com uf alta

vasocontriccao insatisfatoria= temp elevada, sodio baixo , neuropatia autonomica, alimentacao na dialise, anemia, uso de anti hipertensivos

fat cardiacos= disfuncao diastolica

outras=tamponamento, iam, hemorrgia, sepse, reacao ao dialisador, hemolise, embolia gasosa

usar midodrina, sertralina, fludrocortisona

38
Q

interventions to consider in recurrent intradialytic hypotension

A

reassess dry wt
reduce id Na gain
assess id hypoca, hypoK, hypoNg
avoid food intake during hd
adjust antihtn
assess cardiac function
cool dialysate
extend dialysis time or add sessions
sequential Uf or uf remodeling
midodrine

manitol

hemodiafiltracao

uso de diureticos, baixar a ingesta de sodio

39
Q

measures in sindrome do desquilibrio

sindrome do desequilibrio= ocorre pq na uremia tem um aumento da osmolaridade e a queda rapida pode ocorrer a sindrome do desequilibrio

A
  1. shorter tx times of 1-2h- limitar a sessao a 2-2,5h
  2. lowering blood flow rates to 200-250 ml/min
  3. Reducing dialysate flow rate, concurrent flow
  4. dialyzer with small surface area
  5. Mannitol 1g/kg

6-perfil de sodio ou sodio mais alto

7 considerar crrt = hemorragia intracerebral, massa crebral, trauma cerebral

40
Q

pericaridits that occurs within 8 weeks of initiation of hd

A

uremic pericarditis

41
Q

complicacoes da HD

A

sindrome do desequilibrio

embolia gasosa

hemolise

hemorragia do acesso

saida da agulha de puncao

reacao alergica

parada cardiaca

erros na prescricao

42
Q

reacoes anafilaticas

A

type A reactions -raro- ANAFILATICA => dialyzer reaction that occur within 5 to 20 mins and present with pruritus, urticaria, bronchospasm or anaphylactic shock,tosse , dispneia, dor abdominal

causas =oxido etileno, ieca, bacterias,reutilizacao de dialisador

cause of first use syndrome =IgE antibodies to membrane material or ethylene oxide

parara a dialise, nao devolver, pincar as linhas.

antialergico, corticoide, adrenalina- mudar a membrana,tentar hd sem heparina

-Type B=Complement mediated, occur later, chest and back discomfort =30-60minutos, causa desconhecida

continuar a dialise, tentar oxigenio, tentar mudar a membrana

43
Q

complicacoes reacoes anafilaticas

A

tipo A- anafilatica, mais grave, nos primeiro minutos

mediada por igE= calafrios, urticaria, tosse prurido hipotensao estridor PCR

ou altos niveis de bradicinina uso de ieca

reacao com a membrana ou oxido de etileno

procurar a causa, tentar dialisar sem heparina, nao devolver, pincar as linhas

corticoide, adrenalina , antialergicos

tipo B -mediada por complemento apos 15-30minutos

dor nas costas ,nauseas vomitos, dor no peito.

trocar o dialisador

capilar de polisulfona

44
Q

hemolise

chest tightness, back pain, shortness of breath with acute pigmentation of the skin and port wine appearance of the blood in venous line

A

acute hemolysis
discontinue without blood return
check K, peripheral smear, hgb
screen dialysate and blood tubing for contaminants

causas de hemolise= contaminacao por cobre, zinco, nitrato, nitrito e cloramine

dialisato hipoosmolar, hipertermia

ma oclusao da bomba de sangue, dialise de alto fluxo c agulha unica, oclusao parcial do cateter, kink , defeitos na linha

paciente relacionado=esferocitose hereditaria, anemia falciforme, hemolise autoimune

45
Q

embolia gasosa

A

Stop blood pump,clamp venous dialysis line to prevent further air entry
administer O2
volume resuscitation
keep patient supine

air entra no circuito pelo acesso ou pelo circuito do dialisador

defeitos nas conexoes

priming inadequado

medicacao administrada inadequadamente

implante ou retirada de cateter

foam in venous line

pessoal treinado, evitar fluxos muito altos manter nivel de sangue alto no catabolhas

46
Q

ALTERAÇOES HEMODINAMICAS RELACIONADAS A FAV E PTFE

A

imediatas: aumento do debito cardiaco 10-20%

aumento ativ simpatica

diminuicao da resist periferica

aumento da fc

efeitos em 1 semana= aumento do volume sanguineo causando aumento do ve aumento anp e bnp

diminuicao da resistencia vascular

diminuicao da renina e aldosterona

long terms- hipertrofia de ve

aumento debito cardiaco

isquemia coronaria

estenose venosa

47
Q

avf has bounding pupsation, inc aneurysm size, does not flatten when arm raised above the head

A

venous outflow or central venous stenosis

estenose venosa= veias nao colapsam quando eleva o braco , tempo de sangramento prolongado, pressao venosa alta, baixo fluxo,

aneurisma distendido, hiperpulsatil, sopro e fremito param no local da estenose

estenose central= dificuldade de canular, baixo fluxo, aumento pressao venosa, braço edemaciado, veias nao colapsam

pulso e fremito variaveis

estenose arterial= dificuldade de canulacao, pressao arterial negativa , baixo fluxo, hipopulsatil,

fremito e sopro, descontinuo ou diminuido

sindrome de roubo de fluxo

sindrome de roubo de fluxo da coronaria

IC DE ALTO DEBITO

48
Q

complicacoes da fav

A

trombose= dor, palpacao do trombo, ausencia de fremito

estenose= dificuldade de canular, edema doloroso, sangramento prolongado,

icc=dispneia, ortopneia, dispneia paroxistica noturna, edema

neuropatia isquemic= dor distal a anastomose, perda da sensibilidade, fraqueza nas maos e dedos, paralisia

sindrome do roubo=cianose de extremidade, diferenca de temperatura, dor, ulceracao, necrose , gangrena. side to side anastomososis

aneurisma= sinais de sangramento, infeccao, ulcera

infeccao=dor, calor, rubor, edema

49
Q

fav

A

Finding what It Suggests

Head: Facial edema Superior vena cava stenosis

Neck: Scars (prior central venous catheters)/Increased risk of central venous stenosis

Chest: Edema Breast swelling Collateral veins Implantable devices

Central vein stenosis
Increased risk of central vein stenosis

Arm:
Edema Central vein stenosis

Collateral vein(s) Stenosis near the vein(s)
Aneurysms and pseudoaneurysms Outflow stenosis
Visible pulsation Outflow stenosis

Hand:
Cyanosis,pallor, skin necrosis, or dystrophic nails =
Vascular steal syndrome

50
Q

fav

A

Clinical Pearl: True aneurysms are dilations involving the entire vessel wall, whereas pseudoaneurysms are dilations secondary to hematomas that occur at sites of repetitive cannulation. Unlike true aneurysms, pseudoaneurysms are not covered by the vessel wall. Glassy, thin skin or presence of ulceration over an aneurysm or pseudoaneurysm requires urgent surgical evaluation, due to high risk of AV access rupture .

51
Q

arm elevation test

A

s a simple method to diagnose outflow vein stenosis. Under normal circumstances, when the fistula arm is raised above the level of the heart, the fistula will collapse. If an outflow stenosis is present, the area of the fistula distal to the stenosis will remain distended. Note: this test works best with forearm AVFs and is not valid for AVGs. Patients can be taught to perform the arm elevation test as a way to self-monitor their AV accesses

52
Q

Stenotic lesions

A

intensify the thrill over the area of stenosis and lead to loss of the diastolic component.

An extremely strong (“water-hammer”) pulse over an AV access is concerning for venous outflow stenosis.

Weak pulsation suggests a problem with the inflow. In an AV graft, it is normal to feel a strong thrill at the arterial anastomosis that diminishes slightly as you move closer to the venous outflow

53
Q

The pulse augmentation test is used to evaluate the inflow.

A

The AV access is completely occluded several centimeters above the arterial anastomosis with one hand, while the other hand is used to assess the quality of the pulse. Increased pulse intensity (augmentation) with occlusion of the outflow vein is a normal finding. Failure of the pulse to augment when the outflow vein is occluded suggests the presence of inflow stenosis.

The pulse augmentation test may also be used to assess the direction of blood flow in an AVG. When the center of the AVG is occluded, the side with an intensified pulse is the portion of the AVG that is connected to the artery, while the side without pulsation is the portion of the AVG connected to the vein.

The augmentation test. The left hand (A) is used to occlude access outflow while the right (B) is used to assess the intensity of the pulse. From Salman and Beathard, CJASN, 2013.

54
Q

he sequential occlusion test is used to determine the presence of collateral veins.

A

Similar to the pulse augmentation test, one hand is used to occlude the AV access outflow while the other hand is used to palpate the thrill. The AV access is occluded progressively further down the venous outflow tract. If no collateral vein is present, no thrill will be felt. However, if a thrill is palpable despite occlusion of the AV, that indicates the presence of a collateral vein below the point of occlusion.

55
Q

trombose da fav

A

dor, ausencia de pulso

56
Q

estenose

A

sangramento prolingado, edema, dificuldade de canulacao

57
Q

anti has e dialise

A

nao removiveis na dialise= bras,anlodipina, nifedipina (pouco), verapamil pouco, carvedilol zero, labetalol <1%,hidralazina

clonidina 5%

removiveis

minoxidil

<30% diltiazen, benzapril, ramipril, enalapril

atenolol = 75%

lisinopril 50%

metildopa 60%

58
Q

Central vein stenosis

A

Patient has central venous stenosis and has symptoms of venous hypertension (swelling hand, dilated veins).Next step is to do Fistulogram and central venogram.The treatment is angioplasty of central stenosis with or without stentingbut if it become a recurrent event then needs ligation of AVF and creation ofnew access.

K/DOQI Guideline- Indications for Fistulogram

•Swelling of whole fistula arm

Prolonged bleeding >10 mins post dialysis on more than one occasion despite optimisation of anticoagulation regime•

Increase in size of aneurysms•

Persistent problems with scabs >3mm diameter

Unable to achieve dialysis blood flow of at least 300 ml/min•

25% fall from baseline in either achieved blood ow on dialysis or stulaow (transonic measurement within rst 1.5 hrs of HD)•

Recirculation >5% on 2 consecutive dialysis sessions•

Dynamic venous pressure >150 mmHg when measured using 15Gneedles and blood ow 200 ml/min in the rst 2 - 5 mins of dialysis (risingtrend over time is more useful than a single measurement so comparewith baseline).•

Unexplained fall in 2 consecutive URR measured on a 4 hour dialysis Session

59
Q

KTV STANDART DE 2,0

KTV 1,2 3X SEM

A
60
Q

PAC BEM DIALISADO

A

paciente estavel, que “funciona” bem

funcao renal residual

peso seco atingido

sem anemia

sem dmo, doenca ossea

bem nutrido

acompanhamento psicossocial e educacional

encaminhado ao tx

albumina boa

controle da pa , sem hve

que nao tem desconforto

anemia, acidose ou k corrigido

como conseguir isso? fistula first , tratar cuidar do acesso, medir a diurese residual, uso de diuretico, bioimpedancia

dosar albumina,nutricionista, programa educacional

61
Q

adequacao em dialise

A

We recommend a target single pool Kt/V (spKt/V) of 1.4 per hemodialysis session for patients treated thrice weekly, with a minimum delivered spKt/V of 1.2.

(1B) 3.2 In patients with significant residual native kidney function (Kru), the dose of hemodialysis may be reduced provided Kru is measured periodically to avoid inadequate dialysis.

) 3.3 For hemodialysis schedules other than thrice weekly, we suggest a target standard Kt/V of 2.3 volumes per week with a minimum delivered dose of 2.1 using a method of calculation that includes the contributions of ultrafiltration and residual kidney function. (Not Graded )

62
Q

cateter dialise

A
  • Identify type of catheter, tunneled or non-tunneled, trialysis or not, date of placement and location in note
  • Catheter length by side: • Right Internal Jugular 15 cm • Left Internal Jugular 20 cm • Femoral 24 cm
  • No clear maximum recommended duration of non-tunnelled femoral catheter and internal jugular cathete

r • 5 days for femoral (2006 KDOQI vascular access guidelines) • 7 days for the IJ catheter (2006 KDOQI vascular access guidelines)

• No patient should go home with temporary (non-tunneled) catheters. • Most tunneled catheters are not meant to be permanent so need to have plan for fistula/graft or PD catheter placement prior to discharge

63
Q

infeccao de cateter

A

Access-related Infection Catheter-related infection • Give vancomycin 15-20 mg/kg load AND gentamicin or tobramycin 2 mg/kg load (up to max 100 mg gentamicin) (or another antibiotic for gram neg).

Antibiotics given in the last hour of HD.

• Maintenance: 10 mg/kg vanc; gent 1 mg/kg. Monitor levels (vanc trough 15-20, gent trough < 2.0). Levels measured before HD. • Remove line ASAP with s/s of sepsis, persistent fever and bacteremia after 48 hrs, evidence of metastatic infectious, exit-site or tunnel infection, or difficult-to-cure pathogens, e.g. staph aureus, Pseudomonas, Candida/fungi, VRE, multiple-resistant pathogens. ▪ Otherwise, need at least guidewire exchange 2-3 days after starting antibiotic AND resolution of fever.

64
Q

prescricao

A

For initial/acute HD prescriptions: Initiation of treatment to avoid dialysis disequilibrium syndrome (attending dependent) –

• 1st treatment: 90 min, Qb (blood flow rate) 150-200 ml/min, Qd (dialysate flow rate) 400 ml/min • 2nd treatment: 3 hrs, Qb 300, Qd 600 • 3rd treatment: 3.5 to 4 hrs, Qb 350 to 400, Qd 800 • Consider mannitol in extreme cases (e.g. BUN > 150 to 200 or with altered mental status). • Mannitol dose 12.5 g IV q1 hour X 2 doses (be careful if hyperkalemia because can get solvent drag that can potentially worsen serum potassium) • Alternatively consider using higher sodium bath (e.g. 145-150 meq/L). • Also no heparin if concern for pericarditis • Most units have specific dialyzer (generally smaller sized dialyzer) for first start dialysis so ask your dialysis unit charge nurse.

For chronic HD prescriptions • Qb: 400-450 ml/min (if fistula/graft), if catheter 350 (sometimes to 400). Bare minimum Qb is 150 ml/min • Qd: 600-800 ml/min (1.5x QB)

• Rule of 7 for K • usually 2 K bath (If K HIGH > 6.5-7 mEq/L range, discuss with attending before using 1 K bath

65
Q

Current CKD Nomenclature Used by KDOQI

A

Current CKD Nomenclature Used by KDOQI

CKD Categories Definition

CKD CKD of any stage (1-5), with or without a kidney transplant, including both

non–dialysis-dependent CKD (CKD 1-5ND) and dialysis-dependent CKD

(CKD 5D)

CKD ND Non–dialysis-dependent CKD of any stage (1-5), with or without a kidney

transplant (ie, CKD excluding CKD 5D)

CKD T Non–dialysis-dependent CKD of any stage (1-5) with a kidney transplant

Specific CKD Stages

CKD 1, 2, 3, 4 Specific stages of CKD, CKD ND, or CKD T

CKD 3-4, etc Range of specific stages (eg, both CKD 3 and CKD 4)

CKD 5D Dialysis-dependent CKD 5

CKD 5HD Hemodialysis-dependent CKD 5

CKD 5PD Peritoneal dialysis–dependent CKD 5

66
Q

adequacao

A
  • fluxo de sangue adequado
  • dialisador koa
  • tempo de dialise
  • frequencia de dialise
  • fluxo do dialisato
  • tamanho d agulha
  • anticoagulacao adequada

Nefrologia PT (112 decks)

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