S10C93 - Emergencies in renal failure and dialysis patients

Question 1

Uremia: defn

Answer 1

-contamination of blood with urine, occurs in ESRD

Question 2

Azotemia: defn

Answer 2

-build up of nitrogen in the blood

Question 3

Uremia:

Answer 3

• limit protein intake
• urea is the breakdown product of proteins
• uremic state produces free oxygen radicals creating glycation end products leading to atherosclerosis and amyloidosis
• BUN and serum Cr are inaccurate markers of the clinical syndrome of uremia
• uremic encephalopathy - diagnosis of exclusion (r/o structural, vascular, infxs, toxic and metabolic first)

Question 4

ESRD: complications

Answer 4

-uremia
-azotemia
-anemia (from loss of erythropoietin - 85% is produced by kidneys)
-vit D deficiency which then causes decr GI absorption of calcium and secondary hyperparathyroidism leading to renal bone dz
-

Question 5

Dialysis: emergency

Answer 5

-common emergency reasons for dialysis are hyperkalemia, severe acid-base disturbances, pulmonary edema

Question 6

Dialysis: neurologic complications

Answer 6

• CVA occurs in 6% of dialysis pts
• subdural hematoma occurs 10x more frequently in dialysis pts
• uremic encephalopathy
• dialysis dementia: occurs in 4% of dialysis pts
• peripheral neuropathy
• autonomic dysfunction: imotence, psotural dizziness, gastric fullness, bowel dysfxn, reduced sweating

Question 7

Dialysis: cardiovascular complications

Answer 7

• CAD
• HTN (essential, glomerulonephritis, renal artery stenosis, fluid overload)
• heart failure: fluid overload, uremic CM, high-output AV fistula
• pericarditis: uremic, dialysis related, pericardial tamponade

Question 8

Dialysis: hematologic complications

Answer 8

• anemia
• bleeding diathesis
• immunodeficiency

Question 9

Dialysis: GI complications

Answer 9

• anorexia, metallic taste, n/v
• GIB
• diverticulosis, diverticulitis
• ascites

Question 10

Dialysis: complications - renal bone dz

Answer 10

• metastatic calcificaitons
• hyperparathyroidism
• vit D deficiency and aluminum intoxication (osteomalacia)

Question 11

Dialysis: broad complications

Answer 11

• neuro
• cardi
• GI
• hematologic
• renal bone dz

Question 12

Dialysis: stenosis/thrombosis

Answer 12

• not an emergency

- can be treated with angiography/angioplasty w/in 24h

Question 13

Uremic pericarditis

Answer 13

• louder friction rubs than normal
• BUN usually >60mg/dL (168mmol/L)
• inflammatory cells do not penetrate myocardium therefore do not get the typical changes of acute pericarditis, if there are ecg changes in keeping with typical pericarditis then think infxn
• mgmt: dialysis

Question 14

Dialysis related bacteremia

Answer 14

• start with vanco
• add gentamicin if gram negatives suspected
• trial of Abx first before removal of dialysis catheter

Question 15

Antidote for heparin:

Answer 15

protamine 0.01 mg per unit of heaprin dispensed

10-20mg will reverse 1000-2000 units

Question 16

Intra-hemodialysis complications

Answer 16

• hypotention - give fluid or stop dialysis
• dialysis disequilibrium - n/v, HTN, sz, coma, death - stop dialysis, there is an osmolar imbalance
• air embolism - stroke, infarct, dyspnea, chest tightness, cardiac arrest, clamp venous line and lie pt supine, give 100% oxygen to aid reabsorption, consider steroids/heparin/hyperbaric chamber
• electrolyte disturbances
• hypoglycemia

Question 17

Peritoneal dialysis: complications

Answer 17

-peritonitis: abdo pain, fever, rebound tenderness, bugs are s epidermidis, s aureus, strep, gm -, anaerobes, fungi – treat empirically with 1st gen ceph or vanco