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complications of HD case presentation

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Information about complications of HD case presentation
Health & Medicine

Published on December 12, 2008

Author: dkatpar

Source: slideshare.net

Description

in view of a case presentation who has some of complications of HD and was treated promptly.
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بسم الله الرحمن الرحيم

Case Presentation Dr. Abrar Ali Katpar Resident Nephrology / Medicine King Khalid Hospital, Hail, KSA

Pt’s Profile Name -------------------------DOB= 10/11/1406. A 23 years old Male Saudi patient from Hail. Blood Group = AB+ve Serology negative for HBsAg / HCV / HIV This patient was referred from PHC to ER KKH for renal impairment on 14/04/1428 (the first yellow file was opened). Appointment was given to OPD on 21/04/1428. Through OPD he was admitted on 25/04/1428 to start early dialysis which he refused & continued conservative treatment. He presented in ER with SOB + anorexia for 3 days. Found to have severe metabolic acidosis + hyperkalemia & pulmonary edema on 07/02/1429.

Name -------------------------DOB= 10/11/1406.

A 23 years old Male Saudi patient from Hail.

Blood Group = AB+ve

Serology negative for HBsAg / HCV / HIV

This patient was referred from PHC to ER KKH for renal impairment on 14/04/1428 (the first yellow file was opened).

Appointment was given to OPD on 21/04/1428.

Through OPD he was admitted on 25/04/1428 to start early dialysis which he refused & continued conservative treatment.

He presented in ER with SOB + anorexia for 3 days.

Found to have severe metabolic acidosis + hyperkalemia & pulmonary edema on 07/02/1429.

Pt’s Profile He was admitted for investigations & management. Found to have ESRD due to polycystic kidney disease PKD.

He was admitted for investigations & management.

Found to have ESRD due to polycystic kidney disease PKD.

U/S reported

He was started urgent 1 st HD with temporary catheter in right femoral vein on 07/02/1429 time 12:05 am in ICU. 1 st time perm Cath. Was inserted on 12/02/1429. Till Now he is on regular HD thrice a week for 4 hours a session. His present access for HD is Left AVF Which is functioning well.

He was started urgent 1 st HD with temporary catheter in right femoral vein on 07/02/1429 time 12:05 am in ICU.

1 st time perm Cath. Was inserted on 12/02/1429.

Till Now he is on regular HD thrice a week for 4 hours a session.

His present access for HD is Left AVF Which is functioning well.

After the medical record of the patient, we would like to present this case as our routine HD patient.

After the medical record of the patient, we would like to present this case as our routine HD patient.

Presentation of case for discussion His pre HD Data: Dry weight =47kg B.P =129/78 Pulse =84/ min Temp =36.9 RR =14/min O2 Sat. =97% on RA He was prescribed HD Session =4 hrs. Target wt. loss =3.5 kg Heparin only bollus =2000iu Dialysate = FC1+bicarb Dialysate temp =36 C Dialyzer = Pn5 hollow fiber Na + =134 Conductivity =14 Pump =300 Our this patient for maintenance regular HD, came ambulatory on 11/09/1429 at 8:30 am for a routine session of HD.

His pre HD Data:

Dry weight =47kg

B.P =129/78

Pulse =84/ min

Temp =36.9

RR =14/min

O2 Sat. =97% on RA

He was prescribed HD

Session =4 hrs.

Target wt. loss =3.5 kg

Heparin only bollus =2000iu

Dialysate = FC1+bicarb

Dialysate temp =36 C

Dialyzer = Pn5 hollow fiber

Na + =134

Conductivity =14

Pump =300

Our this patient for maintenance regular HD,

came ambulatory on 11/09/1429 at 8:30 am for a routine session of HD.

Investigations Pre HD CBC HB = 8.56 WBC = 6.45 HCT = 25.3 PLT = 209 Biochemistry BUN = 10.79 CREAT= 415 URIC ACID = 257.1 ALB = 39.91 T.PROT.= 63.7 AST = 21 ALT = 24 ALP = 507 GLUC = 6.1 Post HD ECG = WNL CXR = CLEAR Biochemistry BUN ----4.32 GLUC --7.7 Na+ ---144.3 K+ -----3.0

Pre HD

CBC

HB = 8.56

WBC = 6.45

HCT = 25.3

PLT = 209

Biochemistry

BUN = 10.79

CREAT= 415

URIC ACID = 257.1

ALB = 39.91

T.PROT.= 63.7

AST = 21

ALT = 24

ALP = 507

GLUC = 6.1

Post HD

ECG = WNL

CXR = CLEAR

Biochemistry

BUN ----4.32

GLUC --7.7

Na+ ---144.3

K+ -----3.0

12 lead ECG

Started HD session Initiated with antiseptic measure AVF pricked & dialysis started with out any problem till 3 hrs. Patient was monitored as per routine every 30 minutes for Bp Pulse Arterial pressure Venous pressure General condition Complains And other parameters by programmed machine protocols.

Initiated with antiseptic measure AVF pricked & dialysis started with out any problem till 3 hrs.

Patient was monitored as per routine every 30 minutes for

Bp

Pulse

Arterial pressure

Venous pressure

General condition

Complains

And other parameters by programmed machine protocols.

Patient presentation. Suddenly after 3 hours of HD he started complaining of:- Dizziness Lightheadedness Sweating Nausea Cramps and he was About to collapse His Vitals BP = 75/40 Pulse = 110/min&weak Temp = 36 C RR = 18/min O2 Sat. = 90% on RA

Dizziness

Lightheadedness

Sweating

Nausea

Cramps and he was

About to collapse

His Vitals

BP = 75/40

Pulse = 110/min&weak

Temp = 36 C

RR = 18/min

O2 Sat. = 90% on RA

Q. WHAT Is happening?

Quick reflexes SEVERE HYPOTENSION? well Q. WHAT IS CAUSE OF HIS HYPOTENSION? BEFORE ANSWER? Let us GO through 

well

Q. WHAT IS CAUSE OF HIS HYPOTENSION?

BEFORE ANSWER?

Let us GO through 

Complications that occur during Hemodialysis session. Common complications Hypotension Muscle cramps Nausea and vomiting Headache Chest and back pain Febrile reactions First-use syndromes Pruritis Uncommon but serious complications Disequilibrium syndrome Dialyzer reactions Arrhythmias Cardiac tamponade Intracranial bleeding Seizures Hemolysis Air embolism Dialysis associated neutropenia & compliment activation. Hypoxemia.

Common complications

Hypotension

Muscle cramps

Nausea and vomiting

Headache

Chest and back pain

Febrile reactions

First-use syndromes

Pruritis

Uncommon but serious complications

Disequilibrium syndrome

Dialyzer reactions

Arrhythmias

Cardiac tamponade

Intracranial bleeding

Seizures

Hemolysis

Air embolism

Dialysis associated neutropenia & compliment activation.

Hypoxemia.

Frequency of common complications Hypotension = 20 – 30 % Muscle cramps = 5 – 20 % Nausea & vomiting = 5 – 15 % Headache = 5% Chest pain = 2 – 5 % Back pain = 2 – 5 % Febrile reactions = <1 % Itching = 5% Fever and Chills = < 1 % Cardiopulmonary arrest = < 1 %

Hypotension = 20 – 30 %

Muscle cramps = 5 – 20 %

Nausea & vomiting = 5 – 15 %

Headache = 5%

Chest pain = 2 – 5 %

Back pain = 2 – 5 %

Febrile reactions = <1 %

Itching = 5%

Fever and Chills = < 1 %

Cardiopulmonary arrest = < 1 %

Causes of Hypotension during HD Common causes 1. Related to excessive decrease in blood volume Fluctuation in U/F rates High U/F rate Target dry weight set too low. 2. Related to lack of vasoconstriction Acetate-containing dialysis solution. Relatively warm dialysis solution. Food ingestion Tissue ischemia Autonomic neuropathy Anti hypertensive medicine 3 . Related to cardiac factors Cardiac output unusually dependent on cardiac filling: diastolic dysfunction due to LVH, IHD, or other conditions. Failure to increase cardiac rate Ingestion of beta blockers Uremic autonomic neuropathy Aging Inability to increase cardiac output for other reasons: poor myocardial contractility due to age, hypertension, atherosclerosis, myocardial calcification, valve disease, amyloidosis, etc

Common causes

1. Related to excessive decrease

in blood volume

Fluctuation in U/F rates

High U/F rate

Target dry weight set too low.

2. Related to lack of vasoconstriction

Acetate-containing dialysis solution.

Relatively warm dialysis solution.

Food ingestion

Tissue ischemia

Autonomic neuropathy

Anti hypertensive medicine

3 . Related to cardiac factors

Cardiac output unusually dependent on cardiac filling: diastolic dysfunction due to LVH, IHD, or other conditions.

Failure to increase cardiac rate

Ingestion of beta blockers

Uremic autonomic neuropathy

Aging

Inability to increase cardiac output for other reasons: poor myocardial contractility due to age, hypertension, atherosclerosis, myocardial calcification, valve disease, amyloidosis, etc

Uncommon causes Pericardial tamponade. Myocardial infarction. Occult hemorrhage. Septicemia. Arrhythmia. Dialyzer reaction. Hemolysis. Air embolism. Infections (severe & serious).

Uncommon causes

Pericardial tamponade.

Myocardial infarction.

Occult hemorrhage.

Septicemia.

Arrhythmia.

Dialyzer reaction.

Hemolysis.

Air embolism.

Infections (severe & serious).

Common causes of hypotension Excessive or rapid decrease in the blood volume. Failure to use U/F controller Large intra-dialytic weight gain or short treatment. Excessive U/F below the pt’s “dry weight”. Lack of vasoconstriction. Use of acetate-containing dialysis solution Dialysis pt’s are often slightly hypothermic. Food ingestion. Tissue ischemia. Autonomic neuropathy. Antihypertensive medication.

Excessive or rapid decrease in the blood volume.

Failure to use U/F controller

Large intra-dialytic weight gain or short treatment.

Excessive U/F below the pt’s “dry weight”.

Lack of vasoconstriction.

Use of acetate-containing dialysis solution

Dialysis pt’s are often slightly hypothermic.

Food ingestion.

Tissue ischemia.

Autonomic neuropathy.

Antihypertensive medication.

Detection of hypotension Most patients will complain of feeling dizzy, light headedness, or nauseated when hypotension occurs. Some experience muscle cramps. Some times no symptoms whatsoever until the BP falls to extremely low (and dangerous ) levels.

Most patients will complain of feeling dizzy, light headedness, or nauseated when hypotension occurs.

Some experience muscle cramps.

Some times no symptoms whatsoever until the BP falls to extremely low (and dangerous ) levels.

Management of hypotension Fluid administration Slowing the blood flow rate There are 2 potential reasons to lower the blood flow rate: When U/F controller is not used, slowing the blood flow rate makes it easier to limit the amount of UF. At very rapid blood flow rates and at a low cardiac out put, there may be a “steal” effect by the extracorporeal circuit, with diversion of blood from systemic tissue beds.

Fluid administration

Slowing the blood flow rate

There are 2 potential reasons to lower the blood flow rate:

When U/F controller is not used, slowing the blood flow rate makes it easier to limit the amount of UF.

At very rapid blood flow rates and at a low cardiac out put, there may be a “steal” effect by the extracorporeal circuit, with diversion of blood from systemic tissue beds.

Prevention of hypotension Use machine with U/F controller when ever possible. Counsel patient to limit weight gain to < 1kg/day. Do not ultra filter a patient to below dry weight. Keep dialysis solution Na+ level at or above the plasma level. Give daily dose of anti-hypertensive after, not before, dialysis. Use Bicarb-containing dialysis solution when high blood flow rate or high-efficiency dialyzers are used. In selected patients, try lowering the dialysis solution when tempreture to 34-36 oC. Ensure that HCT is > 25-30% pre-dialysis. Do not give food or glucose orally during dialysis to hypotensive-prone patients.

Use machine with U/F controller when ever possible.

Counsel patient to limit weight gain to < 1kg/day.

Do not ultra filter a patient to below dry weight.

Keep dialysis solution Na+ level at or above the plasma level.

Give daily dose of anti-hypertensive after, not before, dialysis.

Use Bicarb-containing dialysis solution when high blood flow rate or high-efficiency dialyzers are used.

In selected patients, try lowering the dialysis solution when tempreture to 34-36 oC.

Ensure that HCT is > 25-30% pre-dialysis.

Do not give food or glucose orally during dialysis to hypotensive-prone patients.

Muscle cramps Pathogenesis of muscle cramps during dialysis is unknown. 3 most important predisposing factors: Hypotension The patient being below dry weight. Use of Na+poor dialysis solution.

Pathogenesis of muscle cramps during dialysis is unknown.

3 most important predisposing factors:

Hypotension

The patient being below dry weight.

Use of Na+poor dialysis solution.

Management of cramps For cramps with hypotension N/S 0.9% is the best on which patient responds quickly. In isolated cramps & acute status Hypertonic solutions Hypertonic saline Dextrose 50%. I V slowly calcium gluconate 10 to 20 ml specially in hypocalcaemic patients.

For cramps with hypotension

N/S 0.9% is the best on which patient responds quickly.

In isolated cramps & acute status

Hypertonic solutions

Hypertonic saline

Dextrose 50%.

I V slowly calcium gluconate 10 to 20 ml specially in hypocalcaemic patients.

ANSWER is Now obvious. This Pt. was having Acute Severe Hypotension with muscle cramps. Dizziness + Light headedness + Nausea + Sweating + & generally he was about to collapse because of sudden drop in BP. Due to removal of fluid more then his dry weight as patient was young so he was tolerating up to dangerous level of low BP without any complain. Due to good response of vascular system, the fluid shift from extra-vascular compartment to vascular compartment was taking place because of good vascular compliance.

This Pt. was having Acute Severe Hypotension with muscle cramps.

Dizziness + Light headedness + Nausea

+ Sweating + & generally he was about to collapse because of sudden drop in BP.

Due to removal of fluid more then his dry weight as patient was young so he was tolerating up to dangerous level of low BP without any complain.

Due to good response of vascular system, the fluid shift from extra-vascular compartment to vascular compartment was taking place because of good vascular compliance.

Management of this case We managed with: Trendelenburg position.  I.V bolus of NS 0.9% 200+300ml over 15 min. Stopped U/F. Reduce Blood Flow pump from 300 to 250 Oxygen given 6 litters. Hypertonic solution Dextrose 50% given. Dialysate Na+ increased to 138. Temperature decreased to 34.5C. Observation vitals. Investigations: Such as ECG + CXR + Hct+ biochemistry.

We managed with:

Trendelenburg position. 

I.V bolus of NS 0.9% 200+300ml over 15 min.

Stopped U/F.

Reduce Blood Flow pump from 300 to 250

Oxygen given 6 litters.

Hypertonic solution Dextrose 50% given.

Dialysate Na+ increased to 138.

Temperature decreased to 34.5C.

Observation vitals.

Investigations: Such as ECG + CXR + Hct+ biochemistry.

Follow up During all above measures patient became stable after 15 minutes his vitals were with in normal limits. We monitored rest of time, HD continued with altering the prescription. At the end of HD he was alright & left AKU ambulatory. He came again for his scheduled next HD after a day. While Going Home He said 

During all above measures patient became stable after 15 minutes his vitals were with in normal limits.

We monitored rest of time, HD continued with altering the prescription.

At the end of HD he was alright & left AKU ambulatory.

He came again for his scheduled next HD after a day.

While Going Home He said 

Thank You

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