Transcript Intern Boot Camp: Dialysis

Intern Boot Camp: Renal Disease
and Dialysis (ie surviving Eckel)
C L A I R E S U L L I VA N
PA G E R 3 1 9 7 7
U H C M C A N D VA M C
At the end of the talk, you will understand this:
Just kidding!!! Don’t
worry, now on to the
basics…
Objectives
 Definitions
 Types of Dialysis
 Access
 Acute indications for dialysis
 How to present a dialysis patient
 Eckel helpful hints
 What you might get called about on Nightfloat
Definitions
 Stages of Chronic Kidney Disease (CKD)
 Leading causes of End Stage Renal Disease (ESRD)?
DM, HTN
Definitions
Renal Replacement Therapy (RRT) includes:
1. Hemodialysis (HD)
2. Ultrafiltration (UF)
3. Continuous Veno-Venous Hemofiltration
(CVVH)
4. Peritoneal Dialysis
5. Renal transplant
Types of Dialysis
 Hemodialysis
(HD): extracorporeal
removal of waste
products (urea,
creatinine) and free
water from the blood
across semipermeable membrane
Types of Dialysis
Ultrafiltration (UF):
-Way to remove extra fluid
volume
-Just know term exists
CVVH:
-Used mainly in ICU for
patients who can’t
tolerate intermittent
dialysis
-Less drastic fluid shifts
and hypotension
-Runs for 24 hours a day
-Done through temporary
catheter
Types of Dialysis
 Peritoneal Dialysis
(PD): patient’s
peritoneal membrane is
dialyzer; can be done at
home.
Access
 Fistula:
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Best choice since directly
connects native artery to vein
Can take up to 6 months to
mature.
Made by Vascular Surgery
 Graft:
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Synthetic tubing connects
artery to vein
Second best choice
Also by Vascular Surgery
More complications such as
thrombosis, outlet
obstructions, aneurysms
Access
 Catheters:
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Can be tunneled or
temporary
Usually into right internal
jugular vein
Indications for Dialysis
 A (acidosis)
 E (electrolytes like high K)
 I (ingestions)
 O (overload)
 U (uremia)
How to Present a Patient on Eckel
Mr. S is a 75 yo M with hx of ESRD 2/2 DM on HD
MWF at CDC East via RUE AVF with nephrologist
Dr. Wish who presents with…
Also, know patient’s dry weight (kg) and vintage.
So you are admitting a patient on Eckel…
 Always ask about details of the last dialysis session:
when, was it a full session, did patient get any meds
(antibiotics, epogen, etc.) during dialysis, blood
draws
 You can get run sheets from dialysis center by
calling. Very helpful with vitals, meds administered,
blood cultures.
Eckel Helpful Hints
 Remember renal dosing of medications. Antibiotics
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are usually loading dose then post-dialysis doses
(vanc 20 mg/kg then 500 mg after dialysis ).
Dialysis techs can draw labs and cultures for you
during session
Dialysis is located on Lakeside 20 and VA 2nd floor
(2B-100)
If patient is anemic, it is better to give blood with HD
Don’t check blood pressure in access arm
More Eckel Helpful Hints
 Never give ESRD patients the following medications:
 Morphine
 Fleet’s enema
 Gadolinium (MRI)
 Maalox
 For patients needing temporary access: computer
order body angio and free text what you need
(temporary right IJ catheter, for example). Also,
call down to angiography. Patient needs to have set
of recent coags since angio prefers INR < 1.2.
Common Eckel Admissions
 SOB/Fluid overload (usually from missed dialysis session)
 Hyperkalemia (usually from missed dialysis session)
 Line infections
 Access issues
 Hypotension (too much fluid taken off at dialysis)
 Hypertensive crisis (usually from missed dialysis session)
You are the Eckel Nightfloat Intern
 LK 50 nurse calls and says “Mr. T (who has stage IV
CKD) is having difficulty breathing. He is currently
satting 88% on RA.”
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What else do you want to know from the nurse right away on
the phone?
What do you ask the nurse to do as you walk all the way over to
Lakeside from Tower 5?
What tests or imaging do you want?
How do you treat SOB in CKD patients?
See the patient and write an event note.
You are the Eckel Nightfloat Intern
You are the Eckel Nightfloat Intern
 Hyperkalemia
 First, make sure sample not hemolyzed
 Diet? New meds? Missed dialysis?
 Treat with insulin, glucose, calcium gluconate, kayexalate,
dialysis, bicarbonate, beta agonists (theoretically)
You are the Eckel Nightfloat Intern
 Odessa pages you and says “Ms. M’s nurse wants to let
you know that the patient has a temp to 39oC.”
 After you put down your Einstein bagel and go see the
patient, you notice tenderness and erythema around
temporary IJ catheter.
 Now what?
 What’s a line holiday?
 Blood cultures growing Staph. Knee-jerk test to order??
You are the Eckel Intern
 Nurse pops into the team room to say that Ms. B just
got back from dialysis and BP is running low in 70s
systolic.
 What else do you want to know?
 Causes of hypotension?
 How do you treat hypotension after dialysis in ESRD
patients?
You are the Eckel Intern
 Toni calls you with admission to Eckel for patient
whose AV graft has not been functioning properly at
dialysis.
 Important parts of physical exam?
 What imaging might be useful?
 Who do you call about access issues?
You are the Eckel Nightfloat Intern
 It is 3 am and nurse calls to tell you that Mr. W’s blood
pressure is 190/100. He is going to dialysis first shift in
the morning.
Do you treat his blood pressure acutely? How?
 ED had checked a troponin on patient, even though he
didn’t complain of chest pain. Critical value of 0.1 called
to you on NF.
Now what?
You are the Eckel Intern
 Lk 50 nurse text pages that Mr. G’s labs drawn
immediately after dialysis reveal hypokalemia to 3.1.
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What do you do? Do you replete potassium? If so, how much?
Important Numbers (thanks Hiloni)
 Melissa –HD/Vascular access coordinator who often
rounds with you on Eckel
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Ext: 41219
Pager: 33968
 Peritoneal Dialysis RN
 Ext: 48305 or 45703
 Dialysis Units
 UH: 41586
 VA: 5181
QUESTIONS?