3. Renal Failure
Innocent bystanders – mostly T2DM/HTN/Obesity
eGFR <60 = >50% loss
Uraemic symptoms
PD vs HD vs Conservative care
Haemodialysis in theory
Intermittent haemodialysis
7. Chronic complications
Cardiovascular
Left ventricular hypertrophy
Bacterial infections
Psychosocial complications
Delerium
Depression
Dementia
Nutritional
Protein energy wasting
8. Presentations to ED
Approximately (355 visits by 143 patients):
20% infection
20% SOB
15% vascular access
15% chest pain / arrythmia
15% GI complaints
(other)
60% admission rates
Average LOS 8 days
9. Mr RF, 30M Electrician
Recent start on haemodialysis
Comes in with shortness of breath
VBG – K+ 7.9
What do you do?
10. Hyperkalaemia
Haemolysis isn’t usually the case
Treatment in ED?
Gluconate (repeat doses)
Care with insulin
Twice the care with sodium bicarbonate
Care with resonium (onset?)
Bowel prep – if youre particularly frustrated
Other electrolyte abnormalities ( Ca / Mg / Phos / Na) – not
common cause of acute presentation, usually another cause
(medications / sepsis)
11. Cardiac complications
T/F ESRD patients carry the same cardiovascular risk as
general population.
T/F Troponins are commonly significantly elevated in patients
on regular dialysis and cannot be trusted as cardiac marker.
13. Pulmonary Oedema
Missed dialysis
Thirst (800mL with LVH)
Cardio renal syndrome
MI
50% of deaths in patients with dialysis
50% mortality in 5 years
14. Mr KC 60M retired accountant
It’s a Sunday. Your friends are at the beach.
Vasculopath 6 admissions for APO recently, including 2 to ICU,
and another 2 with hypertensive crisis (SBP>220)
Attended dialysis on Friday, 2L off.
Complains of severe SOBAR, speaking in phrases
What do you do?
What we did….
16. Mr RF, 68M
History of renal amyloidosis. Presented with SOBOE 3/7 ago,
thought to be fluid overload, treated with frusemide
Now presents again SOBAR.
What’s the approach?
Peri-arrest….
17. Pericarditis / tamponade
Everyone has uraemic pericarditis
Complicated by anti-platelet and anticoagulant use
Poor cardiac reserve
What had happened with Mr. RF (warfarin)
18. Mr. NM, 65M
Nice guy, community HD for ESRF T2DM, stable
Dizzy post dialysis
What will be your approach?
What had happened….
19. Anaemia
Diagnosis of exclusion, especially in HD
( eGFR <30 )
ESA, aim for ~100 (trials)
Bleed during haemodialysis
Malignancies / plasma cell dyscrasias
Platelet dysfunction uraemic toxins
Oesophagitis, gastristis, angiodysplasia, anticoagulation during
HD (~5000 units heparin)
20. Treatment of anaemia
dDAVP (0.2 micrograms/kg, 15 min)
Cryoprecipitate
Withdrawal of medications (e.g. allopurinol)
Transfusion on dialysis
Consideration of future transplant and PRAs
21. Mrs PC, 78F , retired nurse
OCD traits, looks after husband with lung cancer at home.
Sudden onset left knee pain 1/12 ago – managed with OTC
analgesics
Now presents with right ankle pain, unable to weight bear
What would your approach be?
What had happened….
22. CKD Mineral Bone Disorders
Bones
?fracture ?infection
Low threshold for CT – microfractures
Bony aches and pains
Hip and lumbar fractures
What’s the PTH – turnover
Types
Osteitis fibrosa cystica (lytic lesion, painful)
Osteomalacia
Adynamic bone disease (common, ?calcium treatment)
Metastatic calcification (calciphylaxis / vascular – CAD)
23. Mr ST, 60M, casino addict
Vasculopath, 130kg, with femoral Hickman line
“I woke up in a pool of blood.”
What’s your approach?
What had happened…
24. Hickman line complications
Cuff exposed
“it fell out by itself”
Infection – treatment (vanc/gent)
Blocked line (tPA lock)
Broken clamp
Hickman removals (peripheral ED –useful skill)
25. Hickman bleeds
Hope its not a subclavian line….
Pressure, gauze
Xylocaine adrenaline
Red-top tubes
Head-up
Sand-bag
Box-suture
Underlying cause
30. Bacterial infections
Taylor et al 2004, RR of bloodstream infections
AVF
AVG 1.47
Tunnelled 8.49
Non-Tunnelled 9.87
Weijmer et al 2004, site vs CRBSI
Femoral 7.6 per 1000 catheter days
Jugular 5.6
Subclavian 0.7
Bacteraemia AVF 0.04 per 1000 patient days, AVG 0.55 per 1000
patient days Lafrance et al 2008 up to 6.5 for CRBSI
S. aureus (40%), seeding, mortality, MRSA
32. 49M, Fijian
Diabetic with industrial adiposity. Home haemodialysis. Recent
return from family holiday for 7 days.
Presents to Kattaning ED with confusion
What is your approach?
What had happened…
33. Dialysis Dysequilibrium
Pathophysiology
Urea is slow….
Creatinine is a preservative….
Note epilepsy and dialysing drugs out
Urgent CTB
Slow flow dialysis, supportive care, maybe mannitol
34. The surprises from G65
Apologies
Hypotension
Excessive fluid removal
Sepsis
Cardiac tamponage (heparin on HD)
GI haemorrhage (and only the finger knows)
MI / arrythmia (30% ventricular, ~50% AF)
36. Contrast in haemodialysis
No proof to schedule dialysis
Takes up to 3 sessions of dialysis to remove contrast,
depending on type
Some evidence that questions the phenomenon of contrast
induced nephropathy in the first place (CJASN 2016)
No reproducible protection in non-HD CKD patients who had
dialysis post contrast administration (Kid Int 20006) + risk of
dialysis
37. Pain management in HD
Morphine – dirty, dialysed, use half of usual
Codeine – not dialysed
Fentanyl – not dialysed
Buprenorphine – short acting, dialysed out
Hydromorphone – who knows?
This and other medications on – renal drug database
38. Things to know
Months/years on dialysis, cause
Access – creation, complications, function
Symptoms of infection
Last session, duration
Weight and volume status, JVP, blood pressure(s)
Usual intradialytic weight gains
Usual trend of potassium / bicarbonate
Residual urine output
Cardiac history
Clin Nephrol. 2002 Jun;57(6):439-43.
The emergency department care of hemodialysis patients.
Loran MJ1, McErlean M, Eisele G, Raccio-Robak N, Verdile VP.
Author information
Abstract
AIMS:
To describe the emergency department (ED) presentation, evaluation and disposition of maintenance hemodialysis (HD) patients.
MATERIALS AND METHODS:
A retrospective review of adult HD patients seen 1/1-12/31/97. The following was collected: demographics, mode of arrival, chief complaint, etiology of renal failure, evaluation, treatment, disposition, length of stay and facility charges. During the study period, this tertiary care ED had an annual adult census of 45,000. No clinical pathways were in place.
RESULTS:
143 patients made 355 visits: 351 charts were available. Mean patient age was 51 (range 20-86), 62% were male, 51% were white. 70% presented from home, 26% from dialysis. EMS transported 32%. Medicare insured 78%. Etiologies of renal failure included hypertension (33%), diabetes (27%), HIV (7%) and glomerulonephritis (8%). Complaints were related to infection (18%), dyspnea (17%), vascular access (16%). chest pain or dysrhythmia (15%) and gastrointestinal complaints (12%). ED evaluation included CBC (79%), electrolytes (75%), CXR (57%) and EKG (48%). Antibiotics were administered to 21%. HD was performed earlier than scheduled in 14%. Two hundred and eighteen patients (62%) were admitted (ICU 11%, telemetry 22%), 19 (5%) refused admission and 2 expired in the ED. The average hospital length of stay was 7.8 days (range 1-59), with 29% hospitalized more than 1 week, compared to 6.54 days for non-HD patients. The mean facility charge for admitted subjects was $14,758, while the average cost for non-HD admissions was $7,152. Of the 133 patients (38%) who were discharged directly from the ED, the mean length stay was 223 minutes (range 30 to 750) and the mean charge was $658. The mean length of stay for non-HD patients was 124 minutes.
CONCLUSION:
The ED evaluation of adult HD patients involves multiple diagnostic modalities, and patients are usually admitted. The admit rate, ED length of stay for discharged patients and hospital charges for care were substantially higher in the HD patients than in the general population. Further research in the ED care of these complex patients should be undertaken.