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    Add as Friendcomplications of chronic hemodialysis

    by: salwa

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    1 : Complications of chronic hemodialysis therapy and their management Professor. Salwa Ibrahim Cairo University
    2 : Intradialytic Hypotension
    3 : Q1: Definition of IDH
    4 : Hypotension Most common complication in hemodialysis Defined as Decreased systolic blood pressure by >20-30 mmHg from predialysis pressure Systolic blood pressure <100 mmHg
    5 : Q2: CAUSES OF IDH
    6 : Causes of IDH
    7 : Q3: Symptoms of IDH
    8 : Symptoms and signs of IDH Gradual or sudden decrease in B/P tachycardia Cold, clammy skin (diaphoresis) Nausea/Vomiting Cramping Chest pain/angina Yawning, feeling dizzy, sleepy or weak Pallor Decreasing mental status to loss of consciousness Seizure
    9 : Q4: Treatment
    10 : Treatment of IDH Treat the symptoms NS bolus Place patient in trendelenburg position Reduce UF TO ZERO
    11 : Q5: Prevention of IDH
    12 :
    13 : Muscle cramps
    14 : Causes of muscle cramps
    15 : Muscle cramps Painful muscle spasms (usually in extremities) Can occur anytime in dialysis, especially middle to end of treatment Causes: Associated with removal of large amounts of fluid Hypovolumia, Hypotension Changes in electrolytes (blood chemistry) Rapid sodium removal Low potassium, calcium and magnesium levels
    16 : Q:Treatment
    17 : Treatment of muscle cramps Treat the symptoms: Saline bolus, hypertonic glucose Reduce UFR Massage or apply opposing force Prevention: Sodium modeling Assess for accurate target weight Quinine (250-325 mg) 2H before HDx Carnitine supplementation (20mg/kg IV) after each session
    18 : Dialysis Disequilibrium
    19 : Disequilibrium Syndrome Defined as a set of systemic and neurologic symptoms that include Nausea & vomiting Headache Restlessness Slurred speech Seizure and coma
    20 : Cause of Disequilibrium Syndrome Slower transfer of urea from the brain tissue to the blood Fluid shift into the brain due to removal of wastes from the blood stream causing cerebral edema Rapid changes in serum electrolytes, especially in new patients Elevated BUN > 150 BFR to high Treatment time too long Dialyzer to big for first treatments (too efficient)
    21 : Q:Treatment
    22 : Treatment Treat the symptoms Monitor new patients carefully Decrease BFR or termination of dialysis be alert for restlessness, speech/mental changes Hypertonic glucose /HYPERTONIC saline (5 ml 23%) /Mannitol (10-15 g) in severe symptoms Phenytoin 1000 mg loading then 300 mg/day in fitting Prevention Assess new patients electrolyte levels, avoid low dialysate sodium Use a smaller dialyzer, lower BFR and shorter dialysis time for first few treatments
    23 : Chest pain
    24 : CAUSES
    25 : Chest Pain
    26 : Q: MANAGEMENT
    27 : How to manage Angina during dialysis session ECG and cardiac enzyme If dialysis is continued, the administration of oxygen and aspirin, reduction of the desired ultrafiltration and/or blood pump speed, and administration of nitrates or morphine
    28 : Prevention Anemia management (Hb level 10.5-12.5g/dl) Careful PRBCs transfusion if target not met Gentle HD to avoid hypotension Angina during dialysis may be prevented with the administration of nitrates and/or beta blockers prior to the treatment. Stenting/CABG
    29 : Itching
    30 : Itching Causes: Dry skin Secondary hyperparathyroidism Abnormal levels of calcium, magnesium and phosphorus Allergies/dialyzer reaction Uremia with an elevated BUN Treatment: Adequate dialysis to regulate electrolyte levels Prevention: Lotions or medications for dry skin/allergies Control of uremia and secondary hyperparathyroidism Gabapantein
    32 : Chills and fever Infection or septicemia Vascular access Respiratory illness Cold dialysate or malfunctioning thermostat Patient has shaking/shivering without fever Pyrogenic reaction
    33 : Symptoms Infection: Fever during dialysis Feeling cold with a fever Septicemia: Fever, chills, vomiting and headache Hypotensive shock
    34 : Pyrogenic Reaction Fever reaction due to presence of dead bacteria endotoxins Low molecular weight endotoxin fragments may be able to cross any membrane, irrespective of membrane pore size distribution Caused by contamination of: Bicarbonate containers/system Water system
    35 : Symptoms of Pyrogenic Reaction Symptoms Sudden shaking chills, then temperature elevation (1-2 hours after chills) - resolves after end of treatment Note increased pulse before chills develop Hypotension (drop in B/P >30 mm/Hg) Treatment: Remove from dialysis immediately Gather samples of dialysate/blood
    37 : Hypertension Causes: Fluid overload Non-compliance with blood pressure medications Renin overproduction Symptoms (frequently asymptomatic) Gradual or sudden rise in BP Headache, blurring vision Nausea/Vomiting Dizziness Seizure Treatment Review of BP medications Assessment of target weight and fluid removal goal
    39 : Clotting
    40 : Clotting Formation of blood clots in the dialyzer and blood lines Causes Inadequate anticoagulation Low blood flow rate High hemoglobin High UF RATES Intradialytic blood transfusion
    41 : Management Signs of Clotting Dark blood in lines or drip chambers Fibrin in drip chambers Visible clots of dark blood in the drip chamber or dialyzer TMP alarm problems Treatment Anticoagulation Vascular access Needle placement CVC problems
    42 : Haemolysis
    43 : Haemolysis Breakdown or destruction of RBC’s Releases potassium from damaged cells into the blood stream Decreasing the oxygen carrying capacity of the RBC Potentially life threatening
    44 : Q: Causes of haemolysis
    45 : Causes of haemolysis
    46 : Q: How to manage?
    47 : Signs of haemolysis Dialyzer/blood lines Cherry colored blood in venous line Patient: Shortness of breath Chest, abdominal and/or back pain Cardiac arrest Intervention Stop dialysis and DO NOT return blood to the patient
    48 : Air Embolism
    49 : Q: causes of Air embolism?
    50 : Air Embolism Introduction of enough air into extracorpeal system to stop circulation Causes Empty IV bag Air leak in blood lines Air detector not armed Loose connections Separation of blood lines Patient inhales while central vascular catheter is open to air
    51 : Q: symptoms of Air embolism?
    52 : Signs and symptoms of air embolism Extracorpeal System: Air pocket or foam (pink) in venous line Patient: Coughing, shortness of breath Chest pain or pressure Tachycardia Cyanosis Slight paralysis on one side of body (cerebral) Confusion, convulsions, coma Possible cardiac/respiratory arrest
    53 : Q: treatment of Air embolism?
    54 : Management Clamp the venous blood line Stop the blood pump Put the patient in the recumbent position on the left side with the chest and head titled downwards Cardiorespiratory support Supplemental Oxygen Aspiration of air from the atrium/ventricle
    55 : Dialyzer Reactions
    56 : Q: What are dialyzer reactions?
    57 : Type A (Anaphylactic reactions) First 5-30 minutes Moderate-severe Itching, cough, cramps, SOB, Collapse, death Ethylene oxide, AN69 membrane + ACEI , Heparin allergy Stop dialysis immediately Clamp blood lines and discard Cardiopulmonary resuscitation IV antihistaminic, IV steroid
    58 : Prevention Avoid ETO dialyzer Rinse all dialyzer well with increased volumes Stop ACEI Change membrane type Heparin free dialysis
    59 : Reaction B (Hypersensitivity reactions) 30-60 minutes Mild, usually resolves after 1st hour Chest pain, back pain Complement activation Supportive, continue dialysis, O2, antihistamines

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