0071643192.pdf

RENAL AND GENITOURINARY

EMERGENCIES

■ Pseudoaneurysms:Typically present with swelling, bleeding, or infection.
■ Thrombosis
■ High-output heart failure
■ Branham sign: A drop in HR with temporary compression of HD access
site

TREATMENT

■ Treat puncture site bleeding with direct pressure, application of gel foam
soaked in thrombin, other medications/transfusion as listed above.
■ Obtain vascular surgery consult for suspected pseudoaneurysm, thrombo-
sis, uncontrolled bleeding, or high-output heart failure.
■ Direct thrombolytic injection or angiographic clot removal (within 24 hours)
can be used to treat thrombosis.

VASCULARACCESSINFECTION

Can occur in HD catheters or fistulas (grafts > native vein); typically result
from Gram-positive organisms such as Staphylococcus, but Gram-negative
infections are also seen

SYMPTOMS/EXAM

■ Fever or history of documented bacteremia
■ Absence of local signs does notrule out vascular access infection.

TREATMENT

■ Obtain blood cultures.
■ Parenteral antibiotics: Intravenous vancomycin to cover staphylococcal
infection and gentamycin or third generation cephalosporin to cover
Gram-negatives (if suspected).

A 50-year-old female on peritoneal dialysis, presents to the ED with com-

plaint of fever, abdominal pain, and cloudy PD fluid. On examination, she

is well appearing and afebrile, but has a diffusely tender abdomen. The

dialysis catheter site is normal. What peritoneal fluid cell counts would confirm

your suspicion of peritonitis?

Greater than 100 WBC/mm^3 with >50% neutrophils. A positive Gram stain

can also confirm the diagnosis.

Peritonitis

Peritoneal dialysis-related peritonitis is commonly due to Gram-positive organ-
isms (Staphylococcusand Streptococcus), followed by Gram-negative bacteria
and (rarely) anaerobes and fungi. If the culture shows multiple organisms, suspect
bowel perforation.

SYMPTOMS

■ Fever, abdominal pain, cloudy PD fluid

DIAGNOSIS

■ PD fluid with: >100 WBC/mm^3 with >50% neutrophils ora positive Gram
stain.

The most common organisms

in PD-related peritonitis =

Staphylococcusand

Streptococcus.