0071643192.pdf

RENAL AND GENITOURINARY

EMERGENCIES

Dialysis disequilibrium is due

to transient decrease in blood

osmolality and resultant fluid

shifts.

Always consider serious

causes (eg, tamponade, MI,

hyperkalemia) when

evaluating the patient

presenting with “hypotension

during dialysis.”

Complications of Hemodialysis

HYPOTENSION

Commonly due to fluid shifts and often resolves spontaneously or with a small

fluid bolus. Be sure to consider serious causes: Tamponade, infection, MI,

bleeding, hyperkalemia, air embolism, anaphylaxis.

BLEEDING

Dialysis-related bleeding may be due to underlying platelet dysfunction of

ESRD or HD associated transient thrombocytopenia and anticoagulation.

TREATMENT

■ DDAVP, cryoprecipitate, conjugated estrogens and transfusion as with

chronic renal failure (above)

■ Protamine: To reverse heparin, if overanticoagulation is a concern

DIALYSISDISEQUILIBRIUMSYNDROME

Due to rapid changes in body fluid composition and osmolality, typically when

first starting HD; occurs during or immediately after the dialysis session

SYMPTOMS/EXAM

■ Often includes headache, nausea/vomiting, muscle cramping

■ If severe: Altered mental status, seizures, and coma from cerebral edema

TREATMENT

■ Symptoms generally resolve over several hours, but may be treated with

mannitol, if severe.

FISTULA-SPECIFICPROBLEMS

Fistula-specific problems include:

■ Puncture site bleeding: The most common complication

■ True aneurysms: Rare and rarely rupture

TABLE 18.5. Indications for Emergent Dialysis

Severe acid-base disturbance

(metabolic acidosis)

Severe electrolyte disturbance

(hyperkalemia, hypercalcemia)

Certain toxic ingestions

Volume overload

(pulmonary edema, severe HTN)

Uremia

(pericarditis, twitching, N/V, encephalopathy)