First few session care
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Transcript of First few session care
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PANTIPA TONSAWAN, M.D.July 5, 2013
First few session care
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Scope Relation : ESRD , HD & death
Pre HD patient evaluation
HD prescription (initial treatment)
HD complication (Initial treatment)
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Impact : ESRD,HD & death
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USRDS 2012 ADR
Probability of sudden cardiac death in incident dialysis patients
U.S. Renal Data System, USRDS 2012 Annual Data Report
Prob
abili
ty
Month after dialysis
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USRDS 2012 ADR
Causes of death : prevalent dialysis patients, 2008–2010
Cardiac causes
U.S. Renal Data System, USRDS 2012 Annual Data Report
ESRD pt
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USRDS 2012 ADR
Rates of sudden cardiac death : age
Period prevalent dialysis patients, age 20 & older, unadjusted.
U.S. Renal Data System, USRDS 2012 Annual Data Report
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USRDS 2012 ADR
Rates of sudden cardiac death prevalent dialysis patients, by primary diagnosis
U.S. Renal Data System, USRDS 2012 Annual Data Report
2000 2005 2010
Deat
h /1
000
patie
nt y
ears
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USRDS 2012 ADR
Rates of sudden cardiac death following initiation of treatment in incident HD patients
0-90 days : 1/10
U.S. Renal Data System, USRDS 2012 Annual Data Report
2000 2006 2007 2007 2009
Deat
h /1
000
patie
nt y
ears
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Caution !!! : sudden cardiac death
RRT : Hemodialysis Aging : Exp > 65 yrs…>75 yrs Underlying : DM, HT Duration initial treatment :
0-90 days
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Patient evaluation
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Pre HD Evaluation
Patient information
Vascular access
Hemodialysis prescription
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Patient information1.History taking
Indication & complication Acute or chronic HD, hyper K, volume↑
Underlying disease…DM, HT, IHD Active problem ..GI Bleed, MI, stroke
Hemodynamic status Arrhythmia, BP
Medication Anti HT, anti coagulant
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Patient information2.Laboratory data
CBC : Hb/HCT, Platelet…..risk bleeding BUN/Cr : High BUN…..Risk ….DDS Electrolyte : Select : Dialysate solution component Serology: HBV, HCV, HIV…..isolated
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Vascular access : initial useArteriovenous fislula
Arteriovenous graft
HD catheter
Prepare : 3-6 mo….. Maturation
Prepare : 3-6 wk : at least 2 wk after Surgery
immediately use ..complication ?
Prompt ?
Infection ?
Exit site, redness, warm
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Hemodialysis prescription
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Order HD prescription (initial treatment)
Session length : Perform HD 2 hrs BFR : 200 ml/min Dialyzer: Low flux Dialysate solution composition:
Na …, K…., HCO3 …, Ca…, Mg…, Dextrose….. DFR : 500 ml/min Dialysis solution temp. : 36oc Fluid removal order: remove … LiteAnti-coagulant : heparinloading..,maintenance …
(หรอnon-heparin ตามความเหมาะสม) 50 % glucose 50-100 ml intra HD
(พจารณาตามความเหมาะสมของผปวยแตละราย)Daugirdas JT. Acute & Chronic hemodialysis prescription; Handbook of dialysis 2007
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HD prescription (initial treatment)
Daugirdas JT. Acute & Chronic hemodialysis prescription; Handbook of dialysis 2007
Time: initial 2 hr… ↑ 30 min q HD ……until 4 hr
BFR : initial 200-250 ml/min …↑ 30 min q HD ……until 350-400 ml/min
Dialyzer : initial low flux, low SA …. (AIM ….Kt/V 0.6-0.7, URR 40 %)
DFR : 500 ml/min …800ml/min (high BFR)
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HD prescription (initial treatment)
Daugirdas JT. Acute & Chronic hemodialysis prescription; Handbook of dialysis 2007
Dialysate composition :
Temp. : low temp prevent Hypotension 36.5 C
UF : < 1 L /hr, ….if need…sequential HD
Na K Ca HCO3Acute 145 2, 3, 4 3.5 25Chronic 135-145 2,3 2.5 32
Hypertonic solution : 50 % glucose ….DDS
Anticoagulant : depend on patient. condition
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Hemodialysis complications
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Dialysis disequilibrium syndrome Acute neurological complicationConsequence of rapid HD …osmotic gradient
brain Vs plasma caused .. cerebral edema Risk factor
1st session hemodialysis Extreme age : child or aging High BUN level: > 125 mg/dl CNS disorder (stroke, tumor, dementia,hypo Na), head injury (subdural hematoma) ….
Seminars in Dialysis—Vol 20, No 3 2008 pp. 493–498
Pediatr Nephrol (2012) 27:2205–2211
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Dialysis disequilibrium syndrome
IUrea CF :
brain
ICF ICF
: brai
n
IVF ECF
Brain
UreaH20
H2OUrea↑High Osm
HD
Urea
Cerebral edema
Reverse osmotic shift
Urea
slow
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Dialysis disequilibrium syndrome
Diagnosis
Treatment
Clinical : fatigue, mild headache, nausea, vomiting, disturbed consciousness, convulsions… coma.
Common mild..Self limited, fatal.. if severe
Clinical diagnosis (during HD, after HD)+ risk factor Exclusion other condition
Symptomatic treatment/ hypertonic solution/ + stop HD
Seminars in Dialysis—Vol 20, No 3 2008 pp. 493–498
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Prevention
Dialysis disequilibrium syndrome Most important
Dialysis time (2 hours)
Blood flow rate 200 ml/min
Less efficient (small) dialyzer
A goal URR : 0.4–0.45 or diffusive Kt/V of 0.6–0.7
Hypertonic solution
Seminars in Dialysis—Vol 20, No 3 2008 pp. 493–498
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Cardiac arrhythmia, Ischemia, sudden death
DIALYSIS-INDUCED MYOCARDIAL STUNNING
Echocardiogram - Pre HD …normal- During HD …. RWMA abnormality - Post HD 30 min …normal
Positron emission tomography : Measure ..MBF dialysis ….. HD precipitates reductions MBF
CAG …..normal
Effects of hemodialysis on cardiac function ;Kidney International (2009) 76, 371–375
Clin J Am Soc Nephrol 2008; 3: 19–26.
Semin Dial 2007; 20: 220–228
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Cardiac arrhythmia, Ischemia, sudden death
DIALYSIS-INDUCED CARDIAC ISCHEMIA
Myocardial stunning : Occur ….60 %Related to UF (total/rate ) & HD instability
Effects of hemodialysis on cardiac function ;Kidney International (2009) 76, 371–375
High mortalityPET
Long term
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Intradialytic hypotension
Initial treatment : associated cause
High UF rate : limit time Trial & error : set DWHigh dose : anti HTNutrition status : malnutrition …low plasma refilling
Treatment Sequential HD Limit IDWG < 1 kg/day Decrease anti HT ….decrease DW Avoid : eating during HD low Temp.
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Dialyzer reaction
Full brown, Severe reaction Common : 5 min after HD…but delayed 30 min Cause : ETO oxide, AN 69 reaction, contaminated
dialysis solution, reuse
Type A : anaphylactic type
Management : Safest to stop dailysis, without returning blood Cardiorespiratory support
Prevention : proper rinsing, y-irradiated or stream-sterilized dialyzer
First use syndrome
Type B :non-specific
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Dialyzer reaction
Type B :non-specific
Mild symptoms : chest pain, back pain Onset 20-30 min after HD Cause : unknown
Management : Supportive care Differential diagnosis : coronary artery disease
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USRDS 2012 ADR
Post HD care
Complication
Next session HD
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Summary
Cardiovascular : common cause of death HD patient
Risk : aging, DM, HT, HD 0-90 day Pre HD patient evaluation: important
…Recognized risk of HD complication Appropriate HD prescription
…reduce & prevent HD complication Prompt to treatment of complication :
if HD… started