Disclosures

Presenter: Peter Fredericks

Date: 10/27/20
Disclosures: None
Accreditation Statements
Accreditation Statement:
The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for
Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Credit Designation Statement:

The Johns Hopkins University School of Medicine designates this live activity for [1.0] credit(s)
per session for a maximum of [52.0] AMA PRA Category 1 Credit(s)TM . Physicians should claim
only the credit commensurate with the extent of their participation in the activity.

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It is the policy of the Johns Hopkins University School of Medicine that the speaker and
provider globally disclose conflicts of interest. The Johns Hopkins University School of
Medicine OCME has established policies in place that will identify and resolve all conflicts of
interest prior to this educational activity. Detailed disclosure will be made in the instructional
materials.
CME Attendance Activity
Code

Please text 23175 to 443-

541-5052
Dialysis
Emergencies
Peter Fredericks
1/24/2020
Goals
• To propose a framework for evaluating the dialysis dependent
patient presenting to the emergency department
• To discuss some nuanced management considerations for
common presenting complaints in the dialysis dependent
patient
• To recalibrate the understanding of risk and pre-test
probabilities for emergent conditions in the dialysis
dependent patient
Objectives
• Junior learners will be able to identify a differential diagnosis
for the dialysis dependent patient based on chief complaint
• Learners will be able to discuss the initial treatment for the
many dialysis related emergencies
H20 & Na Fluid overload
Potassium Hyperkalemia
Excretable acids Metabolic Acidosis
Urea Azotemia
Phosphate Hyperphosphatemia
 HyperPTH
Vitamin D
Osteodystrophy
Erythropoietin
Anemia
 Heart Failure
Stroke
Fractures
Anemia
Bleeding
Metastatic Calcification
GI Perforation
Dementia
MISSED DIALYSIS
66 yo F presenting
with syncope
ESRD 2/2 HTN on MWF iHD
iCM (EF 55-60%)
CAD s/p PCI w/ DES
AVNRT s/p ablation
T2DM
pAF
Dementia
OLD
Dialysis
Avocados
Bananas
 GFR
RAAS inactivation

HYPERKALEMIA
CMP
Whole Blood K+
EKG
ANY EKG
CHANGES
52
%
46%
T-Wave Tenting

33
%
HYPERKALEMIA
GFR
RAAS inactivation
CMP
Whole Blood K+
EKG
2.8%
HYPERKALEMIA
GFR
RAAS inactivation
CMP β-agonists – 10 mg albuterol
Insulin ± D50 – 5 units insulin
Whole Blood K +
K-wasting diuretics – furosemide
EKG
Calcium
Shift or Excrete
Dialysis
K=8.2
K=7.3
K=7.2
66 yo M presenting with shortness
of breath & leg swelling
ESRD 2/2 HTN on MWF iHD
iCM (EF 55-60%)
CAD s/p PCI w/ DES
AVNRT s/p ablation
T2DM
pAF
Dementia
 ↓GFR → ↑Na+ and ↓H2O clearance

FLUID OVERLOAD
History
Dialysis schedule?
Missed dialysis?
Recent changes to your dialysis course?
What is your access?
Dry weight? Baseline blood pressure?
Still producing urine?
FLUID OVERLOAD
↓GFR → ↑Na+ and ↓H2O clearance

History
Physical Exam
XRay
BNP?
FLUID OVERLOAD
↓GFR → ↑Na+ and ↓H2O clearance

History
Physical Exam
XRay
CV + Respiratory Support
Diuresis
Dialysis
66 yo M presenting with shortness
of breath
ESRD 2/2 HTN on MWF iHD
iCM (EF 55-60%)
CAD s/p PCI w/ DES
AVNRT s/p ablation
T2DM
pAF
Dementia
 Increase in BUN → toxic
accumulation resulting in damage

PERICARDIAL
H+P
Echocardiogram
EFFUSIO
Optimize Hemodynamics
Pericardiocentesis
iHD or CRRT
VASCULAR
ACCESS
PROBLEM
66 yo M presenting with a
“vascular access problem”
ESRD 2/2 HTN on MWF iHD
iCM (EF 55-60%)
CAD s/p PCI w/ DES
AVNRT s/p ablation
T2DM
pAF
Dementia
Infection

Thrombosis

Hemorrhage

Insufficiency
 FISTUL GRAFT
A

Stable Thrombosis
Less Complications Infection
Months to mature Use in 1 week
PERITONEAL CVC

Severity of Disease Bridge to access

Lifestyle Aesthetic
Infections Infections
FISTULA INFECTION
H+P
Bedside US
Sepsis Pathway

Broad Spectrum Antibiotics

Admission
CVC INFECTION
H+P
Cultures – CVC + Peripheral
Sepsis Pathway
Pull Catheter
Broad Spectrum Antibiotics
Admission
PD-ASSOCIATED
H+P
PERITONITIS
PD Gram Stain + Culture
WBC count >100/μL
>50% PMNs

Intraperitoneal Antibiotics
Admission
PD-ASSOCIATED
PERITONITIS
H+P
PD Gram Stain + Culture
Yeast
Pull Catheter
Antifungals
Admission
FISTULA THROMBOSIS
H+P
Bedside US

Vascular Surgery Consult

Admission
CVC THROMBOSIS
H+P
Bedside + Duplex US

Dialysis Nurse
Intraluminal Thrombolytics
FISTULA PSEUDOANEURYSM
H+P (Pinch Test)
Duplex US

Vascular Surgery Consult

± Admission
DASS DIALYSIS ASSOCIATED
STEAL SYNDROME
H+P
Fistula compression + Pulses
Duplex US

Vascular Surgery Consult

Severe Symptoms = Admission
FISTULA HEMORRHAGE
Thrombocytopenia
Platelet Dysfunction
Medications
FISTULA HEMORRHAGE
Digital Pressure ± gel foam, rhThrombin
Suture
• Pressure above & below 2 1
• Figure of 8 stitch 4 3
• Non-cutting needle
ddAVP (0.3 mcg/kg over 10 min)
Reversal of AC (protamine)
Tourniquet + Vascular Surgery Consult
DURING
DIALYSIS
66 yo M presenting with dizziness

ESRD 2/2 HTN on MWF iHD

iCM (EF 55-60%)
CAD s/p PCI w/ DES
AVNRT s/p ablation
T2DM
pAF
Dementia
 Earl Middle Late
y
Hypovolemia
Medications

Blood Loss
Excessive UF

Dialysis Dysequilibrium
Excessive UF
Electrolyte Shifts
IALYSIS DYSEQUILIBRIU
Excessive solute clearance during first
dialysis or hypercatabolism causing
cerebral edema
H+P
Labs

Mannitol
Renal Consult
CODE BLUE
Air in the venous line embolizes and
causes end-organ damage

AIR EMBOLISM
H+P
Labs
Bedside Echocardiogram
Left lateral decubitus head down
100% O2
Hyperbarics
Aspiration of air with CVC