Beruflich Dokumente
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Hazel Daphne Nialga Philippine Society of Nephrology National Kidney and Transplant Institute July 15 , 2011
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HYPOTENSION
The incidence of a symptomatic hypotension during (or immediately following) dialysis ranges from 15 to 50 percent of dialysis sessions
There are two clinical patterns of dialysis-associated hypotension: 1. Episodic hypotension, which occurs during the latter stages of dialysis and associated with vomiting, muscle cramps, and other vagal symptoms (such as yawning). 2. Chronic persistent hypotension, which may occur in longterm patients in whom predialysis systolic blood pressures of less than 100 mmHg ,are frequently observed.
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ETIOLOGY
Common causes
A. Volume related (excessive or rapid decreases in blood volume) 1. A rapid reduction in plasma osmolality, which causes extracellular water to move into the cells.
2. Large weight gain 3. Rapid fluid removal in an attempt to attain "dry weight (Short dialysis ) 4. Inaccurate determination of true "dry weight" . 5. Use of a lower sodium concentration in the dialysate.
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High dialysis solution temprature (> 36c) Autonomic neuropathy (50 percent of patients on HD) Defect in the baroreceptor/afferent side Downregulation of alpha-adrenergic receptors Use of acetate rather than bicarbonate as a dialysate buffer. Intake of antihypertensive medications that can impair cardiovascular stability. Sudden release of adenosine during organ ischemia. [eg. Anemia (HCT< 20 - 25%)]. Ingestion of a meal immediately before or during dialysis
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C. Cardiac factors:
1. Diastolic dysfunction (stiff concentric hypertrophy heart) the effects of hypertension
coronary artery disease uremia itself
2. Impairment of cardiac compensatory mechanisms (Heart rate and contractility) Arrhythmia (atrial fibrilation), which are volumeunresponsive causes of hypotension. Ischemia
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TREATMENT
The acute management of low blood pressure associated with hemodialysis: I. Ultrafiltration should either be stopped or the rate decreased. II. The patient should be placed in the Trendelenburg position.
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Trendelenburg position
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Patients with chronic, debilitating hemodialysis hypotension due to the inability to adequately respond to rapid changes in blood volume may be more likely to tolerate the gradual volume changes associated with peritoneal dialysis.
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I.
II. III.
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Changes in plasma osmolality and/or extracellular fluid volume have been implicated The four most important predisposing factors are :
I. II. III. IV.
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Hypotension Hypovolemia (patient below dry weight) High UF rate (large weight gain) Use of low-sodium dialysis solution (Hyponatremia)
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Other factors that related with hemodialysisassociated cramps: Carnitine deficiency Elevated serum leptin levels Low PTH values and high serum creatine phosphokinase concentrations The origin of a cramp is neural, not muscular.
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CLINICAL FEATURES Most commonly involve the muscles of the lower extremity Cramps occur more often in older, nondiabetic, anxious patients.
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1. 2. 3. 4.
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Prevention
I. Prevention of hypotensive episodes II. Raisening of dialysate-sodium levels to just below the threshold for induction of postdialysis thirst. III.Avoiding low predialysis levels of mg2+, Ca2+, K+. IV.Quinine sulfate . Quinine sulfate before dialysis 250-325 mg (Not FDA approved). V. Carnitine supplementation in dialysis patients. VI.Vitamin E(400 IU) VII.Oxazepam ( 5-10 mg, given 2 hrs prior to dialysis). VIII.Prazosin. IX.Stretching exercises of affected muscle groups. X. Nifedipine, phenytoin, creatine monohydrate, carbamazepine, amitriptyline, and gabapentin.
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HEADACHE: 1. Etiology largely unknown. A subtle manifestation of the disequilibrium syndrome Caffeine withdrawal (coffee drinkers) Metabolic disturbances (eg, hypoglycemia, hypernatremia, hyponatremia), uremia, subdural hematoma, and medication-induced headaches should be considered in patients with recurrent dialysis-associated headaches. Magnesium deficiency psychological factors
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2. Prevention:
1. In this setting, initially altering the dialysis prescription in favor of less intensive and more frequent treatments may avoid these complications. 2. Decreasing dialysis solution sodium 3. A cup of strong coffee 4. A cautious trial of magnesium supplementation
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3. Management
Acetaminophen A cup of strong coffee
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1. 2. 3. 4. 5. 6. 7. 8.
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Prevention:
1. Avoidance of hypotension during dialysis. 2.single predialysis metoclopramide(5-10mg).
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It can lead to death unless quickly detected and treated Air embolism is rare in hemodialysis patients, in part because of the presence of air detectors in hemodialysis machines. Diagnosis: Foam in the venous blood line should make one suspect that air is entering the dialysis system.
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Acute complications during hemodialysis Treatment: I. Clamping the venous line II. Stopping the blood pump III. The patient should be positioned on the left side in a supine position with the chest and head tilted downward.
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Itching
Itching appearing only during the treatment, especially if accompanied by other minor allergic symptoms, may be a manifestation of low-grade hypersensitivity to dialyzer or blood circuit component.
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I.
Bacteremia:
Bacteremia related to the access site infection (venous access, AV fistulas and grafts). Bacteremia may result from contamination of hemodilysis machines ( inadequate disinfection of water treatment , distribution systems or reprocessed dialyzers).
II.
Pyrogen reaction:
Low-grade fever during hemodialysis may be related to pyrogens present in the dialysis solution rather to actual infection.
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a)
b)
Charecteristics of fever:
Patients are afebrile prior to dialysis but become febrile during dialysis. Fever resolves spontaneously after cessation of dialysis. There is one exception to the rule : fever and chills that occur shortly after catheter manipulation (eg, commencement or cessation of dialysis) suggests catheter associated bacteremia. Blood cultures shoulds always be obtained in any febrile HD patients.
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c)
A.
B.
1. 2.
PATHOGENESIS
The cause of the disequilibrium syndrome is controversial The symptoms of DDS are caused by water movement into the brain, leading to cerebral edema. Two theories have been proposed to explain why this occurs: A reverse osmotic shift induced by rapidly urea removal (the plasma becomes hypotonic with respect to the brain cells). Acute changes in the PH of the cerebrospinal fluid and a fall in cerebral intracellular pH.
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The initial dialyses should be gentle, but repeated frequently. The aim is a gradual reduction in BUN, which will be protective but may not prevent mild symptoms such as headache and malaise.
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3. 4.
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ARRHYTHMIAS
Ventricular arrhythmias are common during dialysis and between treatments. Supraventricular arrhythmias are also common. Risk factors for arrhythmias and sudden death in dialysis patients include: coronary artery disease advanced age myocardial dysfunction left ventricular hypertrophy 22/21/
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THE END
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