Dialysis

90%

What % of pts on dialysis use hemodialysis?

10%

What % of pts on dialysis use peritoneal dialysis?

hemodialysis

-Perfusion of blood and a physiologic solution in opposite directions on opposite sides of a semipermeable membrane

-Water, urea, creatinine, potassium, uremic toxins, and drugs move from the blood across the membrane into the dialysate

complications of hemodialysis

-hypotension

-hypertension

-muscle cramps

-N/V

-HA

-chest/back pain

-pruritus

-fever/chills

intradialytic hypotension

insufficient cardiac response to reduced circulating blood volume

trendelenburg position, decrease UF rate, lower temp of dialysate, modify dialysate electrolyte composition, administer normal or hypertonic saline or mannitol

How do you treat intradialytic hypotension?

Midodrine 2-3x/day

How do you treat chronic hypotension?

intradialytic or post HD hypertension

Dialysis removal of antihypertensive meds, RAAS response to abrupt volume removal

adjust medication administration times; Carvedilol BID

How do you treat intradialytic or post HD hypertension?

muscle cramps

Muscle hypoperfusion, hypovolemia, electrolyte and acid/base imbalance

bolus of NS or dextrose, change dialysate Na to higher concentration than serum Na, accurately set dry weight, stretch, massage, Vit E

How do you treat muscle cramps from hemodialysis?

-aneurysm and stenosis

-thrombosis

-infection

What are the vascular access complications with Hemodialysis?

AV fistulas and grafts

Aneurysm and stenosis are more common with ____________

surgical intervention

How are aneurysm and stenosis solved?

thrombosis

clotting of the catheter in hemodialysis

catheter locking solutions containing unfractionated heparin, recombinant tissue plasminogen activator, or sodium citrate installed in the catheter

How can you prevent thrombosis in hemodialysis?

flush with saline, instill rt-PA

How can you treat thrombosis in hemodialysis?

catheter

Infection is more common with __________ access.

antibiotics and maybe removal of graft or catheter

How do you treat infections in HD patients?

preserve the fistula or graft

What is the goal in pts with HD and AV fistula or graft infections?

empiric broad spectrum abx (Vanc + aminoglycoside) narrow after culture results.

How should you treat a patient on HD with AV fistula or graft infections?

2-6 weeks

What is the duration of tx for a patient on HD with AV fistula or graft infections?

sterile technique when accessing catheter, minimizing accessing catheter and duration, mupirocin ointment application at exit site

How can you prevent catheter infections in patient on HD?

empiric broad spectrum abx (vanc + aminoglycoside) narrow after culture resutls

How do you treat catheter infection in pts on HD?

remove it.

If the organism identified in the catheter infection is Pseudomonas, S aureus or Candida what must you do?

6 weeks

What is the duration of tx for catheter infection in patients on HD?

complications of peritoneal dialysis

-exacerbation of DM

-exacerbation of HF

-edema

-pulmonary congestion

-hypercalcemia/hypocalcemia

-chemical peritonitis

-albumin loss

-loss of amino acids

-muscle wasting

-increased adipose tissue

-fibrin formation in dialysate

IP insulin

How do you treat exacerbations of DM in pts on peritoneal dialysis?

diuretics

How do you treat exacerbations of HF, edema, or pulmonary congestion in pts on peritoneal dialysis?

IP heparin

How do you treat fibrin formation in dialysate in pts on peritoneal dialysis?

1 occurrence every 2 years

What is the usual incidence of peritonitis?

peritonitis

major cause of catheter loss

peritonitis

elevated dialysate WBC count greater than 100/mm3 with at least 50% polymorphonuclear neutrophils

pain and cloudy effluent

What symptoms should you suspect a pt on PD to have if they have peritonitis?

peritonitis presentation

-Abdominal pain or tenderness

-Cloudy effluent

-Fever or chills

-Nausea/vomiting

-Inflammation

-Elevated WBC

-Positive cultures

peritonitis dx

you must have atleast 2 of theses conditions

1) abdominal pain or tenderness or cloudy effluent

2) effluent WBC count > 100 or more than 50% PMN leukocytes

3) positive effluent culture

gram positive

What is the more common bacteria in Periontitis?

common peritonitis organisms

-S. epidermidis

-S. aureus

-Streptococci

-E. coli

-Pseudomona

S. epidermidis

What is the most common organism causing peritonitis?

vancomycin and third gen cephalosporin or aminoglycoside

If MRSA is the likely cause what is the empiric tx recommended?

-Cefazolin or other first gen cephalosporin

-third gen cephalosporin or aminoglycoside

If MRSA is less likely what is the empiric tx recommended?

perferred

Intraperitoneal administration is _________ over IV therapy for peritonitis tx.

intermittent intraperitoneal admin

antibiotics are placed during the longest dwell of the day

continuous intraperitoneal administration

antibiotics are placed during every dwell, a larger (loading dose) may be given with 1st exchange

increase dose by 25%

If a pts urine output is > 100 that means the drug is renally eliminated and you should do what?

remove it

What should you do with the catheter immediately after a fungi is identified?

-amphotericin B or flucytosine

-amphotericin B can be replaced with fluconazole, caspofungin or voriconazole when cultures/sensitivities are available

If a yeast if present in fungal peritonitis what drugs should you use?

10 days

How long should you continue oral tx for fungal peritonitis after the removal of the catheter?

-enhanced pt training

-improvements in technology for connector systems

-meds

How can you prevent catheter site infections?

mupirocin BID x 5-7 days each month

What is the intranasal med that is a prophylactic regimen for S aureus exit site infections?

Mupirocin at exit site daily

What topical med is a prophylactic regimen for S aureus exit site infections?

Rifampin 300 mg BID x 5 days, every 3 months

What is the oral med that is a prophylactic regimen for S aureus exit site infections?

bc Scr is lowered from the dialysis machine not the pts kidneys

Why do you not calculate GFR for pts on dialysis?

Baclofen

-anti epileptic med

-helped with muscle spasm in some pts

meaningless

eGFR is __________ in a pt on dialysis.

< 10 mL/min or ESRD

You should use _____________ for drug dosing for pts on dialysis.

relies

Baclofen _______ on the kidneys.

yes

Is gentamicin dialyzable?

no

Is Vancomycin dialyzable?

no bc 90% are protein bound to albumin

Is Phenytoin dialyzable?

plasmapharesis

How could Phenytoin be removed instead of dialysis?

no bc most of it is in the blood

Is Digoxin readily dialyzable?

Poisondex

What did they use to call toxicology?

Dantrolene

better than Baclofen for muscle spasm bc doesn't rely on kidney as much for elimination

hydroxydantrolene

inactive form of Dantrolene

toxic

The metabolite of Meperidine is _________.

supplementary dose

For Ertapenem (Invaz) a ___________ must be administered within 6 hours prior to dialysis.

8-10

If you want to destroy a bug you must be ______ higher than the MIC.

loading dose

For Levofloxacin you must give a __________ with regular dosing to get the concentration up before dialysis.

still give it after dialysis

If you are supposed to give an antibiotic after dialysis at the same time each day what do you do if they do dialysis at different times each day?

drugs that dont rely on the kidney

For dosing in dialysis you should prioritize what drugs?