Medical Emergency in HD

MEDICAL Dr Chin Chee Khin
EMERGENCIES 8/3/2022
IN
NEPHROLOGY
TOPICS TO INCLUDE
• Acute pulmonary oedema
• Malignant hypertension
• Hyperkaelemia
• Metabolic acidosis
• Will concentrate on patients with severe renal failure or on dialysis

Acute Pulmonary Oedema (APO)
• Introduction
• Causes & precipitating factors
• Clinical presentation & investigations
• Diagnosis & differential diagnosis
• Management & prevention
APO -- Introduction
• Fluid accumulation in the lungs resulting in impaired gas exchanges
• High mortality
APO – Causes & Precipitating factors
• Fluid overload – wrong dry weight
-- large interdialytic weight gain
• Cardiac : ischaemic heart disease
:arrhythmias eg Atrial fibrillation
:diabetic cardiomyopathy
:others: valvular heart disease
• Severe hypertension
• Precipitating factors: Anaemia, infection, pulmonary embolus, drugs
e.g. beta blocker, metabolic acidosis
APO – Clinical presentations
• Cough, esp. at night
• Orthopnoea, (cannot lie down to sleep)
• Dyspepsia
• Breathless on mild evertion, at rest
• Cynosis
• Frothy sputum
• Hypoxia (low SPO2)
• Large interdialytic weight gain
APO – Differential diagnosis & Investigation
• Chest infection
• COAD
• CXR, blood test: K+, Hb, ECG, Echocardiogram
• Often arise from combination of multiple factors: IHD + Anaemia +

severe hypertension + infection + Fluid overload + COAD
APO -- Management
• Resuscitation
• Oxygen, sit up patient
• If BP high or chest pain with ECG showing IHD, S/L GTN, transdermal
GTN (Nitroderm), IV GTN
• Diuretics (less effective in severe renal failure)
• Morphine
• Ventilation
• Dialysis : sequential ultrafiltration
APO -- Management
• Treat precipitating causes
• Adjust dry weight
• Treat infection
• Treat anaemia
• Education on fluid intake
APO – controversy in management
• For free standing dialysis centre:
• If your patients presented with severe breathlessness or become

breathless during dialysis, what should you do?
• Start or continue to dialyze the patient? Refer him to nearest
hospital?
Malignant hypertension
Malignant Hypertension
BP > 180/120 mm Hg & presence of organ system affected by the high BP
(Vs Accelerated Hypertension: high BP without symptoms)
Brain: headache, change in sensorium, seizure, papilloedema
Heart: left ventricular failure, APO
Kidney: new onset proteinuria, acute deterioration of renal function

Malignant Hypertension: Management
• BP must be lowered fast, (in hours); as opposed to accelerated
hypertension where BP can be lowered in days or weeks
• S/L GTN
• IV isosorbide dinitrate
• Iv diuretics
• Iv Sodium nitroprusside
• Iv labetalol
• Combine with oral antihypertensive + sedative (shorting acting
Calcium channel blocker e.g. Nifedipine)
Hypertension in renal disease
• Hypertension in patient with ESRD: > 140/90 pre-dialysis & > 130/80
post-dialysis (US and European countries)
• Whether we should maintain our patients’ BP at this level depends on

a number of factors: Age, health status, interdialytic weight gain,
presence of other disease eg. diabetes
• Improve mortality with optimal BP control

• Slow down of renal deterioration esp. in diabetics
Severe hypertension in dialysis patients: pt
1.
• 60 y/o man
• Hd x 1/2 yr.
• Came for dialysis at 6:30 am with BP 220/130 mmHg
• No symptoms
• Did not take his anti-hypertensive that morning.
• What would you do?

• (He has been taking Amlodipine 10 mg om, metoprolol 100 mg bd,
prazocin 2 mg tds on non dialysis days)
Same patient but:
• What would you tell him if he comes at your second or third shift
dialysis sessions (11 am or 4 pm)?
• What would you do if he complained of breathlessness on walking to

your dialysis centre & coughing the previous night?
• Besides asking your doctors to review his antihypertensives, what

other non pharmacological methods to lower his BP?
BP control in patients undergoing dialysis
• Reduce dry weight
• Advise patients to reduce salt intake
• Reduce Sodium concentration in dialysate (conductivity)
• Check Hb: High Hb from too high dose of EPO results in high BP
• Prolonging duration of dialysis
Intradialytic hypertension
• BP increases during dialysis or at the end of dialysis
• 15 % of dialysis population; associated with worse outcome
• Reason not known
• Possible reasons:
• Increased in cardiac output after fluid extraction during dialysis in patients
with volume overload.
• Sympathetic overactivity
• Excessive stimulation of Renin-angiotensin-aldosterone system
• Removal of antihypertensives by dialysis
Intradialytic hypertension - management
• Give anti-hypertensive before dialysis:

• ACE/ARB
• Alpha & Beta-blockers
• Calcium channel blockers
• Reduce dry weight

• Reduce sodium in dialysate
• Do not use high calcium dialysate
• Advice less interdialytic weight gain
Severe hyperkalaemia
• Normal K+ level: 3.5 to 5.3 mmol/L
• Maintain intracellular volume
• Help in muscle cell function
• Role in maintaining normal blood pressure
• Symptoms of hyperkalaemia: subtle

• Tiredness, weak giddy
• Cardiac arrest
Pathophysiology of hyperkalaemia
• Potassium mainly from food
• In the body, mainly intracellular
• Homeostasis depends on normal renal function
• In renal failure, there is decrease in K+ excretion, leading to

hyperkalaemia
• Exacerbating factors: ACE/ACR, high potassium food eg fruits mango,
banana, star fruit
• Sudden cell damage e.g. crush injury, will result in potassium release
into the blood stream
Diagnosis of hyperkalaemia
• Vague symptoms
• Depend mainly on blood K level
• > 6.0 = moderate, > 7 = severe, >8 = life threatening
• Severity also depends on the rate of rise of K+
• Pitfall:
• Stored blood,
• Poorly preserved sample during transport of blood samples,
• Difficult venepuncture
•
Diagnosis of hyperkalaemia
• ECG:
• Tall T waves
• ST depression
• Prolonged PR interval
• Absence P wave
• Widening QRS
• Sine wave pattern
Treatment of hyperkalaemia
• Emergency treatment:
• Lytic cocktail: 10 ml Calcium gluconate + 40 ml Dextrose 50% + 10 u Actrapid
• Shift K+ into cells
• Temporary
• Look for reversible causes
• Correct metabolic acidosis
• Dialysis
• Non emergency treatment:

• Low potassium diet
• GIT cation exchange resin eg. Resonium A (Kalimate)
• Diuretics eg. Frusemide
Metabolic Acisosis
• A clinical condition characterized by increase in plasma acidity
• Normal blood pH 7.36 – 7.42
• Acidosis = pH < 7.36
• Metabolic acidosis increase H+ in plasma but reduced level of
bicarbonate (HCO3 )
• Why pH range?
• Maintain cell and protein (enzyme) function
Metabolic acidosis: pathophysiology
• Blood pH maintain by
• 1: lung – control PaCO2
• 2: kidney: H+ ion excretion to reduce acidosis
Metabolic acidosis-- etiology
• Renal failure
• Sepsis
• Diabetic ketoacidosis
• Drugs e.g. metformin
• Renal tubular acidosis
• Prolong diarrhoea
Metabolic acidosis: presentation &
investigation
• Kussmaul breathing
• ABG: pH < 7.36. severe if <7
• VBG
• Also low HCO3 level at ABG & VBG

• High K+ level
• Look for combination of causes, diabetes, infection, liver failure.
Metabolic acidosis: management
Sodium bicarbonate bolus injection or infusion
Beware of Sodium or fluid overload
Dialysis
Treat underlying exacerbating causes

Medical Emergency in HD

Uploaded by

Copyright:

Available Formats

Medical Emergency in HD

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Medical Emergency in HD

Uploaded by

Copyright:

Available Formats

MEDICAL Dr Chin Chee Khin

• Will concentrate on patients with severe renal failure or on dialysis

• CXR, blood test: K+, Hb, ECG, Echocardiogram

• Often arise from combination of multiple factors: IHD + Anaemia +

• If your patients presented with severe breathlessness or become

BP > 180/120 mm Hg & presence of organ system affected by the high BP

(Vs Accelerated Hypertension: high BP without symptoms)

Brain: headache, change in sensorium, seizure, papilloedema

Heart: left ventricular failure, APO

Kidney: new onset proteinuria, acute deterioration of renal function

• Whether we should maintain our patients’ BP at this level depends on

• Improve mortality with optimal BP control

• What would you do?

• What would you do if he complained of breathlessness on walking to

• Besides asking your doctors to review his antihypertensives, what

• Give anti-hypertensive before dialysis:

• Reduce dry weight

• Symptoms of hyperkalaemia: subtle

• In renal failure, there is decrease in K+ excretion, leading to

• Non emergency treatment:

• Also low HCO3 level at ABG & VBG

Sodium bicarbonate bolus injection or infusion

Beware of Sodium or fluid overload

Treat underlying exacerbating causes

You might also like