Emergency Care in ESRD

Aka: Emergency Care in ESRD, End-stage Renal Disease Emergency Evaluation, Dialysis Emergencies, Hemodialysis Emergency

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II. History: Presenting emergency complaints in ESRD

  1. Abdominal Pain
  2. Chest Pain
    1. Uremic Pericarditis (Cardiac Tamponade risk)
    2. Myocardial Ischemia
  3. Dyspnea
    1. Congestive Heart Failure
  4. Electrolyte abnormalities (see management below)
    1. Hyperkalemia
  5. Fever
    1. See Bloodstream Infections in Hemodialysis
  6. Hypotension or Syncope
    1. See Hypotension in the Dialysis Patient
  7. Generalized symptoms related to inadequate or excessive Dialysis
    1. Nausea or Vomiting
    2. Weakness or Dizziness
    3. Lethargy
  8. Shunt related complications
    1. Shunt thrombosis (or stenosis from intimal hyperplasia)
      1. See evaluation and management below
    2. Shunt bleeding
    3. Steal Syndrome (limb ischemia during Dialysis)
  9. Dialysis related complications (see Hemodialysis)
    1. Dialysis Disequilibrium Syndrome (rare, but potentially lethal)
    2. Hemolysis
      1. May result from nitrates, chloramines or dialysate heated to >46 C
    3. Air Embolism (rare now in U.S.)
      1. With older technology, air emboli complicated as many as 1 in 2000 Dialysis runs
      2. Air emboli could be as large 60-125 ml air
    4. Electrolyte abnormalities
      1. See above
    5. Hypersensitivity Reaction
      1. Dialysis membrane (Anaphylaxis)
      2. Phthalate from PVC tubing
      3. Ethylene oxide (dialyzer sterilization solution)
      4. Polyacrylonitrile in membrane (reaction exacerbated in patients taking ACE Inhibitors related to kinin metabolism inhibition)

III. History

  1. Renal Failure history
    1. Reason for Chronic Renal Failure (e.g. Diabetes Mellitus, Hypertension)
    2. When was Dialysis initially started
    3. Is urine still made
  2. Baseline Vital Signs
    1. Dry Weight
    2. Typical Blood Pressure and Heart Rate
  3. Dialysis schedule
    1. When was last Dialysis and when is next scheduled
    2. Missed Dialysis sessions
    3. In Peritoneal Dialysis, which Dialysis solutions and what is the dialysate appearance
  4. Retained Kidneys (presents additional risks)
    1. Hypertension
    2. Nephrolithiasis
    3. Infection

IV. Exam

  1. Vital Signs
    1. See Hypotension in the Dialysis Patient
  2. Vascular Access site
    1. Audible bruit or palpable thrill
      1. Absence may suggest shunt thrombosis
    2. Infection
      1. Assess site for inflammation or discharge (may be subtle)
  3. Cardiopulmonary findings
    1. New Heart Murmurs
    2. Congestive Heart Failure signs
    3. Pericardial Effusion signs
  4. Neurologic findings
    1. Uremia-induced changes
      1. Lethargy
      2. Altered Level of Consciousness
      3. Myoclonus or asterixis
    2. Subdural Hematoma related changes (increased risk due to Bleeding Diathesis, Hypertension)
      1. Focal neurologic deficits
      2. Altered Level of Consciousness
    3. Thiamine deficiency related changes
      1. Ataxia, Confusion, and Ophthalmoplegia
      2. See Wernicke's Encephalopathy
  5. Gastrointestinal findings
    1. Rectal Exam (for blood)

V. Labs

  1. Comprehensive metabolic panel
    1. Review Serum Creatinine, Blood Urea Nitrogen and serum Electrolytes
  2. Serum Magnesium
  3. Serum Phosphorus
  4. Coagulation tests (INR, PTT)
  5. Complete Blood Count
  6. Urinalysis (if not anuric)

VI. Differential Diagnosis

  1. See End Stage Renal Disease
  2. See Hypotension in the Dialysis Patient
  3. See Hemodialysis
  4. See Bloodstream Infections in Hemodialysis

VII. Management

  1. See Hemodialysis (including precautions regarding venipuncture, Blood Pressure)
  2. See Drug Dosing in Chronic Kidney Disease
  3. See Dialysis Disequilibrium Syndrome
  4. See Bloodstream Infections in Hemodialysis

VIII. Management: Cardiovascular collapse

  1. Hypotension
    1. See Hypotension in the Dialysis Patient
  2. Cardiac Arrest
    1. See Cardiopulmonary Resuscitation
    2. Empiric Calcium Chloride (for presumed Hyperkalemia until Serum Potassium level available)
    3. See Uremic Pericarditis below
  3. Uremic Pericarditis (risk of Cardiac Tamponade)
    1. Presents as Dyspnea, cough and positional Chest Pain (fever may be variably present)
    2. Cardiac Tamponade will present with cardiovascular collapse, Pulsus Paradoxus, EKG electrical alternans
    3. Early Cardiac Ultrasound to evaluate for Cardiac Tamponade
    4. Initiate aggressive fluid Resuscitation
    5. Pursue emergency Dialysis
    6. Emergency Pericardiocentesis if cardiovascular collapse
  4. Sepsis
    1. See Bloodstream Infections in Hemodialysis
    2. See Dialysis-Related Spontaneous Bacterial Peritonitis
  5. Malignant Hypertension (including Hypertensive Encephalopathy)
    1. See Hypertensive Crisis
  6. Acute Pulmonary Edema
    1. Consider strongly if weight at presentation >5 pounds over baseline weight (dry weight) or missed Dialysis
    2. Consult with Nephrology regarding emergent Dialysis
    3. See Acute Pulmonary Edema Management
    4. ESRD specific CHF Management
      1. In general, follow Acute Pulmonary Edema Management standard protocol
        1. Employ Diuretics, ACE Inhibitors, Nitroglycerin< BiPap and oxygen
      2. Furosemide (Lasix) 60-100 mg IV (higher dose)
        1. Avoid Furosemide rate of administration >5 mg/min (risk of Ototoxicity)
      3. Other measures in refractory, severe Fluid Overload in ESRD
        1. Emergent Dialysis
        2. Consider early Endotracheal Intubation or CPAP/BIPAP
        3. Nesiritide
          1. Typically avoided now in CHF exacerbations overall (due to lack of efficacy)
          2. However, not renally metabolized and lowers capillary wedge pressure
          3. Dosing: 2 mcg/kg IV bolus, followed by 0.01 mcg/kg/min IV infusion
          4. Observe for Hypotension (occurs in >10% of cases)
  7. Active bleeding with Coagulopathy
    1. Increased bleeding risk due to prolonged Bleeding Time, uremic Platelet Dysfunction, Heparin over-coagulation
    2. Baseline Hemoglobin is typically poor due to decreased erythropoetin, Hemolysis and Bleeding Diathesis
    3. Consider transfusion for Hematocrit <18%
    4. Prolonged Bleeding Time reversal
      1. Desmopressin (Vasopressin, DDAVP)
        1. Works within 2 hours with a duration of 4-8 hours; may repeat in 8-12 hours
        2. IV or SQ: 0.3 mcg/kg
        3. Intranasal: 82 mcg/kg
      2. Cryoprecipitate (FFP)
        1. Dose: 10 units IV over 10-15 minutes every 12-24 hours
        2. Corrects Bleeding Time for 4 hours
      3. Conjugated Estrogen
        1. Dose: 25 mg daily for 7 days
        2. Effects last 21 days
    5. Prolonged bleeding due to excessive Heparinization
      1. Typically not needed, as duration of Heparin activity is brief
      2. Consider Protamine 1 mg for every 100 units of Heparin (or Protamine 10-20 mg for unknown Heparin dose)
  8. Air Embolism (rare)
    1. Presentation with Chest Pain, Dyspnea, Hypotension (or Cardiac Arrest)
    2. Exam may demonstrate "millwheel" Heart Murmur
    3. Incoming access lines should be clamped
    4. Position patient in trendelenburg and supine or left lateral decubitus position
    5. Consider hyperbaric oxygen
    6. Right ventiricular outflow aspiration has been attempted in Cardiac Arrest due to Air Embolism

IX. Management: Shunt Abnormalities

  1. Shunt thrombosis (or stenosis from intimal hyperplasia)
    1. Maintaining Vascular Access in Renal Failure costs more than $1 billion/year in U.S. (and increasing)
    2. Bruit or thrill over access site is absent in shunt obstruction
    3. Confirm shunt thrombosis with dupplex Doppler Ultrasound
    4. Discuss with nephrology and vascular surgery (or Intervention Radiology) at an early stage
    5. Timing of shunt revascularization depends on patient status
      1. Emergent revascularization or Central Line access (today)
        1. Emergent Dialysis needed (e.g. Hyperkalemia, Fluid Overload)
        2. Central Line Placement is typically recommended
          1. Femoral line preferred in this case to preserve neck and upper extremity vessels for shunts
      2. Urgent revascularization (within 24 hours)
        1. Otherwise stable ESRD patient
    6. Revascularization techniques
      1. Shunt Angioplasty
      2. Directed Thrombolysis at shunt access site
      3. Angiographic removal of clot
    7. Tunneled-cuffed catheter revascularization
      1. Tunneled catheters thrombose commonly (>50% within 1 year)
      2. Tissue Plasminogen Activator (TPA) 1-2 mg in each lumen
      3. Hilleman (2011) Pharmacotherapy 31(10): 1031-40 [PubMed]
  2. Steal Syndrome (limb ischemia during Dialysis)
    1. Presents with distal extremity pain with a cold, pale, numb, weak ischemic changes and absent or weak distal pulse
    2. Management
      1. Coil embolization of collateral Hemodialysis veins (more recent technique) or
      2. Access ligation and banding
  3. Vascular Access Hemorrhage
    1. Carefully monitor for bruit or thrill over the access site before and after procedures to stop bleeding
    2. Apply direct light pressure to puncture site for 10-15 minutes
      1. Firm enough to stop bleeding, but not so firm as to risk vascular obstruction and thrombosis
      2. Apply pressure proximal and distal to the bleeding site
    3. Consider topical agents (in combination with manual pressure)
      1. Consider applying Thrombin impregnated sponges or gelatin sponges (e.g. Gelfoam) to bleeding site
      2. Consider Surgicel or similar
      3. Consider topical TXA on bandage
    4. Consider over-Anticoagulation (during Dialysis) as a cause for bleeding
      1. Protamine 0.01 mg per IU of Heparin
        1. Give 10 to 20 mg Protamine if 1000 to 2000 IU Heparin given
      2. Consider DDAVP
      3. Consider Tranexamic Acid (TXA)
    5. Observe in Emergency Department for 1-2 hours after bleeding has stopped before discharge
    6. See reversal of Bleeding Time above
    7. Life-threatening bleeding
      1. Emergent vascular surgery Consultation
      2. Tourniquet (risk of thrombosis, limb ischemia) or Blood Pressure cuff inflated above systolic Blood Pressure
      3. Monofilament 3-0 simple purse-string Suture over the bleeding site (risk of fistula injury)
        1. Maintain manual pressure above and below the bleeding site to clear blood

X. Management: Electrolyte Disturbance

  1. Hyperkalemia
    1. Presents with weakness, Arrhythmias, Hypotension and EKG changes
    2. See Hyperkalemia Management
    3. Temporize with Calcium Gluconate 10% IV over 2-5 minutes until Serum Potassium level available
    4. Contributing factors
      1. Most likely before Dialysis run (or inadequate dailysis)
      2. Excessive Potassium intake
      3. Hemolysis (secondary to Gastrointestinal Bleeding or similar)
      4. Rhabdomyolysis
      5. See Hyperkalemia due to Medications
  2. Hypermagnesemia
    1. Presents with profound Muscle Weakness and hyporeflexia
    2. Arrhythmia and cardiovascular collapse risk if Serum Magnesium >10 mEq/dl
    3. Temporize with Calcium Chloride or Calcium Gluconate for cardiac stabilization
      1. Use Calcium dosing as in Hyperkalemia Management protocols
  3. Hypercalcemia
    1. Presents with Vomiting, weakness, and Hypertension (Altered Level of Consciousness in severe cases)
    2. Consult nephrology for possible Hemodialysis with low Calcium bath
    3. Fluid challenges (250 ml per bolus) followed by reassessment of fluid status
      1. See Inferior Vena Cava Ultrasound for Volume Status
    4. Consider synthetic salmon Calcitonin

XI. Management: Hospitalization Criteria

  1. Emergency Hemodialysis required
    1. Fluid Overload (with Pulmonary Edema)
    2. Hyperkalemia (especially Serum Potassium >7 or EKG Changes)
  2. Cardiopulmonary conditions
    1. Cardiac Tamponade
    2. Air Embolism (suspected)
    3. Chest Pain during Dialysis
    4. Arrhythmia (Clinically Significant)
    5. Uncontrolled bleeding at Dialysis access site
    6. Severe Refractory Hypertension (Hypertensive Urgency or Hypertensive Emergency)
      1. Diastolic Blood Pressure >130 mmHg despite aggressive management
      2. Malignant Hypertension (especially Hypertensive Encephalopathy)
  3. Neurologic conditions
    1. Altered Level of Consciousness
    2. Disequilibrium Syndrome (suspected)
  4. Gastrointestinal conditions
    1. Gastrointestinal Bleeding (e.g. Peptic Ulcer, Diverticular Bleeding) with hemodynamically significant changes
    2. Persistent Vomiting with inability to maintain oral hydration
  5. Fever with serious findings or risks
    1. Pneumonia
    2. Urosepsis
    3. Shunt-site infection
    4. Central venous catheter related bloodborne infection
    5. Ill or toxic appearance
    6. Dyspnea
    7. Hypotension
  6. Symptomatic Electrolyte disturbance (in addition to Hyperkalemia listed above)
    1. Hypermagnesemia
    2. Hypercalcemia (with cardiovascular or neurologic dysfunction)

XII. References

  1. Campana (2014) Crit Dec Emerg Med 28(4): 2-8
  2. Glauser (2013) Crit Dec Emerg Med 27(10): 2-12
  3. Guest and Coggins in Swadron (2022) EM:Rap 22(8): 7
  4. Mallemat, Swaminathan and Egan in Herbert (2014) EM:Rap 14(10): 5

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