Hemodialysis-related emergencies--Part II

A Case of Brachiocephalic Fistula Steal and the Emergency Physician's Approach to Hemodialysis Arteriovenous Fistula Complications

BACKGROUND

Chronic kidney disease is common in the United States, with many patients maintained on hemodialysis (HD). The process of HD requires vascular access through an arteriovenous (AV) fistula, AV graft, or central venous catheter. Today, as a result of the National Kidney Foundation's "Fistula First" initiative, nearly 55% of HD patients utilize an AV fistula. As there is significant morbidity and mortality associated with fistula placement and recurrent fistula cannulation, emergency physicians must be equipped to recognize and treat fistula complications.

OBJECTIVE

To detail a case study of vascular insufficiency (vascular steal) presenting to an emergency department (ED) and provide an evidence-based approach to the emergency assessment and management of HD AV fistula complications.

DISCUSSION

A 66-year-old man presented to the ED with left upper extremity pain, paresthesias, and loss of grip strength of 1-week duration 15 days after placement of left upper extremity brachiocephalic fistula. He was diagnosed with dialysis access-associated steal syndrome and taken to the operating room for revision. Patients with HD fistulas may experience several complications, including vascular insufficiency, hemorrhage, infection, stenosis, thrombosis, aneurysms, or pseudoaneurysms. Emergency physicians must be able to identify these complications and deliver timely treatment.

CONCLUSIONS

A comprehensive understanding of the appropriate management of AV fistula complications is paramount for the emergency physician. Early recognition and treatment of vascular insufficiency resulting from fistula creation, fistula hemorrhage, fistula infection, stenosis, thrombosis, and aneurysms or pseudoaneurysms is vital to reducing the morbidity and mortality associated with HD.

Treatment of life-threatening hyperkalemia with peritoneal dialysis in the ED

Severe hyperkalemia (serum potassium N 7.0 mmol/L) is an uncommon electrolyte abnormality in patients undergoing maintenance peritoneal dialysis (PD). Hemodialysis (HD) has been suggested as the definitive therapy for severe hyperkalemia in this population,although there is limited data regarding renal replacement options.We report a case of life-threatening hyperkalemia with electrocardiogram changes in a nonadherent PD patient who was successfully treated with standard medical therapy and manual exchanges initiated by emergency department (ED) personnel. The patient did not require HD. This case demonstrates the potential utility of PD as a treatment option for severe hyperkalemia in established dialysis patients when EDs are prepared to deliver exchanges. This report maybe particularly relevant due to the increasing prevalence rate of PD and for centers with limited HD access.

Transposed Arteriovenous Fistulae: Do the Results Justify the Effort?

Transposed arteriovenous fistulae have been utilized in clinical scenarios where simple arteriovenous fistulae have failed or their construction was not possible for anatomical reasons. Despite variability in published reports, transposed arteriovenous fistulae have acceptable patency rates and outperform prosthetic arteriovenous grafts in patency, frequency of intervention to maintain patency, and complication rates.

ED management of acute congestive heart failure in renal dialysis patients

This is a descriptive report of the management techniques used effectively in the emergency department (ED) treatment of acute congestive heart failure (CHF) in renal dialysis patients. Study design included a prospective case series of consecutive renal dialysis patients who presented to the ED of a regional dialysis center in acute CHF. Clinical presentation, ED management, and outcome were recorded. Forty-six patients (38 hemodialysis and 8 peritoneal dialysis) were included in this study. Presentation classifications for these patients were minimal distress (13 patients), moderate distress (16 patients), and severe distress (17 patients). In addition to supplemental oxygen, treatment focused on pharmacological preload and afterload reduction. Patients received sublingual nitroglycerin (NTG) (30 patients), transdermal NTG (36 patients), captopril sublingual (10 patients) nifedipine oral (nine patients), nitroprusside (four patients), morphine sulfate (one patient), NTG infusion (one patient), and clonidine (one patient). There were no deaths in the study group, and 32 of the patients were able to be dialyzed and discharged, including seven patients in the severe group. Six patients required intubation, one of whom was extubated and discharged from the ED after dialysis. Intravascular access was obtained in 29 patients but was used in only six. All patients on nitroprusside drips were weaned during the course of their dialysis. Effective ED management of acute CHF in renal dialysis patients can be accomplished through preload reduction with nitrates and afterload reduction with captopril, nifedipine, and, in severe cases, nitroprusside.

Emergency department evaluation and management of dialysis patient complications

The number of dialysis patients in the United States has markedly increased in recent years to more than 100,000. An emergency physician is increasingly likely to be presented with the challenge of handling the emergent problems of the dialysis patient. This article is a review of the complications seen in the population of hemodialysis and peritoneal dialysis patients, with recommendations for emergency department evaluation and management.

Emergency department presentation of renal dialysis patients: indications for EMS transport directly to dialysis centers

To determine the pattern of emergency department (ED) utilization by renal dialysis (RD) patients, a prospective study was conducted of dialysis patients presenting to the ED of a regional dialysis center. The most common presenting complaints were shortness of breath (SOB), chest pain, abdominal pain, and vomiting; the most common diagnoses were congestive heart failure, chest wall pain, and electrolyte abnormalities. Interventional dialysis (ID), defined as emergent dialysis required to treat the patient's presenting complaint, was required for 30 patients, with the most common presenting complaints of these patients being shortness of breath, weakness, and chest pain. Only SOB was statistically significant in predicting the need for ID (P less than 0.001), with a positive predictive value of 0.63 and a negative predictive value of 0.85. Prehospital implications of these data suggest that RD patients with a chief complaint of SOB should be transported directly to a facility capable of dialysis on an emergent basis.