1 / 30

First few session care

First few session care. PANTIPA TONSAWAN, M.D. July 5, 2013 . Scope.  Relation : ESRD , HD & death .  Pre HD patient evaluation .  HD prescription ( initial treatment ).  HD complication ( Initial treatment ). Impact : ESRD,HD & death .

jody
Télécharger la présentation

First few session care

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. First few session care PANTIPA TONSAWAN, M.D. July 5, 2013

  2. Scope Relation : ESRD , HD & death Pre HD patient evaluation  HD prescription (initial treatment)  HD complication (Initial treatment)

  3. Impact : ESRD,HD & death

  4. Probability of sudden cardiac death in incident dialysis patients Probability Month after dialysis U.S. Renal Data System, USRDS 2012 Annual Data Report

  5. Causes of death : prevalent dialysis patients, 2008–2010 ESRD pt Cardiac causes U.S. Renal Data System, USRDS 2012 Annual Data Report

  6. Rates of sudden cardiac death : age Period prevalent dialysis patients, age 20 & older, unadjusted. U.S. Renal Data System, USRDS 2012 Annual Data Report

  7. Rates of sudden cardiac death prevalent dialysis patients, by primary diagnosis Death /1000 patient years 2000 2005 2010 U.S. Renal Data System, USRDS 2012 Annual Data Report

  8. Rates of sudden cardiac death following initiation of treatment in incident HD patients 0-90 days : 1/10 Death /1000 patient years 2000 2006 2007 2007 2009 U.S. Renal Data System, USRDS 2012 Annual Data Report

  9. Caution !!! : sudden cardiac death  RRT :Hemodialysis Aging : Exp > 65 yrs…>75 yrs  Underlying : DM, HT  Duration initial treatment : 0-90 days

  10. Patient evaluation

  11. Pre HD Evaluation Vascular access Hemodialysis prescription Patient information

  12. Patient information 1.History taking  Indication & complication Acute or chronic HD, hyper K, volume↑  Underlying disease…DM, HT, IHD  Active problem ..GI Bleed, MI, stroke Hemodynamic status  Arrhythmia, BP Medication  Anti HT, anti coagulant

  13. Patient information 2.Laboratory data  CBC :  Hb/HCT, Platelet…..risk bleeding  BUN/Cr : High BUN…..Risk ….DDS  Electrolyte : Select : Dialysate solution component Serology:  HBV, HCV, HIV…..isolated

  14. Vascular access : initial use Arteriovenousfislula Prepare : 3-6 mo ….. Maturation Prompt ? Arteriovenous graft Prepare : 3-6 wk : at least 2 wk after Surgery Infection ? HD catheter Exit site, redness, warm immediately use ..complication ?

  15. Hemodialysis prescription

  16. Order HD prescription (initial treatment) • Session length : Perform HD 2 hrs • BFR: 200 ml/min • Dialyzer: Low flux • Dialysatesolution composition: • Na …, K…., HCO3 …, Ca…, Mg…, Dextrose….. • DFR: 500 ml/min • Dialysis solution temp.: 36oc • Fluid removal order: remove … Lite • Anti-coagulant : heparinloading..,maintenance … (หรือnon-heparin ตามความเหมาะสม) • 50 % glucose 50-100 ml intra HD (พิจารณาตามความเหมาะสมของผู้ป่วยแต่ละราย) Daugirdas JT. Acute & Chronic hemodialysisprescription; Handbook of dialysis 2007

  17. HD prescription (initial treatment) Time: initial 2 hr… ↑ 30 min q HD ……until 4 hr BFR : initial 200-250 ml/min …↑ 30 min q HD ……until 350-400 ml/min Dialyzer: initial low flux, low SA …. (AIM ….Kt/V 0.6-0.7, URR 40 %) DFR : 500 ml/min …800ml/min (high BFR) Daugirdas JT. Acute & Chronic hemodialysisprescription; Handbook of dialysis 2007

  18. HD prescription (initial treatment) Dialysate composition : Temp. : low temp prevent Hypotension 36.5 C  UF : < 1 L /hr, ….if need…sequential HD  Hypertonic solution : 50 % glucose ….DDS Anticoagulant : depend on patient. condition Daugirdas JT. Acute & Chronic hemodialysisprescription; Handbook of dialysis 2007

  19. Hemodialysis complications

  20. Dialysis disequilibrium syndrome Acute neurological complication Consequence of rapid HD …osmotic gradient brain Vs plasma caused .. cerebral edema Risk factor 1st session hemodialysis  Extreme age : child or aging  High BUN level: > 125 mg/dl  CNS disorder (stroke, tumor, dementia,hypoNa), head injury (subdural hematoma) …. PediatrNephrol (2012) 27:2205–2211 Seminars in Dialysis—Vol 20, No 3 2008 pp. 493–498

  21. Dialysis disequilibrium syndrome ICF ECF IVF I Urea CF : brain ICF : brain Brain Urea Urea H2O Urea↑ High Osm Urea H20 slow Reverse osmotic shift HD Cerebral edema

  22. Dialysis disequilibrium syndrome Clinical : fatigue, mild headache, nausea, vomiting, disturbed consciousness, convulsions… coma. Common mild..Self limited, fatal.. if severe Diagnosis Clinical diagnosis (during HD, after HD) + riskfactorExclusion other condition Treatment Symptomatic treatment/ hypertonic solution/ + stop HD Seminars in Dialysis—Vol 20, No 3 2008 pp. 493–498

  23. Dialysis disequilibrium syndrome Prevention Most important Dialysis time (2 hours) Blood flow rate 200 ml/min  Less efficient (small) dialyzer  Hypertonic solution  A goal URR : 0.4–0.45 or diffusive Kt/V of 0.6–0.7 Seminars in Dialysis—Vol 20, No 3 2008 pp. 493–498

  24. Cardiac arrhythmia, Ischemia, sudden death DIALYSIS-INDUCED MYOCARDIAL STUNNING • Echocardiogram • -Pre HD …normal • - During HD …. RWMA abnormality • - Post HD 30 min …normal Semin Dial 2007; 20: 220–228  Positron emission tomography: Measure ..MBF dialysis ….. HD precipitates reductions MBF CAG …..normal Clin J Am Soc Nephrol 2008; 3: 19–26. ;Kidney International (2009) 76, 371–375 Effects of hemodialysis on cardiac function

  25. Cardiac arrhythmia, Ischemia, sudden death DIALYSIS-INDUCED CARDIAC ISCHEMIA Myocardial stunning : Occur ….60 % Related to UF (total/rate ) & HD instability Long term High mortality PET ;Kidney International (2009) 76, 371–375 Effects of hemodialysis on cardiac function

  26. Intradialytic hypotension Initial treatment : associated cause High UF rate : limit time Trial & error : set DW High dose : anti HT Nutrition status : malnutrition …low plasma refilling Treatment  Sequential HD Limit IDWG < 1 kg/day  Decrease anti HT ….decrease DW  Avoid : eating during HD low Temp.

  27. Type A : anaphylactic type Dialyzer reaction • Type B :non-specific  Full brown, Severe reaction  Common : 5 min after HD…but delayed 30 min  Cause : ETO oxide, AN 69 reaction, contaminated dialysis solution, reuse First use syndrome Management : Safest to stop dailysis, without returning blood  Cardiorespiratory support Prevention : proper rinsing, y-irradiated or stream-sterilized dialyzer

  28. Dialyzer reaction Type B :non-specific  Mild symptoms : chest pain, back pain  Onset 20-30 min after HD  Cause : unknown Management :  Supportive care  Differential diagnosis : coronary artery disease

  29. Post HD care Complication Next session HD

  30. Summary  Cardiovascular : common cause of death HD patient  Risk :aging, DM, HT, HD 0-90 day  Pre HD patient evaluation: important …Recognized risk of HD complication  Appropriate HD prescription …reduce & prevent HD complication Prompt to treatment of complication : if HD… started

More Related