Hemodialysis Flashcards

Question

clinical conditions with no anticoagulation or reginal anticoagulation

Answer 1

actively bleeding significant risk for bleeding major thrombi static defect major sx within 7 fays intracranial sx 14 days biopsy of visceral organs with 72h pericarditis

Answer 2

Major sx beyond 7 days biopsy if visceral organs beyond 72h minor sx 8h prior minor sx within 72h

Answer 3

major sx 8h prior

Answer 4

rinse circuit with heparinized saline less thrombogenic dialyzer flush the circuit with 100 to 200 ml 0.9% Nacl every 30 mins avoid blood or platelet transfusion through circuit high blood flow rate limit uf

Answer 5

Higher dialysate Mg

Answer 6

lower dialysate Mg

Answer 7

bacterial contamination and precipitation of Ca and Mg salts

Answer 8

carotid intimal thickness

Answer 9

coenzyme q10

Answer 10

prehd and post hd bp

Answer 11

losartan, fosinopril, ramipril, carvedilol, bisoprolol, propranolol

Answer 12

hypotension arterial interdialitica maior mortalidade, maior atordoamento cardiaco, aumento do risco de trombose da fav causas de hid: peso seco baixo, uf muito alta, tempo muito curto com uf alta vasocontriccao insatisfatoria= temp elevada, sodio baixo , neuropatia autonomica, alimentacao na dialise, anemia, uso de anti hipertensivos fat cardiacos= disfuncao diastolica outras=tamponamento, iam, hemorrgia, sepse, reacao ao dialisador, hemolise, embolia gasosa usar midodrina, sertralina, fludrocortisona

Answer 13

reassess dry wt reduce id Na gain **assess id hypoca, hypoK, hypoNg** avoid food intake during hd adjust antihtn assess cardiac function cool dialysate extend dialysis time or add sessions sequential Uf or uf remodeling midodrine manitol hemodiafiltracao uso de diureticos, baixar a ingesta de sodio

Answer 14

1. shorter tx times of 1-2h- limitar a sessao a 2-2,5h 2. lowering blood flow rates to 200-250 ml/min 3. Reducing dialysate flow rate, concurrent flow 4. dialyzer with small surface area 5. Mannitol 1g/kg 6-perfil de sodio ou sodio mais alto 7 considerar crrt = hemorragia intracerebral, massa crebral, trauma cerebral

Answer 15

uremic pericarditis

Answer 16

sindrome do desequilibrio embolia gasosa hemolise hemorragia do acesso saida da agulha de puncao reacao alergica parada cardiaca erros na prescricao

Answer 17

type A reactions -raro- ANAFILATICA =\> dialyzer reaction that occur within 5 to 20 mins and present with pruritus, urticaria, bronchospasm or anaphylactic shock,tosse , dispneia, dor abdominal causas =oxido etileno, ieca, bacterias,reutilizacao de dialisador cause of first use syndrome =IgE antibodies to membrane material or ethylene oxide parara a dialise, nao devolver, pincar as linhas. antialergico, corticoide, adrenalina- mudar a membrana,tentar hd sem heparina -Type B=Complement mediated, occur later, chest and back discomfort =30-60minutos, causa desconhecida continuar a dialise, tentar oxigenio, tentar mudar a membrana

Answer 18

tipo A- anafilatica, mais grave, nos primeiro minutos mediada por igE= calafrios, urticaria, tosse prurido hipotensao estridor PCR ou altos niveis de bradicinina uso de ieca reacao com a membrana ou oxido de etileno procurar a causa, tentar dialisar sem heparina, nao devolver, pincar as linhas corticoide, adrenalina , antialergicos tipo B -mediada por complemento apos 15-30minutos dor nas costas ,nauseas vomitos, dor no peito. trocar o dialisador capilar de polisulfona

Answer 19

acute hemolysis discontinue without blood return check K, peripheral smear, hgb screen dialysate and blood tubing for contaminants causas de hemolise= contaminacao por cobre, zinco, nitrato, nitrito e cloramine dialisato hipoosmolar, hipertermia ma oclusao da bomba de sangue, dialise de alto fluxo c agulha unica, oclusao parcial do cateter, kink , defeitos na linha paciente relacionado=esferocitose hereditaria, anemia falciforme, hemolise autoimune

Answer 20

Stop blood pump,clamp venous dialysis line to prevent further air entry administer O2 volume resuscitation keep patient supine air entra no circuito pelo acesso ou pelo circuito do dialisador defeitos nas conexoes priming inadequado medicacao administrada inadequadamente implante ou retirada de cateter foam in venous line pessoal treinado, evitar fluxos muito altos manter nivel de sangue alto no catabolhas

Answer 21

imediatas: aumento do debito cardiaco 10-20% aumento ativ simpatica diminuicao da resist periferica aumento da fc efeitos em 1 semana= aumento do volume sanguineo causando aumento do ve aumento anp e bnp diminuicao da resistencia vascular diminuicao da renina e aldosterona long terms- hipertrofia de ve aumento debito cardiaco isquemia coronaria estenose venosa

Answer 22

venous outflow or central venous stenosis estenose venosa= veias nao colapsam quando eleva o braco , tempo de sangramento prolongado, pressao venosa alta, baixo fluxo, aneurisma distendido, hiperpulsatil, sopro e fremito param no local da estenose estenose central= dificuldade de canular, baixo fluxo, aumento pressao venosa, braço edemaciado, veias nao colapsam pulso e fremito variaveis estenose arterial= dificuldade de canulacao, pressao arterial negativa , baixo fluxo, hipopulsatil, fremito e sopro, descontinuo ou diminuido sindrome de roubo de fluxo sindrome de roubo de fluxo da coronaria IC DE ALTO DEBITO

Answer 23

trombose= dor, palpacao do trombo, ausencia de fremito estenose= dificuldade de canular, edema doloroso, sangramento prolongado, icc=dispneia, ortopneia, dispneia paroxistica noturna, edema neuropatia isquemic= dor distal a anastomose, perda da sensibilidade, fraqueza nas maos e dedos, paralisia sindrome do roubo=cianose de extremidade, diferenca de temperatura, dor, ulceracao, necrose , gangrena. side to side anastomososis aneurisma= sinais de sangramento, infeccao, ulcera infeccao=dor, calor, rubor, edema

Answer 24

Finding what It Suggests Head: Facial edema Superior vena cava stenosis Neck: Scars (prior central venous catheters)/Increased risk of central venous stenosis Chest: Edema Breast swelling Collateral veins Implantable devices Central vein stenosis Increased risk of central vein stenosis Arm: Edema Central vein stenosis ``` Collateral vein(s) Stenosis near the vein(s) Aneurysms and pseudoaneurysms Outflow stenosis Visible pulsation Outflow stenosis ``` Hand: Cyanosis,pallor, skin necrosis, or dystrophic nails = Vascular steal syndrome

Answer 25

Clinical Pearl: True aneurysms are dilations involving the entire vessel wall, whereas pseudoaneurysms are dilations secondary to hematomas that occur at sites of repetitive cannulation. Unlike true aneurysms, pseudoaneurysms are not covered by the vessel wall. Glassy, thin skin or presence of ulceration over an aneurysm or pseudoaneurysm requires urgent surgical evaluation, due to high risk of AV access rupture .

Answer 26

s a simple method to diagnose outflow vein stenosis. Under normal circumstances, when the fistula arm is raised above the level of the heart, the fistula will collapse. If an outflow stenosis is present, the area of the fistula distal to the stenosis will remain distended. Note: this test works best with forearm AVFs and is not valid for AVGs. Patients can be taught to perform the arm elevation test as a way to self-monitor their AV accesses

Answer 27

intensify the thrill over the area of stenosis and lead to loss of the diastolic component. An extremely strong (“water-hammer”) pulse over an AV access is concerning for venous outflow stenosis. Weak pulsation suggests a problem with the inflow. In an AV graft, it is normal to feel a strong thrill at the arterial anastomosis that diminishes slightly as you move closer to the venous outflow

Answer 28

The AV access is completely occluded several centimeters above the arterial anastomosis with one hand, while the other hand is used to assess the quality of the pulse. Increased pulse intensity (augmentation) with occlusion of the outflow vein is a normal finding. Failure of the pulse to augment when the outflow vein is occluded suggests the presence of inflow stenosis. The pulse augmentation test may also be used to assess the direction of blood flow in an AVG. When the center of the AVG is occluded, the side with an intensified pulse is the portion of the AVG that is connected to the artery, while the side without pulsation is the portion of the AVG connected to the vein. The augmentation test. The left hand (A) is used to occlude access outflow while the right (B) is used to assess the intensity of the pulse. From Salman and Beathard, CJASN, 2013.

Answer 29

Similar to the pulse augmentation test, one hand is used to occlude the AV access outflow while the other hand is used to palpate the thrill. The AV access is occluded progressively further down the venous outflow tract. If no collateral vein is present, no thrill will be felt. However, if a thrill is palpable despite occlusion of the AV, that indicates the presence of a collateral vein below the point of occlusion.

Answer 30

dor, ausencia de pulso

Answer 31

sangramento prolingado, edema, dificuldade de canulacao

Answer 32

nao removiveis na dialise= **bras,anlodipina, nifedipina (pouco), verapamil pouco, carvedilol zero, labetalol \<1%,hidralazina** **clonidina 5%** removiveis minoxidil \<30% diltiazen, benzapril, ramipril, enalapril atenolol = 75% lisinopril 50% metildopa 60%

Answer 33

Patient has central venous stenosis and has symptoms of venous hypertension (swelling hand, dilated veins).Next step is to do Fistulogram and central venogram.The treatment is angioplasty of central stenosis with or without stentingbut if it become a recurrent event then needs ligation of AVF and creation ofnew access. K/DOQI Guideline- Indications for Fistulogram •Swelling of whole fistula arm Prolonged bleeding \>10 mins post dialysis on more than one occasion despite optimisation of anticoagulation regime• Increase in size of aneurysms• Persistent problems with scabs \>3mm diameter Unable to achieve dialysis blood flow of at least 300 ml/min• 25% fall from baseline in either achieved blood ow on dialysis or stulaow (transonic measurement within rst 1.5 hrs of HD)• Recirculation \>5% on 2 consecutive dialysis sessions• Dynamic venous pressure \>150 mmHg when measured using 15Gneedles and blood ow 200 ml/min in the rst 2 - 5 mins of dialysis (risingtrend over time is more useful than a single measurement so comparewith baseline).• Unexplained fall in 2 consecutive URR measured on a 4 hour dialysis Session

Answer 34

paciente estavel, que "funciona" bem funcao renal residual peso seco atingido sem anemia sem dmo, doenca ossea bem nutrido acompanhamento psicossocial e educacional encaminhado ao tx albumina boa controle da pa , sem hve que nao tem desconforto anemia, acidose ou k corrigido como conseguir isso? fistula first , tratar cuidar do acesso, medir a diurese residual, uso de diuretico, bioimpedancia dosar albumina,nutricionista, programa educacional

Answer 35

We recommend a target single pool Kt/V (spKt/V) of 1.4 per hemodialysis session for patients treated thrice weekly, with a minimum delivered spKt/V of 1.2. (1B) 3.2 In patients with significant residual native kidney function (Kru), the dose of hemodialysis may be reduced provided Kru is measured periodically to avoid inadequate dialysis. ) 3.3 For hemodialysis schedules other than thrice weekly, we suggest a target standard Kt/V of 2.3 volumes per week with a minimum delivered dose of 2.1 using a method of calculation that includes the contributions of ultrafiltration and residual kidney function. (Not Graded )

Answer 36

* Identify type of catheter, tunneled or non-tunneled, trialysis or not, date of placement and location in note * Catheter length by side: • Right Internal Jugular 15 cm • Left Internal Jugular 20 cm • Femoral 24 cm * No clear maximum recommended duration of non-tunnelled femoral catheter and internal jugular cathete r • 5 days for femoral (2006 KDOQI vascular access guidelines) • 7 days for the IJ catheter (2006 KDOQI vascular access guidelines) • No patient should go home with temporary (non-tunneled) catheters. • Most tunneled catheters are not meant to be permanent so need to have plan for fistula/graft or PD catheter placement prior to discharge

Answer 37

Access-related Infection Catheter-related infection • Give vancomycin 15-20 mg/kg load AND gentamicin or tobramycin 2 mg/kg load (up to max 100 mg gentamicin) (or another antibiotic for gram neg). Antibiotics given in the last hour of HD. • Maintenance: 10 mg/kg vanc; gent 1 mg/kg. Monitor levels (vanc trough 15-20, gent trough \< 2.0). Levels measured before HD. • Remove line ASAP with s/s of sepsis, persistent fever and bacteremia after 48 hrs, evidence of metastatic infectious, exit-site or tunnel infection, or difficult-to-cure pathogens, e.g. staph aureus, Pseudomonas, Candida/fungi, VRE, multiple-resistant pathogens. ▪ Otherwise, need at least guidewire exchange 2-3 days after starting antibiotic AND resolution of fever.

Answer 38

For initial/acute HD prescriptions: Initiation of treatment to avoid dialysis disequilibrium syndrome (attending dependent) – • 1st treatment: 90 min, Qb (blood flow rate) 150-200 ml/min, Qd (dialysate flow rate) 400 ml/min • 2nd treatment: 3 hrs, Qb 300, Qd 600 • 3rd treatment: 3.5 to 4 hrs, Qb 350 to 400, Qd 800 • Consider mannitol in extreme cases (e.g. BUN \> 150 to 200 or with altered mental status). • Mannitol dose 12.5 g IV q1 hour X 2 doses (be careful if hyperkalemia because can get solvent drag that can potentially worsen serum potassium) • Alternatively consider using higher sodium bath (e.g. 145-150 meq/L). • Also no heparin if concern for pericarditis • Most units have specific dialyzer (generally smaller sized dialyzer) for first start dialysis so ask your dialysis unit charge nurse. For chronic HD prescriptions • Qb: 400-450 ml/min (if fistula/graft), if catheter 350 (sometimes to 400). Bare minimum Qb is 150 ml/min • Qd: 600-800 ml/min (1.5x QB) • Rule of 7 for K • usually 2 K bath (If K HIGH \> 6.5-7 mEq/L range, discuss with attending before using 1 K bath

Answer 39

Current CKD Nomenclature Used by KDOQI CKD Categories Definition CKD CKD of any stage (1-5), with or without a kidney transplant, including both non–dialysis-dependent CKD (CKD 1-5ND) and dialysis-dependent CKD (CKD 5D) CKD ND Non–dialysis-dependent CKD of any stage (1-5), with or without a kidney transplant (ie, CKD excluding CKD 5D) CKD T Non–dialysis-dependent CKD of any stage (1-5) with a kidney transplant Specific CKD Stages CKD 1, 2, 3, 4 Specific stages of CKD, CKD ND, or CKD T CKD 3-4, etc Range of specific stages (eg, both CKD 3 and CKD 4) CKD 5D Dialysis-dependent CKD 5 CKD 5HD Hemodialysis-dependent CKD 5 CKD 5PD Peritoneal dialysis–dependent CKD 5

Answer 40

* fluxo de sangue adequado * dialisador koa * tempo de dialise * frequencia de dialise * fluxo do dialisato * tamanho d agulha * anticoagulacao adequada

Hemodialysis Flashcards

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