I’m going to start this podcast with a disclosure. This is not an episode for the advanced provider. We are not going to delve into a lot of the critical care aspects of the dialysis patient in this episode. This show is mainly geared towards better explaining the importance of understanding dialysis equipment, the process of dialysis, and some special considerations to have with dialysis patients. Have I said dialysis too many times? I did? Dialysis. There I said it again. Let’s get to it.
**SOAPBOX MINUTE WITH MIKE**
Starting off the show notes with a soap box minute should tell you guys how frustrated I am with the state of education in EMS. If I hear one more person tell a new medic that “that’s just something you need to learn on the job”, I am going to have a stroke. Genuinely sick patients are not guinea pigs. They’re people. Not only that, they’re people that need your help. Encountering a critically ill dialysis patient is not the time or place for on the job training. If there is something you don’t understand, find information on it before you are put into a position where you have to treat it. Rant over.
WHY ARE PATIENTS ON DIALYSIS
There are an estimated 1 in 10 Americans that have some sort of chronic kidney disease, and are on dialysis or are candidates for dialysis therapies. For patients on dialysis, their kidneys can no longer filter waste products or process medications. These patients now require specialized equipment to do the job of the kidneys.
There are three primary types of vascular access used in hemodialysis that prehospital providers will come in contact with.
1. Arteriovenous Fistulas
AV Fistulas are a surgically created connection between an artery and a vein, and are constructed directly from the patient’s own tissue. The downside of this type of access is that it takes several months to mature.
2. Arteriovenous Grafts
AV grafts are used when the patient’s vessels are too small or are unavailable to develop a fistula. After placement, grafts are accessible more quickly than fistulas and can be used in about two weeks. They’re constructed out of synthetic material, but they do not last as long as fistulas.
3. Central Venous Access
Central lines are typically located in the subclavian region, and are used for emergent treatment. The downside to these is that they are significantly more prone to infection and thrombosis than the other two types of access. In following episodes, we will show you how to access central lines in critically ill dialysis patients. (Remember that if yo don’t have a protocol to do this, this procedure is something that you need to consult with medical control over.)
Peritoneal dialysis is an alternative to hemodialysis, often allowing patients to do treatment at home, or while sleeping. The process usually takes about 4-5 hours; there’s a bag of dialysate (fluid solution comprised on patient’s electrolyte needs) that is injected directly into the peritoneal cavity. While in the peritoneal space, the fluids absorbs excess waste products and drains into a collecting bag when finished. This truly a gross oversimplification of the process, but for our intents and purposes, this is what to look for.
This is a pretty straightforward problem, but it’s easy to overcomplicate. Direct pressure over the access site is the best way to stop the bleeding. Unfortunately, many of these patients are on anticoagulants and hemorrhage control can take a long time. There are some times when you have a critically ill dialysis patient with an access hemorrhage and not enough hands to do more than bleeding control. A friend of the show, Ken Hendricks, suggested the use of a tourniquet and a 4×4 or ABD pad to hold direct pressure over the site. It’s important to remember that you are not using the tourniquet as a tourniquet, but simply to hold direct pressure. Don’t crank down on the tourniquet!
While most patients are receiving anticoagulant therapy while on dialysis, it’s important to remember that they can still form clots in their venous access. Keep CVA/TIAs, MIs, DVTs, PEs, etc. in your differential diagnosis when clinically relevant.
This is a moment where we need to reflect on our aseptic technique. I’m not trying to be sanctimonious, but lack of proper cleaning can contribute infection. Sepsis needs to be on the radar for the dialysis patient that presents with hypotension, tachycardia, ALOC, etc.
There are several reasons for this. Patients on dialysis experience severe electrolyte imbalances that can often lead to arrhythmias, i.e. prolonged QT intervals progressing into ventricular rhythms. There are a few links here concerning hypo/hyperkalemia, hypo/hypernatremia, and hypo/hypercalcemia.
Dialysis patients tend to experience delayed relief from sedation and analagesia agents due to impaired kidney function. Remember to closely monitor patients for signs of ALOC and respiratory depression especially when giving multiple doses of opioids and benzodiazepines. Medications tend to process through the kidneys slower and build up more potency when multiple round are given. It is suggested that clinicians use shorter acting agents because of this.
I know that this was a longer post than usual, and we will get onto more excited topics next time. As always, leave your concerns and gripes in the comments, and have a great day!