Question 29

Created on Thu, 06/30/2016 - 00:35
Last updated on Fri, 01/12/2018 - 06:27
Pass rate: 29%
Highest mark: 6.5

Other SAQs in this paper

Other SAQs on this topic

List the pathophysiological changes, system by system, associated with end-stage kidney disease (dialysis dependent), and briefly explain how these may impact on the management when a dialysis dependent patient becomes critically ill.

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College Answer

Pathophysiological change

Management implications

Respiratory:

Prone to pulmonary oedema 

Fluid restriction/ positive pressure ventilation as needed

Cardiovascular:

Hypertension 

Dyslipidaemia, Atherosclerosis, 

Pericarditis 

Appropriate drug therapy, aim higher MAP

targets based on baseline BP Monitor for pericardial effusion

Neurological:

Dialysis   disequilibrium      Polyneuropathy myopathy

and

Low dose dialysis to prevent rapid shifts

Renal:

Low/no urine output 

Fluid prescribing/restriction, nutrition depends on dialysis plan

Metabolic:

Hyperkalaemia

Metabolic acidosis

K+ restriction, Caution with K-sparing drugs

(ARBs, ACE-Is, Spironolactone)

May be worsened by critical illness

Mineral & Bone disorders:

Secondary             hyperparathyroidism,

Hyperphosphataemia, Hypocalcaemia

Phosphate restriction/binders,

Calcitriol and calcium supplementation, Care to prevent fractures

Gastrointestinal:

Impaired gastrointestinal motility

Peptic ulceration & bleeding

Malnutrition

Aspiration risk, enteral feeding difficulty

Stress ulcer prophylaxis

Early feeding

Skin:

Fragile skin 

Meticulous pressure area care

Haematological:

Anaemia

Platelet dysfunction (uraemic)

Appropriate transfusion, EPO

Bleeding risk, DDAVP may have a role

Immunological:

Increased risk of infection 

Antimicrobial        prophylaxis/therapy           as appropriate

Endocrine:

Thyroid dysfunction

Difficult to interpret TFTs during critical illness

Pharmacological:

Altered   clearance               of            renally    excreted medications 

Dose adjustment based on GFR, dialysis regime

Vascular access:

and arterial access

Consider choice of site avoiding site of fistula, Monitor fistula function during critical illness

Discussion

The influence of end-stage renal failure on the management of critically ill patients  has also been asked about in Question 1 from the first paper of 2011.The college's model answer was so good, that I have reproduced it here.

Renal:
Low/no urine output

Metabolic and Endocrine:
Associated
o   Hyperkalaemia
o   Abnormal Ca++
o   Hyperphosphataemia
Need for dialysis determines fluid prescribing, feeding and any protein restriction

Cardiovascular:
Hypertension very common
Atherosclerosis common
Pericarditis common

Respiratory:
Prone to pulmonary oedema

Neurological:
Dialysis disequilibrium

Polyneuropathy and myopathy

Skin:
Fragile skin

Haematological:
Anaemia
Platelet dysfunction

Gastrointestinal:
Impaired gastrointestinal motility
Increased risk of bleeding related to gastric ulceration

Immunological:
Increased risk of infection

Pharmacological:
Altered clearance of medications that have predominant renal excretion

Vascular access:
Fistulas used for dialysis may complicate CVC and arterial access

Issues specific to ESRD raised in this article include:

  • The central veins draining the access arm with the fistula should be protected from venous
    catheters
  • Diet should be potassium- and phosphate-restricted
  • An AV fistula should not be accessed for CRRT or SLEDD, because the sessions are long and the risk of needle dislodgement and lifethreatening haemorrhage is thus greatly increased.
  • In terms of small solute clearance, there is no need to change the dose of dialysis in critically ill ESRD patients when compared to their regular maintenance dose.
  • Hypotonic and hypertonic fluids should be avoided

References

Clermont, Gilles, et al. "Renal failure in the ICU: comparison of the impact of acute renal failure and end-stage renal disease on ICU outcomes." Kidney international 62.3 (2002): 986-996.

Szamosfalvi, Balazs, and Jerry Yee. "Considerations in the critically ill ESRD patient." Advances in chronic kidney disease 20.1 (2013): 102-109.

Arulkumaran, N., N. M. P. Annear, and M. Singer. "Patients with end-stage renal disease admitted to the intensive care unit: systematic review." British journal of anaesthesia 110.1 (2013): 13-20.

Thompson, Stephanie, and Neesh Pannu. "Renal replacement therapy in the end-stage renal disease patient with critical illness." Blood purification 34.2 (2012): 132-137.