Rosen & Barkin's 5-Minute Emergency Medicine Consult (207 page)

See Also (Topic, Algorithm, Electronic Media Element)

Hyperosmolar Syndrome

CODES

• 250.10 type II diabetes mellitus [non-insulin dependent type] [NIDDM type] [adult-onset type] or unspecified type, not stated as uncontrolled, with ketoacidosis
  
• 250.11 type I diabetes mellitus [insulin dependent type] [IDDM] [juvenile type], not stated as uncontrolled, with ketoacidosis
  
• 250.12 Diabetes with ketoacidosis, type II or unspecified type, uncontrolled
  

BASICS

Dialysis complications may be:

• Vascular access related (infection, bleeding)
  
• Nonvascular access related (hypotension, hyperkalemia)
  
• Peritoneal (abdominal pain, infection)
  

• Vascular access related:
  
  • Infections:
    
    • Infections (largely access related or peritonitis) are a major cause of death in dialysis patients.
      
    • Often caused by
      Staphylococcus aureus
      
    • Can present with signs of localized infection or systemic sepsis
      
    • Can also present with minimal findings
      
  • Thrombosis or stenosis:
    
    • Often presents with loss of bruit or thrill over access site
      
    • Must be addressed quickly (within 24 hr) to avoid loss of access site
      
  • Bleeding:
    
    • Can be life-threatening
      
    • Aneurysm
      
• Nonvascular access related:
  
  • Hypotension:
    
    • Most common complication of hemodialysis
      
    • After dialysis: Often owing to acute decrease in circulating blood volume
      
    • During dialysis: Hypovolemia (more commonly) or onset of cardiac tamponade owing to compensated effusion suddenly becoming symptomatic after correction of volume overload
      
    • MI, sepsis, dysrhythmias, hypoxia
      
    • Hemorrhage secondary to anticoagulation, platelet dysfunction of renal failure
      
  • Shortness of breath:
    
    • Volume overload
      
    • Development of dyspnea
      during
      dialysis owing to tamponade, pericardial effusion, hemorrhage, anaphylaxis, pulmonary embolism, air embolism
      
  • Chest pain:
    
    • Ischemic:
      
      • Dialysis patients are often at high risk for having atherosclerotic disease
        
      • Dialysis is an acute physiologic stressor with transient hypotension and hypoxemia that increases myocardial oxygen demand.
        
    • Pleuritic:
      
      • Pericarditis, pulmonary embolism
        
  • Neurologic dysfunction: Disequilibrium syndrome:
    
    • Rapid decrease in serum osmolality during dialysis leaves brain in comparatively hyperosmolar state.
      
• Peritoneal:
  
  • Peritonitis:
    
    • Owing to contamination of peritoneal dialysate or tubing during exchange
      
    • S. aureus
      or
      Staphylococcus epidermidis
      (70%)
      
  • Perforated viscus with abdominal pain that can be severe, fever, brown or fecal material in effluent, or localized tenderness
    
  • Fibrinous blockage of catheter resulting from infection or inflammation
    

DIAGNOSIS

• Vascular access related:
  
  • Bleeding from puncture sites
    
  • Loss of bruit in graft
    
  • Local infection, cellulitis, fever
    
  • Decreased sensation and strength distal to access
    
  • New or increasing size mass adjacent to access site
    
• Nonvascular access related:
  
  • Hypotension before, during, or after procedure
    
  • Palpitations
    
  • Syncope
    
  • Chest pain:
    
    • Ischemic
      
    • Pleuritic
      
  • Hemorrhage:
    
    • GI
      
    • Pleural
      
    • Retroperitoneal
      
  • Shortness of breath:
    
  • Neurologic symptoms (disequilibrium syndrome):
    
    • Headache
      
    • Malaise
      
    • Seizures
      
    • Coma
      
• Peritoneal:
  
  • Abdominal pain
    
  • Cloudy dialysis effluent
    
  • Nausea and vomiting
    
  • Exudates or inflammation at insertion site of Tenckhoff catheter
    

• Careful physical exam:
  
  • Complete set of vital signs including auscultated BP, pulse, respiratory rate, accurate temperature, and pulse oximetry
    
  • Careful physical exam for occult infectious sources (odontogenic, perirectal abscess)
    
  • Auscultation of lungs for evidence of infection (rhonchi) or volume overload (rales)
    
  • Search for other evidence of volume overload (edema)
    
  • Careful cardiac exam including listening for murmurs or rubs
    
• EKG: Look for signs of electrolyte balance or conduction disturbances.
  
• Infection:
  
  • Blood and wound cultures
    
  • Cell count, Gram stain, culture of peritoneal fluid
    
• Bleeding:
  
  • CBC to evaluate anemia and platelet count
    
  • Coagulation studies
    
• Chest pain or shortness of breath:
  
  • Chest radiograph
    
  • ABG
    
  • EKG, cardiac enzymes (if appropriate, based on history)
    
• Neurologic dysfunction: CT of brain for intracranial hemorrhage
  

• Glucose, electrolytes, BUN, and creatinine
  
• CBC
  

• ECG for suspected:
  
  • Hyperkalemia
    
  • Pericarditis
    
  • Effusion
    
  • Tamponade
    
• US of access for possible clotted graft or fistula
  
  • ECHO to assess for pericardial effusion/tamponade
    
• Peritoneal cathergram for blockages
  
• CT scan for pulmonary embolism:
  
  • Dialysis patients are at risk for both bleeding and clotting problems.
    
  • Problematic in renal insufficiency owing to contrast dye load:
    
    • Can be done in renal failure, but contrast is then a fluid bolus and may need to be dialyzed off
      
    • Communicate contrast load to renal team, as dialysis may need to occur for longer-than-normal duration.
      

• Hypotension:
  
  • Sepsis
    
  • Cardiogenic shock, acute MI, tamponade, primary dysrhythmias
    
  • Electrolyte abnormalities leading to dysrhythmias (hyperkalemia and hypokalemia)
    
  • Embolism: Air or pulmonary
    
  • Hypovolemia
    
  • Vascular instability: Autonomic neuropathy, drug related, dialysate related
    
• Neurologic complications:
  
  • Cerebrovascular accident
    
  • Disequilibrium syndrome
    
  • Hyperglycemia or hypoglycemia
    
  • Hypernatremia or hyponatremia
    
  • Hypoxemia
    
  • Intracranial bleed
    
  • Meningitis or abscess
    
  • Uremia
    
• Peritoneal complications:
  
  • Peritonitis
    
  • Hernia incarceration
    
  • Perforated viscus
    
  • Acute abdominal process: Appendicitis, cholecystitis
    

TREATMENT