Assessment & Plan (long)
# End Stage Renal Disease (ESRD)
Hemodialysis vs. Peritoneal dialysis, Treatment location and schedule, Date of last dialysis: ***
Access HD: (fistula, graft, catheter) or ...PD: catheter
fistula - native vein or artery
graft - artificial conduit connecting native vein and artery
catheter - temporary (vascath) or tunneled/permanent (permacath)
- consult IR if weak thrill or pulsatility (stenosis)
- patient making urine?
- assess volume status, oxygen, BP
- potassium
- pH
Routine Management:
- No BP or labs in access arm (No PICC or IVs or subclavian lines in the nondominant arm of CKD 4-5 pt's)
- renal diet (low K and phos)
- dose meds appropriately
- No maintenance IVF
-be very cautious repleting electrolytes
- HTN
- goal Hb 9.5-11, check iron stores, consider ESA as out pt
- Bone mineral disease (phos binder with meals, hold if NPO. calcium binders (Ca carbonate vs sevelamer or lanthanum)
Educational
Contrast Considerations:
if pt still makes urine avoid iodinated contrast. If used, maintain dialysis schedule.
Avoid gadolinium if GFR＜30 (risk of nephrogenic systemic fibrosis), if needed in life-threatening situtaion, dialyze immediately after GAD.
Contrast Nephropathy:
High risk: diabetics, proteinuria, AKI, CKD4-5, heart / liver failure, dehydration.
Pretreatement:
- hold diuretics,
- hold RAAS inhibitor if new med (ok if chronic med and renal fxn at baseline)
- hydrate, NS or NaB (sodium bicarb 150mEq in 1L). infuse 3cc/kg for 1 hour prior to contrast, 1cc/kg for 6 hours after contrast
- consider Mucomyst 1300mg bid, two doses before and after contrast
- supportive care and avoidance of additional injury if contrast injury manifests 12-48 hrs after administration of contrast
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Originally created: September 4, 2021 by jason
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