hemodialysis power point

7/31/2019 Hemodialysis Power Point

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HemodialysisHemodialysis: A Case Presentation: A Case Presentation

Jason Yanich D.D.S.General Practice Residency

The Ohio State University

College of Dentistry

305 West 12th Avenue

Columbus, Ohio 43210-1241Phone: 614-292-2622

Fax: 614-292-4522


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IntroductionIntroduction

Patient Information: Andrew is a 37 yr old white male

requiring dental treatment prior toproposed kidney transplant.

Chief Complaint: I need to get on the transplant list


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Past Medical History (cont.)Past Medical History (cont.)

Medical history: 25 yr hx of Diabetes Mellitus (type I)

Chronic Renal Failure (CRF) With current dx of ESRD 2 to CRF

Coronary Artery Disease (CAD)

No hx of MI

Cath w/ stent placed May 2001


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Past Medical History (cont.)Past Medical History (cont.)

Anemia (2 to ESRD) HTN (5 yr hx) Medically

controlled Hypercholesterolemia - treated

Tobacco abuse


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Past MedPast Medical history (cont.)ical history (cont.)

Left forearm venous anastamosis(straight line graft) in April 2001.

Hemodialysis began on July 2001. Surgical Hx includes several other

procedures (cyst / tumor removal,

artery repair, tendon / nerve surgery)

with no complications.


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MedicationsMedications Clonidine 0.2 mg TID

Norvasc (Amlodipine) 10 mg QD Lopressor (Metoprolol) 50 mg BID

Lasix (Furosemide) 80 mg BID

Zocor (Simvastatin) 20 mg QD

Phoslo (Calcium Acetate) 200 mg with meals

ASA 325 mg QD NPH insulin 14 units Q am and 8 units Q pm

Humalog insulin sliding scale


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Social and FamilySocial and Family HxHx

Single, no children

lives with parents

Mother and father living with HTN

Tobacco abuse


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AllergiesAllergiesPatient states allergies to

morphine and codeine

Reactions:

Morphine n&v

Codeine hearing s

itchiness


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HemodialysisHemodialysis

Hemodialysis is performed by passingthe patients blood through an artificial

kidney. Special tubing carries theblood to and from the dialyzer. The

dialyzer acts as a blood filter and

should attempt to perform the same

functions as the normal kidney.


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The dialyzer is a device housing a semi permeablemembrane and a special diasylate solution.

Blood flows through the compartment of the

membrane and is surrounded on the outside by thediasylate. Blood comes into contact with the

diasylate through the membrane and materials in

the blood and diasylate are exchanged bydiffusion.


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Extracorporeal DialyzersExtracorporeal Dialyzers

DesignsDesigns

Coil Dialyzer 1-2 long membrane tubes coiled around

plastic core Older design

Limited performance

Limited surface area

Lacked uniform flow of dialysate


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Parallel Plate Dialyzer Sheets of membrane mounted on supportscreens and stacked

Multiple parallel channels of flow alongmembranes

Increased performance / thinner channels of

dialysate and blood Minimized blocking of flow and membrane

stretching or deformation


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Hollow Fiber (Capillary) Dialyzer Most effective

Allows Low volume / high efficiencywith low resistance to flow

Fibers create fiber bundle with is

supported by polyurethane at each end Blood flows through the fibers, diasylate

flows around outside


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CapillaryCapillary DialyzerDialyzer

Advantages: Low priming volume and compliance

Easier reuse

Disavantages:

Higher residual blood volume

Potting compound retains residualethylene oxide


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MembranesMembranes

Cellulose Substituted cellulose

(cellulose acetate) Cellulosynthetics

(3 amino compound) Synthetics

Polyamide, PMMA, polysulfone, PAN


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diasylatediasylate

Bicarbonate containing Acetate containing

Generates HCO3-

by metabolism

Both contain similar concentrations of:

Na, K, Ca, Mg, and Cl


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Vascular AccessVascular Access

Permanent Access: Atriovenous fistula

Radial artery to cephalic vein

Safest and longest lasting vascular access

Atriovenous graft

When poor veins exist or there is inadequatearterial system ( diabetes or atherosclerosis)

Autogenous saphenous vein or PTFE

(teflon)


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CatheterCatheter


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CatheterCatheter


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Dental ExamDental Exam Extraoral:

Findings all WNL with exception of markedskin pallor

Intraoral:

buccal mucosa shows bilateral leukoedema andFordyces granules present

Tonsillar tissue still present, soft palate slightlyerythematous

Tongue is fissured and coated

Generalized gingival erythema with recession


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Panorex Note moderate to severe periodontal disease


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Treatment PlanTreatment PlanTreatment in the OR under general

anesthesia was rendered due topatients advanced periodontal disease,

medical history, and moderate dentalanxiety.

Treatment consisted of full mouthextraction and alveoloplasty


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ProcedureProcedure

Antibiotic premed by anesthesia with Ancef(Cefazolin)

General anesthesia via NETT

Extractions performed:

#s 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14,

18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28,29, 30, and 31

Alveoloplasty all four quads


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Complications of RenalComplications of Renal

FailureFailure

Uremia leading to fluid overload,hypertension, and cardiac disease

Azotemia (BUN), metabolic acidosis,and hyperkalemia

Hematologic abnormalities incl.anemia and coagulopathy


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Complications of RenalComplications of Renal

FailureFailure

Decreased host defense and leukocyteabnomalities

Cardiovascular disease and tendencyto develop CHF

Renal Osteodystrophy (with 2hyperparathyroidism)


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Complications of ChronicComplications of Chronic


Altered serum [Ca2+]

Over secretion of PTH

Increased risks of Hep B and C andHIV

Altered/abnormal bleeding & clotting


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Management ConsiderationsManagement ConsiderationsGeneral concerns:

Consultation with physician regardingcontrol of disease, electrolyte balance,

and 2 systemic diseases Monitor BP

Screen for coagulopathy

Avoid nephrotoxic drugs

Adjust dosage of drugs metabolized by

kidney


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Management ConsiderationsManagement ConsiderationsDialysis concerns:

Provide treatment on days in between dialysis

(avoid on day of tx)

Use caution when taking BP (avoid area offistula or graft) or giving IV meds

Coagulation concerns

Tx as potential carrier of HBsAg

Drug dosing and intervals affected by dialysis


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ReferencesReferences

Http://www.kidneydoctor.com/

Http://www.multi-media.com/homehemotoday

Http://www.niddk.nih.gov/health/kidney/summary/hemod

ose/index.htm

Http://www.kumc.edu/SAH/resp_care/cybercas.html


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ReferencesReferences

Replacement of renal function by dialysis / edited by C.

Jacobs ... [et al.] Dordrecht, Netherlands ; Boston : Kluwer

Academic, 1996

Replacement of renal function by dialysis : a textbook of

dialysis / edited by John F. Maher Dordrecht ; Boston :

Kluwer Academic Publishers, 1989

Essentials of anatomy & physiology / Rod R. Seeley, Trent

D. Stephens, Philip Tate St. Louis : Mosby, 1996


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ReferencesReferences Dental management of the medically compromised patient

/ James W. Little ... [et al.] St. Louis, Mo. : Mosby, 2002

Renal dialysis / edited by J.D. Briggs ... [et al.] London ;

New York : Chapman & Hall Medical, 1994

Medical physiology : textbook study guide Garden City,

N.Y. : Medical Examination Pub. Co., 1982 Poland, James

L


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ReferencesReferences Maher J. ed.: Replacement of renal function by dialysis,

3rd. Ed. 1989

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