Those with indwelling devices for dialysis access have an obvious source for contamination and seeding with bacteria. Transplant patients on immunosuppressive therapy additionally are immunocompromised from the medicines required to reduce risk of graft rejection [22]. With sepsis and bacterial infections being common in ESRD patients, the prehospital clinician must be able to recognize patients with severe sepsis and septic shock and treat them with appropriate fluid resuscitation. Clinicians often are hesitant to initiate administration of 30 mL/kg fluid bolus over the first 3 hours, as suggested by the Surviving Sepsis Campaign, due to concern for triggering pulmonary edema and respiratory failure. Studies, however, have suggested that there is no increased harm among ESRD patients, with the caveat that further prospective studies are needed [23, 24].
Rhabdomyolysis
Rhabdomyolysis is caused by muscle breakdown and release of intracellular material including myoglobin, leading to renal damage. In adults, alcohol and drug intoxication, trauma, prolonged immobility, excessive strenuous activity, toxic ingestions, and infections can lead to this syndrome. Symptoms include weakness, myalgia, mental status change, and darkened urine. Assessment for arrhythmias should be done, as prehospital treatment of hyperkalemia may be required, especially in cases involving prolonged extrication with potential crush syndrome. Specific treatment of hyperkalemia will be discussed later in the chapter. The mainstay of treatment for rhabdomyolysis otherwise is adequate resuscitation with crystalloid IV fluids and transport. Hospital admission is often needed for treatment of resulting metabolic abnormalities [25, 26].
Complications of hemodialysis
Hypotension
Hypotension is common during dialysis, occurring in 10%‐50% of patients. Often, this is a direct result of fluid shifts from the dialysis procedure. At times, there may be calibration issues and the patient has an overzealous removal of fluid, leaving him or her intravascularly depleted. Additionally, the medications and temperature shifts commonly found in the dialysis circuit, combined with the patient’s baseline autonomic irritability, frequently contribute to decreased blood pressures [4]. However, care must be given not to attribute all postdialysis hypotension to hypovolemia, as these patients are at higher risk for septic shock, cardiac tamponade, bleeding, myocardial ischemia, and heart failure.
Treatment of hypotension is directed at the cause. Should dialysis‐related hypovolemia be the likely insult, small boluses (250–500 mL) of isotonic crystalloid IV fluid should be considered, followed by reassessment of the patient for response and any respiratory distress [4]. During any care transitions, EMS clinicians should clearly communicate the volume of any administered IV fluids.
Air embolism
Since the patient’s vascular circuit is violated and connected to the outside world during hemodialysis, concern exists for the introduction of air into the patient’s bloodstream. While small amounts of air into the vascular system can be asymptomatic, larger amounts can cause serious sequelae. It is estimated that 3–5 mL/kg of air is the lethal dose [27]. Air traveling through the vasculature toward the brain can cause cerebral blood outflow obstruction, leading to increasing intracranial pressure, altered mental status, and seizures. If air travels into the right side of the heart and migrates to the lung, it can act as a pulmonary embolism and cause dyspnea, chest discomfort, and hemodynamic instability. In rare cases, a heart defect could allow air to pass from the right‐sided circulation into the arterial flow to the body, leading to stroke or myocardial infarction as an arterial gas embolism. A patient with air embolism requires hemodynamic support, high‐flow oxygen, and prevention of further air embolization. The venous line should be clamped, and the blood pump on the dialysis machine should be stopped. Positioning the affected patient in the left lateral recumbent position (right heart up) may help to stabilize trapped air in the right heart, stopping further embolization. Percutaneous aspiration of air from the ventricle in a patient in extremis may be performed by the EMS physician in the field or by qualified staff on arrival to the ED. Hyperbaric oxygen has been established as a treatment modality once the patient is stable enough for therapy [27].
Uncontrolled hemorrhage from shunt site
Patients undergoing hemodialysis have a high‐capacity vascular structure punctured multiple times weekly, leading to increased risk of bleeding. Grafts and fistulas have high blood flow and pressure compared to peripheral veins. Aneurysms are rare, but can occur, and may rupture catastrophically, causing exsanguination [4, 28]. More common is persistent bleeding after dialysis from the needle insertion site. The patient’s underlying platelet dysfunction, daily use of anticoagulants, and heparin use during dialysis can contribute to difficulty obtaining hemostasis. Typically, hemorrhage from the puncture site will respond to firm digital pressure directly over the bleeding site for 10‐20 minutes. If available, a thin layer of commercially available dressing with hemostatic agents (e.g., QuikClot®, HemCon®) or gauze with topical biological agents (e.g., thrombin, TXA) can also be used with direct digital pressure. Layers of gauze and compressive bandages should be avoided as they serve only to soak up blood and often do not provide the adequate direct pressure needed for hemostasis. Proximal tourniquet application should be used only in life‐threatening circumstances as a last resort, as this may result in permanent damage or loss of the patient’s dialysis access. It should be considered in only critical situations [4, 28].
Disequilibrium syndrome
Patients undergoing hemodialysis are at risk for a neurological manifestation of fluid and electrolyte shifts called disequilibrium syndrome. This syndrome may be severe enough to produce altered consciousness, seizures, or coma, although typically it involves mild symptoms of malaise, nausea, and headaches. This syndrome is a diagnosis of exclusion, as many life‐threatening entities can cause similar symptoms. Thus, the renal patient with the new onset of these features requires prompt evaluation. Treatment is similar to that of cerebral edema with consideration of IV hypertonic therapy and termination of dialysis [4, 30].
Complications of peritoneal dialysis
While electrolyte disturbances can occur, they are typically not as severe as in patients on hemodialysis. As the patient’s dialysis exchange occurs over a longer period, there is less gradient with the dialysate and electrolyte shifts are less abrupt.
The most common and serious complication in peritoneal dialysis is peritonitis, contributing to the cause of death for over 15% of peritoneal dialysis patients. The indwelling abdominal catheter is a nidus for infection. Patients with peritonitis may complain of abdominal pain or nonspecific symptoms of nausea, fatigue, or fever. They may range from being asymptomatic to frankly septic, with guarding of the abdomen and hypotension. Signs of peritonitis for the prehospital clinician include a change in the fluid coming from the catheter during a fluid exchange or purulent drainage from the catheter insertion site [31].
The fluid used for dialysis in peritoneal dialysis often contains high amounts of glucose, drawing water out of the body. In rare cases, patients can absorb the glucose and present with a hyperglycemic, hyperosmolar state and resulting critical illness from the same [32].
Special considerations
The missed dialysis patient
According to one study, the United States has one of the highest rates of missed dialysis treatment at 24% [33]. Younger patients consistently are found to have higher rates of compliance issues. As these patients require dialysis to sustain life, the patient who has missed a session (or several) is at higher risk for deterioration with increased rates of all‐cause hospitalization, all‐cause mortality, cardiovascular mortality, and sudden cardiac death [35].
When
