a patient who admits to having missed dialysis sessions presents to EMS, the more likely pathophysiology and required treatments can be inferred. Patients with respiratory distress are likely to have fluid overload. Management may be multimodal. Noninvasive positive‐pressure ventilation can be implemented in the awake patient to improve oxygenation [28]. Nitroglycerin is an option to facilitate fluid shifts by increasing venous capacitance. In the setting of uncomplicated fluid overload from dialysis noncompliance, the patient should be hypertensive and tolerate nitrates well [36]. Should the patient be exhibiting signs of cardiogenic shock, consideration should be given to pericardial tamponade [17].
Diuretics such as furosemide can be used in the renal disease patient, provided he or she makes urine. Careful assessment of the patient’s volume status should be made, as giving diuretics to an intravascularly depleted patient can worsen renal function. In the euvolemic or hypervolemic patient, higher than average doses of diuretic will be needed to overcome renal dysfunction [37].
Hyperkalemia
Dialysis‐dependent patients are already at risk for hyperkalemia; those who miss one or more regular sessions incur even more risk. If an ESRD patient presents with arrhythmia (peaked T‐waves, QRS widening, ventricular fibrillation, or ventricular tachycardia) or is unstable with hypotension or cardiac arrest, empiric management of hyperkalemia is warranted [12, 14, 38].
Intravenous calcium is administered for stabilizing the cardiac membrane. This therapy has a duration of action between 30 and 60 minutes, which may necessitate the need for redosing depending on transport times. Calcium gluconate is dosed at 1,000 mg (10 mL of 10% solution) IV over 2‐3 minutes. Calcium chloride can also be dosed at 500‐1000 mg (5‐10 mL of 10% solution) IV over 2‐3 minutes. Both agents require continuous cardiac monitoring and can be repeated after 5 minutes if ECG changes persist or recur [12, 14, 38].
Sodium bicarbonate can help to alkalinize the blood and promote the shift of potassium to intracellular spaces. This is most effectively administered as an isotonic infusion of a bicarbonate solution with concentration 150 mmol/L (typically three ampules in a liter of D5W), being mindful of the potential for fluid overload. Hypertonic formulations, conversely, have been shown to have a neutral effect on potassium as the solute drag that occurs with the hyperosmolar solution counterproductively increases extracellular potassium. The routine administration of hypertonic sodium bicarbonate is no longer recommended in the prehospital setting. There are data that show benefit in its use in hyperkalemic patients with severe acidosis (pH < 7.2) and in those with a contraindication to calcium (e.g., digoxin toxicity), acting to temporarily stabilize cardiac membranes. The dosing is 50 mEq (50 mL of 8.4% solution, commonly distributed as an ampule/needle combination for EMS and code carts) to be given IV over 5 minutes. This can be repeated every 10‐15 minutes if ECG changes persist or recur. Caution should be taken to ensure the IV line is flushed between calcium and sodium bicarbonate doses, as calcium carbonate can form and precipitate [12, 14, 38].
Albuterol can be given in the usual fashion to shift potassium out of the plasma. It is easily administered to the patient and has the advantage of being noninvasive. It can be given as a continuous nebulizer treatment with 10‐20 mg of albuterol solution in 4 mL of saline over 10 minutes. However, the onset of action is not immediate, the potassium level will rebound if not otherwise treated in the next few hours, and tachyarrhythmia is a possible consequence [12, 14, 38].
Regardless of the medication(s) used in the field, the ESRD patient with hyperkalemia will require definitive management, as these therapies serve only to either prevent arrhythmia or temporarily shift potassium from the plasma. The total body potassium does not decrease. During subsequent transitions of care, it is imperative to communicate clearly about what treatment has been administered. Otherwise, serum potassium assays may be falsely reassuring to the next clinical team.
Rapid sequence intubation and hyperkalemia
The EMS clinician performing rapid sequence intubation (RSI) should avoid depolarizing neuromuscular blocking agents (NMBA) such as succinylcholine in patients who are at risk for being hyperkalemic. Along with the renal failure population, those patients with muscular dystrophy, stroke > 72 hours, crush injury > 72 hours, and burns > 72 hours old are at increased risk of severe hyperkalemia with the use of depolarizing NMBAs due to an upregulation of acetylcholine receptors. Fatal arrhythmias can develop within minutes and the EMS clinician must recognize and appropriately initiate treatment as discussed above. It is recommended that nondepolarizing NMBAs such as rocuronium be used instead for this patient population should RSI be required [39].
Use of dialysis access for resuscitation
The use of an ESRD patient’s dialysis access in the prehospital setting should be reserved for the critical, rapidly decompensating patient when intravenous and intraosseous access cannot be obtained during resuscitation efforts. While the risks of complications (e.g., thrombosis, infection) may ultimately result in the loss of the patient’s graft, fistula, or catheter, these issues can be dealt with later, pending the patient’s survival.
Both AV fistulas and AV grafts can be accessed in a fashion similar to starting a peripheral intravenous line. Gloves, eye protection, and a mask should be used along with aseptic technique to the extent possible. A tourniquet should be loosely applied to the axilla proximal to the access site, tight enough to cause the vessel to engorge, and be removed immediately after cannulation of the fistula or graft. A large‐bore needle (14, 16, or 18 gauge) with or without an angiocatheter should be inserted into the fistula at 20‐35 degrees (45 degrees for graft access) until a flash of blood is seen. The needle should be advanced 3‐4 mm before flattening the angle of insertion flat against the skin and threading the needle alone or with a catheter until the hub rests against the insertion site. The line needs to be secured in place. Due to the high‐velocity blood flow in the graft and fistula, saline lock tubing and a pressure bag for fluids will be needed, especially for access using an angiocatheter. When appropriate, the EMS clinician should assess for a thrill at the access site and relay this information to the receiving facility [40].
Dialysis catheters, whether tunneled or nontunneled, essentially function as central lines. The dialysis catheter usually has two lumens attached to two ports, red and blue. The red port is considered arterial and the blue port venous, tasked with bringing filtered blood from the dialysis machine back to the heart. A third port, white in color, may be present specifically for blood draws and medication administration. In the absence of the white port, the blue “venous” port should be used for emergency administration of drugs and fluids. Personal protective equipment should be donned to keep the procedure as sterile as possible. The port cap should be cleaned with chlorhexidine or alcohol, and the lumen should be clamped while the cap is removed. After cleaning the catheter hub, a syringe should be attached, and the lumen unclamped. As information regarding the locking fluid present in the catheter will likely not be immediately available to the EMS clinician, fluid and blood should be withdrawn with a 10 cc syringe and wasted before administration of medications. This is to prevent inadvertent systemic administration of the locking solution. The lumen should be flushed and clamped after drug administration. Replacement of locking fluid and caps can occur in the hospital setting.
During emergency transport from a dialysis center, the staff at the facility may leave the ESRD patient’s vascular device accessed. EMS personnel should be aware of this as a potential site for emergency drug administration and should protect the access point from trauma.
EMS pearls
Focused history
When the EMS clinician encounters a dialysis patient, a set of focused questions to the patient and any family/dialysis
