SimFridays - RenalSim

This sim focussed on a life threatening presentation of a patient with end-stage renal disease (ESRD). Thanks to Suzy Connor and Andy Connor for their help with this simulation and information for this blog. 

The simulated case: 
A man in his 60s who has haemodialysis on Monday-Wednesday-Friday, presented on a Monday morning (see Fig 1 here) with shortness of breath and fatigue. Investigations revealed pulmonary oedema with hyperkalaemia and anaemia. Their case was discussed with the renal consultant on-call and they were transferred for dialysis.

Afterwards we reviewed management of a major AV fistula bleed.

What did we think? 
In debrief we discussed:

Pulmonary oedema:
Think about what questions you would ask the patient in these circumstances. Important renal points are (n.b. the patient’s “dry weight” is the estimated number of kilograms they aim to weigh following a dialysis session): 

1. Can they produce urine (or recently lost the ability - i.e. previously augmented dialysis with it and now they cannot any longer)? 
2. When is dialysis and which type? This affects when the longest gap between sessions is - see figure 1 and explanation here.
3. Any recent problems during dialysis (e.g. problems with fistula) or any missed sessions that might mean their dry weight hasn’t been reached?
4. Chest pain? Troponin may be tricky to interpret so history is very important for working out if a new myocardial infarction is the cause. Remember renal patients are at high risk of cardiovascular disease.

Other than this, it could be that their dry weight estimate is off e.g. they have lost muscle and fat mass without adjustment of their dry weight so now the body is made up of a higher proportion of water.

If we are considering that a cardiac insult has caused the pulmonary oedema, the troponin result may be helpful if very high or much higher than previous. But obviously could be high from ESRD, so rely more on the ECG and history. Renal disease also puts the patient at risk of uraemic pericarditis which could cause the pulmonary oedema.

In terms of treatments, loop diuretics are unlikely to help even if the patient produces urine as they often don't increase the output. A GTN infusion might help as a holding measure, but the definitive treatment is dialysis.
Hyperkalaemia:
Our hyperkalaemia protocol is found on the G:/ drive. It has a specific stream for fluid overloaded patients with the dextrose given at a higher concentration. 

Insulin and dextrose will work as a holding measure pending urgent dialysis. IV sodium bicarbonate may worsen fluid overload.

Venepuncture and analgesia in ESRD:
This patient has an arteriovenous fistula for dialysis and this is clearly very important for their survival. Avoid the fistula arm (which most likely will be on their non-dominant side) when taking blood, and go as distal as possible. Also avoid BP cuffs on the fistula side. Consider this too when taking blood from a patient who may require dialysis in the future and may therefore may need a AV fistula creating - go dominant side and as distal as feasible. If the attempt fails, escalate early rather than continue attempts.

Pain relief can be tricky when renal function is poor. Generally the plan is to avoid opiates, although if necessary can use immediate-release low dose oxycodone. Avoid NSAIDs unless the patient has no urine output - in this case NSAIDs can actually be used as there is no renal function left to preserve. 

Who to escalate to?
There is always at least one renal physician on-call 24/7: switchboard will advise who is first-on-call. We discussed that in this case it could be that ITU is needed due to the level of organ dysfunction. 
​
Bleeding AV fistula:
For a dialysis patient, their fistula is their lifeline. Fistula problems can easily be life-threatening - have a really low threshold for admission. KidneyCareUK state: “Scabs at needling sites that are raised, enlarging bumps (aneurysms) along the access, shiny skin over the vascular access and/or loss of skin pigment over an aneurysm all require urgent review and, if left untreated, could potentially lead to a life-threatening bleed”.

​For a life-threatening bleed, it is advised as a first step to apply a bottle top over the bleeding fistula (hollow side down) and bandage over the top with firm pressure as per this poster (copied from KidneyCareUK) and their campaign “put a lid on it!”. Remember to raise the arm. 

In hospital, consider whether the massive transfusion protocol is required (via blood bank bleep). We have a major haemorrhage box in resus which contains CAT tourniquets. Watch this video for application instructions. 

To do:
There is a renal guidelines booklet on EDIS  [  ]

CAT tourniquet refresher video  [  ]

Consider the additional questions you might now ask a patient receiving dialysis when they present to the ED  [  ]

If you took part in the sim, you can use this blog as a starter to reflect on your own experience of it   [  ]

Blog by: James Keitley - ED sim fellow - on behalf of the ED sim team.

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For clinical decisions please refer directly to primary sources. This blog may not be updated. All images copyright- and attribution-free in the public domain or taken by the author.