Nova Scotia Health Authority
Nova Scotia Health Authority Renal Program, Central Zone
Renal Program Guide
August 2017
TABLE OF CONTENTS
Page 6
Page 7-12
Page 7
Page 8-9
Page 9
Page 10-11
Page 11-12
Page 12
Page 13-16
Page 14-16
Page 16
Page 16
Page 17
Page 17
Page 18
Page 19-31
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Page 19
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Page 19
Page 20
Page 21
Page 21-22
Page 23-24
Page 24-26
Page 26-27
Page 28-29
Page 29-31
Page 31
Introduction
Inpatient Ward Service
- Inpatient Ward Service
- Rounds on the Ward
- Standard Admission Orders
- Routine Admission Orders for Nephrology Patients – Part 1
- Standard Discharge Orders
- Routine Orders for Dialysis Patients Being Discharged From the Hospital
Renal Clinic Rotation
- Allied Health Professionals for Renal Patients
- Requests for Blood Work from Outside Labs
- Rotations through the Clinic
Nephrology Consult Services
- Options for Dialysis in the ICU/CCU/IMCU
o Isolated Ultrafiltration
o Intermittent Hemodialysis
o SLEDD
o CRRT – only in 3A and 5.1 and 5.2
- Routine Orders for Dialysis Patients being Discharged from the Ward Unit
Hemodialysis Basics
- Acute Start Hemodialysis
- Chronic Hemodialysis
- Emergency Hemodialysis
- ICU Dialysis
- Hemodialysis Schedule
- Ordering Hemodialysis
- Filling out Hemodialysis orders sheet
- Hemodialysis Orders
- Treatment for Multiple Myeloma with High-cut off Dialysis Protocol
- Vascular Access for Hemodialysis
- Hemodialysis Central Venous Catheter Placement
- Catheter Related Blood Stream Infections (CRBSI)
- Empiric Therapy for Central Venous Catheter Related Bacteremia
Page 31-44
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Page 33
Page 34
Page 34
Page 34-35
Page 35-36
Page 36
Page 37-38
Page 38-41
Page 41-43
Page 43-44
Page 44-46
Page 46-50
Page 51
Page 53-55
Page 55-60
Page 55-57
Page 57
Page 57-58
Page 58
Page 59
Page 60
Page 61-65
Page 65-67
Peritoneal Dialysis Overview
- Pre-Op
- Post-Op
- Peritoneal Dialysis Systems and Connectology
- Automated Peritoneal Dialysis (APD) Systems
- Continuous Ambulatory Peritoneal Dialysis Systems
- Peritoneal Dialysis Solutions
o Standard Solutions
▪ Glucose
▪ Calcium
o Specialty Solutions
▪ Extranael® (Icodextrin)
▪ Nutrineal®
- Peritoneal Dialysis Prescriptions
- Assessing Poor PD Fluid Flow or Catheter Malfunction
- Management of PD Leaks
- Refractory Peritonitis
- Antibiotic Prophylaxis and Procedure Prep for PD Patients
- Other Peritoneal Dialysis Issues
Anemia Management in Chronic Kidney Disease
Bone and Mineral Metabolism
- Laboratory Abnormalities
- Testing and Management of CKD-MBD
Pathway for the Management of Parathyroid Hormone Levels in Dialysis Patients
Calcific Uremic Arteriolopathy (Calciphylaxis)
Management of Toxic Ingestions
- Hemodialysis
- Ethylene Glycol
- Lithium
- Salicylates
- Metformin-Associated Lactic Acidosis
- Hemoperfusion
Antidepressant Therapy for Adult Dialysis Patients
Pruritus
Page 67-69
Page 70-71
Page 71-73
Page 71
Page 71
Page 72
Page 72
Page 73
Page 73
Page 74-79
Page 80-83
Restless Leg Syndrome
Renal Adaptation of the WHO 3-STEP Analgesic Ladder
Useful References for Drug Dosing in Chronic Kidney Disease
- Micromedex
- RxTx (eTherapeutics/ eCPS)
- Drug Prescribing in Renal Failure Handbook
- Capital Health IV Drug Therapy Manual
- CDHA Antimicrobial Handbook
- Dialysis of Drugs
Renal Program Phone Numbers and other Phone and Facsimile Numbers
- Centennial Building
- Dickson Building Hemodialysis
- Blood Work Results
- Dartmouth General Hemodialysis Unit
- NSHA Central Zone QEII Health Sciences Centre
- Nova Scotia Satellite Hemodialysis Units
Central Dictation System Instructions and Keypad Function
INTRODUCTION
Welcome to Nephrology at Dalhousie University and Central Zone -Nova Scotia Health Authority. The Central Zone Renal Program is the largest in Nova Scotia and includes treatment of End Stage Renal Disease (ESRD) with Dialysis and Transplantation, General Nephrology, Subspecialty Clinics, Teaching and Research.
In-Patient clinical services consist of the In-Patient General Nephrology Ward, and the
Transplant Unit. The service is always very busy, therefore requires organization and coordination of care with the multidisciplinary team. This guidebook focuses on your rotations that may be on the General Nephrology Ward, the Renal Consult Service or the Outpatient Renal Clinic, and is a guide to the management of Nephrology patients utilizing NSHA Central Zone accepted protocols and useful suggestions.
Outpatient clinical services consist of Hemodialysis, Home Peritoneal Dialysis, Outpatient Hemodialysis, Home Hemodialysis, Nocturnal Hemodialysis, and Out-Patient clinics.
It is hoped that this Guidebook will assist you in the management of your patients and in your learning experience. In an effort to continually improve our service; we welcome feedback on this document.
Guidebook Editors:
Steven D Soroka, MD
Roman V Soroka
Contributors:
Amanda Miller, MD
David Clark, MD
Karthik K Tennankore, MD
Jo-Anne Wilson, PharmD
Jaclyn Tran, Pharmacist
Paula Mossop, RN
Carolyn Bartol, RN
Inpatient Ward Service
The In-Patient Nephrology Ward Is located on the 6th floor of the Centennial Building at the VG site; 6B. The number of beds allotted to General Nephrology is 8, but this can increase to more. To optimize the educational experience, a maximum of 8 – 10 admitted Nephrology patients is the hard cap. If beds are not available, patients may be admitted “Off Service” to other wards at the VG site – from the 3rd floor to the 9th floor.
The 6B ward also has a 4 bed IMCU that is used for surgical and medical patients. Nephrology patients can be admitted to the IMCU directly or transition from the ICU to the IMCU if they require more care than available on the ward. 6A also has an IMCU that may take sicker patients if there are no beds in the 6B IMCU.
6B Ward Numbers
Teaching Room 473-6831
Fax 473-5660
Phone Numbers 473-2635
473-2636
473-1178
Room 6042 (IMCU) 473-5943
The Multidisciplinary Team on the ward includes:
1. Charge RN – available to round with the Medical team in the morning and will help coordinate with other allied health, including home care, etc. for discharge planning
2. Staff Nurses
3. Personnel Support Workers
4. Dietitian – should be asked to see all newly admitted patients and review diet prior to discharge
5. Social Worker – three individuals cover by alphabet
6. Physical Therapy – should be consulted to assess all new patients and review prior to discharge
7. Occupational Therapy – should be consulted on patients as determined by the team
Rounds on the Ward
The Attending or Staff Nephrologist is assigned to the ward service in 2 week blocks. Each staff will inform at what time they will round on the ward patients. There are some set rounds and teaching rounds throughout the week as follows:
| |Monday |Tuesday |Wednesday |Thursday |Friday |
|0800 | | |Renal Program Rounds**** |Teaching Seminar***** |MOTP M&M Rounds******** |
|0900 | | | | | |
|1000 | | | | | |
|1100 |Renal Biopsy Rounds | | | | |
| |7th floor Pathology* | | | | |
|1200 |Nephrology Fellow |Weekly Teaching Rounds*** | | |Fellow/ House Staff |
| |Seminars** | | | |Rounds****** |
|1300 | | | | | |
|1400 | | | | | |
|1500 | | | | | |
|1600 | | | |MOTP Grand Rounds/ | |
| | | | |Interesting Case/ Journal | |
| | | | |Club******* | |
* held the first Monday of each month.
** held alternate Mondays
*** Weekly teaching rounds can be Journal Clubs, Interesting Case Presentations
**** Renal Program Rounds are held in the conference room on the 4th floor clinic area to discuss all the patients admitted to the ward, on the consult service and any problems in the dialysis areas
***** Typically held every Thursday morning. Academic sessions presented by staff, fellows or combined rounds with other specialties
****** Fellow/ House Staff rounds are presented by Nephrology Residents to rotating learners. They are held every two weeks on Friday at noon (if the resident is available)
******* MOTP Grand Rounds are typically held on the third Thursday of every month. MOTP interesting Case/ Journal Club are typically held every second Thursday
******** MOTP M&M Rounds are typically held on the third Friday of every second month
Throughout the year we have guest speakers that may talk at Medical Grand Rounds on Tuesday AM and then present again at 1200 – 1300 —on Tuesday. Special Notices are circulated prior to these events.
Standard Admission Orders
1. Standing orders have been developed and should be used on all new admissions.
2. Please remember to document allergies on the Physician Order Form.
3. Medication Reconciliation should be completed, reviewed, and signed off by the attending Nephrologist.
4. Medications given during dialysis – IV Iron and Recombinant Erythropoietin need to be ordered in the Inpatient chart, as while an inpatient nursing algorithms will not be used.
5. Hemodialysis and Peritoneal Dialysis patients need to have orders written for the inpatient chart, usually by the attending Nephrologist – there is an order sheet to write a first complete order for dialysis and then changes should be written in the Inpatient Chart only. A copy of the current dialysis orders can be obtained by asking the unit to fax them to the ward.
6. All orders on inpatients need to be written in the Inpatient Chart.
7. Remember that when ordering Blood Work that patients can have this done prior to the start of the hemodialysis treatment.
ROUTINE ADMISSION ORDERS FOR NEPHROLOGY PATIENTS - Part 1
1. DIET
← Renal ___________________________________
← Diabetic _________________________________
← Other ___________________________________
2. ACTIVITY
← As Tolerated
← Restrictions_______________________________
3. VITALS
← OD ( BID ( QID ( Other _____________
← Daily Weight
← Pre and Post Weights for Hemodialysis Patients
← Measure Urine Output ( Q Shift
( Daily
← Measure Ins and Outs ( Q Shift
( Daily
4. INVESTIGATIONS
← Diagnostic Imaging ________________________
________________________
( Labs - ( Electrolytes -Daily X _____days then _______
- ( Urea -Daily X _____days then _______
- ( Creatinine -Daily X _____days then _______
- ( CBC -Daily X _____days then _______
- ( Transferrin Saturation and Ferritin
- ( PTH
- ( Ca and PO4 -Daily X _____days then _______
- ( Urinalysis ( 24 hr urine
- ( Other __________________________________
__________________________________
__________________________________
5. DIALYSIS ORDERS
( Hemodialysis (see dialysis order sheet)
( PD (see peritoneal dialysis order sheet)
6. MEDICATIONS – See Medication Reconciliation
7. DIALYSIS MEDICATIONS
( ESA
• Aranesp ___________________
• Eprex _____________________
•
( IV Iron (See IV Iron order sheet)
8. NEW DIALYSIS START
( A new start package is needed prior to discharge (including CORR form filled out and sent to the dialysis unit prior to discharge).
9. UPON DISCHARGE, PLEASE FAX A COPY OF:
a. Interim Report
b. Medication Reconciliation
c. Last three dialysis run sheets
d. Any orders needed on the outpatient dialysis chart
e. Request copy of discharge summary when dictating
( Dickson Building Dialysis Unit: 473-3943
( Home Unit Satellite Dialysis Program: 473-5598
( Dartmouth General Hospital Dialysis: 465-8398
( Home Unit Peritoneal Dialysis Program: 473-2412
Physician/NP Signature: ______________________
Physician/NP Name: __________________________
(Print)
CPSNS License #: __________________________
Standard Discharge Orders
1. Upon discharge it is important that:
a. The interim report and medication reconciliation are faxed to the appropriate dialysis unit – a specific sheet has been developed for this. If the discharge summary is done using the eDischarge than this should be faxed with the electronic Discharge Medication Reconciliation to the appropriate unit (Please refer to the eSummary and Discharge Med Rec tabs in Clinical Portal).
b. Dialysis orders and the last three dialysis treatment sheets are sent to the appropriate dialysis unit.
c. If the patient is a NEW DIALYSIS START and will be receiving hemodialysis as an outpatient – a New Dialysis Start Package MUST be filled out and sent to the Dickson Centre Hemodialysis Unit Prior to discharge. This package consists of the Initial Registration for CORR (Canadian Organ Replacement Registry), Charlson Comorbidity Index, Frailty Scale Score, Consent for treatment, initial orders, problem list, and requisitions for chest x-ray and abdominal x-ray, as well as singed algorithms for ESA and IV iron.
Routine Orders for Dialysis Patients being Discharged from the Hospital
This sheet or a sticker should be placed on the Inpatient chart of all patients that are chronic dialysis patients.
The information on the sticker will be to direct the inpatient unit to send information to the appropriate unit.
This patient will be receiving HEMODIALYSIS or PERITONEAL DIALYSIS when they are discharged from the hospital. (Please circle)
In order to help with their transition to outpatient treatment, please do the following:
Please fax the following to:
Dickson Building Hemodialysis: 473-3943
Home Dialysis (Satellite Hemodialysis Patients): 473-5598
Dartmouth Dialysis: 465-8398
Peritoneal Dialysis: 473-2412
HI Hemodialysis: 473-3602
The Interim Report
The Medication Reconciliation
The most recent completed dialysis orders
The last three hemodialysis treatment sheets or,
The last three peritoneal dialysis treatment sheets
Thank you, we appreciate your help.
Renal Clinic Rotation
The NSHA Central Zone Renal Program has an outpatient clinic area on the 4th floor of the Dickson Building. The clinic is operational Monday to Thursday with active clinics and there is also RN coverage for Friday. The schedule of physician and specialty Nurse Practitioner clinics is listed below.
| |MONDAY |TUESDAY |WEDNESDAY |THURSDAY |FRIDAY |
|AM |R. Panek |N. Finkle |R. Panek |S Soroka ADPKD Clinic | |
| | |B. Kiberd |M. Wood | | |
| | | |P. Poyah | | |
| | | | | | |
| |C. Dipchand |C. Dipchand |S. Soroka |M. West (Fabry) | |
| |M. West |K. West | | | |
| |D. Clark | S. Welcher (Overflow) | | | |
| | | | | | |
|AM shift |C Dipchand |R Panek |C Dipchand |R Panek |C Dipchand |
|0800 to 1200 |S Soroka |K Tennankore |S Soroka |K Tennankore |S Soroka |
| |M West | |M West | |M West |
|Aft Shift |B Kiberd |N Finkle |B Kiberd |N Finkle |B Kiberd |
|1200 to 1700 |T Keough-Ryan |P Poyah |T Keough-Ryan |P Poyah |T Keough-Ryan |
| |K West | |K West | |K West |
|PM Shift |On Call Staff and Fellow |On Call Staff and Fellow |On Call Staff and Fellow |On Call Staff and Fellow |On Call Staff and Fellow |
|1700 to 2300 | | | | | |
MWF Morning: Christine Dipchand Office Number: 473-5160
Pager Number: 2631
Steven Soroka Office Number: 473-2099
Pager Number: 498-5054
Michael West Office Number: 473-5160
Pager Number: 2104
MWF Afternoon: Bryce Kiberd Office Number: 473-2099
Pager Number: 2178
Tammy Keough-Ryan Office Number: 473-2099
Pager Number: 498-4870
Kenneth West Office Number: 473-5543
Pager Number: 2188
TT Morning: Roman Panek Office Number: 473-4021
Pager Number: 1224
Karthik Tennankore Office Number: 473-2099
Pager Number: 2733
TT Afternoon: Neil Finkle Office Number: 473-5160
Pager Number: 7868
Penny Poyah Office Number: 473-5160
Pager Number: 2135
The HI Hemodialysis Unit is open six days a week for two shifts a day. The Nephrologist on the consult service at the HI will round in the dialysis unit every day.
Ordering Hemodialysis
When rounding on the consult service all acute patients need to be seen as early as possible (at least before 1000 am). The hemodialysis charge nurse should be called at 473-7544 or 473-5188 to discuss who may need dialysis that day.
If the hemodialysis is for a new acute then the central venous access should be in place and radiologically confirmed. The optimal length of catheter is usually 12.5 to 15 cm for the Rt IJ, 15 to 20 cm for the Lt IJ and 24 cm for a femoral catheter.
In addition to the regular hours of operation there is always a nurse on call. The Nephrologist or Fellow can page the nurse on call for Hemodialysis.
Filling out Hemodialysis orders sheet:
1. Frequency - “Daily”- all acute or unstable pts, evaluate pt prior to each Rx.
“Chronic" stable chronic pts may only need adjustments from the routine orders.
2. Dialyzer
For acutes-order Revaclear. The standard for chronic HD pts is Revaclear or Revaclear max for selected patients.
3. Method
"Conventional" refers to intermittent HD. HD time includes solute removal + ultrafiltration (UF). Can also have isolated UF if pt very volume overloaded - may permit a greater rate of fluid removal with less hemodynamic compromise.
URR (Urea Reduction Ratio) is used to assess adequacy of dialysis, with a target of > 65 %.
The calculation is (Pre Urea – Post Urea)/ PreUrea x 100 %
4. Dialysate
Sodium: standard is 137 mM.
Sodium "ramping" is occasionally ordered for patients with high fluid removal goals who develop cramps or hypotension - the program has a standard protocol for ramping Na - but this should only be ordered if this is part of the standing or routine orders or after consultation with fellow or staff.
The dialysate Na can be set as low as 130 mM and as high as 155 mM in cases of hypo or hyperNa.
Potassium: 1.0, 1.5, 2.0, 2.5, 3.0, 3.5 or 4.0 mM/L available. Goal is predialysis K+ 4.0 - 5.5, post dialysis K+ 3-3.5. (To guesstimate: 7 – pt’s K+ ~= dialysate K+). Standard is 2.0 to 2.5 mM.
Calcium: "regular" is 1.25 mM. Also have 1.00 available for hypercalcemia and 1.50 mM and 1.75 mM available for hypocalcemia.
Bicarbonate: the standard buffer, generally use 34 mM which we call Normal, other choices are Low which is 29 and High which is 41.
Phosphate: No PO4 in dialysate, if patient is hypophosphatemic, you can order to add a non oil containing Fleet PO4 enema, 30, 60, 90 ml to acid bath.
Magnesium: 0.375, 0.5, 0.75 mM; usual is 0.75, and adjust as needed to maintain the serum Mg within the 0.91 – 1.15 mM range.
5. Target weight (TW) and fluid removal.
TW = pt’s euvolemic weight at the end of dialysis - i.e. No peripheral or pulmonary
edema, normal JVP, normal BP, and no s/s ECFV depletion - cramps, dizziness,
orthostatic hypotension.
Stable patients: establish TW by physical exam with reference to patient's current
weight; Hemodialysis nurses determine amount of fluid to remove using the pre-dialysis
and target weight.
Acute In patients: Inpatients are ill and are often losing lean body mass or muscle and
often replace this with fluid. An assessment of target weight with volume assessment
should be done on a regular basis, especially if the patient is not gaining weight
between treatments.
6. Anticoagulation
Regular heparin: 1000 IU bolus and 500 – 1000 IU/hr.
Tight = 0 bolus, 500 IU/hr, or 500 IU bolus and no to 250 IU/hr.
No heparin = 0 bolus, 0 infusion, N/S flushes - use for patients with bleeding,
coagulopathy, or pre/post surgery. The risk of tight or no heparin is dialyzer clotting
(blood loss), so need to balance risk of bleeding to risk of clotting system.
We also have protocols for HITT positive patients – Danaparoid or Argatroban if
Danaparoid is not available.
7. Blood Flow (Qb)
Standard is “Maximize at RN discretion”, up to 400 ml/min
Generally slower Qb's for first few runs to avoid dialysis disequilibrium (e.g. 250
mL/min).
8. BP maintenance
Standard is saline; occasionally Albumin 25%. In some ICU pts already on inotropes,
dopamine may occasionally be used.
9. Blood Work
Laboratory tests can be ordered drawn at the start of the dialysis treatment to decrease
the need for venipuncture. Only order NECESSARY Blood Work.
HEMODIALYSIS ORDERS
PPO 0417: Routine Hemodialysis:
Hemodialysis Treatment Therapy:
( Conventional ( Daily ( Nocturnal
Ideal Body Weight __________ kg
Fluid removal ___________ kg
Number of hours of dialysis ___________
Times per week___________
Dialyzer: ( Revaclear ( Revaclear max ( Other _________
Blood flow rate ___________ mL/min
Potassium __________
8. Calcium: (1 mmol (2 mEq) (1.25 mmol (2.5 mEq) (standard)( 1.5 mmol (3 mEq) ( 1.75 mmol (3.5 mEq)
9. Bicarbonate ( Low 29 mM or 2.7 ( Normal 34 mM or 3.2 ( High 41 mM or 3.9
10. Sodium________ (standard 137) Sodium ramping ___________
11. Magnesium: ( 0.375 mM ( 0.5 mM ( 0.75 mM (Standard)
12. Dialysate Temperature per patient body temperature – max. 36°C ___________
13. Dialysate flow rate___________ mL/min)
14. Anticoagulation:
( Heparin: Loading dose ______ units Infusion date ________ units/h Duration ___________
( Flushes
( Other ( Danaparoid Protocol ( Argatroban Protocol
15. Code Status ______________
16. PO4 additives ____________ for Nocturnal or low PO4
Once the full set of orders has been written you can refer back and just make changes to the parameters you want to change.
There are standing orders for CRRT – Please use them to order these modalities.
PPO 0214 CRRT No Anticoagulation:
(critical%20care).pdf
PPO 0213 CRRT with Anticoagulation:
(critical%20care).pdf
PPO 0106: Admission Hemodialysis Orders:
Treatment for Multiple Myeloma with High-cut off Dialysis Protocol
Following is a protocol for high cut off hemodialysis for patients with multiple myeloma and light chain cast nephropathy. Patient s that should be considered for this treatment would be those with diagnosed multiple myeloma and light chain or cast nephropathy. The high cut off dialyzer has the ability to remove larger substances like light chains. In general, larger doses of loading and maintenance heparin are needed to prevent circuit clotting.
[pic]Patient: Allergies:
Items preceded by a bullet (·) are active orders. Items preceded by a checkbox (□) are only to be carried out if checked
1. Code Status ___________________________
2. This therapy will only be started if the patient will be started on chemotherapy. This therapy will be discontinued if the patient stops chemotherapy.
3. Hemodialysis Treatment
□ Routine:
o 6 hours for 1 day, then
o 8 hours daily for 5 of 6 days (with induction chemotherapy), then
o 8 hours 3 days per week for 2 weeks, then
• 6 hours 3 times per week
• NOTE: No dialysis on Sundays unless otherwise indicated
□ Other:_________________________________________________________________
___________________________
o Weight pre and post hemodialysis
o Blood Pressure pre and post hemodialysis
o Pulse pre and post hemodialysis
o Temperature pre and post hemodialysis
o
□ Investigations:
• Profile, sodium, potassium, chloride, bicarbonate, urea, creatinine, calcium, phosphorous, magnesium, albumin, serum free light chains (To be completed PRIOR to Hemodialysis Treatment)
• Pre-dialysis sodium, potassium, chloride, bicarbonate, urea, creatinine, calcium, phosphorous, magnesium, albumin (To be completed at EACH Hemodialysis Treatment)
• Pre-dialysis serum free light chains EVERY Tuesday OR Wednesday
4. High-cut off (HCO) Hemodialysis (HD)
• Dialyzer: □Gambro 1100 HCO-HD □ Other: ______________
• Dialysate flow rate 500ml/min
• Blood flow rate 250 ml/min
• Ideal Weight or Fluid removal ___________ (Sodium)___________
• Potassium ___________
• Bicarbonate ___________
• Magnesium ___________mmol/L
• Calcium ___________mmol/L
• PO4 additive ___________
• 100 mL of 25% Albumin Intravenously in last ONE hour of each dialysis treatment
• Anticoagulation
□ Heparin Loading Dose ___________ units
Infusion dose units/hour
□Normal saline flushes EVERY 30 minutes
□Other: _________________________________________________________________________________________________________________________
5. Monitoring
• Notify MD if serum free light chains < 500 mg/L
• Notify MD if hemodialysis orders require adjustment due to predialysis sodium, potassium, chloride, bicarbonate, urea, creatinine, calcium, phosphorous, magnesium levels
RECOMMENDATIONS;
|Discontinue HCO-HD if serum free light chains < 500 mg/L or if Chemotherapy is discontinued by Hematology |
|If serum free light chains > 500 mg/L at 6 weeks, MD to reassess need for ongoing intermittent HD |
Prescriber’s Signature____________________________ Date (yyyy/mm/dd): _____________________________________
Prescriber’s Name_______________________________ Reg. No.______________________________________________________
Vascular Access For Hemodialysis
Arterio-venous fistula (AVF) is the preferred access choice for hemodialysis patients.
Compared to other accesses, AVF have:
• Best patency rate and require fewer interventions
• Lower complication rates
• Lower incidence of infection, stenosis and steal syndrome
• Lower morbidity
• Improved blood flow over time
Surgical creation of an anastamosis of patients own artery to vein. A new fistula should be allowed to mature for ~8 weeks. Ideally AVF should be matured for 3-4 months prior to cannulation. Auscultation of a “bruit” and palpation of a “thrill” should be present as well as discernible vessels for cannulation.
Arterio-venous graft (AVG) is the second preferred access choice.
Creation of an AVG; surgical implantation of a synthetic material (eg.PTFE “Gortex”) to connect artery to a vein. The location for the graft placement in the forearm, upper arm or thigh is determined by each patient’s unique anatomical restrictions.
A new PTFE dialysis AV graft should not be cannulated until swelling has gone down enough to allow palpation of the course of the graft—ideally 3 weeks after placement. Ideally, no attempt should be made to cannulate the graft for at least 14 days after placement. You should be able to auscultate a bruit but may not feel a thrill along the graft.
CD1173MR Consultation AV-Fistula to be completed and faxed to 473–2412.
Central Venous Catheters:
Short-term catheters (Non Tunneled Catheter) should be used for acute dialysis and for a limited duration. Short-term catheter tips should be in the superior vena cava (SVC) and confirmed by using chest radiograph or fluoroscopically at the time of placement before initiating dialysis therapy. Non-cuffed femoral catheters should be used in bed-bound patients only ultrasound-directed cannulation minimizes insertion complications and should be used when available Easote MyLabFive Ultrasound machine is available in the treatment of the Dickson Dialysis Unit.
Long-term catheters (Tunneled Cuffed Catheter) should be used in conjunction with a plan for permanent access the preferred insertion site for tunneled cuffed venous dialysis catheters is the right internal jugular vein. The tip within the right atrium confirmed by fluoroscopy for optimal flow.
Other options include the right external jugular vein, left internal and external jugular veins, subclavian veins, femoral veins, and translumbar and transhepatic access to the IVC. Subclavian access should be used only when no other upper-extremity or chest-wall options are available.
Tunneled Cuffed Catheter inserted in the Interventional Radiology suite: Victoria General (VG) site or Halifax infirmary site CBC, INR and PTT within the last seven days the tunneled catheter can be used immediately for hemodialysis but no heparin is given on the day of insertion.
|Fax requests CD0013MR Diagnostic Imaging Consultation Request to Interventional radiology suite: | |
|VG site : telephone number 902-473-5477 Fax number 902-473-2018 | |
|Halifax Infirmary site: telephone number 902-473-5327 Fax number 902-473-8626 | |
Please refer to the following policies;
CDHA CC 50-050 Care of the Tunnelled Hemodialysis Central Venous Catheter:
CDHA CC 50-045 Hemodialysis Access, Dysfunction, Care of using Thrombolytic Therapy - Alteplase:
CDHA CC 50-049 Care of Non-Tunnelled Hemodialysis CVC:
HEMODIALYSIS CENTRAL VENOUS CATHTER PLACEMENT
The following list is the supplies included on the ‘central line cart’ needed for central venous catheter placement. There are two carts: one in the Dickson Hemodialysis procedure room, the other in the 6B ward supply room.
o Central line tray for line insertion
o Standard procedure tray
o Drapes - disposable split sheet
o Spd, sterile towels and bowls
o Gloves - sterile assorted sizes: 6, 6.5, 7, 7.5, 8, 8.5.
o Gowns - disposable, sterile
o Surgical caps
o Mask with ear loops
o Disposable scalpels size 10 , 11
o Scalpel blades 10, 11, 12, 15
o IV catheters assorted: sizes 16, 18, 20
o Needles-assorted: 18 gauge needle 1.5 inches, 22 gauge 1.5 inches, 25 gauge 5/8 inches, 25 gauge 1.5 inches
o Syringes---3mLs, 5ml syringes and 10mLs
o blunt needle, blunt filter needle
o Sterile saline syringes 10 mLs
o 1% Xylocaine (individual packets)
o Lubricating jelly
o Swabs—alcohol, , Chlorhexidine swab stiks—large and small
o Sponges: 2 by 2, 4 by 4, 4 by 6
o Tape Assorted---Transpore, waterproof, Micropore, Cloth
o Opsite: small and large
o Sutures, -2.0 silk, 3.0 and X412H
o Band aides: small and large
* Temporary internal jugular vas caths are generally 16 cm in length, and temporary femoral vas caths are generally 20 cm in length.
Catheter Related Blood Stream Infections (CRBSI)
In our Hemodialysis Program, over 60% of patients currently have central venous catheters (CVC) as their prevalent access. Blood stream infections associated with CVCs represent a significant cause of morbidity and mortality in this population.
Signs and Symptoms of CRBSI Include:
• Temperature, chills/rigor, and/or malaise
• ↑ WBC
• Site discomfort, redness, swelling, and/or drainage
Investigations:
• Blood cultures from the CVC and peripheral site (if possible).
If unable to obtain a culture from a peripheral site: draw aerobic culture from the other CVC lumen.
• If purulent drainage present at the CVC: swab site for culture and sensitivity and gram stain.
The following table is to guide assessment of infections related to the Central Venous Catheter
| |Definition |
|Exit Site Infection |Purulent discharge at exit site |
| |OR |
| |Erythema, tenderness, induration (2 of 3) at exit site with a positive culture or serous discharge |
|Tunnel Infection |Purulent discharge or aspirate from a tunnel or pocket site not contiguous with exit site |
| |OR |
| |Erythema, tenderness, induration (2 of 3) at a tunnel or pocket site not contiguous with exit site with a positive |
| |culture of serous discharge or aspirate from the site. |
|Catheter Related |Case Definition: Blood Stream Infection (BSI) |
|Bacteremia |Criterion 1: Recognized pathogen cultured from at least one blood culture, unrelated to infection at another site. |
| |OR |
| |Criterion 2: At least one of: fever (>38°C core), chills, hypotension, AND common skin contaminant* cultured from ≥|
| |2 blood cultures drawn on separate occasions and positive laboratory results are unrelated to infection at another |
| |site. |
| | |
| |*Common Skin Contaminants: Diphtheroids, Corynebacterium spp., Bacillus spp., Propionibacterium spp., |
| |coagulase-negative staphylococci (including S. epidermidis) viridans group streptococci, Aerococcus spp., |
| |Micrococcus spp. |
| | |
| |CVC-Associated BSI |
| |A laboratory-confirmed bloodstream infection where a central venous catheter (CVC) or umbilical catheter (UC) was |
| |in place for >2 calendar days on the date of the positive blood culture (CVC), with day of device placement being |
| |Day 1. |
| |AND |
| |A CVC or UC was in place on the date of the positive blood culture or the day before. If a CVC or UC was in place |
| |for >2 calendar days and then removed, the BSI criteria must be fully met on the day of discontinuation or the next|
| |day. |
| | |
| |Relapse vs. New Infection |
| |Same microorganism (as best as can be determined by the data available – e.g. species, antibiotic sensitivity, |
| |etc.) isolated from a subsequent blood culture: |
| |• If less than 10 days from a negative culture OR less than 10 days from completion of appropriate antibiotic |
| |therapy, consider as a relapse and DO NOT REPORT. |
| |•If more than 10 days from a negative culture (if culture was done) AND more than 10 days from completion of |
| |appropriate antibiotic therapy, REPORT as a NEW infection. |
| | |
• Source: Canadian Nosocomial Infection Surveillance Program (CNISP): Surveillance for Central Venous Catheter Associated Blood Stream Infections (CVC-BSI) in Intensive Care Units. 2015 CVC-BSI Surveillance Protocol. Final January 12 2015.
Empiric Management for CRBSIs: It important to consider patient specific factors, including history of infections (ie MRSA or gram negative rod bacteremia) and allergies.
Current Practice for Empiric Management of CRBSIs:
• Cefazolin 2 g IV direct post hemodialysis.
If cefazolin is contraindicated (known allergy) or clinical history of resistant bacteria:
• Vancomycin Less than 50 kg: 1,000 mg x 1 dose, then 750 mg at each dialysis
50 to 75 kg: 1,500 mg x 1 dose, then 1,000 mg with at each dialysis
More than 75 kg: 2,000 mg x 1 dose, then 1,500 mg at each dialysis
*Dose based on dry weight. See pre-printed order for details.
If gram negative coverage is required:
• Ceftazidime 2 g IV direct post hemodialysis.
If ceftazidime is contraindicated: Gentamicin or tobramycin (consult renal pharmacist)
Antimicrobial therapy and duration of therapy to be tailored based on the organism which grows. See the NSHA Antimicrobial Handbook for details. The catheter may require removal or exchange over guidewire as determined by the Nephrology team upon investigation.
PERITONEAL DIALYSIS OVERVIEW
The Peritoneal Dialysis Program at NSHA Central Zone resides on the 6th floor of the Victoria Building. There is a main office which houses the charts, and rooms for training and clinics.
The main contact numbers are as follows:
Peritoneal Dialysis Program
Phone – 473-6527
473-6524
Fax – 473-2412
Doctor Room 240
Phone – 473-2298
473-5920
Nurses Room
Phone – 473-1184
473-1185
473-1183
(Ward Aid) 473-5588
After hours the On-Call Nurse for the PD program can be contacted through locating – 473 2220 – ask for the Home Dialysis On-Call Nurse.
Peritoneal Catheter Insertion
The consult form and packet for PD catheter insertion needs to be filled out and given to Cindy Everett, the PD Coordinator in the Renal Clinic, 4th Floor Dickson.
Consultation Peritoneal Catheter
To: Doctor_________________________ Date:___________________________
Opinion Only (
OR Priority: ( 1-within 2 weeks ( 2-within 2-6 weeks ( 3-within 6-8 weeks
( Outpatient ( SDA ( Inpatient
Please assess for peritoneal catheter: ( Insertion ( Removal ( Removal & Insertion
Diabetic: ( Yes ( No
Hernia Repair: ( Yes ( No
( umbilical ( inguinal ( umbilical & inguinal
( ventral ( epigastric ( hiatal
Currently on Anticoagulants:
( ASA ( Plavix ( Warfarin ( N/A
( Stop Anticoagulants_____ days pre-op ( Do not stop Anticoagulants
Cardiac Work-up Required: ( Yes ( No
Current Modality: ( Predialysis ( PD ( IHD-M-W-F ( IHD-T-TH-S ( SHD-M-W-F ( SHD-T-TH-S
Satellite Site___________________________________
Temporary Residence: Staying at PPL ( Yes ( No Relative/Friend ( Yes ( No.
If yes, provide address & phone #_________________________________________________________
There are three options for Surgery:
1. Day surgery – patient not admitted
2. Same day admit surgery – patient admitted post surgery for 2-3 days.
3. Admit pre surgery – patient admitted or in hospital prior to surgery – usually to optimize for surgery or to manage anticoagulation.
PPO 0275 Pre/Post operative Peritoneal Dialysis Catheter Insertion:
Pre-Op:
• Hold calcium and iron for 1 week pre-op, as well as ASA and anticoagulants
• A bowel preparation pre-catheter insertion is extremely important. We use Senna 8.6 mg po BID and Lactulose 30 ml po BID to QID if no bowel movement by day 4.
• Antobiotics are given: CefUROime 1.5 g IV in the OR or Vancomycin 1 g IV if allergic to penicillin or cephalosporin.
• Pre-Op anesthesia consultation through the preadmission clinic and exit site marking through the home dialysis unit are also done.
Post-Op:
• We have pre-printed post-op orders for PD catheter insertion – these are usually filled out prior to surgery and are also available on the ward.
• Continue to hold calcium and iron for 1 week post-op.
• Bowel medications are continued to achieve a soft bowel movement every day.
Peritoneal Dialysis Systems and Connectology
A PD transfer set/catheter adapter remains connected to the end of the PD catheter to allow the connection of dialysate bags and cycler tubing. If capable, the patient is taught to change the PD catheter transfer set every six months. If the patient is not capable, a PD nurse changes this transfer set/catheter adaptor approximately every six months, when the patient is seen in clinic for follow-up.
Automated Peritoneal Dialysis (APD) Systems
Systems that utilize a cycler machine to do CCPD, CCPD-high dose
The Home Choice® is the Baxter cycler that delivers Dianeal® solution. This cycler has a pump with a speed of 200 ml per minute.
At NSHA Central Zone all of our patients use the Baxter system.
Continuous Ambulatory Peritoneal Dialysis Systems
Systems that use a manual bag and gravity to do CAPD exchanges. Manual bags are composed of a fill bag with dialysate and a drain bag incorporated in a sterile system. At the end of the exchange the catheter is capped. For home CAPD, our patients generally use the Twinbag® system by Baxter.
Peritoneal Dialysis Solutions
Standard Solutions
- Glucose concentrations: 0.5%, 1.5%, 2.5% and 4.25%. Osmolality increases with the increases in glucose concentration. Dianeal® is the glucose-based solutions.
- Calcium concentration: standard (“PD101” 1.75 mmol/L or 3.5 mEq/L) and low calcium (“PD4” 1.25 mmol/L or 2.5 mEq/L). Note: Most patients use low Ca+ concentration bags with the Luer-lock connections.
- Volume: 1.5L, 2L, 2.5L, 3L, 5L. Not all solutions are available in all volumes.
Specialty Solutions
Extranael® (Icodextrin): A glucose polymer (7.5% solution) based solution that metabolizes to maltose, for patients with ulteafiltration problems. Recommended for one 8 to 12-hour dwell per day.
***NOTE: Patients with diabetes using Extraneal should check their capillary blood glucose using an approved monitor only, as there is a risk of hypoglycemia if the blood glucose is measured using a device that does not differentiate maltose from glucose. The approved monitors are: Abbott Precision Extra, Bayer Contour and Breeze-2, Roche Accutrend and GC are all monitors manufactured by Lifescan. There is also a risk of allergic skin reactions with Extraneal® so patients should be advised. Additionally, it should be avoided in those allergic to corn or cornstarch.
Nutrineal®: An amino acid based solution used for patients with malnutrition secondary to poor oral intake. Recommend for one 6-hour exchange during the day coinciding with a meal. Clinical trials have not shown consistent benefit with the use of this solution and we are only using this solution in a few patients.
Peritoneal Dialysis Prescriptions
For all PD prescriptions, volume and frequency of exchanges, additives and Target Weight (TW) need to be ordered. Specify the TW as “full” or “drained” weight. “Target weight (full)” includes the instilled volume of fluid. An “exchange” includes the fill, dwell and drain time of a specified volume. Individual patient prescriptions and documentation are available from the PD unit: 473-6524 from 0800 to 1530.
PPO 0276 Peritoneal Dialysis:
1. CAPD (Continuous Ambulatory Peritoneal Dialysis)
Sample Prescription of CAPD: CAPD: 2 litre volume QID, Target weight 68.0 kg (full)
- 4-5 exchanges/day with long dwell overnight.
- Dwell times average 4-6 hours during day and 8-10 hours overnight.
- TW includes the volume of the exchange.
- Patients with diabetes require an order for the frequency of blood glucose monitoring. This usually coincides with PD exchanges but may be less frequent in stable patients.
2. APD or Automated Peritoneal Dialysis with includes:
CCPD (Continuous Cyclic Peritoneal Dialysis) and
HD CCPD* (High Dose CCPD)
Sample prescription CCPD: Total volume: 12 litres (5 exchanges of 2 litre volume overnight plus last fill of 2 litres) Therapy Time: 9 hours, Exchange volume: 2 litres, Target weight: 70 kg (full)
- 3-6 exchanges/night with long day dwell. Exchanges are delivered overnight utilizing a machine with last fill exchange of >500 mls. The last fill is left indwelling during the day for 12-16 hours. Patient reconnects to machine at night to drain and resume overnight exchanges.
- Overnight exchange volume and day volume may differ. If patient has back pain/herniated, he/she may tolerate larger exchange volume at night with smaller volume during day.
- TW includes the volume of day exchange.
- Patients with diabetes require an order for the frequency of blood glucose monitoring.
- Patients with diabetes are generally managed with doses of s.c. Insulin, one prior to dialysis on the night cycler and one in the morning post dialysis. The patient may require the larger dose at night.
Sample Prescription HD-CCPD: Total Volume: 14 litres (5 exchanges of 2 litre volume overnight plus last fill of 2 litres + midday exchange of 2 litres) Therapy time: 9 hours, Exchange volume: 2 litres, Target weight: 70 kg (full)
- Frequent exchanges/night with >500 ml day dwell.
- While it is preferable to have a day dwell, the dry day may be used for patients who do not tolerate day exchanges (i.e. back pain/herniated, recent abdominal surgery or increased fluid absorption)
- Target weight is generally an empty weight unless patient has a small day dwell.
- Patients with diabetes require an order for the frequency of blood glucose monitoring.
- Patients with diabetes are generally managed with 2 doses of s.c. insulin, one prior to dialysis on the night cycler and one in the morning port dialysis. The patient may require the larger dose at night.
ASSESSING POOR PD FLUID FLOW OR CATHETER MALFUNCTION
You may be called when there is a problem with fluid filling or draining. The most common reasons are fibrin or blood clot in the catheter, change in position of the catheter related to constipation or omental wrap. An approach to this is shown on the next page.
[pic]
Management of PD Leaks
Exit Site Leak
These occasionally occur during the first weeks following catheter implantation in patients who are considered at risk for exit site leak in the postoperative period (i.e. immunosuppressed, diabetic, frail, obese or very thin). If the patient requires dialysis, small volume IPD (750 ml) should be administered cautiously. Staff should ensure the patient is complete empty at the conclusion of the flushes. If leak does occur, Home PD should be delayed a further 2-3 weeks. Depending on the severity of the leak, it may be necessary to hemodialysis the patient temporarily.
Late exit site leak is less common and may be related to accidental pulling on the catheter or due to conditions that raise intra-abdominal pressure (i.e. lifting heavy objects). Home PD may have to be interrupted and the patient scheduled for 2-3 weeks of hemodialysis until the problem resolves.
Intra-Abdominal Leak/Hernia
Occasionally PD fluid may leak internally and present with swelling in the genitalia or abdominal tissues. Patients may present with evidence of hernia. In these cases, it may be necessary to do a CT Scan, and possibly have a surgical consult and temporarily hold Home PD.
When surgical repair is indicated, or until the leak resolves on its own, the patient is usually maintained on low volume CAPD, or switched to hemodialysis. When Home PD is resumed, dialysis volumes are usually decreased, and then very gradually increased. Some patients on cyclers may be able to continue dialysis at home by reducing volumes and remaining dry during the day. If patients on CAPD undergo more than one hernia repair and develop a subsequent hernia, it is usually recommended that the patient change to an APD regimen with lower abdominal pressure.
Peritonitis Guidelines
Peritonitis generally managed as outpatients unless severe or patients unable to manage at home. Diagnosis requires 1 of the following 3 and high PD effluent cell count (see below):
- abdominal pain
- cloudy dialysate fluid
- positive culture of dialysate fluid
A PD effluent cell count with WBC >100 cells/µ and >50% neutrophils with or without positive cultures in addition to the above symptoms is diagnostic for PD peritonitis. Patients are instructed to bring the first bag noted to have cloudy fluid to the nearest laboratory and it is then sent for C&S, Gram stain, and cell count with differential. There are other causes of abdominal pain to consider, i.e. constipation, pancreatitis, ischemic bowel, etc. Even if there is true peritonitis, consider “surgical causes” such as appendicitis (abdominal pain is localized rather than diffuse).
Refractory Peritonitis
- If no decrease in cell counts in 3 days or if count fell initially and then increased, repeat culture and consider possibility of secondary peritonitis due to ischemic bowel, cholecystitis diverticulitis or appendicitis
- Refractory peritonitis is defined as failure to respond to appropriate antibiotics within 5 days.
- Consider temporary discontinuation of PD – arrange for temp HD
- Catheter removal – required for virtually all fungal peritonitis, and for serious refractory bacterial peritonitis, or if the clinical condition is not improving within 5 days of starting antibiotics.
- If UF failure with peritonitis (weight gain/ECFB overload), alter regimen (i.e. shorten dwells, hypertonic bags, Icodextrin/Extraneal® more frequent exchanges, IPD).
- Note that Icodextrin is compatable with antibiotics, so can be put into Icodextrin exchange.
- Stable pts may be discharged and continue therapy at home.
For management of any complicated peritonitis, please contact Dr. K Tennankore, or the Nephrologist covering the Home Therapies unit.
Peritonitis Management
For Empiric Management of Peritonitis refer to pre-printed order PPO0395MR
For the Management of Confirmed Pathogen Peritonitis, refer to pre-printed order– PPO0394MR
Empiric Management of Peritonitis Associated with Peritoneal Dialysis
For patients with suspected Peritoneal Dialysis Peritonitis, empiric antibiotic therapy is initiated as soon as possible. Intraperitoneal (IP) administration is preferred (6 hour long dwell). The following is the preferred empiric antibiotic regimen (See Empiric Management of Peritonitis Associated with Peritoneal Dialysis Pre-Printed Order PPO0394MR)
|CeFAZolin – weight based dosing |
|( Less than 50 kg CeFAZolin 1,000 mg IP daily x 5 days |
|( 50 kg – 100 kg CeFAZolin 1,500 mg IP daily x 5 days |
|( 100 kg or greater CeFAZolin 2,000 mg IP daily x 5 days |
|AND |
|CeftAZIDime – weight based dosing |
|( Less than 50 kg CeftAZIDime 1,000 mg IP daily x 5 days |
|( 50 kg or greater CeftAZIDime 1,500 mg IP daily x 5 days |
However for Suspected or Previous Methicillin-Resistant Staphylococcus aureus (MRSA) or Cephalosporin Allergy (not intolerance), give Vancomycin instead of CeFAZolin (Vancomycin 1,000 mg IP x one dose [weight less than 50kg]; 1,500 mg IP x one dose [weight 50-100 kg ]; or 2,000 mg x one dose [weight greater than 100 kg]).
In addition, if Cephalosporin Allergy (not intolerance), give Gentamicin/Tobramycin instead of CeftAZIDime (Gentamicin/Tobramycin 40 mg IP daily x 5 days [weight less than 50 kg] or Tobramycin 60 mg IP daily x 5 days [ weight 50 kg or greater]). Gentamicin and tobramycin are interchangeable and require the same mg/kg dosing. AVOID Gentamcin/Tobramycin greater than 5 Days.
Note: Hold oral iron, phosphate binders such as calcium carbonate (Tums®) until peritonitis has resolved. Heparin 500 units/L of Dianeal® fluid is added IP for fibrin until effluent is clear.
Antibiotics are reassessed within 72 HOURS of initiation based on culture and sensitivity results. See Management of Confirmed Pathogen Peritonitis Pre-Printed Order (PPO0394MR).
Management of Confirmed Pathogen Peritonitis Associated with Peritoneal Dialysis
Discontinue empiric antibiotic therapy. Choice of subsequent antibiotic therapy based on culture and sensitivity and patient allergy status (Table 1). Intraperitoneal (IP) administration is preferred (6 hour long dwell). Confirm compatibility of IP antibiotics with PD solution prior to administration (Table 2).
Note: For patients on gentamicin/tobramycin, monitor pre (trough) gentamicin/tobramycin level before the fourth dose. Additional serum gentamicin/tobramycin level should be carried out twice weekly. Audiograms at baseline (right away) and again if gentamicin/tobramycin anticipated to exceed 10 days.
Table 1. Antibiotic Protocol for Confirmed Pathogen Peritonitis
|Antibiotic Protocol for Confirmed Pathogen Peritonitis |
|Specific to|Coagulase Negative Staphylococcus & Streptococci |Enterococcus |
|Organism |Cefazolin 1,000 mg IP daily (1,500 mg if weight 50-100 kg or|Vancomycin Vancomycin 1,000 mg IP every 5 days (1,500 mg if weight |
|Treatment |2,000 mg if weight greater than 100 kg) |50-100 kg or 2,000 mg if eight greater than 100 kg) |
|should be |If Cephalosporin Allergy or MRSA: Vancomycin 1,000 mg IP |Alternative: Ampicillin 125 mg/L every exchange (Continuous dosing |
|based on |every 5 days (1,500 mg if weight 50-100 kg or 2,000 mg if |only) |
|culture and|eight greater than 100 kg) |Treatment duration: 3 weeks |
|sensitivity|Treatment duration: 2 weeks | |
|results | | |
| |Staphylococcus aureus |Pseudomonas Aeruginosa |
| |Cefazolin 1,000 mg IP daily (1,500 mg if weight 50-100 kg or|Difficult to eradicate. May require catheter removal. |
| |2,000 mg if weight greater than 100 kg) |Double coverage based on sensitivities |
| |If Cephalosporins Allergy: |Ceftazidime 1,500 mg IP daily (1,000 mg if weight less than 50 kg) +|
| |Vancomycin 1,000 mg IP every 5 days (1,500 mg if weight |Ciprofloxacin 500 mg PO bid (if sensitive) |
| |50-100 kg or 2,000 mg if eight greater than 100 kg) |Given duration of therapy, Gentamicin/Tobramycin should be avoided |
| |Treatment duration: 3 weeks (4 weeks for bacteremia) |due to risk of vestibular/ototoxicity. However, if required, give |
| | |Gentamicin/Tobramycin 60 mg IP once daily (40 mg if less than 50 |
| | |kg). |
| | |Treatment duration: 3 weeks or more |
| |MRSA |Stenotrophomonas Maltophilia |
| |Vancomycin 1,000 mg IP every 5 days (1,500 mg if weight |Difficult to eradicate. May require catheter removal |
| |50-100 kg or 2,000 mg if eight greater than 100 kg) |Double coverage based on sensitivities |
| |Treatment duration: at least 3 weeks (4 weeks for bacteremia)|Trimethoprim/Sulfamethoxazole (Consider higher dose†) + |
| | |Ciprofloxacin 500 mg po bid |
| | |[Ceftazidime 1,500 mg IP daily (1,000 mg if weight less than 50 kg) |
| | |may be used if susceptible] |
| | |† To provide approximately 5 mg/kg/day of trimethoprim component |
| | |(i.e. 1 DS tab PO bid for 75 kg person) |
| | |Treatment duration: 3 weeks or more |
| |Gram Negative (Klebsiella, E coli, Proteus) |Culture Negative |
| |Adjust antibiotics based on sensitivities. |Continue gram positive coverage (Cefazolin or Vancomycin) |
| |Preferred: Ceftazidime 1,500 g IP daily (1,000 mg if weight |Discontinue Gentamicin/Tobramycin (if used for empiric therapy); |
| |less than 50 kg) |Change gram negative coverage to |
| |Alternative: Cefazolin 1000 mg IP daily (1,500 mg if weight |Ceftazidime 1,500 mg IP daily (1,000 mg if weight less than 50 kg) |
| |50-100 kg or 2,000 mg if weight greater than 100 kg) |Treatment duration: 2 weeks |
| |or | |
| |Ciprofloxacin 500 mg PO BID may be used if susceptible. | |
| |Given duration of therapy, Gentamicin/Tobramycin should be | |
| |avoided due to risk of vestibular/ototoxicity. However, if | |
| |required, give Gentamicin/Tobramycin 60 mg IP once daily (40 | |
| |mg if less than 50 kg) | |
| |Treatment duration: 3 weeks | |
| |Fungal/Yeast/Mycobacteria |Polymicrobial |
| |Catheter removal. Systemic antifungal treatment based on |Consider bowel perforation until proven otherwise and suggest CT |
| |sensitivities. |scan & surgical consult |
| | |Adjust antibiotics based on sensitivities. |
| | |Given duration of therapy Gentamicin, Gentamicin/Tobramycin should |
| | |be avoided due to risk of vestibular/ototoxicity. However, if |
| | |required, give Gentamicin/Tobramycin 60 mg IP once daily (40 mg if |
| | |less than 50 kg) |
| | |Treatment duration: 3 weeks or more |
Table 2. Compatibilities of Antibiotics with Dianeal Peritoneal Dialysis (PD) Solutions. Antibiotic not in this table may not be compatible. (Prepare immediately prior to use)
|DRUG |DIANEAL PD SOLUTION |
|Peritoneal Dialysis, Home Hemodialysis, Hemodialysis |Darbepoetin alfa 0.45 mcg/kg every week |
| |OR |
| |Darbepoetin alfa 0.9 mcg/kg every 2 weeks |
| |OR |
| |Epoetin alfa 100 units/kg every week |
• Subsequent ESA dose based on Nephrology Anemia Management ESA Protocol -See Appendix C-F.
• Consider initial ESA hyporesponsiveness if there is no increase in hgb concentration from baseline after the first 12 weeks of ESA treatment on appropriate weight-based dose titration. Avoid repeated escalations in ESA dose beyond double the initial weight-based dose.
• Consider subsequent ESA hyporesponsiveness if after treatment at stable doses of ESA, they require 2 increases in ESA, doses up to 50% beyond the dose at which they had been stable. Avoid repeated escalations in ESA dose beyond double the dose at which they have been stable.
• Assess reasons for ESA hyporesponsiveness - see Appendix G.
The following are available on line:
CC 50-003 Appendix A - ESA Dosage Adjustment Table
CC 50-003 Appendix B - ESA Dosage Interval Adjustment Table
CC 50-003 Appendix C - ESA Hyporesponsiveness Flow Chart
CC 50-003 Appendix D - Hgb ESA Algorithm Page 1 Assess Hgb Status - Nephrology Anemia Management ESA Protocol - 6 Week Cycle
CC 50-003 Appendix E - IV Iron Algorithm Page 2 Assess Hgb Status - Nephrology Anemia Management ESA Protocol - IV Iron
CC 50-003 Appendix F - Oral Iron Algorithm Page 3 Assess Hgb Status - Nephrology Anemia Management ESA Protocol - Oral Iron
CC 50-003 Appendix G - Hgb ESA Assess Hgb Status - Nephrology Anemia Management ESA Protocol - 4 Week Cycle - Home Hemodialysis
1. Pre-Printed Physician Order
PPO0491 MR Iron Therapy- Nephrology:
2015%20%20Iron%20Therapy.pdf
PPO0399 MR Erythropoiesis Stimulation Agents (ESA):
015%20Erythropoiesis%20Stimulating%20Agent%20ESA_0.pdf
2. Patient Education Pamphlets
Erythropoiesis Stimulation Agent Therapy and Chronic Kidney Disease WQ85-1493 November 2013
Oral Irons and Chronic Kidney Disease WQ85-1469 November 2013
Injectable Iron and Chronic Kidney Disease WQ85-1495 November 2013
Bone and Mineral Metabolism
As kidney function declines, especially to GFR less than 30 ml/min, increasing abnormalities in mineral metabolism are seen. Disorders of calcium, phosphorus and vitamin D metabolism lead to over stimulation of the parathyroid glands resulting in excessive secretion of PTH. Abnormalities of mineral metabolism lead to changes in bone structure and function resulting in bone abnormalities. Mineral abnormalities and bone abnormalities are thought to lead to extra skeletal calcification of the vasculature. All three of these processes are interrelated and are responsible for significant morbidity and mortality in patients with CKD.
CKD-MBD (Chronic Kidney Disease – Mineral Bone Disease) is a systemic disorder of mineral and bone metabolism due to CKD manifested by either one or a combination of the following:
– Laboratory abnormalities (of calcium, phosphorus, PTH, or vitamin D metabolism)
– Bone disease (abnormalities in bone turnover, mineralization, volume, linear growth, or strength)
– Vascular or other soft tissue calcification
Laboratory Abnormalities
Overview of Secondary Hyperparathyroidism (SHPT)
The three major factors leading to secondary HPT in patients with CKD are hypocalcemia, hyperphosphatemia, and decreased active vitamin D production. Structural changes in the parathyroid glands (hyperplasia) and functional abnormalities (higher levels of calcium are required to suppress PTH) further increase production and release of PTH. Chronically high levels of PTH lead to bone disease and extra skeletal calcification.
Hypocalcemia
Hypocalcemia occurs due to multiple interrelated factors. Phosphate retention interferes with the production of active vitamin D. Deficiency of active vitamin D causes decreased intestinal absorption of calcium and impairs the calcemic action of PTH on bone. Since calcium levels are an important regulator of PTH secretion from the parathyroid glands, phosphate retention and vitamin D deficiency ultimately lead to increased secretion of PTH through their effect on decreasing calcium levels.
Hyperphosphatemia
In early CKD, phosphate retention by the kidneys leads to transiently higher phosphorus levels which decrease the blood levels of calcium, which then stimulates PTH secretion. Phosphorus retention does not result in hyperphosphatemia in early CKD, because PTH increases the excretion of phosphate in the urine and returns serum phosphorus and calcium levels to normal.
This normalization of phosphorus occurs, however, at the expense of a higher prevailing blood level of PTH. Elevated PTH levels not elevated phosphorus levels, are the earliest marker of abnormal bone mineral metabolism. Phosphate retention interferes with adequate kidney production of active vitamin D. Vitamin D deficiency develops causing decreased intestinal absorption of calcium and skeletal resistance to the calcemic action of PTH. Vitamin D resistance also occurs. The overall result is hypocalcemia which allows increased PTH secretion. As kidney function declines, the kidneys become less able to maintain phosphorus by increasing renal excretion. Hyperphosphatemia becomes evident in patients with CKD stage 4 and worsens as GFR declines. In addition to an indirect effect on PTH levels via vitamin D and hypocalcemia, hyperphosphatemia can increase PTH levels through a direct effect on the parathyroid gland. Higher levels of phosphorus may also directly affect the function of the parathyroid glands by inducing hyperplasia.
Decreased Active Vitamin D Production
Many patients with CKD lack 25(OH)D3 the precursor for active vitamin D. Lack of precursor makes it difficult for the kidney to make active vitamin D even if it is still functionally capable in earlier stages of CKD. Vitamin D resistance develops early in CKD due to a decrease in the number of vitamin D receptors (VDRs) in bone, intestine, and parathyroid gland. Normally the kidneys would make more active vitamin D to fulfill the increased need. However, phosphate retention likely interferes with vitamin D activation in the kidney and a relative deficiency of active vitamin D develops. As CKD progresses, the kidneys become less able to convert 25(OH)D3 to the active form, 1,25(OH)2D3, also called calcitriol.
Low serum levels of active vitamin D result in decreased absorption of calcium from the intestine. Also, there is skeletal resistance to the calcium-mobilizing action of PTH likely due to deficiency of active vitamin D. Less calcium is therefore available to bind to the calcium-sensing receptor (CaSR) on the parathyroid cells resulting in increased release of PTH. Activated vitamin D directly inhibits PTH production by binding to the vitamin D receptor on the nucleus in the chief cells of the parathyroid glands. Fewer vitamin D receptors and lower levels of active vitamin D in CKD allow higher PTH levels.
Changes in the Parathyroid Gland
The constant stimulation of the parathyroid glands by elevated phosphorus levels and decreased calcium levels, together with decreased active vitamin D and fewer VDRs, causes an increase in the number of cells in the gland. This hyperplasia leads to the increased production of PTH because PTH secretion correlates to the size of the gland. A decline in the number of CaRs on the parathyroid cells results in a decrease in the sensitivity of the parathyroid glands to calcium levels. A higher level of serum calcium (a higher set point) is needed to suppress secretion of PTH compared to normal subjects.
Laboratory Investigations: Routine bloodwork is ordered according to the Admission Hemodialysis Orders, this includes:
1. Every 6 weeks: Calcium, phosphorus, albumin. PTH ordered if on Vitamin D Analogue or cinacalcet (Sensipar®).
2. Every 3 months: PTH (unless on Vitamin D Analogue or cinacalcet, as above)
|Target |Serum Calcium |Serum Phosphate |iPTH |
|CSN 2006 Hemodialysis |Normal range |Normal range |10.6 - 53 pmol/L |
| |2.2 – 2.6 mmol/L |0.78 – 1.53 mmol/L | |
Notes:
• For our dialysis patients we use corrected calcium (for albumin). In certain circumstances, ionized calcium may be indicated.
• We do not routinely order vitamin D levels. Manufacturers of Vitamin D Analogues specify not to use other Vitamin D products or derivatives concomitantly.
Treatment:
Renal Dietitians obtain diet histories and provide assessments for diet and phosphate binder therapy. Vitamin D Analogues and cinacalcet (Sensipar®) are prescribed according to the Pathway for the Management of Elevated Parathyroid Hormone Levels in Dialysis Patients.
Phosphate Binders:
1. Calcium carbonate (chewable = Tums®, tablets = Caltrate® or other):
Specify strength of tablets® (elemental calcium per tablet): Regular strength Tums® (200 mg), extra strength Tums® (300 mg), and ultra-strength Tums® (400 mg), or specify elemental calcium dose for other calcium tablets.
• Starting Dose: Tums® Regular Strength 1 tablet PO TID with meals.
• Maximum daily dose of elemental calcium: 1500 mg.
2. Sevelamer (Renagel ®):
Tablet strength: 800 mg
• Starting dose usually sevelamer 800 mg PO TID.
• Maximum daily dose = 2400 mg PO TID.
Fill out exception status form for NS Pharmacare patients. Renassist Program available (patients with private insurance).
Approx. cost of sevelamer 800 mg PO TID= $150 monthly
3. Lanthanum (Fosrenal®):
Tablet strengths: 250 mg, 500 mg, 750 mg, or 1000 mg
• Starting dose usually lanthanum 500-750 mg PO TID.
• Maximum daily dose 1000 mg PO TID.
Fill out exception status form for NS Pharmacare patients.
Approx. cost of lanthanum 500 mg PO TID = $200 monthly
4. Magnesium hydroxide (Milk of Magnesia®):
Tablet strength: 311 mg of magnesium hydroxide (130 mg elemental magnesium)
Solution strength: 80 mg magnesium hydroxide per mL (33 mg of elemental magnesium).
• Starting dose is magnesium hydroxide 311 mg PO daily or 400 mg magnesium hydroxide suspension (5 mL)
Vitamin D Analogues:
5. Alfacalcidol (One-Alpha®): Tablets and drops available.
Each capsule contains 0.25 mcg or 1 mcg alfacalcidol. Liquid drops contain 2mcg per mL.
• Starting dose is 0.25 mcg PO three times weekly (or daily)
• Titrate q6-12 weeks. Maximum doses are usually limited by serum calcium and phosphate.
Approx. cost of alfacalcidol 0.25 mcg PO daily (starting dose) = $15 monthly
6. Calcitriol (Rocaltrol®)
Each capsule contains 0.25 mcg or 0.5 mcg calcitriol
• Calcitriol has been activated by the liver ( consider in patients with hepatic dysfunction.
• Starting dose is 0.25 mcg PO three times weekly (or daily)
• Titrate q6-12 weeks. Maximum doses are usually limited by serum calcium and phosphate.
Approx. cost of calcitriol 0.25 mcg PO daily (starting dose) = $45 monthly
7. Calcitriol (Calcijex®)
Injection strengths are 1 mcg or 2 mcg per mL
• Starting dose is 0.5 mcg IV three times weekly. Increase dose by 0.25-0.5 mcg every 2-4 weeks.
Approx. cost of calcitriol 0.5 mcg IV three times weekly (starting dose) = $80 monthly
Calcimimetic:
8. Cinacalcet (Sensipar®):
Tablet strengths: 30 mg, 60 mg, or 90 mg.
• Starting dose is 30 mg PO daily. * must be taken at least 12 hours prior to drawing PTH level.
• Titrate to maximum dose 180 mg PO daily.
Fill out exception status form for NS Pharmacare patients. Sensipar AIDe Program available (all patients)
Consult Renal Pharmacist for initiation and monitoring.
Approx. cost of cinacalcet 30 mg PO daily (starting dose) = $330 monthly
Prescribing criteria for cinacalcet:
Not responding to optimal doses of Vitamin D analogues or phosphate binders (calcium or non-calcium based) AND one of the following:
a. Patient does not respond adequately, cannot take, or is intolerant to Vitamin D analogues and Phosphate Binders.
b. Patient is either not a surgical candidate, has been waitlisted for parathyroidectomy (requires “bridge therapy”), or is awaiting kidney transplant.
c. Patient is symptomatic due to hyperparathyroidism (ie bone pain, itching, myalgia, profound neuropathy).
Helpful online resource:
The Following are available on line:
1. Pathway for the Management of Elevated Parathyroid Hormone. See page 55
2. Assistance Program Enrollment Forms:
Renassist Plus Enrollment Form
Sensipar AIDe Program Enrollment Form
C. Patient Education Pamphlets:
Renagel® (Sevelamer) and hemodialysis WQ85-1464 October 2012
Fosrenol® (Lanthanum) and hemodialysis WQ85-1466 October 2012
One-Alpha® (Alfacalcidol) and hemodialysis WQ85-1470 October 2012
Sensipar® (Cinacalcet) to treat secondary hyperparathyroidism in chronic kidney disease WQ85-1465 October 2012
[pic]
Calcific Uremic Arteriolopathy (calciphylaxis)
Calciphylaxis is a rare, but devastating complication of CKD-MBD which is characterized by areas of painful, ischemic necrosis that can develop on areas with maximum adipose tissue. These areas can progress to ulcers, which often become infected. Risk factors for calciphylaxis include hyperphosphatemia, hypercalcemia, hyperparathyroidism, and medications including calcium based phosphate binders, vitamin D, and warfarin. The clinical diagnosis of calciphylaxis can be confirmed with skin biopsy or radionuclide bone scan. Calciphylaxis carries a high mortality risk and requires multiple interventions: intensifying dialysis, reducing calcium and phosphate levels, chemical or surgical parathyroidectomy, stopping medications that increase risk of calciphylaxis (including calcium based binders, vitamin D, and warfarin), cinacalcet, bisphosphonates, hyperbaric oxygen, and sodium thiosulfate.
Sodium thiosulfate (STS): an old drug used for cyanide poisoning. Many case reports support using parenteral STS for the treatment of calciphylaxes based on clinical improvement. Although the mechanism of action in calciphylaxis is unclear, it is postulated STS chelates calcium from precipitates in the body, which results in a soluble calcium thiosulfate salt that can be removed by dialysis. STS also may have antioxidant activity.
STS Dosage: Start STS 12.5-25 g IV 3 times weekly (after dialysis) for a minimum duration of 3 months. Although duration of therapy can extend well beyond 3 months, given the high cost of IV STS (approximately $282 per dose), it is reasonable to consider stepping down to oral therapy when the lesions have healed. A bone scan is required prior to step down to oral therapy (repeat after 6 months). There are significant cost savings with compounded oral capsules: STS 600 mg PO TID ( 1 month supply is approx. $45.
Notes:
Consult NSHA IV Manual for STS monograph:
and the policy developed by the Renal Program for IV to Oral stepdown of STS.
Contact Dr. Steven Soroka or Dr. Jo-Anne Wilson for follow up on all cases of calciphylaxis.
Immunization
Infections are a significant cause of morbidity and mortality in patients with chronic kidney disease. Patients with end stage renal disease who are undergoing chronic dialysis are in frequent contact with the health care system, which increases risk of exposure to respiratory pathogens. There are rare transmissions of hepatitis B and/or C that may occur during dialysis. In addition to routine immunization, Health Canada recommends patients with chronic kidney disease receive influenza, pneumococcal, and hepatitis B vaccines:
1. Influenza
Each year, NSHA Occupational Health updates staff on seasonal influenza vaccine information. There are Flu Champions who provide vaccinations for patients and staff. Patients are screened annually.
Type of vaccine: non-replicating, subunit, proteins.
2. Pneumococcal
Pneumococcal vaccine screening occurs for all new dialysis patients. All patients with chronic kidney disease require 2 doses of pneumococcal polysaccharide vaccine (Pneumovax®23), 5 years apart. If patients are immunocompromised, they also require pneumococcal conjugate vaccination (Prevnar®13).
Type of vaccine: Pneumovax®23 = non-replicating, subunit, polysaccharide.
Type of vaccine: Prevnar®13 = non-replicating, subunit, polysaccharide, conjugate.
Timing of Pneumococcal vaccines:
a. All patients with chronic kidney disease:
Pneumovax®23 Pneumovax®23[pic]
5 years
b. Immunocompromised patients only:
[pic]
[pic]
Note: PPSV23 = Pneumovax®23, PCV13 = Prevnar®13
PPO0397 Pneumococcal, Influenza and Tdap Vaccination: (WM).pdf
3. Hepatitis B
Patients with chronic kidney disease or on chronic dialysis are screened for hepatitis B. Hepatitis B Surface Antigen (HBsAg) is detected in acute or chronic hepatitis B infections. Hepatitis B surface antibody (HBsAb) titres greater than 12 million units/mL indicate recovery and immunity from hepatitis B infection or successful protection from vaccination against hepatitis B. Chronic kidney disease patients are screened at baseline then have HBsAg and HBsAb drawn yearly after the immunization series is completed.
Type of vaccine: Recombivax®= non-replicating, subunit, recombinant hepatitis B vaccine.
HBsAg negative patients: HBsAb titres are less than 12 million units/mL
Give first series: hepatitis B vaccine recombinant (preservative free) 40 mcg IM (deltoid) as a series of 3 doses: 0, 1, and 6 months.
Note: Patients with CKD receive a higher dose of Recombivax® than the general population.
After 1st series, if HBsAb still negative
Give second series: hepatitis B vaccine recombinant (preservative free) 40 mcg IM (deltoid) as a series of 3 doses: 0, 1, and 6 months.
After 2nd series, if HBsAb still negative
No further vaccine required
If HBsAb titre drops to less than 12 million units/mL after previously documented seroconversion
Give booster hepatitis B vaccine recombinant (preservative free) 40 mcg IM (deltoid)
Note: One time only
Helpful links:
NSHA Occupational Health’s Flu Campaign:
CDC 2012 Guidelines for Vaccinating Kidney Dialysis Patients and Patients with Chronic Kidney Disease:
Canadian Immunization Guide. Part 3: Vaccination of
Appendix
A. PPO0513 Hepatitis B Immunization for Dialysis or Pre Dialysis patients (CrCl less than 30mL/min)and Age Less Than 65 years or a Transplant Candidate):
B. PPM0513MR Hepatitis B Immunization (Medication Records –Titres and Vaccine Administration)
Patient Education Pamphlets
NSHA: Hepatitis B Vaccine and Kidney Disease WQ 85 1425 December 2011
Nova Scotia Department of Health and Wellness:
Important Information about Influenza and Influenza Vaccine
Important Information about Hepatitis B and Hepatitis B Vaccine
Important Information about Pneumococcal Disease and Pneumococcal Conjugate Vaccine
Important -Information about Pneumonia and Pneumococcal Polysaccharide Vaccine
Link:
Management of Toxic Ingestions
All poisonings should be managed with the supervision of Renal Fellow and staff Nephrologist.
Hemodialysis
• For solutes that have low MW, not protein bound, water soluble
• Concurrent: renal failure, acid-base disturbance, electrolyte or volume abnormality correctable by dialysis
• Requires vascular access and anticoagulation
Methanol
• Industrial solvent/ windshield washer fluid, antifreeze
• T1/2 variable: 12-20 hours, minimum lethal dose 50-100 ml
• Metabolism – oxidation to 1) formaldehyde and 2) formic acid
• Clinical manifestations
Early Stage (< 6 hrs): non-specific, mild or transient: inebriation, drowsiness
Delayed Stage (6-30 hrs): Vertigo/N/V abdominal pain
• Restless, dyspneic (Kussmaul breathing)
• Blurred vision (papilledema, disc hyperemia) → blindness
• Seizures, opisthotonus, coma → death
• Lab findings: AGMA, osmolar gap, ↑ formate level, ↑ lactate level, ↑ amylase (pancreatitis)
• Toxic levels: >10mmol/L (50 mg% or 500 mg/L)
ANY level with anion gap metabolic acidosis requires aggressive therapy
• 4 ml methanol has caused blindness - 15 ml of methanol can be lethal
• Metabolized by alcohol dehydrogenase - has lower affinity for methanol than ethanol.
• Metabolized into formic acid - causes the large anion gap metabolic acidosis.
• Prognosis dependant on amount of methanol metabolized and determined by the time between ingestion and treatment, the amount of ethanol on board, the degree of acidosis and the extent of the visual disturbance.
• Diagnosis is usually made by history and biochemical landmarks. An anion gap metabolic acidosis with an osmolar gap between measured and calculated osmolality is classic (calculated osmolality = Na x 2 + urea + glucose). The difference represents the mosmoles of methanol and can be used to guess the level until levels are available.
Management
Hemodialysis and Ethanol or Fomepizole
Ethanol is given as an antidote - orally or by IV. Aim for a blood level of 100 mg% (20-25 mmol/L). The alcohols are distributed across total body water. In some cases Fomepizole has been used without dialysis and usually without Ethanol.
Oral Ethanol
loading dose of 40 gm ethanol. (Absolute or 95% ethanol has SG of 0.8 gm/mL.) This works out to 50 mL of absolute ethanol or 120 mL of 40% ethanol like scotch. The maintenance dose is 12 mL of absolute or 30 mL (1 oz) of whisky per hour with frequent measurements to ensure levels as above.
IV Ethanol
Begin with IV bolus of 0.5 gm ethanol/ Kg
Aim for plasma ethanol concentration of 20-30 Mmol/L
NOTE: Must be diluted to a 15% solution or less to be non toxic. Mix 72 mL absolute ethanol in 500 mL D5W or NS to give a solution of 10 gm/100 mL i.e. 100 gm/L. A 70 Kg man gets 350 mL of this solution or 35 gm. This is followed by a maintenance of 10 gm (100 ml) per hour. Continue infusion even if dialysis is in progress to make up for metabolized ethanol.
Fomepizole
- for acute management of methanol or ethylene glycol intoxication
- Loading dose: 15 mg/kg
- Maintenance: 10 mg/kg q 12 h X 4 doses
- 15 mg/kg q 12 h until M or EG level < 3 mM
- Slow infusion over 30 minutes
- During HD dose every 4 hours
Hemodialysis indicated for serum methanol levels > 10 – 15 Mmol/L or even at lower levels if anion gap metabolic acidosis is present.
Insert long femoral vein catheter (24 cm) and use an F200 (large surface area) dialyzer and dialyze at Qb of 300 or more
Dialysis nurse to add ethanol to dialysate 320 mL of absolute ethanol (95%) to 5L of acid concentrate (this is to avoid blood ethanol from being dialyzed out). Ethanol will not be added to the dialysate if Fomepizole is being used.
Prolonged dialysis often needed. We have a computer program available to estimate likely required duration using initial levels + patient height and weight and dialysis blood pump speed see attached excel sheet – the program will be available on the Nephrology Web site --- add URL.
Continue to dialyze to target methanol level < 5 mmol/L and end of dialysis, using above estimating program.
PD is less effective but may be of some use in those who cannot be hemodialyzed. Add ethanol to the PD fluid.
During dialysis ethanol levels could be checked every 4 hours, but methanol and metabolites are only needed at start/end of dialysis and about 2 hours before estimated end time from estimating formula
Ethylene Glycol
Component of antifreeze and solvents. Dialysis indicated for level > 10 Mmol/L or lower levels with anion gap met acidosis
T 1/2 is 3 hours
Lethal dose ~ 100 mL.
S/S - neurological– drunkenness to coma, tachypnea, pulmonary edema, flank pain and RF
Classically, but not always, crystalluria (needle shaped or envelope shaped crystals)
Management is same as methanol intoxication, i.e. ethanol + dialysis and Fomepizole can also be used.
Lithium
Therapeutic range: 0.4-1.3 mEq/L
Toxic manifestations may appear >1.5 mEq/L
Clinical manifestations:
Acute intoxication: N/V, neuromuscular irritability, coarse tremor, ataxia, slurred speech, confusion, fever, stupor, coma, CV collapse.
Chronic intoxication: polyuria & NDI, renal acidification, defects, CIN, thyromegaly.
Lab manifestations: leukocytosis; ECG: flattened T's, AV blocks, QT prolongation.
Management
Well hemodialyzable
Hemodialysis for 8-12 hours
Indications for Dialysis:
Anyone with Li > 6 mEq/L
Chronic Li therapy with level> 4
Lithium level of 2.5-4 if renal insufficiency, major neuro symptoms, or hemodynamic instability
Lithium level of 1 after 30 hrs
Goal: sustained level 1 meq/L 8 hrs post HD
• Dialyze 8-12 hours and monitor post plasma Li levels q4h for 36 hours
• Monitor for post HD rebound as slow equilibration between extra and intracellular lithium May require repeated HD treatments
Salicylates:
Aspirin, oil of wintergreen (topically)
Minimum lethal dose 10 g ASA; levels useful 6 hrs post ingestion
Acute ingestion: 1 tab/kg = severe (1 tab = 325 mg)
Metabolism – ASA hydrolyzed to salicylic acid → glycinated to salicyluric acid in liver→ excreted via kidneys; urine pH > 7.0 enhances excretion
Clinical manifestations
Chronic ingesters: HA, tinnitus, ↓hearing, dizziness, weakness N/V, ↑RR, confusion
Acute/severe intoxications: above + fever, seizures, coma, ARDS
Acid base disturbances:
Respiratory alkalosis → resp alk + AG metabolic acidosis
Management
Systemic and urine alkalization urine: goal urine PH >7.5
Hemodialysis
Indications: A difficult judgment and each severe case should be carefully considered with the nephrologist. Typical dialysis indications include:
Salicylate level > 7 mmol/L
Seizures/coma
Severe metabolic acidosis, esp. with RF
Non-cardiogenic pulmonary edema
Esp. if elderly, smoker, acute on chronic ingestion
Metformin-Associated Lactic Acidosis:
Following acute overdose or accumulation in a patient on stable dose of Metformin with decreasing renal/liver function/excretion.
Metformin blocks pyruvate dehydrogenase complex with a resulting Type B lactic acidosis in drug accumulation. Often superimposed Type A Lactic acidosis.
Toxic dose not known, but significant risk if >2g/day in setting of renal/liver dysfunction.
Main morbidity is due to metformin-associated lactic acidosis (MALA).
Lactate levels may not become elevated for 6 h after ingestion.
Mortality rate 30-50%
Clinical manifestations:
• Nonspecific: anorexia, somnolence, lethargy, nausea, vomiting, epigastric pain
• Hypotension, hypothermia, respiratory failure, cardiac dysrhythmia
• Hypoglycemia and/or hyperglycemia in severe poisonings
• Elevated lactate, often over 20
Management:
Dextrose gtt if hypoglycaemia
Bicabronate gtt is controversial
Hemodialysis:
Indications:
- Lactate > 15-20
- Severe metabolic acidosis (pH < 7.1)
- Failure to improve with supportive care/bicarbonate
- Associated renal failure (creat > 160, oliguria) or liver failure (INR > 1.5) as unable to clear on own
- Shock
- Decreased LOC
- Fluid overload
- Extended dialysis sessions recommended (CRRT) –some evidence for IHD
Dialysis can be discontinued when Lactate < 3 and pH > 7.35
Be aware of potential for lactate rebound after dialysis discontinued.
Hemoperfusion
Charcoal hemoperfusion may be indicated for the immediate removal of protein-bound and/or lipid-soluble medications such as barbiturates and salicylates. Charcoal hemoperfusion takes advantage of the large adsorption capacity of active carbon for medication removal. At this time, there are no known contraindications for hemoperfusion; however, careful monitoring is required for patients with coagulation disorders.
Hemoperfusion alone can be used for medium to large molecular weight toxins in the presence of intact renal function.
Hemoperfusion in combination with hemodialysis can be used for medium to large molecular weight toxins in the presence of uremia and/or metabolic acidosis.
The decision pertaining to the duration and/or termination of hemoperfusion therapy is determined by the physician based on the individual needs of the patient. In addition to removing toxins, the charcoal may bind certain medications, calcium, glucose and coagulation proteins. Monitoring medication, glucose and calcium levels, as well as, coagulation studies as prescribed.
Standard procedure is to use the charcoal hemoperfusion cartridge in tandem with a high flux, high efficiency hemodialysis filter, with the charcoal first in the arterial circuit.
Increased amounts of heparin are needed to prevent the cartridge from clotting; load with 3000 IU and maintenance 1500 – 2000 IU per hour.
The Adsorba 300 C® cartridge may be used up to 8 hours, alone, or in series with the hemodialysis dialyzer.
Depending on the drug and level, one dialysis session of 5 hours with charcoal and hemodialysis membrane may be enough and levels should be checked to determine if a second dual run is needed or additional dialysis with just a high flux membrane is needed. The high flux hemodialysis membrane will remove many of the drugs on their own.
Antidepressant Therapy for Adult Dialysis Patients
The following table is a support tool and is not all encompassing. To be used at the discretion of the healthcare professional.
|Medications |Starting Dose (SD) |Dialyzed |General: Caution withdrawal(taper gradually |Estimated Monthly $/ |
|Generic |(maximum dose) | |after prolonged use |Pharmacare |
|(Brand) |*Changes in ESRD | |Initial ↑ suicide and possible precipitation of| |
| |ADULT | |hypomania/mania. | |
| |DIALYSIS | | | |
| | | |Common Adverse Effects |Comments | |
|Selective Serotonin Reuptake Inhibitors (SSRI) |
|Citalopram |SD: 10 mg/ day |No |GI: nausea, vomiting, |-QT prolongation, |$25.00 |
|(Celexa) |(40 mg) | |diarrhea, bloating, weight|especially at doses |√ Covered |
|10, 20, 30, 40 mg scored |*max 20 mg in >60 years| |loss (or weight gain), |> 40 mg/day | |
|tabs |old | |constipation |-Fewest drug | |
| |*Active metabolites, | |CNS: agitation , anxiety, |interactions | |
| |use with caution | |insomnia, headache, fine |-Least tremor | |
| | | |tremor, akathisia, | | |
| | | |sedation, fatigue | | |
| | | |CV: orthostatic | | |
| | | |hypotension, dizziness, QT| | |
| | | |prolongation | | |
| | | |Other: sweating, | | |
| | | |anticholinergic, sexual | | |
| | | |dysfunction, SIADH, ↑ risk| | |
| | | |of bruising and bleeding, | | |
| | | |↑ risk fractures | | |
| | | |Rare: serotonin syndrome | | |
| | | | | | |
| | | | | | |
| | | |*Withdrawal symptoms: | | |
| | | |FINISH (flu, insomnia, | | |
| | | |nausea, imbalance, sensory| | |
| | | |changes, hyperactivity) | | |
|Escitalopram |SD: 5 mg/ day |No | |-S enantiomer of |$65.00 |
|(Cipralex) |( 10 mg/ day) | | |Citalopram |× Not a benefit |
|10, 20 mg scored tabs | | | |-Twice as potent as | |
| |*Use with caution | | |citalopram | |
| | | | |-QT prolongation, | |
| | | | |especially at doses | |
| | | | | > 20 mg/day | |
| | | | |-Least sexual | |
| | | | |dysfunction, | |
| | | | |headache, fatigue, | |
| | | | |and tremor | |
|Fluoxetine |SD: 10 mg/ day |No | |Least weight gain |$40.00 |
|(Prozac) |(80 mg/ day) | | |Long half-life (5 |√ Covered |
|10, 20 mg caps, 4 mg/ml |*Long t½, use with | | |week washout) | |
|solution |caution. | | | | |
|Paroxetine |SD: 10 mg/ day |No | |-Most |$30.00 |
|(Paxil) |(30 mg/ day) | | |anticholinergic side|√ Covered |
|IR: 10, 20, 30, 40 mg tabs | | | |effects (caution in | |
|CR: 12.5, 25 mg |*T ½ prolonged. Use | | |the elderly), weight| |
| |with caution. | | |gain, sedation, | |
| | | | |constipation, and | |
| | | | |sexual dysfunction | |
| | | | |-Also used for | |
| | | | |pruritis | |
|Sertraline |SD: 25 mg/ day |No | |-Most diarrhea & |$25.00 |
|(Zoloft) |(200 mg/ day) | | |male sexual |√ Covered |
|25, 50, 100 mg caps |*Active metabolite is | | |dysfunction | |
| |renally excreted, ↑dose| | |-Few drug | |
| |carefully. | | |interactions | |
|Serotonin/Norepinephrine Reuptake Inhibitors (SNRI) |
|Desvenlafaxine ER (Pristiq) |SD: 25 mg/ day |No |GI: nausea, vomiting, |-Less sexual |$110.00 |
|50, 100 mg tabs |(Alternative: 50 mg | |diarrhea, bloating, |dysfunction |× Not a benefit |
| |every 2 days) | |weight loss, |-Ghost tablets | |
| |*Variability in drug | |constipation | | |
| |clearance. | |CNS: agitation, anxiety,| | |
| | | |insomnia, abnormal | | |
| | | |dreams, headache, | | |
| | | |sedation, fatigue, | | |
| | | |tremor, weakness | | |
| | | |CV: ↑ BP (not | | |
| | | |duloxetine), orthostatic| | |
| | | |hypotension, dizziness, | | |
| | | |QT prolongation (not | | |
| | | |duloxetine) | | |
| | | |Other: sweating, | | |
| | | |anticholinergic, SIADH, | | |
| | | |sexual dysfunction, | | |
| | | |blurred vision | | |
| | | |Rare: Serotonin syndrome| | |
|Duloxetine |Avoid |No | |-NS Pharmacare: only|$130.00 |
|(Cymbalta) |*Not recommended in | | |approved for |√ Exception status |
|30, 60 mg caps |product monograph for | | |diabetic neuropathy,|only |
| |patients with ESRD. | | |exception status | |
| | | | |-Also used for | |
| | | | |peripheral | |
| | | | |neuropathy | |
|Venlafaxine XR |SD: 37.5 mg/ day |No | |-Low weight gain |$25.00 |
|(Effexor) |(112.5 mg/ day) | | |-Few drug |√ Covered |
|37.5, 75, 150 mg caps |*Decreased clearance | | |interactions | |
| |and T ½ prolonged. | | |-Also used for | |
| |*Variability in drug | | |peripheral | |
| |clearance | | |neuropathy | |
| | | | |-Caution: withdrawal| |
| | | | |effects | |
|Serotonin Modulators: Serotonin Antagonists/ Reuptake Inhibitor (SARI) |
|Trazodone |SD: 25 mg/ day HS |No |GI: nausea, constipation |-Mostly used for |$20.00 |
|(Desyrel) |(400 mg/ day) | |CNS: sedation, weakness, |sleep |√ Covered |
|50, 75, 100, 150 mg scored |*↑ dose carefully, | |lethargy, fatigue, |-Less cardiac side | |
|tabs |divide dose in the | |headache, agitation, |effects than TCAs | |
| |elderly | |confusion | | |
| |For insomnia, usual | |CV: dizziness, ↓ BP, QT | | |
| |SD: 12.5-25 mg HS | |prolongation | | |
| | | |Other: anticholinergic, | | |
| | | |priapism | | |
| | | |Rare: Serotonin syndrome | | |
|Dual Action Antidepressant: NaSSA ( Mirtazapine) and NDRI (Bupropion) |
|Mirtazapine |SD:7.5 mg/ day |No |GI: constipation |-Also used for |$25.00 |
|(Remeron) |(22.5 mg/ day) | |CNS: fatigue, sedation, |pruritis |√ Covered |
|30 mg scored tabs | | |weakness, headache |-Good choice for | |
|RD: 15, 30, 45 mg tabs |*Increased plasma | |CV: ↑ cholesterol, QT |patients with | |
| |concentrations | |prolongation |insomnia | |
|NaSSA = Noradrenergic/ | | |Other: ↑ appetite, weight|-Less sexual | |
|Specific Serotonergic Agent | | |gain, anticholinergic |dysfunction | |
| | | |Rare: serotonin syndrome,|-Can aggravate | |
| | | |neutropenia |restless legs | |
| | | | |syndrome | |
| | | | |-RD tabs (orally | |
| | | | |disintegrating) | |
| | | | |available | |
|Bupropion SR |SD:100 mg/ day (SR) |No |GI: nausea, vomiting |-Also used for |$25.00 |
|(Wellbutrin) |150 mg/ day (XL) | |constipation |smoking cessation |√ Covered |
|SR: 100, 150 mg tabs, XL: 150,| | |CNS: anxiety, agitation, |-Contraindicated in | |
|300 mg tabs |(150 mg/ day) | |headache, insomnia, |seizure disorders | |
| | | |tremor, ataxia, vivid |-Do not crush or | |
| |*Risk of accumulation | |dreams, paranoia |split | |
|NDRI= Norepinephrine/Dopamine |of toxic metabolites | |CV: tachycardia, |-Less sexual | |
|Reuptake Inhibitor |(can cause | |dizziness |dysfunction, than | |
| |dysrhythmia, wide QRS | |Other: sweating, |SSRI/SNRI | |
| |complex) | |anticholinergic, weight |-Less precipitation | |
| | | |loss, menstrual |of mania | |
| | | |irregularities |-XL formulation = | |
| | | |Rare: ↑ seizure risk |ghost tablets | |
|Tricyclic Antidepressants (TCA): prescribed for neuropathic pain. |
|*Do not use in patients with significant cardiovascular disease, glaucoma, symptomatic prostatic hypertrophy. |
|Nortriptyline |SD: 10 mg/ day HS |No |GI: nausea, vomiting, |-Least hypotensive |$75.00 |
|(Aventyl) |(100 mg/ day) | |diarrhea, constipation |TCA |√ Covered |
|10, 25 mg caps |*Can divide doses at | |CNS: sedation, fatigue, |-Generally better | |
| |higher daily doses | |headache, orthostatic |tolerated TCA | |
| | | |hypotension, dizziness, | | |
| | | |tremor, confusion | | |
| | | |CV: QT prolongation, ↑HR,| | |
| | | |↓BP, palpitations, ECG | | |
| | | |abnormalities | | |
| | | |Other: anticholinergic, | | |
| | | |sweating, ↑appetite, | | |
| | | |weight gain, less sexual| | |
| | | |dysfunction than | | |
| | | |SSRI/SNRI | | |
| | | |Rare: serotonin syndrome,| | |
| | | |SIADH | | |
|Imipramine |SD:10 mg/ day HS |No | | |$45.00 |
|(Tofranil) |(200 mg/ day) | | | |√ Covered |
|10, 25, 50, 75mg tabs |*↑ dose carefully | | | | |
| |*Can divide doses at | | | | |
| |higher daily doses | | | | |
|Amitriptyline |SD:10 mg/ day HS |No | |-Often used for |$25.00 |
|(Elavil) |(150mg/ day) | | |sleep, irritable |√ Covered |
|10, 25, 50, 75 mg tabs |*Can divide doses at | | |bowel disease and & | |
| |higher daily doses | | |chronic pain | |
References: Available upon request.
Prepared by Kayla Richard and Thomas Parker (Pharmacy Students) and the Renal Program Pharmacy Team:
Dr. Jo-Anne Wilson, BScPharm, ACPR, PharmD and Jaclyn Tran, BScPharm, ACPR
Overview of Pruritus
Pruritus is a common complication experienced by ESRD patients and significantly reduces the quality of life. Over 40% of patients undergoing hemodialysis suffer from chronic pruritus. The pathogenesis of chronic kidney disease-associated pruritus is not clearly known.
Differential Diagnosis *adapted from Toronto Notes 2014
S –scabies or lice (infestations)
C –cholestasis
R –renal (see below)
A –autoimmune
T –tumours (malignancy)
C –chemicals ( DRUGS (see below)
H –hematology (polycythemia, lymphoma, leukemia, myeloma)
E –endocrine (thyroid, parathyroid, diabetes)
D –depression and psychosis
Urticaria or fixed drug eruptions: new medications (especially aspirin, antidepressants, and opioids)
Uremia-related causes: xerosis, hemodialysis inadequacy, anemia, and secondary hyperparathyroidism.
Considerations
• Check Ca/Phosphate/PTH
• Heparin allergy (switch to NS flush)
• HD adequacy
• LFTs/TSH/Ferritin
• Change dialyzer
Non-Pharmacologic Treatment:
Skin Hydration
• Use gentle cleansers and moisturizers.
• Apply moisturizing creams or ointments (not lotions) BID after bathing: Glaxal Base®, Uremol® cream, Nivea® cream, and creamy Vaseline®
Bathing
• Avoid hot water, hot tubs, and dry saunas. Use lukewarm water.
• Try a colloidal oatmeal bath or adding 4 tablespoons of baking soda (sodium bicarbonate) to the bath.
Minimize skin irritation
• Use gentle towels for drying.
• Apply topical products by dabbing rather than rubbing.
• Wear loose, cotton clothing rather than woolen or synthetic fabrics.
Minimize scratching
• Fingernails should be trimmed as well to prevent excessive scratching,
Pharmacologic Treatment:
Localized pruritus:
Topical steroids
Note: Use ointment on thick, lichenified lesions; low potency agents are preferred on face and in folds.
• Hydrocortisone 1% cream (low potency)
• Betamethasone valerate 0.1% cream (medium potency)
Apply sparingly BID PRN for 3 months or less.
Capsaicin 0.025% cream
Note: May take 2-4 weeks for onset.
Apply sparingly BID-QID.
Generalized pruritus:
First Generation Oral Antihistamines
Note adverse effects: Drowsiness, anticholinergic side effects, QT prolongation.
• Hydroxyzine
Starting dose: 10mg PO TID PRN. Titrate weekly to a max of 25 mg PO TID.
• Diphenhydramine
Starting dose: 25mg PO BID-TID PRN. Titrate weekly to a maximum of 50 mg PO QID.
Second Generation Oral Antihistamine
Note: Require dosage adjustment
• Desloratadine
Dosage: 5mg PO q48h or 5 mg PO three times weekly, given qHD
• Cetirizine
Dosage: 5mg PO daily or 5 mg PO three times weekly, given qHD
GABA Analogues
Note: consider in patients with neuropathic pain. Likely removed by dialysis (give post HD).
• Gabapentin
Starting dose: 100mg PO daily post-HD. Titrate weekly to a max dose of 300 mg PO HS.
• Pregabalin
Starting dose: 25mg PO once daily post-HD. Titrate weekly to a max dose of 75 mg PO HS.
Refractory pruritus:
Consider dermatology consult for differential diagnosis.
Tricyclic Antidepressant
Note adverse effects: anticholinergic, QT prolongation, ↑ HR, ↓ BP, caution in cardiac disease and seizures.
• Doxepin
Starting dose: 10mg PO qHS PRN. Titrate by 10-25mg weekly to a max dose of 50 mg po qHS.
Restless Leg Syndrome
Adapted from BC Renal Restless Leg Syndrome (RLS) Algorithm in Hemodialysis Patients and RxTx
Restless leg syndrome (RLS) is a condition characterized by an irresistible urgency to move the legs and occurs when resting or lying in bed. It is common and extremely distressing condition experienced by many dialysis patients. RLS should only be managed with pharmacologic therapy if symptoms are significant, impairing quality of sleep and/or quality of life.
Causes
Potential causes/contributing factors of RLS to consider prior to pharmacologic treatment:
• Iron deficiency
• Insomnia
• Family history
• Rheumatoid arthritis or Sjogren’s
• Pregnancy
• Mimic disorders (ie movement disorders, anxiety, neuropathy)
• Drug-related causes:
o dopamine antagonists (ie metoclopramide, antispychotics)
o antidepressants (ie mirtazapine, SSRIs, SNRIs, TCAs)
o other: carbamazepine, lithium, alcohol, caffeine, nicotine
|Non-Pharmacologic Treatment |
|Exercise |Enable patient to move the legs during dialysis. |
| |Encourage exercise 3 times weekly during the daytime. |
|Good sleep hygiene |Avoid napping during the day or at dialysis. |
| |Establish a good sleep environment and schedule. |
|Relaxation |Consider massages. |
|Mental alertness |Try cross word puzzles or card games. |
Pharmacologic Treatment:
|Dopaminergic treatment: |
| |
|*If RLS symptoms occur during HD, give medication prior to HD |
|Levodopa/ carbidopa |Carbidopa blocks the peripheral|Initial dose: 50/12.5mg PO qHS |Levodopa acts fast (~20 mins). |
|Intermittent RLS |breakdown of levodopa . |when needed |CR formulation also available. |
| |Levodopa is converted to |Titrate weekly to max of 200/50mg|AE: hypotension, dizziness, nausea, constipation, |
| |dopamine in the CNS. |per day. |edema. Caution if psychosis. |
| | | |Augmentation can occur. |
|Ropinirole |Dopamine agonist |Initial dose: 0.25mg PO qHS. |Ropinirole and Pramipexole: Take 2 hours prior to HS |
|Persistent RLS | |Titrate by 0.25 mg weekly. |(or HD). |
| | |Max of 3mg daily in RLS. | |
| | |Note: higher doses are used in |Note: pramipexole product monograph does not provide |
| | |Parkinson’s (up to 18mg). |dosing in ESRD. |
| | | | |
| | | |Rotigotine: Very expensive and not covered by NS |
| | | |Pharmacare. No dosage adjustment necessary for renal|
| | | |impairment (including HD) |
| | | | |
| | | |AE: nausea, dizziness, fatigue, edema, insomnia, |
| | | |compulsive behaviour. Less hypotension and |
| | | |augmentation than with levodopa. Caution if |
| | | |psychosis. |
|Pramipexole |Dopamine agonist |Starting dose: 0.125mg PO qHS. | |
|Persistent RLS | |Titrate by 0.125 mg every 1-2 | |
| | |weeks. | |
| | |Max dose of 0.75 mg per day. | |
|Rotigotine |Dopamine agonist |Starting dose: 1mg patch daily | |
|Persistent RLS | |transdermally. | |
| | |Titrate by 1 mg weekly. | |
| | |Max of 3mg patch daily. | |
|If refractory to dopaminergic treatment: |
|Gabapentin |GABA Analogue |Starting dose: 100mg PO qHS. |Consider if also having neuropathic pain or pruritus.|
| | |Titrate (100 mg/week) to a max |AE: drowsiness, dizziness. |
| | |dose of 300 mg per day. | |
|Pregabalin |GABA Analogue |Starting dose: 25mg PO qHS. | |
| | |Titrate (25 mg/week) to a max | |
| | |dose of 75 mg per day. | |
|Other (refractory symptoms): |
|Clonazepam |Benzodiazepine |Starting dose: 0.5 mg PO qHS. |Short term therapy only. |
| | | Titrate (0.5 mg/week) to a max |AE: falls, sedation, dependence/tolerance. |
| | |of 2 mg per day. | |
|Clonidine |Central Alpha Agonist |Starting dose: 0.05 mg PO qHS. |Only if patient is not hypotensive. |
| | | |AE: sedation, dry mouth |
|Renal Adaptation of the WHO 3-STEP Analgesic Ladder ( Barakzoy, 2006; Murtagh, 2006; Salisbury, 2009; Glick, 2011, Castro 2013) |
|WHO 3-STEP Ladder |Analgesic |Recommendation |Adverse Effects |
|Step 1: Mild Pain |Acetaminophen ± Adjuvents |The National Kidney Foundation |Do not exceed 4 g per day to avoid |
| |(Gabapentin doses up to 300 |recommends acetaminophen as the |hepatotoxicity. |
| |mg/day or Pregabalin 100 |non-narcotic analgesic of choice for | |
| |mg/day are considered |mild-to-moderate pain in ESRD. | |
| |generally safe in ESRD) | | |
| |AVOID Non- Steroidal |Topical gels generally considered |Loss of residual renal function, sodium and |
| |Anti-Inflammatory Drugs |safe. Oral agents discouraged in |water retention, hypertension, hyperkalemia, |
| |(NSAIDs) (e.g., Ibuprofen, |patients with residual urine output, |and increased gastrointestinal bleeding risk |
| |Naproxen) |advanced age, or multiple |when compounded by uremic-induced poor |
| | |co-morbidities. |platelet function. |
|Step 2: Moderate Pain |Tramadol |Use with caution. Safer than |Side effects are similar to those of opioids:|
| | |oxycodone, although dose adjustment |nausea, central nervous system (CNS) |
| | |may be necessary due to renal |depression, and constipation. Tramadol may |
| | |clearance. |cause seizures in conditions associated with |
| | | |a lowered seizure threshold. Risk for |
| | | |serotonin syndrome with concomitant |
| | | |serotonergic medications. |
| |Oxycodone |Use with extreme caution. No data |Nausea, CNS depression, and constipation. |
| | |available on dialysis of oxycodone. | |
|Step 3: Severe Pain |Hydromorphone |Use cautiously. Hydromorphone has been|Nausea, CNS depression, and constipation. |
| | |used without adverse effects in |Metabolite accumulation may cause |
| | |dialysis patients, but there are no |neuro-excitation with agitation, confusion |
| | |data concerning dialysis of the |and hallucinations. |
| | |metabolites, and metabolite | |
| | |accumulation is a risk. | |
| |Fentanyl |Recommended. Appears safe, at least |Nausea, CNS depression, and constipation. |
| | |over short periods. It is largely | |
| | |cleared by the liver, and metabolites | |
| | |are inactive. | |
|DO NOT USE Codeine, Morphine, Meperidine, and Propoxyphene: Renally Excreted metabolites can accumulate in CKD causing neurotoxicity. |
Useful References for Drug Dosing in Chronic Kidney Disease
Micromedex
• Available on the Nova Scotia Health Intranet. From the homepage, select Clinical and Administrative Application Links ( Micromedex
• Enter drug name in Main Keyword Search field, then select Drugdex® Evaluation Results, which will lead to comprehensive drug information. Scan to the Dosing Information section for details about dosing for a variety of patient populations, including renal failure and dialysis.
• Information regarding extracorporeal elimination may be found in the Pharmacokinetics section.
• Dialyzability information may also be located in the Toxicology Treatment section.
Tip: press CTRL F and find ‘dialysis’ to quickly locate the information
RxTx (Formerly eTherapeutics/ eCPS)
• Available on the Nova Scotia Health Intranet. From the homepage, select Clinical and Administrative Application Links ( RxTx (formerly eCPS/ eTherapeutics)
• Electronic database includes product monographs from the manufacturers as well as monographs developed by the Canadian Pharmacists Association (CPhA) with general dosing recommendations.
• RxTx includes dosage forms and strengths available in Canada.
Renal Pharmacotherapy
• Golightly LK, et al. Renal Pharmacotherapy: Dosage Adjustments of Medications Eliminated by the Kidneys. Springer, 2013.
• Available online:
• Great resource for dose adjustment in renal dysfunction. Often sites Drug Prescribing in Renal Failure Handbook (see below) plus adds several other sources.
Drug Prescribing in Renal Failure: Dosing Guidelines for Adults and Children
• Aronoff, George R., et al., eds. Drug Prescribing in Renal Failure Dosing Guidelines for Adults and Children. 5th ed. Philadelphia: American College of Physicians, 2007.
• Fifth edition available electronically through the Provincial Hospitals Library Catalogue:
Note: search “Drug Prescribing in Renal Failure”
• Useful for dose reductions, dialyzability data and therapeutic pearls
The Renal Drug Handbook
• Ashley C and Dunleavy A. The Renal Drug Handbook. Fourth Edition. Oxford and New York: Radcliffe Publishing Ltd, 2014.
• There is a PDF of the 3rd edition (2009) available online:
• Provides renal drug dosing information. Also provides information on pharmacokinetics, drug interactions, and administration.
Dialyze-IHD: Dialyzability of Medications in Patients Undergoing Intermittent Hemodialysis
• Maintained by BC Renal and available online free:
• Contains useful information in an easy to use format! Gives bottom line dosing and dialyzability plus background information (molecular weight, excretion, halflife, protein binding, volume of distribution, plasma clearance).
• PDF poster (drug, dosing, dialyzability only) updated in 2013 also available online:
NSHA Central Zone IV Drug Therapy Manual
• Available on the NSHA Central Zone Intranet. From the homepage, select Services Clinical and Administrative Application Links( IV Drug Therapy Manual and search by generic drug name
• Contains basic dosing information and sometimes indicates doses should be administered post-dialysis (an indication of probable extracorporeal elimination). Also contains drug specific minimum volume information.
Dialysis of Drugs
• Handbook produced by the Renal Pharmacy Consultants annually. Current book, poster, and app available for purchase online:
• The 2013 publication is available free online:
• Includes description of determinants of drug dialyzability and dialyzability tables for hemodialysis with conventional and high permeability dialyzers and peritoneal dialysis.
The Sanford guide to antimicrobial therapy
• The e-book is available electronically through the Provincial Hospitals Library Catalogue:
Note: search “Sanford guide”
• Up to date information on infectious syndromes, pathogens, and treatment guidelines.
• Search individual drugs for monographs for drug dosing in renal dysfunction, including peritoneal dialysis, hemodialysis, and CRRT dosing.
Antimicrobial Handbook, 2012 Edition
• Published by the Antimicrobial Agents Subcommittee of the District Drugs & Therapeutics Committee at Nova Scotia Health, Central Zone.
• Available in pdf format on the Nova Scotia Health Intranet. From the homepage, select Services Pharmacy – Intranet ( Pharmacy Department Publications (Antimicrobial Handbook
• Refer to the Antimicrobial Dosing Guidelines section for dosing recommendations based on creatinine clearance/ hemodialysis/ PD/ CRRT
* Currently our antimicrobial handbook is out of date (2012) and drug dose adjustments should be verified in other sources (ie Sanfords). Update coming soon.
Renal Program Phone Numbers and other Phone and Facsimile Numbers
By Building
Centennial Building
6B Ward
Teaching Room – 473-2649
Fax – 473-5660
Phone Numbers – 473-2635
473-2636
473-1178
Room 6042 – 473-5943
Back Office – 473-7229
6B IMCU
Fax – 473-6862
Phone Numbers – 473-5937
473-5938
473-2609
Transplant Coordinators
Janice – Kidney Transplant
Phone – 473-5503
Belinda – Kidney Pancreas Transplant
Phone – 473-2686
Heather – Living Donor Coordinator -
Telehealth Room –
Peritoneal Dialysis Program
Phone – 473-6527
473-6524
Fax – 473-2412
Doctor Room 240
Phone – 473-2298
473-5920
Nurses Room
Phone – 473-1184
473-1185
473-1183
(Ward Aid) 473-5588
Allied Health Room
Access Nurse – Paula Mossop
Phone – 473-6857
Phone – 473-3518
PharmD – Jo-Anne Wilson
Phone – 473-5418
Clinical Pharmacist – Jaclyn Tran
Phone – 473-5025
Pager -1098
Data Entry – Phone – 473-3654
3rd Floor Radiology and Interventional Radiology
Ultrasound – 473 -7405 or 473-5457
Interventional Radiology
473 – 5477
473-7785
473-1859 (direct to MD)
MRI – 473-5506
Nuclear Medicine – 473-7510
Halifax Infirmary Diagnostic Imaging
Ultrasound – 473 -1640
Interventional – 473-5327
473-4244 (direct to MD)
Halifax Infirmary Emergency Department
473-2781
Dickson Building Hemodialysis
Section 6 - Hemodialysis
Phone – 473-2747
473-2755
Fax – 473-2759
Section 6 Conference Room – 473-1175
Dickson Building 6 Floor
Room 616 – Conference Room
Phone – 473-7759
Room 646 – Biomedical Room
Phone – 473-2209
Section 5 and 7
Phone – 473-4017
Section 1-4 – Main Dialysis Room
Phone – 473-5518
473-7544
Fax – 473-3943
Satellite Dialysis Program – 6 West Rm 235
0730-1530 :
Charge Nurse Phone – 473-5284
Fax – 902-425-3803
Unit Clerk Phone – 473-2155
Renal Program Administration
Alicia MacDonald – Assistant
Phone – 473-4160
Fax – 473-7545
Phone – 473-5130
Phone – 473-3967
Phone – 473-5517
Clinical Nurse Educators:
Krista Chaulk-- 473-5868Carolyn Bartol – 473 -4944
Renal Dieticians
Pamela Dill 473-7547 pager: 2504
Anastasia MacAlpine 473-6564 pager: 2725
Tracy Gower 473-7547 pager 2725
Dickson 5th Floor
Physician Offices
Physician Assistant Phone # Pager
Dipchand, Christine 473-5160 2631
Finkle, Neil 473-5160 7868
Hirsch, David 473-4021 2143
Keough-Ryan, Tammy 473-2099 498-4870
Kiberd, Bryce 473-2099 2178
Panek, Roman 473-4021 1224
Poyah, Penny 473-4021 458-3193
Soroka, Steven 473-2099 498-5054
Karthik Tennankore 473-2099 2733
West, Kenneth 473-5543 2188
West, Michael 473-5160 2104
Specialty Nurse Practitioners
David Landry 473 -5641 pager 2405
Marsha Wood 473 – 2095 pager 6003
Sohani Welcher 473 -8413 pager 6004
Assistants
Judy Eisnor (Team Lead): 473-5543
- Assistant to Dr Kenneth West
: 473-4612
- Education Program Administrator
: 473-5160
- Assistant to Dr Neil Finkle, Dr Christine Dipchand, Dr Michael West & Clinical Support to Dr. Ken West
: 473-4021
- Assistant to, Dr David Hirsch, Dr Roman Panek, and Dr Penny Poyah
: 473-2099
- Assistant to Dr Steven Soroka, Dr Bryce Kiberd, Dr. Tammy Keough-Ryan and Dr. Karthik Tennankore
Booking Clerk – Phone – 473-3895
Dickson 4th Floor
Transplant Pod
Phone – 473-4650
Room 4094 – 473-4668
Room 4093 – 473-4661
Room 4092 – 473-4651
Renal Clinic
Registration Desk
Phone – 473-3895
Fax – 473-3974
Clinic Nurses Office
Phone – 473-5244
Fax – 425-4886
Clinic Pod – 473-4670
Ward Clerk Phone Rufina /Small Work Station– 473-3184
Dictation area – 473-1612/473-7251
Research Work Station – 473-7243
Microscope and Urinalysis Room – 473-4630
Room 4114
Renal Clinic Nurses:
PD Access nurse Cindy Everett – 473-7326
Charge Nurse Cindy Douglas – 473-5833
Lori Algee – 473-1543
Susan Betts – 473-5217
Barb Hirtle – 473-5833
Patient Representative Service
Local: 473-2133
Toll-free number: 1-855-799-0990 Email: healthcareexperience@cdha.nshealth.ca
Blood Work Results
Bayers Road Lab Phone: 454-1661
Fax: 454-1667
QEII Lab Phone: 473-2266
Renal IT Support Bethune Building
Systems analyst Niall Sheehy – 473-4464
Dartmouth General Hospital Hemodialysis Unit
Main Phone – 465-8390/465-8392
Charge Nurse: Cindy Kelly
Nova Scotia Satellite Hemodialysis Units
Liverpool
Phone – 354-3174
Fax – 354 - 3383
Berwick
Phone – 538-1297
Fax – 538-3943
Pictou
Phone – 485-2307
Fax – 485-5144
Springhill
Phone – 597-7180 ext. 180
Fax – 597-3017
Truro
Phone – 893-5554 ext. 2403
Fax – 895-5845
Antigonish
Phone – 867-4744
Fax – 867-4158
Dictation Instructions for eScription
Important: Always use your own DictationID even if you are dictating for the attending physician. The system will create your own voice profile based on this ID. If you do not know your ID please call 902-‐473-‐2568.
1. Lift handset and dial 902-‐473-‐5300 or 1-‐888-‐940-‐8088 (long distance)
2 Enter your UserID followed by the # key
3. If you are clinician who dictates for an Attending you will be prompted for the attending PMB#. If you are an Attending Staff you will not be prompted for this number, continue to step 4.
Enter Attending physician PMB# followed by the # key
Important: If you do not know the attending physicians
PMB#, you will not be able to continue
4. Enter your Facility code* followed by the # key
5. Enter Worktype followed by the # key
Enter patients MRN followed by the # key
6. You will hear an intermittent tone -‐ press 2 to begin recording:
Please note you will be in record mode until you interrupt it with a keypad function (see chart at right)
7. When dictation on that chart is complete -‐ press 8 to complete the report – then to continue -‐ repeat steps 3 through 6 or to complete the last report and disconnect press 5 you will hear "goodbye" and may then hang up
When you press 8 to complete your dictation or 5 to complete dictation and disconnect -‐ the system will provide you with a Job ID # -‐ this is a confirmation number assigned to each individual dictated report. You should write down this # as it will be the reference number in the dictation system.
Instead of pressing 8 to complete report then 5 to disconnect, simply press 5 to complete your final report and disconnect. You will be given the Job ID# of the last report dictated and the system will say ‘Good Bye’.
KEYPAD FUNCTIONS
Throughout your dictation you can utilize ANY of the following features by entering the corresponding number to assist you in completing your dictation.
1. PAUSE - Press 1 to put dictation on hold for 15 min.If not resumed before 15 min. is up, the report will be sent through to transcription.
2. RECORD/STOP - Press 2 t begin your dictation
3. SKIPBACK/PLAY - Press 3 for an incremental rewind with automatic playback Press 2 to stop playback
4. FAST FORWARD - Press 4 for an incremental fast forward
5. COMPLETE REPORT/DISCONNECT – Press 5 to complete the last report and disconnect.
6. STAT REPORT - Press 6 any time after you enter worktype # and before you complete the report. The system will confirm that you have indicated that this report is a priority. Priority reports will be transcribed within 24 hours.
7. REWIND - Press 7 for rewind then 3 for playback
8. COMPLET REPORT - Press 8 to complete report or press 5 to complete report and disconnect
9. INTERRUPT REPORT - Press 9 to put correct dictation in “holding pattern.’ You must complete this dictation within 24 hours or the system will automatically end the report.
* Facility Codes
|Description |Facility Codes |
|QEII Health Sciences Centre |1 |
|Dartmouth General Hospital |2 |
|Cobequid Community Health Centre |3 |
|Hants Community Hospital |4 |
|The Nova Scotia Hospital |5 |
|East Coast Forensic Hospital |6 |
|Eastern Shore Memorial Hospital |7 |
|Musquodoboit Valley Memorial Hospital |8 |
|Twin Oaks Memorial Hospital |9 |
|Private Practice |10 |
* WorkTypes to HPF
|WT # |Worktype Name |HPF |
|1 |Operative Report |Operative Reports |
|2 |Discharge Summary Report |Discharge Summary |
|3 |Ambulatory Care Clinic Letter |Ambulatory Care Reports |
|5 |Day Patient Cardiac Catherization |Diagnostic Reports |
|7 |NSCC Consultation Report |Consulation Records |
| |NSCC Gynaecology Disposition Report |Ambulatory Care Reports |
|8 | | |
|9 |NSCC Progress Report |Progress Notes |
|11 |ECFH Court Report |Court Documents |
|21 |Transfer Summary Report |Transfer Reports |
|22 |Death Report |Discharge Summary |
| |Intent to Discharge Summary Report | |
|23 | |Discharge Summary |
|24 |ECFH Discharge Summary |Discharge Summary |
|32 |Assessment Report |Assessment Forms |
| | |DOES NOT FLOW |
|33 |ECFH Criminal Code Review Board | |
|WT # |Worktype Name |HPF |
| | |Ambulatory Care Reports |
|34 |ECFH Clinic Letter | |
| | |Mental Health Progress Note |
|35 |Mental Health Progress Note | |
| | |Ambulatory Care Reports |
|36* |Mental Health Clinic Letter | |
|41 |Inpatient Consultation Report |Consultation Records |
| | |Ambulatory Care Reports |
|42 |Home Visit Consultation | |
| | |Ambulatory Care Reports |
|43 |Telemedicine Consultation | |
|44 |ECFH Risk Assessment |Assessment Forms |
|45 |ECFH Third Party Correspondence |Voice Only |
| |Case Summary/Clinical Review/Chart Review |Ambulatory Care Reports |
|47 | | |
| |Non-‐Invasive Vascular Diagnostics Lab | |
|51 | |Diagnostic Reports |
|52 |Electrophysiology Study |Diagnostic Reports |
|55 |ECFH Assessment |Assessment Forms |
|61 |Emergency / Trauma Report |Trauma Forms |
|63* |Emergency Room Consultation |Consultation Records |
| | |Ambulatory Care Reports |
|66 |Third Party Correspondence | |
| |NSCC Patient Management Conference Note |Ambulatory Care Reports |
|71 | | |
| 92 |NSCC Radiotherapy Completion Report |Ambulatory Care Reports |
| | |Ambulatory Care Reports |
|93 |NSCC Transfer of Care | |
| |NSCC Chart Review/Phone Consultation Report |Ambulatory Care Reports |
|97 | | |
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