As you enter the dialysis center, you see your patient, Mr. Barilla, a 44-year-old-male, lying on the ground. Staff at the center tell you he’d just completed his dialysis treatment. He seems confused and reports he’s nauseated and wants to go home and rest. As he’s preparing to get up out of the dialysis chair, he begins to have a seizure, which staff describe as a generalized, tonic-clonic seizure that lasted about three minutes. They help him to the floor and call 9-1-1. Now, they’re reporting that he’s “out of it.”
During your assessment, you find Mr. Barilla to be semi-conscious, responding to tactile stimuli with moaning and withdrawal. As you work to open and clear his airway, you tell your partner that he appears to be postictal. You ask the staff about his past medical history. Looking at his chart, they tell you he’s a new patient with a history of hypertension and diabetes, and that he was recently diagnosed with renal failure.
Understanding Renal Failure
The kidneys are important organs—they work to filter the blood, concentrating the waste products into urine, which is then excreted. As the kidneys filter out waste, they also regulate water and electrolytes, such as potassium and sodium. They secrete erythropoietin, a substance that stimulates the creation of red blood cells, and they also play a role in maintaining blood pressure through the regulation of water and the release of rennin, which functions to facilitate the constriction of blood vessels through the renin-angiotension system. Kidney failure can disrupt all of these systems, which will ultimately affect every system in the body.
Failure of the kidneys, known as renal failure, has a variety of causes, some of which are acute and some that are more chronic in nature. A common acute cause of renal failure is hypoperfusion or shock. Regardless of the cause of shock, decreased perfusion to the kidneys can cause them to fail. Chronic causes include diabetes, hypertension and Lupus. Drugs, such as ibuprofen, naproxen and lithium, can also cause renal failure. When a patient develops renal failure, whatever the cause, they’ll have difficulty—or the complete inability—to perform the functions mentioned above. Maintaining appropriate levels of sodium and potassium in the body is crucial for cardiac function as well as other body functions, including those of the nervous system.
As patients develop renal failure, they’ll begin to show signs of chemical imbalance. Early signs and symptoms may include lethargy, swelling of extremities, abdominal pain and a decrease in urinary frequency. Later signs may include coma, cardiac arrhythmias and, if not treated, death. Diagnosis of renal failure is multifaceted, including evaluation of urine and blood. The treatment is focused on finding the underlying cause of failure.
Patients need to monitor their intake of sodium, potassium and water, and they may also need to modify the medications they take. The kidneys are the primary organ of drug excretion. If they aren’t working appropriately, the body has a decreased ability to eliminate drugs. If this happens, patients may develop toxic levels of their medications. Damage to the kidneys can’t be repaired, but if it’s caught early enough, the disease progression can be slowed. At some point in the disease progression, the renal failure patient will require dialysis.
Dialysis replaces the functions of the kidneys. There are two common versions of dialysis: hemodialysis and peritoneal dialysis. Hemodialysis is completed by running the patient’s blood through a dialysis machine. The process must occur two-to-four times a week and takes several hours.
Patients undergoing hemodialysis will have a fistula placed, commonly in their arms, to allow for repetitive vascular access. You can feel and see the fistula externally. A couple different versions exist, but they all create a point of access to the patient’s vascular system. When you see a fistula in a patient’s arm, you should avoid using that arm for blood pressures or IV placement, as this could damage the fistula. When a patient goes in for hemodialysis, two needles are placed in their fistula—one to take the blood out of the body and the other to return it after dialysis. The blood is pumped past a semi-permeable membrane with a solution, known as dialysate, on the other side of the membrane. The dialysate pulls the waste products across the membrane out of the blood as the blood passes.
The blood is then returned to the body. Peritoneal dialysis uses the patient’s peritoneum as the filtering membrane. The patient will have 2–3L of dialysis fluid placed into their abdomen. As the patient’s blood circulates through the abdomen, waste products are drawn out of the blood across the peritoneal membrane. This process takes about four to five hours. The fluid is then drawn out of the abdomen into a collection bag and discarded.
Complications of Dialysis
Although it’s a necessary process that allows many renal failure patients to survive, dialysis has some complications. After hemodialysis, bleeding from the fistula may be difficult to control; peritoneal dialysis can cause peritonitis and disequilibrium syndrome may occur with either form of dialysis. Because neither hemodialysis nor peritoneal dialysis can regulate exactly the amount of sodium and potassium to remove it from the body, the patient may experience an electrolyte imbalance after dialysis. Disequilibrium syndrome can present with headache, coma and cardiac arrest, and it’s most likely the cause of our patient’s seizure.
In addition, because neither hemodialysis nor peritoneal dialysis can regulate exactly the amount of sodium and potassium to remove it from the body, the patient may experience an electrolyte imbalance after dialysis. This is known as disequilibrium syndrome and can present with confusion, headache, coma and cardiac arrest, and it’s most likely the cause of our patient’s seizure. EMS providers should maintain an open airway and ventilate as necessary.
If the patient is seizing, providers treating them should aim to protect them from injury. Consider contacting ALS for pharmacological intervention. ALS should also be careful with placement of IVs, ensuring they aren’t using the arm with the fistula. When administering medications, remember the patient with renal failure will have a decreased ability to eliminate that drug from their body, which increases the potential for toxic effects. If evaluating cardiac rhythms, changes associated with electrolyte abnormalities may be seen. If the patient is in cardiac arrest, follow current American Heart Association guidelines.
Remember, however, if the arrest was caused by an electrolyte abnormality or pH alteration in the body, chances of successful resuscitation are limited until the underlying cause of the arrest have been corrected. In this situation, providers should transport the patient to a facility with more definitive care. Providers should always be aware that patients with renal failure can present to EMS at any stage of their disease. So treat supportively and be prepared for potential deterioration.