Key Points
- Stabilize ABCs; begin targeted evaluation without delaying life-saving therapy.
- Use system-specific risk tools to guide testing and disposition.
- Order high-yield tests first; escalate imaging when indicated.
- Start evidence-based initial therapy and reassess frequently.
Algorithm
- Primary survey and vitals; IV access and monitors.
- Focused history/physical; identify red flags and likely etiologies.
- Order system-appropriate labs and imaging (see Investigations).
- Initiate guideline-based empiric therapy (see Pharmacology).
- Reassess response; arrange consultation and definitive management.
Clinical Synopsis & Reasoning
For Hemodialysis Vascular Access Issues Infection Prevention, frame the differential by acuity and pathophysiology, then align diagnostics to the leading hypotheses. Prioritize stabilization while obtaining high‑yield studies such as BMP (Renal/electrolytes), UA ± culture (Hematuria/proteinuria/infection), Renal ultrasound (selected) (Obstruction). Incorporate bedside imaging and targeted labs to define severity and identify complications; synthesize results with clinical trajectory to refine the working diagnosis and disposition needs.
Treatment Strategy & Disposition
Initiate disease‑directed therapy alongside supportive care, titrating to objective response. Pharmacologic options commonly include IV Fluids, Electrolyte repletion. Use validated frameworks (e.g., Access Complications & Actions) to guide escalation and site of care. Address precipitating factors, de‑escalate empiric therapies with data, and arrange follow‑up for monitoring and risk‑factor modification; admit patients with instability, high risk of deterioration, or needs for close monitoring.
Management Notes
Avoid blood draws and BP cuffs on access arm. Rotate cannulation sites.
Epidemiology / Risk Factors
- CKD/AKI, nephrotoxins; obstruction
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|---|---|---|
| BMP | Renal/electrolytes | AKI/lyte changes | |
| UA ± culture | Hematuria/proteinuria/infection | Findings vary | |
| Renal ultrasound (selected) | Obstruction | Hydronephrosis |
Access Complications & Actions
| Issue | Response |
|---|---|
| Infection (catheter) | Remove/replace; antibiotics |
| Thrombosis/stenosis | Angioplasty/thrombectomy |
| Steal syndrome | Vascular consult; DRIL procedure |
| Aneurysm | Surgical evaluation |
| High output heart failure | Evaluate and band if needed |
Pharmacology
| Medication | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| Acetaminophen | Analgesic/antipyretic | Hours | Symptom control as appropriate | Hepatotoxicity (overdose) |
| Ondansetron | 5-HT3 antagonism | Minutes | Antiemesis if needed | QT prolongation |
Prognosis / Complications
- Reversibility by cause; electrolyte/volume complications
Patient Education / Counseling
- Explain red flags and when to seek emergent care.
- Reinforce medication adherence and follow-up plan.
References
- KDOQI Vascular Access Guideline — Link