A dialysis patient classification system for establishing nurse/patient ratios

In Connecticut, dialysis-related patient classification systems have taken on greater significance as state regulations deemphasize traditional nurse/patient ratios. The patient classification system devised for the Rockville General Hospital End Stage Renal Disease Unit is based on a process-oriented system and addresses both the physiologic and psychologic needs of the patient. Use of the system has provided nurses with a more efficient and effective means of matching patient care needs with daily staffing assignments. This article addresses the development of a patient classification system tool and the validity and reliability studies conducted to test the tool.     

Prolonged unconsciousness in a patient on automated peritoneal dialysis.

A 79-year-old man with end-stage renal disease treated by automated peritoneal dialysis was referred to the emergency department for altered consciousness. The first investigations, including toxicology screening, failed to reveal the precise etiology. The patient was treated for a possible seizure. After the progression of central nervous system depression with bradypnea, the patient was intubated and mechanically ventilated. It appeared later on that he had ingested by mistake one of his wife's medications, baclofen. Baclofen was detected in the blood sampled on admission at a level above the therapeutic range. Baclofen is mainly excreted by the kidney. A short-term administration of low-dose of baclofen is not effectively removed by peritoneal dialysis and may result in prolonged but reversible coma.     

Occult hypoglycemia in a diabetic patient on peritoneal dialysis.

In a patient with diabetes mellitus undergoing icodextrin continuous ambulatory peritoneal dialysis, the interference caused by icodextrin metabolites in bedside glucose analyzers led to an overestimation of capillary glucose levels and the potential for inappropriate therapy. We report this case to raise an awareness of this among emergency care providers who are at the front-line treating diabetes emergencies.     

维持性血液透析患者社区护理探讨

目的 探讨维持性血液透析患者的社区护理对策。方法 采用观察、访谈法连续到病人家中三天，调查31例维持性血液透析患者心理及社会支持状况。结果 87％维持性血液透析患者有焦虑紧张心理，有低水平社会支持的危险。结论 护士对维持性血液透析患者进行一系列社区护理是非常必要的。     

Ertapenem-associated seizures in a peritoneal dialysis patient

OBJECTIVE: To report a case of a patient undergoing peritoneal dialysis who developed refractory seizures after 2 doses of ertapenem. CASE SUMMARY: A 56-year-old white man with end-stage renal disease requiring continuous ambulatory peritoneal dialysis experienced 5 seizures following 2 doses of ertapenem 500 mg given intravenously. The first generalized tonic-clonic seizure occurred 16 hours after the second ertapenem dose and lasted 3 minutes. Three hours after his first seizure, the patient experienced 2 more seizures 15 minutes apart, lasting 3 minutes each. After suffering a fifth seizure, the patient became apneic and pulseless and was not resuscitated, as he had previously requested a "do not resuscitate" status. DISCUSSION: Carbapenem treatment has been associated with simple partial, complex partial, and generalized tonic-clonic seizures, with generalized seizures representing the most frequently occurring type. Safety data from 7 published clinical trials of ertapenem revealed a seizure incidence of 0.18%. To our knowledge, there are no previously published reports of ertapenem neurotoxicity in patients undergoing peritoneal dialysis. Moreover, little information is available regarding the pharmacokinetics of carbapenems in end-stage renal disease. Ertapenem pharmacokinetics were not tested in any patients receiving peritoneal dialysis during published clinical trials. CONCLUSIONS: Our patient experienced 5 seizures, possibly induced by ertapenem, as validated by the Naranjo probability scale. Clinicians administering ertapenem to patients undergoing peritoneal dialysis should use caution, as clinical experience with the agent is limited and pharmacokinetic data are lacking.     

Peritoneal dialysis in the critically ill patient.

The use of peritoneal dialysis on an acute basis is increasing each year. Peritoneal dialysis pulls waste products and excess water out of the blood stream and into dialysate solution in the peritoneal cavity. When patients are unstable hemodynamically, have severe cardiovascular disease, already require peritoneal dialysis, or are small children, peritoneal dialysis is the preferred treatment. Patients may be dialyzed using either a cycler or manual peritoneal dialysis. Patients should be monitored carefully for volume status, bowel status, and infection. Potential complications include problems with access, infection, pain, respiratory status, fluid imbalance, and potassium imbalance. Special consideration should be given to nutritional status because critically ill patients often need increased intake. Drug therapy needs modification because excretion of drugs by the kidney is delayed. Patient and family support is important because of decreased ability to understand, anxiety, loss of control, and change in body image. Treatment termination also may be an issue.     

A single-pass batch dialysis system: an ideal dialysis method for the patient in intensive care with acute renal failure

PURPOSE OF REVIEW: Conventional intermittent hemodialysis and continuous veno-venous hemofiltration are the opposite poles of current treatment modalities for patients with acute renal failure in the intensive care unit. Because both intermittent and continuous renal replacement techniques have several disadvantages, alternative treatment strategies have been developed. This review summarizes relevant information on these new hybrid techniques, and special attention is paid to the use of a single-pass batch dialysis system in the intensive care unit. RECENT FINDINGS: Prospective controlled studies have been published from several centers that use standard dialysis equipment for hybrid techniques, called sustained low-efficiency dialysis or slow extended dialysis. Their common therapeutic aim is to provide an easy-to-perform treatment with reduced solute clearances maintained for prolonged periods of time. These studies have documented that sustained low-efficiency dialysis offers (1) solute removal that is comparable with that obtained with intermittent hemodialysis and continuous veno-venous hemofiltration, even if high substitution fluid rates are used, (2) cardiovascular tolerability like that observed with continuous veno-venous hemofiltration, (3) significantly reduced heparin use in comparison with continuous veno-venous hemofiltration, (4) simple handling and high acceptance by the intensive care unit staff, (5) reduced treatment costs, and (6) the possibility of nocturnal treatments, allowing unrestricted patient access for daytime procedures. SUMMARY: Sustained low-efficiency dialysis is increasingly being used as renal replacement therapy in critically ill patients in the intensive care unit. It combines several advantages of both intermittent and continuous techniques. The procedural simplicity, particularly if single-pass batch dialysis is used, makes it an ideal treatment for patients with renal failure in the intensive care unit.     

Sterile peritonitis in the peritoneal dialysis patient.

Peritonitis is a serious and common problem in the peritoneal dialysis (PD) population. Abdominal pain, fever, and cloudy PD fluid usually heralds the onset of infective peritonitis. However, in up to 20% of cases, no organism is identified. In these situations, diagnosis can be made only by excluding a microbiological cause and performing a cytological examination of the PD fluid to determine the cellular or noncellular constituents. This review examines the differential diagnosis of sterile peritonitis and uses cytological examination to facilitate the appropriate diagnosis.