381 Appendix I: Fifty Case Reports—Work in Progress AI Case Scenario #44: Poor Catheter Care This somewhat debilitated patient came for placement of permanent access. On removing the dressing covering the Tesio catheters this is what it looks like (Fig. A.44.1). No signs of infection, and the catheter has worked just fine for now al- most one year. Fig. A.43.2. Fig. A.44.1. 382 Access for Dialysis: Surgical and Radiologic Procedures AI Fig. A.45.1. Comments The author thinks it makes common sense for the dialysis unit (may it be the nephrologist, RN, DON, technician) to change/check the catheter dressing, clean the area, including the catheter; sutures should be removed 10-14 days after catheter placement. Case Scenario #45: Malplaced Dual Lumen catheter These two elderly ladies share a few problems in addition to advanced age (Fig. A.45.1-2). Both have left subclavian vein cuffed, tunneled catheters that are nonfunctioning (lady in Fig. A.45.1 also has a gastrostomy feeding tube). Catheter 383 Appendix I: Fifty Case Reports—Work in Progress AI in Figure A.45.1 is a split ash (poorly primed, blood in the red port) (same dialysis unit as cases 43 and 44) and catheter in Figure A.45.2 is an OptiFlow sutured to the wing. The long scar leading up to the exit site suggests some unusual surgical tech- nique at time of placement (Fig. A.45.2). The main problem with these examples is low and poorly positioned exit sites. This suggests inability to access the central vein or in this case being occluded due to sucking against the lateral SVC wall (Fig. A.45.3). Fig. A.45.2. 384 Access for Dialysis: Surgical and Radiologic Procedures AI Comments Much morbidity and suffering would be prevented by paying attention to a few basic principles, and details of the steps for the specific procedure to be performed (skills and knowledge), or is it a matter of attitude? Consider each catheter placement a life saving procedure. Use micropuncture technique, portable ultrasound and fluoroscopy. Also, mark the catheter tract and exit site. The skin moves considerably from supine (head down) to standing, especially in females and obese individuals (see Chapter 5 for catheter placement techniques). Case Scenario #46: Catheter Infection Patient, a 47 year old female, arrives in the office for permanent access place- ment. The only access is a right IJ tunneled (2 cuff) OptiFlow catheter. She has a temperature of 102 F, and has chills and sweatening. On exam there are no forearm cephalic veins, but a possible L upper arm cephalic vein (to be worked up later!) (Fig. A.46.1). She had not dialyzed in five days. The catheter tract is red, somewhat tender (arrow) (Fig. A.46.2). The outer cuff is exposed. Treatment Patient was urgently taken to dialysis treatment, given 1g vancomycin IVPB at completion. Then the catheter was removed; did not require any surgical incision. Infected catheters can usually easily be pulled. One stitch was placed around the tract at x (Fig. A.46.2) to prevent backbleeding. Blood cultures grew Staph aureus. Fig. A.45.3. 385 Appendix I: Fifty Case Reports—Work in Progress AI Fig. A.46.1. Fig. A.46.2. After 48 hours of no fever, clinically improved, wbc = 6.7, a left IJ split ash catheter was placed. A left arm AV access (Fig. A.46.1) is scheduled in 10-14 days. Comments The author strongly advises against suturing the wings to the skin. Only one suture at exit site is needed, tied around catheter and into the groove remaining when the wing is removed, i.e., split ash. To all manufacturers of catheters: Remove the wings? To all surgeons: Do not suture the wing to the skin. Case Scenario #47: Subclavian Vein Catheter Patient (69 year old) with a left subclavian (!!) vein catheter as only access (Fig. A.47.1). There is an old clotted left forearm AV graft. There are scars from previous chest/neck catheters (arrows) (Fig. A.47.2). Duplex shows right IJ open, right sub- clavian vein open. 386 Access for Dialysis: Surgical and Radiologic Procedures AI Fig. A.47.1. Fig. A.47.2. Fig. A.47.3. 387 Appendix I: Fifty Case Reports—Work in Progress AI Solution 1. A right forearm radio-cephalic primary AV fistula was created. The proximal side branch was left intact (arrow) (Fig. A.47.3). 2. A right subclavian vein cuffed, tunneled catheter placed using the micro- puncture technique, portable ultrasound and fluoroscopy (subcutaneous tract drawn in Fig. A.47.2). 3. The left IJ cuffed tunneled catheter was removed. Comments A most burning question remains; why wasn’t her right cephalic vein used in the first place; and how did it survive I.V.’s and blood draws for so long? Case Scenario #48: The Elderly This 94 year old mentally alert man had a right infected IJ catheter removed. After one week (3 sessions) of femoral vein catheter dialysis a left IJ was placed, now working well two weeks later. This visit is for preoperative permanent access place- ment. His main concern was not to be able to have another catheter should this one fail. After discussion with him and family we decide to just keep the current cath- eter. Ten days later he suffered a stroke. Fig. A.48.1. 388 Access for Dialysis: Surgical and Radiologic Procedures AI Comments The management of the elderly with ESRD is challenging and requires much common sense. Factors to be considered include: short survival, severe comorbidity, mental capacity, fragile skin, social and family support. The author initially relies more on temporary cuffed tunneled catheters. Case Scenario #49: Osteomyelitis of Clavicle-Sternal Joint Patient is a 29 year old diabetic on dialysis for 6 months with a percutaneous right IJ catheter as only access. She has a hard lump over the clavicle-sternal joint since ~ 4-6 months after a SCV stick for I.V. access (Fig. A.49.1). She has been on long term I.V. antibiotics (mostly in ICU). She comes for permanent access (will need a PTFE graft). After discussion with referring doctor the left IJ was exchanged with a split ash over a single guidewire technique (Chapter 5, Fig. 5.2). Permanent access will be placed when infection free (negative blood cultures and normal white cell count) and stable off antibiotics for >4 weeks. Comments A native AV fistula would be most desirable in this setting. Patient has no accept- able peripheral veins at this time. Fig. A.49.1. 389 Appendix I: Fifty Case Reports—Work in Progress AI Fig. A.50.1. Case Scenario #50: Malplaced PD Catheter Young girl with poor drainage of PD catheter, the pigtail was lodged in the right upper quadrant (Fig. A.50.1). Solution The old catheter was removed and a new inserted at the periumbilical transrectus (arrow) (see chapter 6 for surgical technique). Comments The below umbilicus midline incision for PD catheter insertion is suboptimal. It also tends to misdirect the pigtail catheter into the right or left side of the abdomen, to be engulfed by the omentum. (Chapter 6). APPENDIX II Access for Dialysis: Surgical and Radiologic Procedures, 2nd ed., edited by Ingemar J.A. Davidson. ©2002 Landes Bioscience. Prescription Drug Administration in ESRD and Dialysis: A Preliminary Guide Mark Durso This brief appendix is a guide to altered drug effects in renal failure patients. It is not meant to be a prescription reference. For specific drug choices and dosing, refer to your institution’s clinical pharmacist. Prescription Drug Administration in ESRD and Dialysis It is important to understand the physiologic and biochemical effects of drugs in patients with renal disease. A decrease in glomerular filtration rate (GFR) associated with ESRD impacts the metabolism and clearance of these drugs. To further com- plicate matters, levels of many drugs are affected by the processes of CAPD or he- modialysis. This chapter will briefly summarize some of the strategies used in determining appropriate dosage and drug monitoring, as well as specific adjust- ments and considerations of many commonly used drugs in a table. Regardless of renal function status, drug concentration is a function of several factors. Bioavailability is the rate and amount of a dose to enter systemic venous circulation to yield the maximum drug concentration in the shortest time. While drugs administered intravenously retain an essentially normal bioavailability in ESRD patients, it is orally administered medications that can be affected at multiple levels in ESRD patients. Drug absorption across gastrointestinal membranes may be reduced or elimi- nated in ESRD. Uremic gastrointestinal symptoms, including nausea and vomiting, may prevent sufficient drug breakdown in the stomach. Enzymatic changes in ure- mia, including those in intestinal epithelia and salivary urea may metabolize drug compounds too early, interfere with acid hydrolysis or chelate active compounds. Gastroparesis lengthens the time a drug remains in the stomach, which delays bioavailability, while diarrhea shortens the intestinal contact time, reducing or elimi- nating absorption by the small bowel. Drugs metabolized or changed by the liver may be impacted by these gastrointes- tinal factors, by diminished compound binding to the plasma protein or by de- creased transformation of the drug on arrival to the liver, resulting in larger amounts of nonmetabolized drug being cleared by the portal system, effectively diminishing potential bioavailability. Drug distribution may be highly variable in ESRD patients. Distribution is the amount of dispersal of drug over a given time, and is a factor of drug amount, plasma concentration and solubility factors. Protein-bound drugs are water soluble, and demonstrate a narrow distribution in the extracellular fluid space. This can be affected by patient fluid status (edema vs dehydration), ascites and muscle wast- ing. Decreased binding of these drugs can occur in ESRD with low albumin [...]... 5-1 0mg q12 1-1 .5mg load 0.2 5-0 .5mg q24 20 0-6 00mg bid 5 0-1 00mg q24 5 0-1 00mg bid 0. 1-0 .6mg bid 1-1 6mg q24 Usual Dose 100 100 100 100 % q24 100 100 % q24 100 100 100 100 75 7 5-1 00 2 5-7 5% q36 100 50% q48 100 100 100 % Usual Dose for GFR 1 0-5 0 ml/min 100 50 50 1 0-2 5% q48 100 3 0-5 0% q96 100 100 100 % Usual Dose for GFR < 10 ml/min AII % Usual Dose for GFR > 50 ml/min 396 Access for Dialysis: Surgical and Radiologic. .. 100 100 100 75 100 100 50 50 25 % Usual Dose for GFR 1 0-5 0 ml/min 100 -measure free levels 100 100 100 50 100 100 25 25 10 % Usual Dose for GFR < 10 ml/min AII % Usual Dose for GFR > 50 ml/min 398 Access for Dialysis: Surgical and Radiologic Procedures Usual Dose 2-1 0mg q24 Brand Name 3 0-6 0mg q 4-6 NR = not recommended Morphine 2-1 0mg q4 5 0-1 00mg q 3-4 Demerol Meperidine Propoxyphene 5mg q6 65mg q 6-8 Hydrocodone... tapered 0.1 5-0 .30 mg/kg bid 5 mg/kg bid 5 mg/kg bid 1 g bid 1-3 mg/kg/d 5 mg/d 15 mg/kg/d over 4h Usual Dose 100 100 100 100 100 100 100 100 100 % Usual Dose for GFR > 50 ml/min 100 100 100 100 100 75 100 100 % Usual Dose for GFR 1 0-5 0 ml/min 100 100 100 100 NR 50 100 100 % Usual Dose for GFR < 10 ml/min Appendix II: Prescription Drug Administration in ESRD and Dialysis 393 AII Zovirax Brand Name CMV... Pravachol Lovastatin Statins (Anti CHO) Drug 50 100 no data 100 100 q4 100 100 100 100 100 % Usual Dose for GFR > 50 ml/min 25 50 avoid 75 100 q 4-6 100 100 100 100 100 % Usual Dose for GFR 1 0-5 0 ml/min avoid 50 avoid 50 100 avoid 100 100 100 100 100 % Usual Dose for GFR < 10 ml/min Appendix II: Prescription Drug Administration in ESRD and Dialysis 397 AII Pepcid Brand Name Cimetidine Lasix Bumex Furosemide... 7.5mg/kg q12 Usual Dose % Usual Dose for GFR 1 0-5 0 ml/min % Usual Dose for GFR < 10 ml/min 100 100 100 100 0. 4-1 .0mg/kg q24 100 100 1g q1 2-2 4 check levels 100 100 100 100 0. 4-1 .0mg/kg q24 100 50 1g q2 4-9 6 check levels 100 100 100 100 0. 4-1 .0mg/kg q48 100 50 1g q 4-7 days check levels CONSIDER DOSING BASED ON DRUG LEVELS AND PHARMACO KINETICS CONSIDER DOSING BASED ON DRUG LEVELS AND PHARMACO KINETICS CONSIDER... 1 0-5 0 no no use GFR 1 0-5 0 no no use GFR 1 0-5 0 50mg 2 5-5 0mg no no no no use GFR 1 0-5 0 use GFR 1 0-5 0 use GFR 1 0-5 0 no no use GFR 1 0-5 0 2 0-2 5 2 5-3 0 no no use GFR 1 0-5 0 use GFR 1 0-5 0 no data no data use GFR 1 0-5 0 no data no data no data no data no data no data no data no data no data no data use GFR 1 0-5 0 use GFR 1 0-5 0 use GFR 1 0-5 0 use GFR 1 0-5 0 use GFR 1 0-5 0 Antifungals Fluconazole Ketoconazole Amphotericin... Diuretics 100 0 mg load 30 0-4 00mg q24 1. 0-1 .6mcg/kg/day 1-2 mg q 8-1 2h 4 0-8 0mg bid 1 0-1 5mg qid Reglan Metoclopramide Gastric Empty 1 5-6 0mg q24 2 0-6 0mg q24 400mg bid or 40 0-8 00mg qhs 15 0-3 00mg qhs 2 0-4 0mg qhs Usual Dose Lansoprazole Omeprazole Prilosec Tagamet Ranitidine Proton Pump Inhib Zantac Famotidine H2 R-A GI Drugs Drug 100 -measure free levels 100 100 100 100 100 100 100 75 50 100 -measure free levels 100 ... Drug 100 q8 100 100 q6 100 q8h 160/800 q12 28 mg/kg q12h 5 mg/kg q8h 100 q12 5 0-7 5 500mg load 250mg q2 4-4 8 Q 8-1 2 2g q 4-8 h q 8-1 2h 160/800 q18 15 mg/kg q2 4-4 8h 5 mg/kg q1 2-2 4h % Usual Dose for GFR 1 0-5 0 ml/min 100 q2 4-4 8 50 500mg load 250mg q48 q24 2g q12h q24h 160/800 q24 6 mg/kg q4 8-9 6h 2.5 mg/kg q24h % Usual Dose for GFR < 10 ml/min AII % Usual Dose for GFR > 50 ml/min 394 Access for Dialysis: Surgical. .. and pharmaco kinetics Consider dosing based on drug levels and pharmaco kinetics Consider dosing based on drug levels and pharmaco kinetics Other ABX Vancomycin levels use gfr . q24 100 100 100 Pravastatin Pravachol 1 0-4 0mg q24 100 100 100 Fluvastatin Lescol 2-1 0mg q24 100 100 100 Simvastatin Zocor 5-4 0mg q24 100 100 100 Atorvastatin Lipitor 1 0-8 0mg q24 100 100 100 Antiplatelet Aspirin. 4 0-8 0mg bid 100 100 100 Bumetanide Bumex 1-2 mg q 8-1 2h 100 100 100 CNS/Endocrine Levothyroxine Synthroid 1. 0-1 .6mcg/kg/day 100 100 100 Phenytoin Dilantin 100 0 mg load 100 -measure 100 -measure 100 -measure 30 0-4 00mg. q8 100 100 100 Amlodipine Norvasc 5mg q24 100 100 100 396 Access for Dialysis: Surgical and Radiologic Procedures AII % Usual Dose % Usual Dose % Usual Dose for GFR for GFR for GFR Drug Brand