ࡱ>  9<./012345678 }bjbjSS 11P1xx (!& /@2(2227V9t9<0222222$y+pVy:77::V22Ϫ``U`U`U:220`U:0`U`U e H2 L$/T$$ QHH T::`U:::::VV`U::::::::::::::::x :  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 Page 19 Page 19 Page 19 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 Isolated Ultrafiltration Intermittent Hemodialysis SLEDD 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 Page 33 Page 33 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 Standard Solutions Glucose Calcium 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: MondayTuesdayWednesdayThursdayFriday0800Renal Program Rounds****Teaching Seminar*****MOTP M&M Rounds********090010001100Renal Biopsy Rounds 7th floor Pathology*1200Nephrology Fellow Seminars**Weekly Teaching Rounds***Fellow/ House Staff Rounds******1300140015001600MOTP 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 Standing orders have been developed and should be used on all new admissions. Please remember to document allergies on the Physician Order Form. Medication Reconciliation should be completed, reviewed, and signed off by the attending Nephrologist. 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. 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. All orders on inpatients need to be written in the Inpatient Chart. 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. MONDAYTUESDAYWEDNESDAYTHURSDAYFRIDAYN. FinkleP. PoyahT. Keough-RyanS. WelcherAMR. PanekN. FinkleR. PanekS Soroka ADPKD ClinicB. KiberdM. WoodP. PoyahPMD. HirschK. TennankoreD. HirschD. LandryC. DipchandC. DipchandS. SorokaM. West (Fabry)M. WestK. WestD. Clark S. Welcher (Overflow) Patients are referred to Nephrology from various sources, and the request for Nephrology consultation is triaged into Priority 1 Urgent, Priority 2 - Semi Urgent, Priority 3- Routine and Priority 4 Elective Patients, and Priority 5 Elective that may just be a letter sent. When patients are seen within the clinic area, they are usually first seen by either the Licensed Practical Nurse or Registered Nurse who obtain height as well as weight, blood pressure and updated medication lists on the initial and subsequent visits. There is a multidisciplinary team available within the clinic to provide patients and families with support and education. They are as follows: Registered Nurses Provide education and support to patients and families. Provide phone call and follow up and review blood work on certain patients. Provide scheduled group education sessions on Health Promotion and Treatment Options Will provide patient and family education for all new erythropoietin stimulating agent starts. Erythropoietin stimulating agents are covered through the provincial formulary, but a form needs to be filled out to register the patient for this special access program. Additional forms may need to be filled out if the patient requires the ESA to be given by the VON nurse. Renal Dietitian Will see patients at the request of the Nephrologist or specialty Nurse Practitioner. Will also provide on-going telephone or in person counselling and support. The ambulatory care sheet has space to document what dietary counselling and support is needed such as salt restriction, phosphate restriction, etc. Dickson Building Hemodialysis Patients - Pamela Dill 902-473-7547 pager: 2504 Community Dialysis: (Peritoneal, Satellite Hemo and, Halifax Infirmary) - Anastasia MacAlpine MWF 902-473-6564 and (Home Hemo) Tracy Gower TTS 902-473-7547; pager for both is 2725 Inpatients Ruth Plant 902-473-4414 Renal Clinic Laura Brady 902-473-2696 pager: 2511 Dartmouth General Hospital: - Erica Reynolds 902-464-3464 Renal Clinic, Clinical Lead Cindy Douglas Contact person for any issues or concerns for clinic operations Peritoneal Dialysis (PD) Coordinator Cindy Douglas. Responsible for coordinating peritoneal dialysis catheter placement and removal. Consultation form for PD catheter placement or removal should be filled out and sent to Cindy who will coordinate with the surgeons. See the Dialysis Access Section. Vascular Access Nurse Paula Mossop Handles all requests for creation of arteriovenous fistulas. A dialysis access AV Fistula consult sheet should be sent to Paula, who will coordinate this with the surgeons. See the Dialysis Access Section for more details. Renal Pharmacists Will see patients at the request of the renal team. -Examples: medication reviews, vaccination history and administration, allergy assessment, medication counselling and pharmacokinetic monitoring. Will provide in person or telephone support for patient. Is a resource for drug information questions to the Renal team. Jaclyn Tran, Clinical Pharmacist (Monday-Friday) Phone: 902-473-5418, pager: 1098 Jo-Anne Wilson, Clinical Pharmacy Coordinator (Monday-Thursday) 902-473-5418 Nephrology/Transplant Social Work Coverage Nephrology and Transplant Patients with last names A G Amy Fredericks Phone: 473-4043 (Office Centennial Rm. 7-019) Pager: 498-6513 Nephrology and Transplant patients with last names H M Leah Oickle/Carol Miller Phone: 473-4087 (Office Centennial Rm. 7-028) Pager: 458-1092 Nephrology and Transplant Patients with last names N Z Michelle Jensen Phone: 473-3872 (Office Centennial Rm. 7-017) Pager: 498-1157 Social Work Resource Specialist: Kira Kelly Phone: 471-6569 Kidney Donor Patients John Thompson Phone: 473-4056 (Office Centennial Rm. 7-018) Pager: 458-0660 Liver Transplant Patients Wendy Roberts . Phone: 473-7458 (Office Centennial Rm. 6-210) Pager: 458-3238 VG Site Main Social Work Office Phone 473-5180 Fax 473-4429 Please see the contacts table at the end of the manual for the specific details on who to contact. Requests for blood work from outside Labs If the patient has had laboratory or diagnostic imaging done and the results are not available on the chart or within the computer system, the nurses or unit clerk can be asked to phone or request information be faxed to the clinic. Rotations through the clinic If you are doing a clinic rotation, a schedule should be set up so that you know which physician you will be working with on each day you are in clinic. Morning clinics start with the patients arriving at 8:30 am, and should be ready for the physician to see at 9:00 am. Afternoon clinics, the patients are booked to arrive in the clinic at 12:30 pm to be seen by 1:00 pm. However, during peak clinical times in the hospital, parking can be a problem and patients may be late arriving. Please introduce yourself to the clinic staff that will help orientate you to the clinic. If the assigned Nephrologist is not available, ask the other Nephrologist down in the clinic at the time, as they may have new, or interesting return patients for you to see. Nephrology Consult Service Nephrology consults can be requested from all NSHA Central Zone Sites, as well as the IWK. We will see all consults in person at all sites at the QEII HSC. During the day the Nephrologist covering the ward receives outside calls for advice, consultation or transfer. Most consults are faxed to the office, but many times you may be called directly. The expectation is too see each consult within 24 hours, depending on the urgency. An updated list of the consults should be maintained and be signed out on the weekends. Any patients on dialysis in the ICUsS, CCU or IMCU should be reviewed in the morning and the charge nurse in the Halifax Infirmary Hemodialysis Unit should be called to plan which patients may need dialysis 473-5026 or 473-5027 at the HI site and the charge nurse in the Dickson Building Hemodialysis Unit should be called at 473-7544 or 473-5518 to arrange for unit, IMCU or 3A ICU hemodialysis. Options for dialysis in the ICU/CCU/IMCU: CRRT in 3A, 5.1 and 5.2 Indicated for hemodialysis required and the patient is on inotropes. Not for severe hyperK or toxic ingestions. SLED Slow Low Efficient Dialysis hemodialysis for unstable, hypotensive patients. Intermittent Hemodialysis regular 3 to 4 hour treatments. Isolated Ultrafiltration fluid removal only dialysate is in bypass need to order dialyzer, fluid removal target, and anticoagulation. Patients admitted to the Halifax Infirmary (HI) will receive treatment at the HI, and those admitted to the VG site will receive treatment at that site. However, hemodialysis can be done anywhere there is a connection to water, a drain and a plug for the machine. This may require a change on a tap. There are 2 rooms in ER (24 and 25) that can be used for HD, 3 stations in the 3.1 IMCU that are set up for HD. Admitted Chronic hemodialysis patients may return to their routine dialysis shift, but may also be moved to the evening shift to accommodate emergencies. Therefore, these patients should be seen at least once a week to ensure that the orders are kept current. Any new patients to dialysis that are discharged and will be on dialysis as an outpatient need a new patient start package filled out prior to discharge see the inpatient section. If the patient is a chronic dialysis patient then the dialysis unit should place on the inpatient chart a request for information to be sent by fax at discharge. Routine Orders for Dialysis Patients being Discharged from the Hospital This sheet or sticker should be placed on the Inpatient chart of all patients that are chronic dialysis patients. These patients will be receiving HEMODIALYSIS or PERITONEAL DIALYSIS when they are discharged from the hospital. (Please circle) To help with their transition to outpatient treatment, please do the following: Please fax the following to: Dickson Building Hemodialysis: 473-3943 HI Dialysis: 425-3602 Home Dialysis (Satellite Hemodialysis Patients): 473-5598 Dartmouth Dialysis: 465-8398 Peritoneal Dialysis: 473-2412 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 Please ensure that a copy of the discharge summary is sent to the appropriate outpatient dialysis unit which may include: Dickson Centre Unit Dartmouth General Hemodialysis Unit Satellite Hemodialysis Unit Peritoneal Dialysis Unit Thank you, we appreciate your help. Hemodialysis Basics Acute Start Hemodialysis Initial orders CORR form and Co morbidity Index ESA orders IV Iron orders Dialysis Access Dialysis Access Nurse CVC insertion protocols including use of site right machine Initial blood work including what routine blood work for Tx pts Chronic Hemodialysis tPA for CVC Routine blood work and review including the My Nephrology data base Empiric antibiotics for CVC or bacteremia Transonics monitoring of AVFs and AVGs and IR Rounds and Coverage of the Dickson Dialysis Unit Dartmouth General Hospital Dialysis Unit coverage and transfer orders Satellite Hemodialysis Units transfer orders Emergency Hemodialysis Poisoning and Intoxications ICU Dialysis SLEDD CRRT Hemodialysis is the most common modality used for kidney replacement therapy, and within our program there are a number of Hemodialysis Units. The main unit is within the Dickson Building at the Victoria General Site at the QEII HSC. There is also a unit within the Dartmouth General Hospital and several Satellite Units outside of the HRM. The Dickson Unit is open Monday to Saturday and runs three shifts a day 0700 to 2300. Each shift during the day is covered by a group of Nephrologists and a Specialty Nurse Practitioner. MondayTuesdayWednesdayThursdayFridayAM shift 0800 to 1200C Dipchand S Soroka M West R Panek K TennankoreC Dipchand S Soroka M West R Panek K TennankoreC Dipchand S Soroka M West Aft Shift 1200 to 1700B Kiberd T Keough-Ryan K West N Finkle P Poyah B Kiberd T Keough-Ryan K West N Finkle P Poyah B Kiberd T Keough-Ryan K West PM Shift 1700 to 2300On Call Staff and FellowOn Call Staff and FellowOn Call Staff and FellowOn Call Staff and FellowOn Call Staff and FellowMWF 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 pts 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 = pts 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: http://healthforms.cdha.nshealth.ca/sites/default/files/PPO0417MR%20March%2015%202016%20Routine%20Hemodialysis%20Orders.pdf 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 __________ Calcium: (1 mmol (2 mEq) (1.25 mmol (2.5 mEq) (standard)( 1.5 mmol (3 mEq) ( 1.75 mmol (3.5 mEq) Bicarbonate ( Low 29 mM or 2.7 ( Normal 34 mM or 3.2 ( High 41 mM or 3.9 Sodium________ (standard 137) Sodium ramping ___________ Magnesium: ( 0.375 mM ( 0.5 mM ( 0.75 mM (Standard) Dialysate Temperature per patient body temperature max. 36C ___________ Dialysate flow rate___________ mL/min) Anticoagulation: ( Heparin: Loading dose ______ units Infusion date ________ units/h Duration ___________ ( Flushes ( Other ( Danaparoid Protocol ( Argatroban Protocol Code Status ______________ 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: http://healthforms.cdha.nshealth.ca/sites/default/files/PPO0214MR%20Jan%2020%202014%20CRRT%20No%20Anticoagulation%20(critical%20care).pdf PPO 0213 CRRT with Anticoagulation: http://healthforms.cdha.nshealth.ca/sites/default/files/PPO0213MR%20Mar%2016%202011%20Prismaflex%20CRRT%20Orders%20Citrate%20Calcium%20Chloride%20Regional%20Anticoagulation%20(critical%20care).pdf PPO 0106: Admission Hemodialysis Orders: http://healthforms.cdha.nshealth.ca/sites/default/files/PPO0106MR%20Apr%2027%202015%20Admission%20Hemodialysis%20Orders.pdf 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.  INCLUDEPICTURE "https://docs.google.com/drawings/u/0/d/sLX8vuqQzAFhWvR-g4J7-Xg/image?w=240&h=1&rev=1&ac=1" \* MERGEFORMATINET Patient: Allergies: Items preceded by a bullet () are active orders. Items preceded by a checkbox (%) are only to be carried out if checked Code Status ___________________________ This therapy will only be started if the patient will be started on chemotherapy. This therapy will be discontinued if the patient stops chemotherapy. Hemodialysis Treatment % Routine: 6 hours for 1 day, then 8 hours daily for 5 of 6 days (with induction chemotherapy), then 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:_________________________________________________________________ ___________________________ Weight pre and post hemodialysis Blood Pressure pre and post hemodialysis Pulse pre and post hemodialysis Temperature pre and post hemodialysis % 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 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  Prescribers Signature____________________________ Date (yyyy/mm/dd): _____________________________________ Prescribers 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 patients 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 graftideally 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  HYPERLINK "http://healthforms.cdha.nshealth.ca/sites/default/files/CD1173MR.pdf" Consultation AV-Fistula to be completed and faxed to 4732412. 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  HYPERLINK "http://healthforms.cdha.nshealth.ca/sites/default/files/CD0013MR_0.pdf" 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;  HYPERLINK "http://policy.nshealth.ca/Site_Published/DHA9/policy_details.aspx?policyDetails.QueryId.Id=59159" CDHA CC 50-050 Care of the Tunnelled Hemodialysis Central Venous Catheter:  HYPERLINK "http://policy.nshealth.ca/Site_Published/DHA9/document_render.aspx?documentRender.IdType=6&documentRender.GenericField=&documentRender.Id=63952" http://policy.nshealth.ca/Site_Published/DHA9/document_render.aspx?documentRender.IdType=6&documentRender.GenericField=&documentRender.Id=63952  HYPERLINK "http://policy.nshealth.ca/Site_Published/DHA9/policy_details.aspx?policyDetails.QueryId.Id=48705" CDHA CC 50-045 Hemodialysis Access, Dysfunction, Care of using Thrombolytic Therapy - Alteplase: HYPERLINK "http://policy.nshealth.ca/Site_Published/DHA9/document_render.aspx?documentRender.IdType=6&documentRender.GenericField=&documentRender.Id=63956" http://policy.nshealth.ca/Site_Published/DHA9/document_render.aspx?documentRender.IdType=6&documentRender.GenericField=&documentRender.Id=63956  HYPERLINK "http://policy.nshealth.ca/Site_Published/DHA9/policy_details.aspx?policyDetails.QueryId.Id=51984" CDHA CC 50-049 Care of Non-Tunnelled Hemodialysis CVC: http://policy.nshealth.ca/Site_Published/DHA9/document_render.aspx?documentRender.IdType=6&documentRender.GenericField=&documentRender.Id=63954 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. Central line tray for line insertion Standard procedure tray Drapes - disposable split sheet Spd, sterile towels and bowls Gloves - sterile assorted sizes: 6, 6.5, 7, 7.5, 8, 8.5. Gowns - disposable, sterile Surgical caps Mask with ear loops Disposable scalpelssize 10 , 11 Scalpel blades 10, 11, 12, 15 IV catheters assorted: sizes 16, 18, 20 Needles-assorted: 18 gauge needle 1.5 inches, 22 gauge 1.5 inches, 25 gauge 5/8 inches, 25 gauge 1.5 inches Syringes---3mLs, 5ml syringes and 10mLs blunt needle, blunt filter needle Sterile saline syringes 10 mLs 1% Xylocaine (individual packets) Lubricating jelly Swabsalcohol, , Chlorhexidine swab stikslarge and small Sponges: 2 by 2, 4 by 4, 4 by 6 Tape Assorted---Transpore, waterproof, Micropore, Cloth Opsite: small and large Sutures, -2.0 silk, 3.0 and X412H 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 DefinitionExit Site InfectionPurulent discharge at exit site OR Erythema, tenderness, induration (2 of 3) at exit site with a positive culture or serous discharge Tunnel InfectionPurulent 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 BacteremiaCase Definition: Blood Stream Infection (BSI) 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 (>38C core), chills, hypotension, AND common skin contaminant* cultured from e" 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: Day surgery patient not admitted Same day admit surgery patient admitted post surgery for 2-3 days. 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:  HYPERLINK "http://healthforms.cdha.nshealth.ca/sites/default/files/PPO0275MR%20Dec%201%202015%20Pre%20Post%20Operative%20Periotoneal%20Dialysis%20Catheter%20Insertion_DOCUSATE%20REMOVED.pdf" http://healthforms.cdha.nshealth.ca/sites/default/files/PPO0275MR%20Dec%201%202015%20Pre%20Post%20Operative%20Periotoneal%20Dialysis%20Catheter%20Insertion_DOCUSATE%20REMOVED.pdf 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:  HYPERLINK "http://healthforms.cdha.nshealth.ca/sites/default/files/PPO0276MR%20Dec%201%202015%20Peritoneal%20Dialysis_DOCUSATE%20REMOVED_0.pdf" http://healthforms.cdha.nshealth.ca/sites/default/files/PPO0276MR%20Dec%201%202015%20Peritoneal%20Dialysis_DOCUSATE%20REMOVED_0.pdf 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.  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/ 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  HYPERLINK "http://healthforms.cdha.nshealth.ca/sites/default/files/PPO0395MR%20April%203%202012%20Empiric%20Management%20of%20Peritonitis.pdf" http://healthforms.cdha.nshealth.ca/sites/default/files/PPO0395MR%20April%203%202012%20Empiric%20Management%20of%20Peritonitis.pdf For the Management of Confirmed Pathogen Peritonitis, refer to pre-printed order PPO0394MR  HYPERLINK "http://healthforms.cdha.nshealth.ca/sites/default/files/PPO0394MR%20Mar%2029%202012%20Management%20of%20Peritonitis.pdf" http://healthforms.cdha.nshealth.ca/sites/default/files/PPO0394MR%20Mar%2029%202012%20Management%20of%20Peritonitis.pdf 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 PeritonitisSpecific to Organism Treatment should be based on culture and sensitivity resultsCoagulase Negative Staphylococcus & Streptococci Cefazolin 1,000 mg IP daily (1,500 mg if weight 50-100 kg or 2,000 mg if weight greater than 100 kg) If Cephalosporin Allergy or MRSA: Vancomycin 1,000 mg IP every 5 days (1,500 mg if weight 50-100 kg or 2,000 mg if eight greater than 100 kg) Treatment duration: 2 weeksEnterococcus Vancomycin Vancomycin 1,000 mg IP every 5 days (1,500 mg if weight 50-100 kg or 2,000 mg if eight greater than 100 kg) Alternative: Ampicillin 125 mg/L every exchange (Continuous dosing only) Treatment duration: 3 weeksStaphylococcus aureus Cefazolin 1,000 mg IP daily (1,500 mg if weight 50-100 kg or 2,000 mg if weight greater than 100 kg) If Cephalosporins Allergy: Vancomycin 1,000 mg IP every 5 days (1,500 mg if weight 50-100 kg or 2,000 mg if eight greater than 100 kg) Treatment duration: 3 weeks (4 weeks for bacteremia)Pseudomonas Aeruginosa Difficult to eradicate. May require catheter removal. Double coverage based on sensitivities Ceftazidime 1,500 mg IP daily (1,000 mg if weight less than 50 kg) + Ciprofloxacin 500 mg PO bid (if sensitive) 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 or moreMRSA Vancomycin 1,000 mg IP every 5 days (1,500 mg if weight 50-100 kg or 2,000 mg if eight greater than 100 kg) Treatment duration: at least 3 weeks (4 weeks for bacteremia)Stenotrophomonas Maltophilia Difficult to eradicate. May require catheter removal Double coverage based on sensitivities 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 moreGram Negative (Klebsiella, E coli, Proteus) Adjust antibiotics based on sensitivities. Preferred: Ceftazidime 1,500 g IP daily (1,000 mg if weight less than 50 kg) Alternative: Cefazolin 1000 mg IP daily (1,500 mg if weight 50-100 kg or 2,000 mg if weight greater than 100 kg) 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 weeksCulture Negative Continue gram positive coverage (Cefazolin or Vancomycin) Discontinue Gentamicin/Tobramycin (if used for empiric therapy); Change gram negative coverage to Ceftazidime 1,500 mg IP daily (1,000 mg if weight less than 50 kg) Treatment duration: 2 weeksFungal/Yeast/Mycobacteria Catheter removal. Systemic antifungal treatment based on sensitivities.Polymicrobial Consider bowel perforation until proven otherwise and suggest CT 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) DRUGDIANEAL PD SOLUTIONDRUGDIANEAL PD SOLUTIONDRUGDIANEAL PD SOLUTIONCeFAZolinYesCeftAZIDimeYesGentamicin/TobramycinYesCeFAZolin+ CeftAZIDimeYesCeftAZIDime+ Gentamicin/TobramycinYesGentamicin/Tobramycin+ VancomycinYesCeFAZolin+ Gentamicin/TobramycinYesCeftAZIDime+ VancomycinYesVancomycinYes Antibiotic Prophylaxis and Procedure Prep for PD Patients Abdominal Ultrasound Patient should be drained (empty) prior to test. Cardiac Catheterization or Angiogram For Patients with daily urine output > 250 ml use N Acetylcysteine (Mocumyst) 600 mg pd bid on day before and day of procedure. Available in liquid form at 6N Pharmacy. Hydration is required prior to, during, and post procedure (0.45% saline 1mL/kg). Patient should be instructed to arrive drained (empty) for angiogram, and CAPD exchanges to resume ASAP after procedure. ERCP (Endoscopic Retrograde Cholangio Pancreatography) Amoxicillin 2 gm PO 1 hour pre-procedure Patient should be drained ("empty") prior to procedure. Patient should be drained (empty) prior to test. Colonoscopy (Sigmoidoscopy/Proctoscopy) Patient should be drained (empty) prior to procedure. Bowel prep is required for colonoscopy, sigmoidoscopy or proctoscopy. Colyte 2 3 liters is the preferred only preparation. Never use regular fleet enema because of risk of increased PO4, and do not use Mg citrate due to potential problems with electrolytes. Antibiotic prophylaxis is not necessary for sigmoidoscopy or proctoscopy. Antibiotic prophylaxis is necessary for colonoscopy: Ampicillin 1 gm IP in night bag/long well prior to procedure or oral amoxicillin 2 grams 1 hour before procedure. CT Scan for Assessment of PD Leak 50 ml of Visipaque (available from Radiology) is added IP to the dialysis solution regardless of the volume of the exchange. It is preferred the patient hold at least 2L as this may make the leak more visible on the scan. Once the solution is dwelling the patient walks around (as able) for 2 hours. Drain at end of scan and resume dialysis. Cystoscopy /Upper GI Bowel prep as per Radiology request except use Colyte, not mag-citrate or PO4 containing enemas. (See under Colonoscopy) Antibiotic Prophylaxis not generally used for upper GI procedures unless suspected liver or gallbladder infection. If infection: Amoxicillin 2 gm po 1 hour pre procedure or Ampicillin 2 gm IM or IV 30 minutes pre procedure. If allergic to Penicillin: Clindamycin 600 mg po 1 hour pre or 600 mg IV 30 min pre procedure Patient should be drained ("empty") prior to procedure. Dental Procedures Prophylaxis for endocarditis is only recommended in high risk patients (hemodialysis and PD patients do not meet the high risk criteria ) For high risk due to other factors: Amoxicillin 2 gm po 1 hr pre or Ampicillin 2gm IM or IV 30 min pre procedure. If allergic to Penicillin: Clindamycin 600 mg po 1hour pre or 600 mg IV 30 min pre procedure OR Cephalexin 2.0 gm po 1 hour pre procedure OR Azithromycin or clarithromycin 500 mg po 1 hour pre procedure Gastroscopy Patient should be drained ("empty") prior to procedure. Gynecological procedures (Invasive procedures i.e. Uterine biopsy and D&C. NOT for routine PAP) Amoxicillin 2 gm 1 hour pre procedure. Flagyl 500 mg 1 hour pre procedure and 500 mg 12 hours post procedure. If allergic to penicillin, clarithromycin 500 mg 1 hour pre-procedure. Patient should be drained ("empty") prior to procedure. Iliac Dopplers Patient should be drained ("empty") prior to test. Stress Test Patient should be drained ("empty") prior to test. Wet Contamination Contamination when the tubing system is open or unclamped, potential for organisms to enter the peritoneal cavity. Administer Cefazolin 1.5 g IV or 2 grams IP X 1 dose to prevent peritonitis. Other Peritoneal Dialysis Issues Hemoperitoneum Small concentration of red blood cells which results in bloody appearance to effluent. Causes may be benign to significant Pathology. Noted post surgical implantation of catheters, post abdominal surgery; associated with ovulation and menstrual bleeding; warfarin use; pancreatitis; metastases; ischemic bowel; encapsulating sclerosing peritonitis. May clear with flushes as in post catheter implantation. Add heparin 500 u/L to prevent catheter obstruction. Heparin not absorbed across peritoneal membrane and will not have systemic effect on anticoagulation. Assessment of Peritoneal Dialysis Prescription Adequacy of dialysis may be assessed by Adequest and membrane characteristics may be assessed by PET. Doing these studies must be arranged in advance with the Charge Nurse. Prior to either study, the patient must be stabilized on peritoneal dialysis for 1 month and be peritonitis free for 1 month. Peritoneal Equilibration Test (PET) Determines the rapidity of solutes moving across the peritoneal membrane. Patients with rapid transport characteristics are better managed with shorter dwell periods (i.e. CCPD) to minimize dextrose absorption and improve ultrafiltration. Patients with slow transport characteristics require CAPD with longer dwell periods. To perform PET: Drain overnight effluent, send sample for Cr, Urea, Glucose, volume instill 2.5% dialysis solution. At 0 hours send effluent sample for Cr, Urea and Glucose At 2 hours send effluent and blood samples for Cr, Urea and Glucose, to blood tests At 4 hrs send complete effluent for Cr, Urea, Glucose and Volume. To calculate the transport characteristic, determine the Dialysate/Plasma ratio and plot on graph to ascertain characteristics. Anemia Management in Chronic Kidney Disease (CKD) Decreased Erythropoietin (EPO) production in renal failure contributes to anemia. Iron deficiency is very common. Many patients with advanced CKD are in a negative iron balance as a result of decreased dietary intake, impaired absorption from the gut and increased iron losses. This is particularly true in hemodialysis (HD) patients, for whom supplemental iron is often essential to keep pace with blood loss and the requirement for erythropoiesis. Iron therapy is a highly effective means of replacing iron deficits and can enhance erythropoiesisallowing for lower requirements of erythropoiesis stimulating agents (ESA) therapy. Most patients require ESA plus iron therapy (intravenous or oral). The majority of renal patients are managed by the nurse and pharmacist led Nephrology Anemia Management Protocol (Appendix A-G). Laboratory Investigations Profile, Transferrin Saturation (TSAT), and Ferritin. Profile, TSAT, Ferritin on all chronic according to the nurse and pharmacist led Nephrology anemia management protocol (Appendix A-D). Treatment Oral Iron Therapy: Ferrous sulfate 300 mg -900 mg /day. If oral iron ineffective or oral iron intolerant, recommend intravenous (IV) iron therapy. See Nephrology Anemia Management Oral Iron Protocol- Appendix B and Iron Therapy pre-printed physician order PPO 0491 MR. IV Iron Therapy: Loading dose: Replete iron stores with Iron SUCROSE 100 mg IV direct three times per week for 10 doses (Cumulative dose of 1 gram). Administer undiluted, slowly over 2- 5 minutes. OR if iron sucrose unavailable, give: Sodium ferric gluconate complex 125 mg in 100 mL 0.9% sodium chloride IV three times per week for 8 doses (Cumulative dose of 1 gram). Infuse over 1 hour. Do not administer more than 2 courses of iron (reload) replacement in a row. Maintenance dose: Iron SUCROSE 100 mg IV direct every 1-4 week(s) on Monday and Tuesday. Administer undiluted, slowly over 2-5 minutes. OR if iron SUCORSE unavailable, give: Sodium ferric gluconate complex 125 mg in 100 mL 0.9% sodium chloride IV on Monday and Tuesday. Infuse over 1 hour. See Nephrology Anemia Management IV Iron Protocol - Appendix A and Iron Therapy pre-printed physician order PPO0491 MR. ESA Therapy: Iron should be given prior to ESA therapy if TSAT < 20% or Ferritin < 100. Darbepoietin alfa (Aranesp) is our standard ESA. Epoetin alfa (Eprex) is generally used in patients who have had an adverse reaction to Aranesp. Target hemoglobin (Hgb) 95-115 g/L. Suggested Initial Doses of ESA Therapy ( See ESA pre-printed physician order PPO0399 MR): CKD, Non-DialysisDarbepoetin alfa 0.45 mcg/kg every 2 weeks OR Darbepoetin alfa 50 units/kg every weekPeritoneal Dialysis, Home Hemodialysis, HemodialysisDarbepoetin alfa 0.45 mcg/kg every week OR Darbepoetin alfa 0.9 mcg/kg every 2 weeks OR Epoetin alfa 100 units/kg every weekSubsequent 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:  HYPERLINK "http://policy.nshealth.ca/Site_Published/DHA9/document_render.aspx?documentRender.IdType=5&documentRender.GenericField=&documentRender.Id=60200" \t "blank" CC 50-003 Appendix A - ESA Dosage Adjustment Table  HYPERLINK "http://policy.nshealth.ca/Site_Published/DHA9/document_render.aspx?documentRender.IdType=5&documentRender.GenericField=&documentRender.Id=60202" \t "blank" CC 50-003 Appendix B - ESA Dosage Interval Adjustment Table  HYPERLINK "http://policy.nshealth.ca/Site_Published/DHA9/document_render.aspx?documentRender.IdType=5&documentRender.GenericField=&documentRender.Id=60204" \t "blank" CC 50-003 Appendix C - ESA Hyporesponsiveness Flow Chart  HYPERLINK "http://policy.nshealth.ca/Site_Published/DHA9/document_render.aspx?documentRender.IdType=5&documentRender.GenericField=&documentRender.Id=60206" \t "blank" CC 50-003 Appendix D - Hgb ESA Algorithm Page 1 Assess Hgb Status - Nephrology Anemia Management ESA Protocol - 6 Week Cycle  HYPERLINK "http://policy.nshealth.ca/Site_Published/DHA9/document_render.aspx?documentRender.IdType=5&documentRender.GenericField=&documentRender.Id=60198" \t "blank" CC 50-003 Appendix E - IV Iron Algorithm Page 2 Assess Hgb Status - Nephrology Anemia Management ESA Protocol - IV Iron  HYPERLINK "http://policy.nshealth.ca/Site_Published/DHA9/document_render.aspx?documentRender.IdType=5&documentRender.GenericField=&documentRender.Id=62978" \t "blank" CC 50-003 Appendix F - Oral Iron Algorithm Page 3 Assess Hgb Status - Nephrology Anemia Management ESA Protocol - Oral Iron  HYPERLINK "http://policy.nshealth.ca/Site_Published/DHA9/document_render.aspx?documentRender.IdType=5&documentRender.GenericField=&documentRender.Id=60211" \t "blank" CC 50-003 Appendix G - Hgb ESA Assess Hgb Status - Nephrology Anemia Management ESA Protocol - 4 Week Cycle - Home Hemodialysis Pre-Printed Physician Order PPO0491 MR Iron Therapy- Nephrology:  HYPERLINK "http://healthforms.cdha.nshealth.ca/sites/default/files/PPO0491MR%20Oct%2023%20" http://healthforms.cdha.nshealth.ca/sites/default/files/PPO0491MR%20Oct%2023%20 2015%20%20Iron%20Therapy.pdf PPO0399 MR Erythropoiesis Stimulation Agents (ESA):  HYPERLINK "http://healthforms.cdha.nshealth.ca/sites/default/files/PPO0399MR%20Jan%2022%202" http://healthforms.cdha.nshealth.ca/sites/default/files/PPO0399MR%20Jan%2022%202 015%20Erythropoiesis%20Stimulating%20Agent%20ESA_0.pdf Patient Education Pamphlets Erythropoiesis Stimulation Agent Therapy and Chronic Kidney Disease WQ85-1493 November 2013  HYPERLINK "http://www.cdha.nshealth.ca/patientinformation/nshealthnet/1493.pdf" http://www.cdha.nshealth.ca/patientinformation/nshealthnet/1493.pdf Oral Irons and Chronic Kidney Disease WQ85-1469 November 2013 Injectable Iron and Chronic Kidney Disease WQ85-1495 November 2013  HYPERLINK "http://www.cdha.nshealth.ca/patientinformation/nshealthnet/1469.pdf" http://www.cdha.nshealth.ca/patientinformation/nshealthnet/1469.pdf 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: Every 6 weeks: Calcium, phosphorus, albumin. PTH ordered if on Vitamin D Analogue or cinacalcet (Sensipar). Every 3 months: PTH (unless on Vitamin D Analogue or cinacalcet, as above) Target Serum Calcium Serum Phosphate iPTH CSN 2006 Hemodialysis Normal range 2.2 2.6 mmol/L Normal range 0.78 1.53 mmol/L 10.6 - 53 pmol/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: 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. 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 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 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: 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 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 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: 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: Patient does not respond adequately, cannot take, or is intolerant to Vitamin D analogues and Phosphate Binders. Patient is either not a surgical candidate, has been waitlisted for parathyroidectomy (requires bridge therapy), or is awaiting kidney transplant. Patient is symptomatic due to hyperparathyroidism (ie bone pain, itching, myalgia, profound neuropathy). Helpful online resource: http://ukidney.com/ The Following are available on line: Pathway for the Management of Elevated Parathyroid Hormone. See page 55 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 http://www.cdha.nshealth.ca/patientinformation/nshealthnet/1464.pdf Fosrenol (Lanthanum) and hemodialysis WQ85-1466 October 2012 http://www.cdha.nshealth.ca/patientinformation/nshealthnet/1466.pdf One-Alpha (Alfacalcidol) and hemodialysis WQ85-1470 October 2012 http://www.cdha.nshealth.ca/patientinformation/nshealthnet/1470.pdf Sensipar (Cinacalcet) to treat secondary hyperparathyroidism in chronic kidney disease WQ85-1465 October 2012 http://www.cdha.nshealth.ca/patientinformation/nshealthnet/1465.pdf  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:  HYPERLINK "http://chdintra.cdha.nshealth.ca/departmentservices/Pharmacy/IVDrug/Monographs/sodiumThiosulfate.pdf" http://chdintra.cdha.nshealth.ca/departmentservices/Pharmacy/IVDrug/Monographs/sodiumThiosulfate.pdf 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: 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. Pneumococcal Pneumococcal vaccine screening occurs for all new dialysis patients. All patients with chronic kidney disease require 2 doses of pneumococcal polysaccharide vaccine (Pneumovax23), 5 years apart. If patients are immunocompromised, they also require pneumococcal conjugate vaccination (Prevnar13). Type of vaccine: Pneumovax23 = non-replicating, subunit, polysaccharide. Type of vaccine: Prevnar13 = non-replicating, subunit, polysaccharide, conjugate. Timing of Pneumococcal vaccines: All patients with chronic kidney disease: Pneumovax23 Pneumovax23 INCLUDEPICTURE "https://docs.google.com/drawings/u/0/d/sB_tMTaE11BibHXWs_1DcFQ/image?w=113&h=3&rev=1&ac=1" \* MERGEFORMATINET  5 years Immunocompromised patients only:  INCLUDEPICTURE "https://lh4.googleusercontent.com/XyxDb1vDFjJPjlPzKyTHd81lzxdSPTPa8cl_SVohLOaoppYHsr_zToIJg9q07MxDu1pTHeevDEDA-3liA8_TBGU0jGZ0pyIzUXzO_WQlU7Uq1H3SwssB2kAWQWk59ZUJO-eOgGf_ybGMvAeaww" \* MERGEFORMATINET   INCLUDEPICTURE "https://lh3.googleusercontent.com/sA5VUDg-YdvVhsTfSyuHEoBbzbvY5aZkv1kIdfcHY-HWwvXuu-aBJEF20P1wrbbGVo-Ujvs62jn8bhn-cg6JllZpXki8s-97pWMbmj9L_29cF1RuXTeWbCtLDHbUCGXNkMPKg-iQkFXN18YMpw" \* MERGEFORMATINET  Note: PPSV23 = Pneumovax23, PCV13 = Prevnar13 PPO0397 Pneumococcal, Influenza and Tdap Vaccination:  HYPERLINK "http://healthforms.cdha.nshealth.ca/sites/default/files/PPO0397MR%20Dec%202%202013%20Influenza%20Pneumococcal%20Tetanus%20Diphtheria%20Pertussis%20Vaccination%20(WM).pdf" http://healthforms.cdha.nshealth.ca/sites/default/files/PPO0397MR%20Dec%202%202013%20Influenza%20Pneumococcal%20Tetanus%20Diphtheria%20Pertussis%20Vaccination%20(WM).pdf 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 Healths Flu Campaign:  HYPERLINK "http://www.cdha.nshealth.ca/employee-health/immunizations/influenza-flu-0" http://www.cdha.nshealth.ca/employee-health/immunizations/influenza-flu-0  HYPERLINK "http://www.cdc.gov/vaccines/pubs/downloads/dialysis-guide-2012.pdf" CDC 2012 Guidelines for Vaccinating Kidney Dialysis Patients and Patients with Chronic Kidney Disease:  HYPERLINK "http://www.cdc.gov/dialysis/PDFs/Vaccinating_Dialysis_Patients_and_Patients_dec2012.pdf" http://www.cdc.gov/dialysis/PDFs/Vaccinating_Dialysis_Patients_and_Patients_dec2012.pdf Canadian Immunization Guide. Part 3: Vaccination of  HYPERLINK "http://www.phac-aspc.gc.ca/publicat/cig-gci/p03-chroni-eng.php" \l "a2" http://www.phac-aspc.gc.ca/publicat/cig-gci/p03-chroni-eng.php#a2 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):  HYPERLINK "http://healthforms.cdha.nshealth.ca/sites/default/files/PPO0513MR%20Jan22%202015%20Hepatitis%20B%20Immunization_Dialysis_Predialysis.pdf" http://healthforms.cdha.nshealth.ca/sites/default/files/PPO0513MR%20Jan22%202015%20Hepatitis%20B%20Immunization_Dialysis_Predialysis.pdf B. PPM0513MR Hepatitis B Immunization (Medication Records Titres and Vaccine Administration) http://healthforms.cdha.nshealth.ca/sites/default/files/PPM0513MR.pdf Patient Education Pamphlets NSHA: Hepatitis B Vaccine and Kidney Disease WQ 85 1425 December 2011  HYPERLINK "http://www.cdha.nshealth.ca/patientinformation/nshealthnet/1425.pdf" http://www.cdha.nshealth.ca/patientinformation/nshealthnet/1425.pdf 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: http://novascotia.ca/dhw/CDPC/immunization.asp 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 <2.5 if ESRD or increasing levels after admission or Li still> 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 Generic (Brand) Starting Dose (SD) (maximum dose) *Changes in ESRD ADULT DIALYSISDialyzedGeneral: Caution withdrawal(taper gradually after prolonged use Initial ! suicide and possible precipitation of hypomania/mania.Estimated Monthly $/ PharmacareCommon Adverse EffectsCommentsSelective Serotonin Reuptake Inhibitors (SSRI)Citalopram (Celexa) 10, 20, 30, 40 mg scored tabsSD: 10 mg/ day (40 mg) *max 20 mg in >60 years old *Active metabolites, use with cautionNo GI: nausea, vomiting, diarrhea, bloating, weight loss (or weight gain), constipation CNS: agitation , anxiety, insomnia, headache, fine 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)-QT prolongation, especially at doses > 40 mg/day -Fewest drug interactions -Least tremor$25.00 " Covered Escitalopram (Cipralex) 10, 20 mg scored tabsSD: 5 mg/ day ( 10 mg/ day) *Use with caution No -S enantiomer of Citalopram -Twice as potent as citalopram -QT prolongation, especially at doses > 20 mg/day -Least sexual dysfunction, headache, fatigue, and tremor$65.00 Not a benefitFluoxetine (Prozac) 10, 20 mg caps, 4 mg/ml solutionSD: 10 mg/ day (80 mg/ day) *Long t, use with caution.No Least weight gain Long half-life (5 week washout)$40.00 " CoveredParoxetine (Paxil) IR: 10, 20, 30, 40 mg tabs CR: 12.5, 25 mg SD: 10 mg/ day (30 mg/ day) *T prolonged. Use with caution. No -Most anticholinergic side effects (caution in the elderly), weight gain, sedation, constipation, and sexual dysfunction -Also used for pruritis$30.00 " Covered Sertraline (Zoloft) 25, 50, 100 mg capsSD: 25 mg/ day (200 mg/ day) *Active metabolite is renally excreted, !dose carefully. No -Most diarrhea & male sexual dysfunction -Few drug interactions $25.00 " CoveredSerotonin/Norepinephrine Reuptake Inhibitors (SNRI)Desvenlafaxine ER (Pristiq) 50, 100 mg tabs SD: 25 mg/ day (Alternative: 50 mg every 2 days) *Variability in drug clearance.No GI: nausea, vomiting, diarrhea, bloating, weight loss, constipation 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 -Less sexual dysfunction -Ghost tablets $110.00 Not a benefitDuloxetine (Cymbalta) 30, 60 mg caps Avoid *Not recommended in product monograph for patients with ESRD.No -NS Pharmacare: only approved for diabetic neuropathy, exception status -Also used for peripheral neuropathy$130.00 " Exception status onlyVenlafaxine XR (Effexor) 37.5, 75, 150 mg caps SD: 37.5 mg/ day (112.5 mg/ day) *Decreased clearance and T prolonged. *Variability in drug clearance No-Low weight gain -Few drug interactions -Also used for peripheral neuropathy -Caution: withdrawal effects $25.00 " CoveredSerotonin Modulators: Serotonin Antagonists/ Reuptake Inhibitor (SARI)Trazodone (Desyrel) 50, 75, 100, 150 mg scored tabsSD: 25 mg/ day HS (400 mg/ day) *! dose carefully, divide dose in the elderly For insomnia, usual SD: 12.5-25 mg HSNo GI: nausea, constipation CNS: sedation, weakness, lethargy, fatigue, headache, agitation, confusion CV: dizziness, ! BP, QT prolongation Other: anticholinergic, priapism Rare: Serotonin syndrome-Mostly used for sleep -Less cardiac side effects than TCAs $20.00 " CoveredDual Action Antidepressant: NaSSA ( Mirtazapine) and NDRI (Bupropion) Mirtazapine (Remeron) 30 mg scored tabs RD: 15, 30, 45 mg tabs NaSSA = Noradrenergic/ Specific Serotonergic AgentSD:7.5 mg/ day (22.5 mg/ day) *Increased plasma concentrationsNo GI: constipation CNS: fatigue, sedation, weakness, headache CV: ! cholesterol, QT prolongation Other: ! appetite, weight gain, anticholinergic Rare: serotonin syndrome, neutropenia-Also used for pruritis -Good choice for patients with insomnia -Less sexual dysfunction -Can aggravate restless legs syndrome -RD tabs (orally disintegrating) available$25.00 " CoveredBupropion SR (Wellbutrin) SR: 100, 150 mg tabs, XL: 150, 300 mg tabs NDRI= Norepinephrine/Dopamine Reuptake Inhibitor SD:100 mg/ day (SR) 150 mg/ day (XL) (150 mg/ day) *Risk of accumulation of toxic metabolites (can cause dysrhythmia, wide QRS complex)NoGI: nausea, vomiting constipation CNS: anxiety, agitation, headache, insomnia, tremor, ataxia, vivid dreams, paranoia CV: tachycardia, dizziness Other: sweating, anticholinergic, weight loss, menstrual irregularities Rare: ! seizure risk-Also used for smoking cessation -Contraindicated in seizure disorders -Do not crush or split -Less sexual dysfunction, than SSRI/SNRI -Less precipitation of mania -XL formulation = ghost tablets$25.00 " CoveredTricyclic Antidepressants (TCA): prescribed for neuropathic pain. *Do not use in patients with significant cardiovascular disease, glaucoma, symptomatic prostatic hypertrophy. HYPERLINK "about:blank" Nortriptyline (Aventyl) 10, 25 mg capsSD: 10 mg/ day HS (100 mg/ day) *Can divide doses at higher daily dosesNo GI: nausea, vomiting, diarrhea, constipation CNS: sedation, fatigue, headache, orthostatic 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-Least hypotensive TCA -Generally better tolerated TCA $75.00 " Covered HYPERLINK "about:blank" Imipramine (Tofranil) 10, 25, 50, 75mg tabsSD:10 mg/ day HS (200 mg/ day) *! dose carefully *Can divide doses at higher daily dosesNo $45.00 " Covered HYPERLINK "about:blank" Amitriptyline (Elavil) 10, 25, 50, 75 mg tabsSD:10 mg/ day HS (150mg/ day) *Can divide doses at higher daily dosesNo -Often used for sleep, irritable bowel disease and & chronic pain $25.00 " Covered 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 Sjogrens Pregnancy Mimic disorders (ie movement disorders, anxiety, neuropathy) Drug-related causes: dopamine antagonists (ie metoclopramide, antispychotics) antidepressants (ie mirtazapine, SSRIs, SNRIs, TCAs) other: carbamazepine, lithium, alcohol, caffeine, nicotine Non-Pharmacologic TreatmentExerciseEnable patient to move the legs during dialysis. Encourage exercise 3 times weekly during the daytime.Good sleep hygieneAvoid napping during the day or at dialysis. Establish a good sleep environment and schedule.RelaxationConsider massages.Mental alertnessTry cross word puzzles or card games. Pharmacologic Treatment: Dopaminergic treatment: *If RLS symptoms occur during HD, give medication prior to HDLevodopa/ carbidopa Intermittent RLSCarbidopa blocks the peripheral breakdown of levodopa . Levodopa is converted to dopamine in the CNS.Initial dose: 50/12.5mg PO qHS when needed Titrate weekly to max of 200/50mg per day. Levodopa acts fast (~20 mins). CR formulation also available. AE: hypotension, dizziness, nausea, constipation, edema. Caution if psychosis. Augmentation can occur. Ropinirole Persistent RLSDopamine agonistInitial dose: 0.25mg PO qHS. Titrate by 0.25 mg weekly. Max of 3mg daily in RLS. Note: higher doses are used in Parkinsons (up to 18mg). Ropinirole and Pramipexole: Take 2 hours prior to HS (or HD). Note: pramipexole product monograph does not provide 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 Persistent RLS Dopamine agonist Starting dose: 0.125mg PO qHS. Titrate by 0.125 mg every 1-2 weeks. Max dose of 0.75 mg per day.Rotigotine Persistent RLSDopamine agonistStarting dose: 1mg patch daily transdermally. Titrate by 1 mg weekly. Max of 3mg patch daily.If refractory to dopaminergic treatment:Gabapentin GABA AnalogueStarting dose: 100mg PO qHS. Titrate (100 mg/week) to a max dose of 300 mg per day.Consider if also having neuropathic pain or pruritus. AE: drowsiness, dizziness. Pregabalin GABA AnalogueStarting dose: 25mg PO qHS. Titrate (25 mg/week) to a max dose of 75 mg per day.Other (refractory symptoms):ClonazepamBenzodiazepineStarting dose: 0.5 mg PO qHS. Titrate (0.5 mg/week) to a max of 2 mg per day.Short term therapy only. AE: falls, sedation, dependence/tolerance.ClonidineCentral Alpha AgonistStarting 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 LadderAnalgesicRecommendationAdverse EffectsStep 1: Mild PainAcetaminophen Adjuvents (Gabapentin doses up to 300 mg/day or Pregabalin 100 mg/day are considered generally safe in ESRD)The National Kidney Foundation recommends acetaminophen as the non-narcotic analgesic of choice for mild-to-moderate pain in ESRD.Do not exceed 4 g per day to avoid hepatotoxicity. AVOID Non- Steroidal Anti-Inflammatory Drugs (NSAIDs) (e.g., Ibuprofen, Naproxen)Topical gels generally considered safe. Oral agents discouraged in patients with residual urine output, advanced age, or multiple co-morbidities.Loss of residual renal function, sodium and water retention, hypertension, hyperkalemia, and increased gastrointestinal bleeding risk when compounded by uremic-induced poor platelet function.Step 2: Moderate PainTramadolUse with caution. Safer than oxycodone, although dose adjustment may be necessary due to renal clearance.Side effects are similar to those of opioids: nausea, central nervous system (CNS) depression, and constipation. Tramadol may cause seizures in conditions associated with a lowered seizure threshold. Risk for serotonin syndrome with concomitant serotonergic medications.OxycodoneUse with extreme caution. No data available on dialysis of oxycodone.Nausea, CNS depression, and constipation.Step 3: Severe PainHydromorphoneUse cautiously. Hydromorphone has been used without adverse effects in dialysis patients, but there are no data concerning dialysis of the metabolites, and metabolite accumulation is a risk.Nausea, CNS depression, and constipation. Metabolite accumulation may cause neuro-excitation with agitation, confusion and hallucinations.FentanylRecommended. Appears safe, at least over short periods. It is largely cleared by the liver, and metabolites are inactive.Nausea, CNS depression, and constipation.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:  HYPERLINK "http://link.springer.com/book/10.1007%2F978-1-4614-5800-5" http://link.springer.com/book/10.1007%2F978-1-4614-5800-5 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:  HYPERLINK "http://libcat.nshealth.ca/" http://libcat.nshealth.ca/ 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:  HYPERLINK "http://www.ayurvedavignan.in/freeEbooks/Renal-Drug-Handbook.pdf" http://www.ayurvedavignan.in/freeEbooks/Renal-Drug-Handbook.pdf 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:  HYPERLINK "http://www.dialyzeihd.com/" http://www.dialyzeihd.com/ 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:  HYPERLINK "http://www.bcrenalagency.ca/resource-gallery/Documents/Dialyze%20IHD%20Nursing%20Poster%20BCKD%202013_0.pdf" http://www.bcrenalagency.ca/resource-gallery/Documents/Dialyze%20IHD%20Nursing%20Poster%20BCKD%202013_0.pdf 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:  HYPERLINK "http://renalpharmacyconsultants.com" http://renalpharmacyconsultants.com The 2013 publication is available free online:  HYPERLINK "http://homedialyzorsunited.org/wp-content/uploads/2013/04/2013-Dialysis-Drugs.pdf" http://homedialyzorsunited.org/wp-content/uploads/2013/04/2013-Dialysis-Drugs.pdf 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:  HYPERLINK "http://libcat.nshealth.ca/" http://libcat.nshealth.ca/ 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  -;<=P[\abxcQ<'<(jhQhQOJQJUmHnHu)h #hp[^B*CJ2OJQJ^JaJ2ph#h/NB*CJ2OJQJ^JaJ2ph)h]thp[^B*CJ8OJQJ^JaJ8ph#hp[^B*CJ8OJQJ^JaJ8phhs5B*CJHOJQJph$h]thA5B*CJHOJQJph$h]th N5B*CJHOJQJph)hs5B*CJHOJQJ\^JaJHph)hp[^5B*CJHOJQJ\^JaJHph)hp[^5B*CJbOJQJ\^JaJbph <P\bt&^gdp[^gdU@$dw1$7$8$H$a$gdU@ d1$7$8$H$gdsd1$7$8$H$^`gdJ&d 1$7$8$H$^`gdJ&dd1$7$8$H$^gdp[^bstzŵxhYJJYJYJY>Y>JYhN^OJQJmH sH hAeEhp[^OJQJmH sH hAeEhsOJQJmH sH hAeEhp[^5OJQJmH sH hN^5OJQJmH sH 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hAeEhp[^5OJQJmH sH hAeEhp[^OJQJmH sH hAeEhp[^5H*OJQJhAeEh 0JOJPJQJhAeEh OJQJhAeEh~OJQJUhAeEhp[^OJQJhAeEhp[^5OJQJhaOOJQJ^Jh3OJQJ^J#4#5#6#7#8#9#:#;#<#=#>#?#@#A#B#C#D#E#F#G########^gdp[^^gdp[^gdgdp[^#### $ $6$N$O$W$g$$$$$$$$$%0%1%X%Y%l%m%%%gdp[^`gdp[^^gdp[^%%%%%%%%% .HI\x%&WXgdp[^^gd~`gdp[^^gdp[^ 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: HYPERLINK "mailto:healthcareexperience@cdha.nshealth.ca"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 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 Enter your Facility code* followed by the # key Enter Worktype followed by the # key Enter patients MRN followed by the # key 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) 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. 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. RECORD/STOP - Press 2 t begin your dictation SKIPBACK/PLAY - Press 3 for an incremental rewind with automatic playback Press 2 to stop playback FAST FORWARD - Press 4 for an incremental fast forward COMPLETE REPORT/DISCONNECT Press 5 to complete the last report and disconnect. 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. REWIND - Press 7 for rewind then 3 for playback COMPLET REPORT - Press 8 to complete report or press 5 to complete report and disconnect 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 DescriptionFacility CodesQEII Health Sciences Centre1Dartmouth General Hospital2Cobequid Community Health Centre3Hants Community Hospital4The Nova Scotia Hospital5East Coast Forensic Hospital6Eastern Shore Memorial Hospital7Musquodoboit Valley Memorial Hospital8Twin Oaks Memorial Hospital9Private Practice10 WorkTypes to HPF WT #Worktype NameHPF1Operative ReportOperative Reports2Discharge Summary ReportDischarge Summary3Ambulatory Care Clinic LetterAmbulatory Care Reports5Day Patient Cardiac CatherizationDiagnostic Reports7NSCC Consultation ReportConsulation Records 8NSCC Gynaecology Disposition ReportAmbulatory Care Reports9NSCC Progress ReportProgress Notes11ECFH Court ReportCourt Documents21Transfer Summary ReportTransfer Reports22Death ReportDischarge Summary 23Intent to Discharge Summary Report Discharge Summary24ECFH Discharge SummaryDischarge Summary32Assessment ReportAssessment Forms 33 ECFH Criminal Code Review BoardDOES NOT FLOWWT #Worktype NameHPF 34 ECFH Clinic LetterAmbulatory Care Reports 35 Mental Health Progress NoteMental Health Progress Note 36* Mental Health Clinic LetterAmbulatory Care Reports41Inpatient Consultation ReportConsultation Records 42 Home Visit ConsultationAmbulatory Care Reports 43 Telemedicine ConsultationAmbulatory Care Reports44ECFH Risk AssessmentAssessment Forms45ECFH Third Party CorrespondenceVoice Only 47Case Summary/Clinical Review/Chart ReviewAmbX{*D\]gdp[^ ^`gdp[^^gdp[^8Tg:Fey gdp[^^gd^gdp[^:FG`dfxz.IYa|} (VǾǪǾҟzqeWDzhAeEhp[^5H*OJQJhAeEh=5OJQJh=5OJQJhp[^5OJQJ!hAeEhp[^B*OJQJ^JphhAeEhjOJQJhAeEhZ>;OJQJhbOJQJhAeEhp[^5OJQJhZ>;5OJQJhAeEhp[^OJQJhZ>;OJQJhAeEhOJQJhAeEhp[^OJQJmH sH hZ>;OJQJmH sH -.HI|}($a$gdFQ$^`a$gdp[^^gdjgdjgdp[^^gdp[^(-V7]5[d1$7$8$H$^gdp[^< d1$7$8$H$^< gdp[^ ^`gdp[^^gdp[^^gdp[^ d1$7$8$H$gdp[^Vuy %&LPT\_{5ع}qf}hAeEhp[^OJQJhAeEhp[^5OJQJhAeEhp[^OJQJmHsH hAeEhewOJQJ^JmHsHhp[^OJQJ^JmHsHhewOJQJ^JmHsH hAeEhp[^OJQJ^JmHsHhewOJQJ^JmHsH hAeEhp[^OJQJ^JmHsHhewOJQJ^JhAeEhp[^OJQJ^J 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