Associate Professor, University of Illinois College of Medicine
Daily dialysis decreases the fluid removal at each treatment medicine 3604 generic cefuroxime 250 mg mastercard, decreasing the risk of hypotension during dialysis medicine 3605 buy cefuroxime. Daily dialysis also allows the patient to eat a high-protein diet to ensure that the needs of pregnancy are met symptoms 9dp5dt cheap 250mg cefuroxime with visa. Increasing the intensity of dialysis in peritoneal dialysis patients is difficult. Late in pregnancy, women have difficulty with severe abdominal distension, and exchange volume may have to be decreased. It becomes necessary to increase the frequency of exchanges even to maintain the same level of dialysis. A combination of frequent daytime exchanges and nighttime cycler is often necessary. Some have raised the question whether increased dialysis might have a detrimental effect by causing electrolyte abnormalities or by removing progesterone. Measurements of serum progesterone levels during dialysis in pregnant dialysis patients are variable. Brost and colleagues (1999) measured pre- and postdialysis progesterone levels in seven pregnant dialysis patients. Changes in serum progesterone ranged from a 52% decrease in levels to an 8% increase (Brost, 1999). Changes in serum progesterone were not associated with changes in home uterine activity monitoring. With the recognition of the risk of soft tissue calcification in long-term dialysis patients, a Chapter 39 / Obstetrics and Gynecology in Dialysis Patients 741 2. There is some production of calcitriol by the placenta that may increase serum calcium. If the woman requires phosphate binders, 1 to 2 g of elemental calcium should be sufficient. Over the long term, dialysate calcium should be low enough to minimize soft tissue calcification, but over the short term of pregnancy, calcium should be sufficient for the fetal skeleton. Skeletal abnormalities have been described in one baby born to a dialysis patient. For women who need phosphate binders, calcium-containing binders are the only group known to be safe in pregnancy. Often, phosphate binders are no longer required, and it may be necessary to add phosphorus to the bath. For women who do not need phosphate binders, calcium can be provided in a lower dose separate from meals. Experience with cinacalcet in pregnancy is limited to a few case reports of use in primary hyperparathyroidism. Hypercalcemia may suppress the fetal parathyroid glands and cause neonatal tetany. Metabolic alkalosis carries an increased risk in pregnant women who have a concurrent respiratory alkalosis; however, in the few instances where arterial blood gases have been done, compensatory hypercapnia has occurred in women with severe metabolic alkalosis. When this bicarbonate concentration is not available, bicarbonate can be removed by increasing ultrafiltration and replacing the losses with saline. Since thirst is normal, the pregnant woman will take in enough water to normalize serum sodium if it is high at the end of dialysis. With daily dialysis, fluid removal should be modest enough to make sodium modeling unnecessary. Determination of optimal postdialysis weight is problematic in pregnant dialysis patients. Recommended weight gain for women who become pregnant at their ideal body weight is 11.
Disruption of the sheath is then confirmed by a repeat radiocontrast injection after the new catheter has been inserted 7 medications that cause incontinence discount cefuroxime 500mg free shipping. The balloon angioplasty technique results in restoration of catheter blood flow rates sufficient for dialysis in the great majority of patients (Rasmussen treatment centers discount cefuroxime 500 mg on-line, 2010; Shanaah medications 3605 order discount cefuroxime on-line, 2013). Moreover, the fear of calciphylaxis and skin necrosis with warfarin therapy tends to limit its use in dialysis patients. Central vein or intracardiac thrombosis can occur in association with large, indwelling catheters, and these can rarely result in embolic complications. Intra-atrial thrombi need prolonged systemic anticoagulation (for 6 months or longer) and followup for resolution. Large clots adherent to the end of the catheter or to the vessel wall can be clinically silent or can give rise to embolic events. Treatment options for a ball thrombus or a catheter-associated right atrial thrombus include simple catheter removal, systemic or catheterassisted fibrinolytic therapy, and, rarely, thoracotomy with thrombectomy. The incidence increases with the use of stiff, nonsilicone catheters; with the use of the subclavian approach (presumably because of higher angular stresses on the catheter in the subclavian position); and in patients with previous catheter-related infections. Collateral vessels usually develop but may not be adequate to relieve extremity edema. Stenosis or occlusion of the subclavian vein, brachiocephalic vein, or superior vena cava usually presents with venous hypertension (swelling of the breast, shoulder, neck, and face) or vascular access dysfunction (high venous pressure on dialysis, inadequate dialysis and prolonged bleeding). Occlusion of multiple central veins in the chest can result in the development of superior vena cava syndrome. Careful history and examination will often reveal multiple central venous catheter scars in such patients. Ligation of the vascular access produces the most rapid improvement but sacrifices the access. Initial anticoagulation (with heparin followed by warfarin) and elevation of the upper extremity on the involved side may ameliorate the symptoms and signs if thrombosis is present. More definitive therapy usually is required: Balloon angioplasty has been used for stenosis, but the lesion tends to recur. However, stent placement rarely solves the problem long term, because stenosis can reoccur around the stent. Stenosis in the subclavian vein sometimes can be relieved by an axillary vein to internal jugular vein bypass. Over the long term, indwelling catheters can develop adhesions to venous or atrial endothelium. Adherence should be suspected when an attempt to remove the catheter induces severe pain or requires significant traction. The heart or mediastinum may be pulled to one side when visualized under fluoroscopy. Removal of adhered catheters is a challenge and can require invasive techniques, including laser dissection or open surgical removal. It is not uncommon to see a fractured port or clamp on a tunneled dialysis catheter. This can lead to suction of air or inability to double lock the port after dialysis, with an increased risk of bleeding (Amin, 2011). Often, one can replace one or both ports or clamps using replacement kits for specific catheters without having to change the entire catheter.
Furthermore treatment brown recluse bite buy discount cefuroxime, many dialysis patients have some residual renal function medicine 5e generic cefuroxime 500mg online, accounting for some renal drug removal medicine shoppe locations order cefuroxime 500 mg with visa. The postdialysis dose will replace drug lost during hemodialysis and drug removed due to nonrenal and residual renal excretion; thus, the amount of postdialysis dose may vary considerably and should be adjusted on the basis of the plasma drug levels achieved (see below). Although the strategy is simple, its efficacy and safety have not been evaluated, and there is a concern for otovestibular toxicity if treatment is prolonged. As with any aminoglycoside dosing, serum drug levels should be obtained to ensure therapeutic levels and avoidance of toxicity. The strategy for amikacin is similar to that for dosing gentamicin or tobramycin; however, the loading dose should be 5. One-half of the normal (nonuremic) dosage should be administered after hemodialysis. Monitoring of serum aminoglycoside levels is especially important in cases of serious infection where maximal efficacy is of paramount importance and during prolonged use where otovestibular toxicity is common. The volume of distribution for aminoglycosides in dialysis patients is similar to that for nonuremic patients; therefore, peak serum levels should be similar to those in nonuremic patients given a similar dosage with a similar trough (predose) serum concentration. In nonuremic patients, the dosing interval of the aminoglycosides is adjusted based on the trough (predose) level, as trough levels >2 mg/L (gentamicin, tobramycin) or 10 mg/L (amikacin) are associated with toxicity. In dialysis patients, the altered pharmacokinetics of aminoglycosides may lead to difficulties in dosing. For example, when gentamicin is given posthemodialysis, the magnitude of a subsequent predialysis level will depend on the frequency of dialysis, as well as on the amount Chapter 35 / Infections 653 administered and the gentamicin half-life. With daily or even every-other-day dialysis, therapeutic peak levels of approximately 4. Clarithromycin doses should be reduced by 50% in those patients with CrCl <30mL/min and given after dialysis. Additional dose adjustments are necessary if coadministered with the protease inhibitors atazanvir and ritonavir, which may increase the serum concentration of clarithromycin. To date, telithromycin is the first and only agent on the market in the United States. Compared with the macrolides, the ketolides have additional activity against multiresistant Streptococcus pneumoniae, S. In hemodialysis, the recommended dose is 600 mg once daily, and when renal impairment is accompanied by hepatic impairment, the dose should be further reduced to 400 mg once daily.
Exit-site infection can be diagnosed when there is erythema medicine 5 rights cefuroxime 500 mg online, discharge medicine 6 times a day purchase generic cefuroxime, crusting conventional medicine discount cefuroxime 500mg without prescription, and tenderness at the skin exit site, but no tunnel tenderness or purulence. The patient should be investigated for nasal carriage of Staphylococcus and if present, treated with intranasal mupirocin cream (half tube twice a day to each nostril for 5 days) to prevent future infections. Tunnel infection is infection along the subcutaneous tunnel extending proximal to the cuff toward the insertion site and venotomy. Typically, there is marked tenderness, swelling, and erythema along the catheter tract in association with purulent drainage from the exit site. In the presence of drainage or signs of systemic infection, the catheter should be removed immediately and antibiotic therapy prescribed. Milder cases present with fever or chills, whereas more severe cases exhibit hemodynamic instability. Patients may develop septic symptoms after initiation of dialysis, suggesting systemic release of bacteria and/or endotoxin from the catheter. There can be signs of metastatic infection, including endocarditis, osteomyelitis, epidural abscess, and septic arthritis. Gram-positive organisms are the causative organisms in the majority of cases, but gram-negative infections occur in a very sizeable minority. In hemodialysis, the venous catheter is a lifeline that sometimes can be replaced only with great difficulty. Thus, the guidelines include a variety of catheter salvage maneuvers, which involve use of antibiotic-containing catheter locks or replacing the infected catheter with a new catheter in the same location over a guidewire. However, these catheter salvage techniques should be used only in limited, defined circumstances. Monitor predialysis trough levels if possible (Cefazolin may be used in place of vancomycin in units with a low prevalence of methicillin-resistant staphylococci) Vancomycin: 20-mg/kg loading dose infused during the last hour of the dialysis session, and then 500 mg during the last 30 min of each subsequent dialysis session Gentamicin (or tobramycin): 1 mg/kg, not to exceed 100 mg after each dialysis session Ceftazidime: 1 g iv after each dialysis session Cefazolin: 20 mg/kg iv after each dialysis session For Candida Infection An echinocandin (caspofungin 70 mg iv loading dose followed by 50 mg iv daily; intravenous micafungin 100 mg iv daily; or anidulafungin 200 mg iv loading dose, followed by 100 mg iv daily); fluconazole (200 mg orally daily); or amphotericin B iv, intravenous. They too, recognize the difficulties in obtaining cultures from peripheral veins in hemodialysis patients, and believe that a practical alternative is to simply draw blood cultures from the dialysis circuit. Blood from the circuit during dialysis probably represents peripheral blood rather than localized catheter blood, and so a positive blood culture drawn from the bloodline may reflect a source of bacteremia other than at the catheter. If there is evidence of septic thrombosis, endocarditis, or osteomyelitis, or of severe sepsis with hypotension, then the dialysis catheter needs to be removed immediately. Dialysis should be continued with a temporary catheter inserted at a different location. When a peripheral blood sample cannot be obtained, blood samples may be drawn during hemodialysis from bloodlines connected to the dialysis catheter. If absolutely no alternative sites are available for catheter insertion, then exchange the infected catheter over a guidewire. If the symptoms persist or if there is evidence of a metastatic infection, the catheter should be removed. Antibiotic Therapy Empirical antibiotic therapy should include vancomycin and coverage for gram-negative bacilli, based on the local antibiogram. For cefazolin, use a dosage of 20 mg/kg (actual body weight), rounded to the nearest 500-mg increment, after dialysis.