Post-Dialysis Vomiting in ESRD Patients with Permanent Catheters
Immediately assess for catheter-related complications (infection, thrombosis, or disconnection) and dialysis-related factors (hypotension, electrolyte shifts, ultrafiltration rate), as these are the most common and treatable causes of post-dialysis vomiting in permanent catheter patients.
Immediate Assessment Priorities
Catheter-Related Complications
Evaluate for catheter infection first, as this is the leading cause of catheter-related morbidity in dialysis patients:
- Exit site examination: Look for redness, crusting, exudate, or tunnel drainage 1
- Systemic signs: Check for fever, chills, hemodynamic instability 1
- Blood cultures: Obtain immediately if catheter-related bacteremia is suspected 1
- Infection occurs in approximately 13% of permanent jugular catheter patients and represents the most common complication 2
Catheter Thrombosis and Dysfunction
- Thrombosis occurs in approximately 22% of permanent catheter patients and can cause inadequate dialysis leading to uremic symptoms including nausea and vomiting 3
- Check catheter flow rates and adequacy of dialysis session 1
- Assess for signs of inadequate clearance that may manifest as uremic symptoms 1
Closed Connector Device Issues
If closed connector devices are being used (as recommended), verify proper connection 1:
- Improper connection can lead to air embolism or bleeding complications 1
- Patients with limited manual dexterity should receive assistance with connections 1
- Training and extra care are essential to prevent catastrophic complications 1
Dialysis-Related Factors
Intradialytic Hypotension and Ultrafiltration
- Rapid fluid removal can cause hypotension leading to nausea and vomiting 4
- Review ultrafiltration rate and blood pressure trends during the session 4
- Nausea occurs in approximately 28% and vomiting in 12% of maintenance hemodialysis patients 4
Electrolyte Disturbances
- Check serum electrolytes immediately if symptoms develop postoperatively or post-dialysis 5
- Rapid shifts in potassium, calcium, or phosphate can trigger gastrointestinal symptoms 1
- For patients on intensive hemodialysis, maintain dialysate calcium ≥1.50 mmol/L to prevent imbalances 1
Management Algorithm
If Infection is Suspected
Exit site infection without systemic symptoms 1:
- Apply topical antibiotics with proper local care
- Do NOT remove catheter initially
- Monitor for progression
Tunnel infection with drainage 1:
- Initiate parenteral anti-staphylococcal/anti-streptococcal antibiotics
- Culture exit site
- Remove catheter only if infection fails to respond to therapy
Catheter-related bacteremia 1:
- Remove catheter immediately if patient remains symptomatic >36 hours
- Remove catheter in any clinically unstable patient
- Initiate parenteral antibiotics appropriate for suspected organisms
- Minimum 3 weeks of systemic antibiotic therapy required
- Blood cultures must be negative for ≥48 hours after antibiotic cessation before placing new permanent access
If Thrombosis is Suspected
- Catheter thrombosis requires manipulation or replacement 3
- Mean time to requiring manipulation is 4.1 months 3
- Ensure adequate anticoagulation during dialysis sessions 1
If Dialysis-Related
- Reduce ultrafiltration rate in subsequent sessions 4
- Adjust dialysate composition (calcium, phosphate) per guidelines 1
- Consider antiemetic therapy for symptomatic relief 4
- Monitor electrolytes and correct abnormalities 5
Critical Pitfalls to Avoid
- Do NOT delay catheter removal in unstable patients with suspected bacteremia - this is life-threatening and requires immediate action 1
- Do NOT needle puncture into areas of suspected pseudoaneurysm or infection 1
- Do NOT assume vomiting is benign - inadequate dialysis is associated with increased hospitalization and mortality 1
- Do NOT place new permanent access until cultures negative ≥48 hours post-antibiotics 1