A 64-year-old female with ESRD and nonischemic cardiomyopathy with a left ventricular ejection fraction of 20% underwent IHD the day before. She developed flash pulmonary edema and is currently on epinephrine infusion for hemodynamic support.
Which of the following modalities would be MOST effective for fluid removal in this patient?
Correct Answer: B
SCUF is used exclusively to remove fluids and therefore a useful modality to treat isolated fluid overload. SCUF is not useful in patients who are uremic or hyperkalemic, because solute removal is minimal. SCUF can safely remove up to 8 L of fluid per day. The slow rate of fluid removal is beneficial in patients who have a tenuous hemodynamic status.
A 55-year-old male with history of diabetes mellitus, hypertension, and ESRD has been admitted to the ICU following a polytrauma. He suffered a mild concussion of his brain and multiple orthopedic injuries including a fractured pelvis and pelvic bleeding which required coiling in the interventional radiology suite. He is protecting his airway and has been hemodynamically stable for the past 24 hours. He is being started on IHD, as his blood urea nitrogen (BUN) is 180 mg/dL and creatinine is 8 mg/dL. Following IHD, he develops nausea, vomiting, and altered mental status concerning for dialysis disequilibrium syndrome.
Which of the following interventions if used is MOST likely to prevent the occurrence of this syndrome?
Correct Answer: A
Dialysis disequilibrium syndrome can occur when using aggressive/rapid RRT in a severely uremic patient. The shift of water into brain tissue due to the abrupt lowering of plasma tonicity during IHD may lead to an acute increase in intracranial pressure and cerebral hypoperfusion. Caution should be exercised in patients who are at risk of cerebral edema prior to initiation of RRT. To avoid brain edema caused by large variations in osmolality, several preventative measures can be employed. They include targeting a reduction in the plasma urea nitrogen of 40% at the most, reducing blood and dialysate flow, using a small dialyzer, and limiting the length of treatment. The use of a sodiumenriched dialysate may further reduce the risk. Dialysis disequilibrium syndrome is a significant risk with rapid clearance in severe azotemia when instituting RRT.
A 55-year-old female with a history of chronic obstructive pulmonary disease and chronic kidney disease on peritoneal dialysis (PD), presents to the emergency department with fever, dry cough, and wheezing. She does not complain of any abdominal pain. An upper respiratory tract infection is suspected. On admission, her hemoglobin is 9.8 mg/dL, white blood cell count is 11.2 K/µL, and lactate 3.8 mmol/L. Her vital signs are:
She has been afebrile since admission.
What is the MOST appropriate next step in the management of this patient?
Correct Answer: C
Lactate is the most commonly used buffer in PD solutions. An abnormal lactate value is often seen in PD patients presenting to the ED. It does not necessarily indicate tissue hypoperfusion or gut ischemia. This patient with acute respiratory symptoms needs to be treated and observed for any further worsening. Hyperlactatemia could be a coincidental occurrence in patients who undergo PD.
What is the recommended delivered dose of the effluent in CRRT?
Two large randomized controlled trials found no significant difference in mortality with effluent doses above 20 to 25 mL/kg/h. There were no significant differences in the secondary outcomes such as renal recovery and nonrenal organ failure as well. Of note, there were a few serious adverse events in the higher-intensity group. The KDIGO clinical practice guidelines recommend delivering an effluent dose of 20 to 25 mL/kg/h for CRRT in patients with AKI. Higher effluent rates confer no mortality benefit compared to a rate 20 to 25 mL/kg/h.
A 34-year-old female with a history of hypertension and diabetes is admitted to the ICU after an exploratory laparotomy following a motor vehicle accident. Her vital signs include HR 110 bpm and BP 90/66 mm Hg. She is currently intubated and mechanically ventilated and has developed AKI requires RRT. It is anticipated that she would need several trips to the operating room in the next few days for debridement and subsequent closure of the abdomen.
Which of the following would be the MOST efficient modality of RRT in this patient?
PIRRT is a renal replacement modality wherein treatment sessions last over 8 to 12 hours but are intermittent (about three times a week). It is a hybrid treatment wherein the hemodynamic stability achieved with CRRT is combined with the intermittent nature of IHD. Diffusion, convection, or a combination of the two techniques could be used with this modality. It is especially useful in patients who are not hemodynamically stable enough to initiate IHD but require several interruptions in therapy (potentially due to required procedures) which would make provision for CRRT challenging. To be effective, CRRT needs to be performed over 24 hours with minimal interruptions. As PIRRT has scheduled time off of dialysis and anticoagulation, procedures could be strategically scheduled over those times. PIRRT is sometimes referred to as sustained low-efficiency (daily) dialysis (SLEDD), sustained low-efficiency (daily) diafiltration (SLEDD-f), extended daily dialysis (EDD), or slow continuous dialysis (SCD). SCUF exclusively removes fluid and would be ineffective in patients requiring solute clearance as well. PIRRT is an effective hybrid renal replacement modality in hemodynamically unstable patients who are anticipated to have interruptions in CRRT.
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