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Emergencies In Nephrology PowerPoint Presentation

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Description : Check out this medical PowerPoint presentation titled "Emergencies in Nephrology”.

This medical PowerPoint presentation is about nephrology, the branch of medicine that focuses on the study, diagnosis, and treatment of kidney diseases.

The emergencies that can occur in nephrology include Acute kidney injury (AKI), Hyperkalemia, Hypertensive crisis, Acute glomerulonephritis and Nephrotic syndrome.

Tags : Emergencies in Nephrology, kidney diseases, Acute kidney injury, Hyperkalemia, Hypertensive crisis, Acute glomerulonephritis, Nephrotic syndrome,Nephrology, Nephrology PowerPoint presentation

Published on : Jun 07, 2023 | Views : 772 | Downloads : 2

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Slide 1-

Emergencies in Nephrology Management
Slide 2-

Topics Hyperkalemia Hyponatremia PD associated peritonitis Volatile alcohols Afterthoughts
Slide 3-

Hyperkalemia
Slide 4-

Case 62 year old woman h/o ESRD who presented with progressive leg weakness for one day. VS: HR 16-20, BP 213/88, RR 16, SaO2 100% on 4L NC, T 35.4 Phys. Exam: Somewhat confused, marked regular bradycardia, R. femoral PC, unable to move lower extremities. Na+ 138 mmo/L, HCO3 24 mmo/L, Cl- 104 mmo/L, WBC 6, K+ 9.8 mmo/L
Slide 5-

Case: EKG prior to Treatment
Slide 6-

Case: EKG prior to Treatment
Slide 7-

Case: EKG after Treatment (Hemodialysis)
Slide 8-

I. Treatment of Hyperkalemia Obtain EKG Calcium chloride: 0.25-0.5mEq/kg (one Amp) Modifies myocardial excitability Onset: 1-3 minutes Duration: 30-60 minutes
Slide 9-

II. Treatment of Hyperkalemia Glucose and Insulin, one Amp of D50 and 10 units IV Increases intracellular uptake of Potassium Onset: 5-10 minutes Duration: 2 hours
Slide 10-

III. Treatment of Hyperkalemia Albuterol, 1-2 neb treatments Increases intracellular uptake of Potassium Onset: 30-40 minutes Duration: 2-6 hours Does not work in up to 20% of patients
Slide 11-

Hyperkalemia: Treatment Sequence
Slide 12-

Hyponatremia
Slide 13-

Genuinely Hyponatremic? Pseudohyponatremia No Genuinely hypotonic? Hyperglycemia Radiocontrast Mannitol No Diluting Defect? Primary Polydipsia Beer Potomania No Assess Extracellular Volume GI Fluid Loss Adrenal Insufficiency Diuretics Cerebral Salt Wasting Burns and 3rd-Space Fluid Loss Endurance Exercise SIADH Glucocorticoid Deficiency Hypothyroidism (Reset Osmostat) NSIAD Endurance Exercise Edema-forming States Heart Failure Cirrhosis Nephrosis High Low Not AVP Mediated AVP Mediated Normal Yes Renal Failure? Inability to excrete Water Yes
Slide 14-

Genuinely Hyponatremic? Pseudohyponatremia No Genuinely hypotonic? Hyperglycemia Radiocontrast Mannitol No Diluting Defect? Primary Polydipsia Beer Potomania No Assess Extracellular Volume GI Fluid Loss Adrenal Insufficiency Diuretics Cerebral Salt Wasting Burns and 3rd-Space Fluid Loss Endurance Exercise SIADH Glucocorticoid Deficiency Hypothyroidism (Reset Osmostat) NSIAD Endurance Exercise Edema-forming States Heart Failure Cirrhosis Nephrosis High Low Not AVP Mediated AVP Mediated Normal ADH Absent Low U Osm ADH Present High U Osm Yes Renal Failure? Inability to excrete Water Yes
Slide 15-

Hyponatremia in Hospitalized Patients 196 Consecutive Patients 154 Hypotonic 186 Hyponatremic 137 Not Due to RF Alone Lab Error Hyperglycemic Renal Failure -10 -32 -17 [Na+]<130 mmol/L Anderson RJ et al. Ann Intern Med. 1985;102:164-168.
Slide 16-

Hyponatremia Symptoms Mild Symptoms Headache Irritability Nausea / Vomiting Mental Slowing Unstable Gait / Falls Confusion / Delirium Disorientation Severe Symptoms Stupor / Coma Seizure Respiratory Arrest
Slide 17-

Osmotic Demyelination
Slide 18-

Hyponatremia: Rate of Correction Sterns J Am Soc Nephrol 1994:4 1552
Slide 19-

Hyponatremia: Rate of Correction { Chronic Cases(n=38) AcuteCases(n=18) { Sterns J Am Soc Nephrol 1994:4 1552
Slide 20-

Hyponatremia: Treatment Algorithm Hyponatremia Acute (<48 hours) or Chronic (>2 days or Unknown)? High risk for rapid overcorrection and Osmotic Demyelination? Severe Symptoms and at risk for major complications? Treatment
Slide 21-

Avoiding ODS in Patients With Chronic HN Population at risk: HN with [Na+]≤120 mmol/L of >48 h duration, eg, thiazide, typical SIADH Accommodation to HN complete; at risk for ODS Increased vigilance in patients at high risk for ODS [Na+]≤105 mmol/L Alcoholism, malnutrition, hypokalemia, advanced liver disease Minimum correction: 4-8 mmol/L per 24 h; 4-6 mmol/L if ODS risk elevated Limits not to exceed: 10-12 mmol/L in any 24 h, 18 mmol/L in any 48 h with normal ODS risk 8 mmol/L in any 24 h if ODS risk elevated Verbalis JG et al. Am J Med. 2013;126:S1-S42.
Slide 22-

Hyponatremia: Treatment Options Verbalis JG et al. Am J Med. 2013;126:S1-S42.
Slide 23-

Hypertonic Saline (3%) 513 mEq/L of Sodium and 513 mEq/L of Chloride (Total of 1026 mOsm/L) Administration will add NaCl to the body, but it will increase body tonicity and move water from the intracellular fluid compartment to extracellular fluid compartment.
Slide 24-

Hypertonic Saline (3%) 513 mEq/L of Sodium and 513 mEq/L of Chloride (Total of 1026 mOsm/L) Administration will add NaCl to the body, but it will increase body tonicity and move water from the intracellular fluid compartment to extracellular fluid compartment. In the absence of urinary water loss… 1 ml/kg/hr of 3% saline will increase serum sodium by about 1 mmol/L each hour. For a 70kg woman, 70ml/hr of 3% saline 12 mmol over 12 hours OR 35 ml/hr of 3% saline will increase by 6 mmol over 12 hours.
Slide 25-

Symptomatic Acute Hyponatremia For severe sx, 100 mL of 3% NaCl infused IV over 10 minutes; repeat x 2 as needed For mild to moderate sx with a low risk of herniation, 3% NaCl infused at 0.5-2 mL/kg/h Anticipate that 3% NaCl infused at 1 mL/kg/h will raise [Na+] approximately 1 mmol/L/h Measure [Na+] every 2 hours; all formulae are approximations Rate of correction need not be limited if HN known to be acute; otherwise observe chronic HN daily correction limit Verbalis JG et al. Am J Med. 2013;126:S1-S42.
Slide 26-

Case from 8/8/17 – Spin Call
Slide 27-

Desmopressin Replacement of urinary water loss with D5W Starting dose: Desmopressin 2 mcg iv If NO response: Desmopressin 4 mcg iv Strategy I: Desmopressin 2 mcg q6-8h AND infusion of low dose hypertonic saline (10 – 30 mL/hour) Strategy II: Desmopressin 2 mcg once and repeat prn to avoid excessive increase in serum Na
Slide 28-

PD Associated Peritonitis
Slide 29-

Case 60 yo man ESRD on PD with abdominal pain and vomiting for two days. VS with fever at 100.8 F, abdomen distended and diffusely tender without guarding or rebound. WBC 8.7, lac 1.9, fluid cell ct 774 (99% neutrophils), fluid gram stain GPCPC Given IV Vancomycin, Cefotaxime. Later started IP Vancomycin and Ceftazadime.
Slide 30-

Hospital Day 2 Abdominal pain worsened and developed worsening distention and mild guarding. WBC 21.5, lac 2.6, fluid cell ct 3,958. Antibiotic coverage was broadened by adding IV Flagyl and Fluconazole. CT A/P preliminarily read as mild ileus.
Slide 31-

Hospital Day 3 Abdominal pain persisted, exam unimproved. WBC 16, lac 1.6. Original fluid culture updated to S. Viridans and mixed anaerobes. Final CT result: “Probable acute appendicitis. No peri-appendiceal abscess. Small loculated collection along the peritoneal dialysis catheter within the subcutaneous fat.” Intra-operatively found rupture appendix; underwent appendectomy, washout and Tenckhoff catheter removal.
Slide 32-

“Surgical” Peritonitis In PD Uncommon and/or under-reported and/or goes undiagnosed. Retrospective chart analysis at one institution of 133 PD patients with peritonitis of any cause between 2004 and 2006 revealed 6 surgical causes1. Another similar study between 1990 and 1998 also revealed 6 cases2. 1. Yehia, M, et al. Is computerized tomography useful in identifying abdominal catastrophes in patients presenting with peritonitis?Perit Dial Int. 2008 Jul-Aug;28(4):385-90. 2. Charles C, et al. Emergency laparotomy in patients on continuous ambulatory peritoneal dialysis. Am Surg. 2001 Jul;67(7):615-8.
Slide 33-

Diagnostic Dilemmas Presence of free air on KUB is unreliable. Presentation atypical and non-localizeable. Partial treatment causes protracted course of symptoms and delays cultures. CT may be less sensitive.
Slide 34-

Case 60 yo man ESRD on PD with abdominal pain which started this morning 4 hours after dialysis was completed. Patients last fill is with 2.5% dextrose, 1.8 liters. VS normal, abdomen mildly tender without guarding, very significant rebound. WBC 8.7, lac 0.3, fluid cell ct 7380 (97% neutrophils), fluid gram stain yields no organism Given IP Vancomycin and Cefotaxime as “midday” exchange at 3:30pm, CCPD was resumed at 10:00 pm. On day two the pain and rebound has substantially improved, fluid cell ct 560. Culture yield GPC. Later that week – Staph epi
Slide 35-

Peritonitis Clinical diagnosis: Abdominal pain and cloudy fluid. Diagnostic criteria: Cell count with WBC > 100/μL (after a dwell time of at least 2 hours), with at least 50% polymorpho- nuclear neutrophilic cells. Presumtive diagnosis: bacterial PD associated peritonitis. Peritoneal Dialysis Int, 30: 393-423, 2010
Slide 36-

Peritonitis: Antibiotics Peritoneal Dialysis Int, 30: 393-423, 2010
Slide 37-

Antibiotic Orders Navigator: Dialysis Ren CAPD
Slide 38-

Peritonitis: Catheter Removal Peritoneal Dialysis Int, 30: 393-423, 2010
Slide 39-

Volatile Alcohols
Slide 40-

Volatile Alcohols Methanol, ethylene glycol, and isopropanol or isopropyl alcohol are commonly referred to as the toxic alcohols Methanol: windshield washer fluid and many industrial solvents Ethylene glycol: constituent of antifreeze Isopropanol: rubbing alcohol- antiseptic Easily accessible regardless of whether ingestion is intentional or accidental (eg, when a child ingests the poison) Volatile alcohols affect the anion gap and the osmolar gap.
Slide 41-

Anion Gap versus Osmolar Gap Anion Gap: Na+ – (Cl- + HCO2-) = around 12 Osmolar Gap: Osmmeassured – Osmcalculated = Osmgap Osmcalculated = 2xNa + Glucose + Urea (all in mmol/L) OR 2xNa + (Glucose/18) + (Urea/2.8) (if Na is in mmol/L and Glucose and BUN are measured in mg/dL).
Slide 42-

Anion Gap HAGMA – caused by the gain of acid NAGMA – caused by the loss of HCO3-
Slide 43-

Osmolar Gap Osmmeassured Osmcalculated OG Osmcalculated EOG OG – Solutes (in mosm/L) not accounted for in the estimation EOG – Presence of unexpected solutes (in mosm/L) like volatile alcohols
Slide 44-

Volatile Alcohols Methanol, ethylene glycol, and isopropanol are commonly referred to as the toxic alcohols Methanol: windshield washer fluid and many industrial solvents Ethylene glycol: constituent of antifreeze Isopropanol: rubbing alcohol- antiseptic Easily accessible regardless of whether ingestion is intentional or accidental (eg, when a child ingests the poison) Methanol and ethylene glycol produce a metabolic acidosis with an increased osmolal gap Isopropanol rapidly metabolizes to acetone, also produces an increased osmolal gap but does not produce a metabolic acidosis unless concomitant hypotension causes lactic acidosis
Slide 45-

Case A 55 year-old man with a history of alcoholism presented to the ED confused and oliguric Vitals: T 37.1 BP 169/79 HR 105 RR 42 99% RA Basic labs 144 4.7 104 9 12 2.4 114 ABG: 7.08 / 12 / 143 / 4 Anion Gap: 31 Lactate: >20 mmol/L Serum toxin screen: negative for EtOH, ASA, acetaminophen Serum osmolality: 345 mOsm/kg Osmolal gap: 45 mOsm/kg
Slide 46-

Ethylene glycol: 47 mg/dL
Slide 47-

Hospital Course Admitted to the MICU and intubated Fomepizole administered Hemodialysis Worsening encephalopathy & seizure HD Seizure
Slide 48-

ppt slide no 48 content not found
Slide 49-

Outcome CNS Neurologic function remarkably recovered Renal function did not recover Anuric, now on HD Patient has no recollection of consuming ethylene glycol
Slide 50-

Ethylene Glycol Rapidly absorbed by intestine, peaks 30-60 minutes t1/2 3-8 hrs, 18hrs with EtOH Metabolism: 80% liver, 20% renal Renal clearance ~30 mL/hr Dialyzable w/ clearance ~145-230 mL/hr Contributes 1 mOsm/L per 6.2 mg/dL in serum Page 50 N Engl J Med. 2007 Feb; 356(6):611. N Engl J Med. 2007 May; 356:2006-7.
Slide 51-

Ethylene Glycol Metabolism Osmolal Gap Anion Gap Netherlands Journal of Medicine. 2010 Jul;:68(7/8):320-323. Urine Urine
Slide 52-

Osmolal Gap & Anion Gap vs. Time Intensive Care Med 30: 1842–1846, 2004
Slide 53-

Ethylene Glycol Complications Falsely incr. lactate Metabolic derangement End-organ damage (renal, CNS) Urine Urine CNS depression
Slide 54-

Falsely elevated lactate CMAJ. 176(8):1097-99
Slide 55-

Management N Engl J Med 1999; 340:832-8. N Engl J Med 2009; 360:2216-23
Slide 56-

Effect of Dialysis Toxicological Sciences. 85, 491–501 (2005)
Slide 57-

Differential Clin J Am Soc Nephrol. 2008 Jan;3(1):208-25. Epub 2007 Nov 28 UpToDate. Emmett, M. 2010 Jun. “Plasma osmlal gap“
Slide 58-

Differential: Size of the Osmolar gap
Slide 59-

Case 44 yo male with prior Mallory Weis tear and EtOH abuse p/w hematemesis. Drinking half gallon of vodka daily, last drink 6 hours PTA. Denies NSAID use No witnessed episodes of hematemesis in ED & Hgb 13 Admitted for EtOH withdrawal 1:1 sitter given SI
Slide 60-

HOD#4 Physical exam unremarkable in the AM… Return to bedside to reassess pt given Cr 2.1 on late AM labs (0.9 upon admission)
Slide 61-

Physical Exam VS: 98.5 92 125/76 16 98% RA GEN: Obtunded. Unresponsive to sternal rub. Sitter reading a novel in the corner. HEENT: Pupils dilated, reactive to light LUNG: CTAB, breathing unlabored HEART: RRR, no m/r/g ABD: SNDNT EXT: No c/c/e. NEURO: Obtunded as above. No gag reflex. SKIN: No rash or diaphoresis.
Slide 62-

RRT: Labs
Slide 63-

Laboratory abnormalities of toxic ingestions
Slide 64-

Follow up on our patient…
Slide 65-

Management of isopropyl alcohol toxicity CNS depression, nausea, vomiting, and abd pain Complications: neurogenic hypotension, coma, pulmonary edema, hematemesis, and hemorrhagic tracheobronchitis Fomepizole not indicated Serum elimination half-life ~2.5 to 8 hours vs >10 hours if converted to acetone Volume resuscitation +/- pressors Hemodialysis for refractory hypotension Asymptomatic unintentional ingestions can be d/c’ed from ED.
Slide 66-

Afterthoughts
Slide 67-

When are Dialysis Patients Volume Overloaded Mon Tue Wed Thu Fri Sat Sun Volume Status and Serum Urea