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Nephrologic Emergencies

This article discusses three challenging cases in nephrologic emergencies, including a patient with a poor responsiveness, a patient with metabolic acidosis and increased osmolal gap, and a patient with a red rash and decreased mental status.

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Nephrologic Emergencies

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  1. Nephrologic Emergencies Jeff Kaufhold MD FACP Nephrology Associates of Dayton July 2009

  2. Case 1 • 81 y/o WF with poor responsiveness • Family couldn’t wake her up • Saw FP day before and felt OK • Squad found her unresponsive • Monitor in squad showed HR 30 • Transcutaneous pacing initiated

  3. Case 1 • In ER, HR 20 without pacer • Atropine given without improvement • EKG with 3rd degree AV Block • Transvenous pacer placed • Labs sent, foley placed • Respiratory failure and intubated

  4. EKG http://library.med.utah.edu/kw/ecg/image_index/index.html

  5. Case 1- Past Medical History • CKD with Cr 1.9 • HTN • Afib • Cirrhosis- cause unknown • Paracentesis this week for ascites

  6. Case 1- Meds • Cardizem CD 300mg QD • Lasix 40mg QD • Digoxin 0.125mg QD • Enulose 15cc QD • Remeron 30mg QD • Aldactone 100mg QD* • Neutraphos K 1 packet TID*

  7. Case 1 • BP dropped and dopamine initiated • Labs: • ABG 7.08/23/273/6.9 on vent • CK 56, troponin 0.11 • Na 131 K 8.3 Cl 100 CO2 9 AG 22 • BUN 34 Cr 4.7 • Dig 2.3 Phos 12.1 Mag 2.4

  8. Case 1 • Bicarb, D50, Insulin • Albuterol 4 puffs • Kayexalate 30 gm • Digibind 1 vial • Repeat K and ABG • Nephrology contacted

  9. Case 1 • Family gave consent for hemodialysis • Catheter placed, transferred to ICU • Hemodialysis on 0 K bath x1 hr then 2 K • During dialysis rhythm became Afib in 90’s • TV Pacer turned off

  10. EKG after treatment

  11. EKG after HD started

  12. Case 1 • Admission day • 0530 K 8.3 • 0730 K 7.5 • 1200 K 4.5 • 1300 K 4.3 • Next morning • 0500 K 4.2

  13. Case 1 Summary • Renal function improved to Cr1.9 with hydration • DC’d off neutraphos and aldactone • Synthroid started for TSH 50.09 • Outpt followup for cirrhosis

  14. Case 2 • 65 y/o WF found unresponsive • Had been depressed due to poor health • History of alcoholism requiring admissions • Various bottles of alcohol at scene per squad

  15. Case 2 • In ER completely unresponsive • Vitals stable but no gag • Intubated for airway protection • Physical exam unremarkable except • Thin, mildly malnourished • open ulcers on legs • Lungs scattered rhonci

  16. Case 2 • Past Medical History per niece • Diabetes mellitus • Chronic leg ulcers • HTN • Alcoholism • Tobacco abuse • Depression

  17. Case 2- Meds • Glucotrol XL 10 mg QD • Altace 5mg QD • Zoloft 50mg QD • Recently finished antibiotic for leg ulcers • Home remedy- rubbing alcohol for legs

  18. Case 2- Labs • ABG 7.29/32/365/17 • Na 130 K 3.9 Cl 108 CO2 14 • Glu 78 BUN 31 Cr 1.1 AG 8 • Acetone neg • Lactic acid 1.3

  19. Case 2 • DOA neg, ASA neg • EtOH 0.86

  20. Case 2 • Why doesn’t this make sense? • Metabolic (and respiratory) acidosis • Nongapped with neg acetone, neg lactate • Ethanol should give a gapped acidosis

  21. Case 2 • Calculated serum osmolality 275 • 2Na + Glu/18 + BUN/2.8 • Measured serum osmolality 353 • Osmolal gap 78 • Normal osmolal gap <10

  22. Case 2- Increased Osmolal Gap • Ethanol • Ethylene glycol • Methanol • Isopropyl alcohol • All should have an increased anion gap also • …except isopropyl

  23. Case 2 • Review of history- • Pt was found with various bottles of alcohol • Mostly vodka, some isopropyl • When sober, would wipe legs ulcers with isopropyl • When drunk, apparently would drink it

  24. Case 2 • Pt emergently dialyzed x 8 hrs • Isopropyl, methanol, ethylene glycol levels “sent out”

  25. Case 2- Summary • Pt began to wake up at end of dialysis • Extubated the following day • No long term neurologic adverse effects • Renal function remained stable • Psych and crisis evaluations

  26. Indications for Dialysis • A acidosisE electrolyte abnormalities I intoxication/poisoningO fluid overloadU uremia symptoms/complications

  27. Dialysis for Intoxications • T theophylline • A aspirin • B barbiturates • L lithium • E ethylene glycol, methanol • M metformin

  28. Case #3 • 68 y/o AAM sent in from chronic hemodialysis unit where staff noticed • a diffuse red rash/discoloration to skin of chest and face • Hypertension uncharacteristic for this patient did not respond to clonidine 0.2 mg) • Decreased mental staus

  29. Case #3 • PMH – ESRD, DM2, PVD, HTN, CAD • PSH – b/l BKA, CABG, PTCA (8 months prior), Left UE A/V fistula, Penile implant • All – NKDA • Soc – married, no tobacco/EtoH, independent, high functioning

  30. Case #3 • Meds • Phoslo 667 mg I TID meals • Nephrocaps QD evening meal • Accupril 10mg QD • Atenolol 12.5 mg BID • ECASA QD • Glucotrol XL 2.5 mg qd • Tylenol, Lomotil PRN • Viagra 50 mg PRN

  31. Case #3 • Exam T-98, P-95, R-22, 170/63 • Skin – diffuse redness to face, chest, hands (palmar) no macules, papules, ecchymosis, discrete lesions • HEENT – lips swollen, poss periorbital edema • H – RRR, L – clear • Abd – soft, nontender, no hepatospleenomegaly, no rebound • Ext – L a/v fistula + thrill/bruit

  32. Case #3 • ABG 7.43/43/54/29/88% on Room air • CBC • WBC – 10.4 • RBC – 1.21 • Hgb – 7.0 • HCT – 11.0 • MCV – 86 • PLT – 69,000 • Sample is grossly hemolyzed

  33. Case #3 • Na-139, K-3.8, Cl-102, HCO3-29 • BUN-38, Cr-6.0 • Glu 424 • CPK-545, CK-MB-22.8 (4%) • Troponin I 2.7

  34. Case #3 • Differential for Hemolysis • Liver disease • Hypersplenism • Infection (Clostridial sepsis, babesiosis, malaria, bartonella, E. coli O157) • Microangiopathies (TTP/HUS, Valvular prosthesis) • Autoimmune (warm/cold Ab) • Infusions – IVIg, Rhogam, Hypotonic saline, blood transfusion • Oxidant agents – dapsone, nitrites, snake bites • Hemoglobinopathies, Enzyme deficiencies, membrane deficiencies

  35. Case #3 • More lab results • Albumin – 3.1 • Total bilirubin – 13.9, indirect – 12.6 • Retic % 3.2 • AST-238, ALP-43, ALT-37, GGT<8 • LDH – 4591 • Haptoglobin – 36 (49-297) • Myoglobin - 2017

  36. Case #3 • Intravascular hemolysis, thrombocytopenia, altered mental status in a renal failure patient • Thrombotic Thrombocytopenia Purpura • Pt received therapuetic plasmapheresis (TPE) alternating with hemodialysis. Stabilized in 4-5 days. Suffered NQWMI day one

  37. Case #4 • 62 y/o CM presents with confusion and altered mental status • Family states he was normal yesterday but has been unable to “clear the cobwebs” today. Seems as though he is getting progressively more sleepy as the day goes on. • PMH – DM2 diet controlled, HTN • PSH – Appy, L femur fx with internal fix • All - NKDA

  38. Case #4 • Soc – retired school teacher, married, independent, Tobacco 60 pack-years, EtoH-social (daily) • Meds • Accuretic 10/12.5 md QD • ASA QD

  39. Case #4 • Exam T-98.6 P-88 R 14 140/80 80kg • Neuro – sleepy, follows simple commands, poor historian, communications are incoherent. Pupils are 4 mm, equal and reactive. Neck supple. Reflexes brachial/patellar normal. • H-RRR, no JVD, L-slight expiratory wheeze left • Abd – soft nontender no HSM • Ext – no edema

  40. Case #4 • CT Head – normal • ABG 7.41/40/98/25/99% on room air • Na-108, K-3.2, CL-76, HCO3-23, • BUN – 23, Cr-0.8 • Glu-96 • CXR – left upper lobe peripheral density • Sosm – 226, Uosm – 560 mosm/kg

  41. Case #4 • Hyponatremia • Hypo-osmolar, Euvolemic, but this patient has neurologic manifestations • Treatment • Restoration of serum sodium, goal 120Meq/L • Na deficit OR: • Free Water Excess • Monitor Na q2 hours, neuro checks • Investigate underlying cause

  42. Case #4 • Hyponatremia • Restoration of serum sodium, goal 120Meq/L • Na deficit: (120-108Meq/L)(0.6)(80kg) • =576 Meq of sodium needed to correct • One liter of 3% NaCl has 513 Meq Na • Correct 0.5 Meq/L each hour (12 Meq/L over 24 hours) • Hang one liter NaCl 3% at 40 cc/hr through central line. • Monitor Na q2 hours, neuro checks • Investigate underlying cause

  43. Case #4 • Hyponatremia • Restoration of serum sodium, goal 120Meq/L • Free Water Excess: • 108 mEq/L * 48 L = 120 mEq/L in X L • (108*48)/120 = 43.2 L • Excess = 4.8 L of free water to get rid of • Give NS to volume expand • Give Lasix to begin diuresis • Check urine vol, sodium hourly • Replace the sodium • Eg: (40 mEq/L * 0.5 L) = 20 mEq or 39 cc of 3% • Keep track of the water lost.

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