Emergencies in Nephrology - PowerPoint Presentation

Slide1

Emergencies in Nephrology

Management

Slide2

Topics

Hyperkalemia

Hyponatremia

PD associated peritonitis

Volatile alcohols

Afterthoughts

Slide3

Hyperkalemia

Slide4

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, HCO

3

24

mmo

/L,

Cl

-

104

mmo

/L, WBC 6,

K

+

9.8

mmo

/L

Slide5

Case: EKG prior to Treatment

Slide6

Case: EKG prior to Treatment

Slide7

Case: EKG after Treatment (Hemodialysis)

Slide8

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

Slide9

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

Slide10

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

Slide11

Hyperkalemia: Treatment Sequence

Slide12

Hyponatremia

Slide13

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 3

rd

-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

Slide14

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 3

rd

-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

Slide15

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.

Slide16

Hyponatremia Symptoms

Mild Symptoms

Headache

Irritability

Nausea / Vomiting

Mental Slowing

Unstable Gait / Falls

Confusion / Delirium

Disorientation

Severe Symptoms

Stupor / Coma

Seizure

Respiratory Arrest

Slide17

Osmotic Demyelination

Slide18

Hyponatremia: Rate of Correction

Sterns J Am Soc

Nephrol

1994:4 1552

Slide19

Hyponatremia: Rate of Correction

{

Chronic

Cases

(n=38)

Acute

Cases

(

n

=18)

{

Sterns J Am Soc

Nephrol

1994:4 1552

Slide20

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

Slide21

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 elevatedLimits 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 elevatedVerbalis JG et al.

Am J Med. 2013;126:S1-S42.

Slide22

Hyponatremia: Treatment Options

Treatment

Term

of Use

Comment

Fluid Restriction

Short

or Long

Cheap. Not well tolerated or observed. Not

effective unless U

Osm

low.

Hypertonic Saline

Short

Reliable,

cheap. Not suitable for patients with volume overload. Requires care to avoid over-rapid correction.

Isotonic

Saline

Short

Cheap. Effective only when

volume depletion is cause of HN.

Demeclocycline

Long

Variable efficacy, nephrotoxic,

not FDA approved.

Urea

Long

No USP formulation, not FDA approved, not well

tolerated, and acceptance is poor.

Vaptans

Short or Long

Elegant.

Conivaptan IV only; short-term use. Tolvaptan short or long term.

Verbalis

JG et al.

Am J Med

. 2013;126:S1-S42.

Slide23

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.

Slide24

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.

Slide25

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/hMeasure [Na+] every 2 hours; all formulae are approximationsRate of correction need not be limited if HN known to be acute; otherwise observe chronic HN daily correction limitVerbalis

JG et al. Am J Med. 2013;126:S1-S42.

Slide26

Case from 8/8/17 – Spin Call

Slide27

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

Slide28

PD Associated Peritonitis

Slide29

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.

Slide30

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.

Slide31

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.

Slide32

“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 causes

1

.

Another similar study between 1990 and 1998 also revealed 6 cases

2

.

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.

Slide33

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.

Slide34

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

Slide35

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

Slide36

Peritonitis: Antibiotics

Peritoneal Dialysis

Int

,

30: 393-423, 2010

Slide37

Antibiotic Orders

Navigator:

Dialysis

Ren

CAPD

Slide38

Peritonitis: Catheter Removal

Peritoneal Dialysis

Int

,

30: 393-423, 2010

Slide39

Volatile Alcohols

Slide40

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.

Slide41

Anion Gap versus

Osmolar

Gap

Anion Gap:

Na

+

– (Cl

-

+ HCO2-) = around 12

Osmolar

Gap:

Osmmeassured – Osmcalculated = OsmgapOsmcalculated = 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).

Slide42

Anion Gap

HAGMA – caused by the gain of acid

NAGMA – caused by the loss of HCO3

-

Slide43

Osmolar Gap

Osm

meassured

Osm

calculated

OG

Osm

calculated

EOG

OG – Solutes (in

mosm

/L) not accounted for in the estimation

EOG – Presence of unexpected solutes (in

mosm

/L) like volatile alcohols

Slide44

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 gapIsopropanol rapidly metabolizes to acetone, also produces an increased osmolal gap but does not produce a metabolic acidosis unless concomitant hypotension causes lactic acidosis

Slide45

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

Slide46

Ethylene glycol:

47

mg/

dL

Slide47

Hospital Course

Admitted to the MICU and intubated

Fomepizole

administered

Hemodialysis

Worsening encephalopathy & seizure

HD

Seizure

Slide48

Slide49

Outcome

CNS

Neurologic function remarkably recovered

Renal function did not recover

Anuric

, now on HD

Patient has no recollection of consuming ethylene glycol

Slide50

Ethylene Glycol

Rapidly absorbed by intestine, peaks 30-60 minutes

t

1/2

3-8

hrs

, 18hrs with

EtOH

Metabolism: 80% liver, 20% renal

Renal clearance ~30 mL/

hr

Dialyzable w/ clearance ~145-230 mL/

hrContributes 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.

Slide51

Ethylene Glycol Metabolism

Osmolal

Gap

Anion Gap

Netherlands Journal of Medicine.

2010 Jul;:68(7/8):320-323.

Urine

Urine

Slide52

Osmolal

Gap & Anion Gap vs. Time

Intensive Care Med

30: 1842–1846, 2004

Slide53

Ethylene Glycol Complications

Falsely incr. lactate

Metabolic

derangement

End-organ damage (renal, CNS)

Urine

Urine

CNS depression

Slide54

Falsely elevated lactate

CMAJ

. 176(8):1097-99

Slide55

Management

N

Engl

J Med

1999; 340:832-8.

N

Engl

J Med

2009; 360:2216-

23

Slide56

Effect of Dialysis

Toxicological Sciences

. 85, 491–501 (2005)

Slide57

Differential

Clin J Am Soc Nephrol

. 2008 Jan;3(1):208-25. Epub 2007 Nov 28

UpToDate. Emmett, M. 2010 Jun. “Plasma osmlal gap“

Slide58

Differential: Size of the

Osmolar

gap

Slide59

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

withdrawal1:1 sitter given SI

Slide60

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)

Slide61

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.

Slide62

RRT: Labs

ABG

pH

7.4

PCO2

45

PO2

141

Chemistry

Na

145

K

3.5

Cl

107

CO2

27

BUN

3

Cr

2.1

Lactate

1.1

UDS

Benzo

Pos

Opioid

Neg

Cocaine

Neg

Urinalysis

Spec

grav

1.010

Protein

Neg

Blood

Neg

Leuk

est

Neg

Ketones

Pos

Serum

Osm

Measured

345Calculated 289

Slide63

Laboratory abnormalities of toxic ingestions

Slide64

Follow up on our patient…

Slide65

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.

Slide66

Afterthoughts

Slide67

When are Dialysis Patients Volume Overloaded

Mon

Tue

Wed

Thu

Fri

Sat

Sun

Volume Status and Serum Urea