Acute Kidney Injury：急性肾损伤课件

AcuteKidneyInjuryFY1TeachingNov30th2011DrJackBondST5NephrologyAcuteKidneyInjury-ObjectivesTorecogniseAKITodifferentiatebetweenpre-renal,renalandpostrenalcausesofAKITorecogniseandmanagehypovolemiaTomanagehyperkalemiaandpulmonaryodemaToknowindicationsforemergencydialysisHowtocallanephrologistwithoutgettingshoutedat11/21/2011June2009NCEPODConclusions-SummaryThereweresystematicfailingsinAKIcareFailuresin:RecognitionandmanagementofAKIRecognitionandmanagementofcomplicationsReferralandsupportFailuresinrecognitionoftheacutelyillAKIQuestionsPleasecompletethequestionnaireAnythingyouwanttoaskaboutAKIWillanswerthemanonymouslyduringthelectureManagingAKIIsyourpatientreallysick?GethelpVolumeassess+fluidchallengeU+Es+bloodgasUrinedipU/SabdoNephrologyreferralDefinitionofAKIRiseinserumcreatinine>50%frombaselineOrUrineoutput<0.5ml/kg/hrfor6hoursCreatininecriteriaUrineoutputcriteria≥50-100%riseinCrUrineoutput<0.5ml/kg/hr

for6hours(=240mlat80kg)SIMPLIFIEDRIFLEORAKINDEFINITION

UsuallybasedonCreatininerise

LossandEndstagecomponentsofRIFLEnowdropped101-200%riseinCrUrineoutput<0.5ml/kg/hr

for12hours(=480mlat80kg)>200%riseinCrUrineoutput<0.3ml/kg/hrfor24hours

oranuria12hoursRiskorAKIN1InjuryorAKIN2FailureorAKIN3HighsensitivityHighspecificityOliguriaWhichscenarioisAKI?1.85male,D+V,creat120,usually802.82female,D+V,Urea15.2,Creat1503.60male,diabetic,creat250,usual2004.74male,legionellapneumonia,Na118,Creat130,usualcreat705.63female,diabetic,myocardialinfarct,eGFR25,usualeGFR3511/21/2011SlowriseinCruntileventuallyanewsteadystateisreachedLargeacutedropinGFRwitholigoanuriaOnlyasmallearlyriseinCr:noteasytorecogniseasAKISuspectAKIinasickpatientwith

amodestriseintheircreatinineGFRfallsrapidlytonearzero-onlyshownbyoliguria11/21/2011EffectofAKIonoddsofdeath

ChertowGMetalJAmSocNephrol

2005Riseinserumcreat>50%baselinebaselinecreatinineof80mmol/LRisesto120mmol/LSignificantkidneyinjuryThisisthemomenttoact–itistoolatewhenthecreatininereaches400Thingsthatdon’tdiagnoseAKIUrea–notspecificeGFR–usedinChronicKidneydiseaseElectrolytesdisturbanceAresultofAKI,butnotspecificCase66yearoldmanisadmittedtoA+Ewithbreathlessness.Hehasbeenunwellforaweek,coughingupphlegmandhavingfevers.Hispastmedicalhistoryincludesdiabetesandhypertension.Hismedicationismetformin,aspirin,ramipril,atenololandsimvastatin.Onexaminationheisunwell.HisobsareBP85/50,HR115,Sats92%onair,RR25,Temp38.3.Youhearcoarsecracklesontherightsideofhischest.ACXRconfirmspneumonia.HisbloodresultscomebackwhichshowNa130,K4.5,Urea14.3,Creat189.Thenurseasksyoutoassesshimashehasn'tpassedurinesinceadmission.CaseOutlinethemanagementyouwouldundertakeinA+E.Whatisthelikelycauseforhisrenalfailure?Whatinvestigationswouldyouorderandwhy?Whatriskfactorsareevidentinthisman'scasethatmakehimmorelikelytohaverenalfailure?ManagingAKIIsyourpatientreallysick?GethelpVolumeassess+fluidchallengeU+Es+bloodgasUrinedipU/SabdoNephrologyreferralAKIriskfactorsMostpeoplehave>1riskfactorAgeDrugs(ACEi,diuretics,NSAIDS)ChronickidneydiseaseHypovolemia/SepsisDiabetesAKI:causesImportanttoattempttocategorisebroadlyintooneof3groupssepsis/hypovolemia70%drugrelated,acuteGN20%obstruction10%PRE-RENALRENALPOST-RENALCauseofAKI–3tests3assessmentsresultina45%36monthssurvival,comparedwith15%for0assessmentsFluid/volumeassessment PREUrinalysis RENALUltrasound POST11/21/2011QuestionWhichoftheseisthemostusefulindicatorofhypovolaemia?:capillaryrefilltime>5secondsjugularvenouspulsenotvisibleat30ºposturalpulserise>30bpmsystolicbloodpressure<95mmHgsystolicBPrisewith

250mlsalinebolus>20mmVolumeassessment-keyMEWSscoreCaprefillBP,HR,PosturalBPJVPAuscultatelungsPeripheralodemaUrineoutputVolumeassessmentYouaretheFY1coveringorthopedics.Youhavebeenaskedtosee74femalepost#NOFasshehaslowurineoutputPMH-diabetes,hypertensionCreat150,baseline100,urineoutput20mlsinlasthourCRT2secs,BP110/50,HR98,JVP??,chestcoupleofcreps,noedemaIspatientfluiddepleted,euvolemicoroverloaded?Howmuchfluidwouldyouprescribe?VolumemanagementMostpatientsarehypovolemic(70%)Ifnotgrosslyoverloaded–fluidchallenge-500ml+recheck“Normal”BPfor75yearold–150/70-apostopBPof110isrelativelyhypotensiveVolumeassessmentFurosemideinARF–meta-analysis

-Hoetal2006,BMJ

DoesnotimprovemortalityDoesnotreduceneedfordialysisUrinalysis-thispointstowardsintrinsicrenaldiseaseIe

glomerulonephritis-bloodandproteinuriaondipstick=nephrologyreferralAKIinvestigationsu/surinarytract-suspectobstructioninmenwithprostaticsymptoms-palpablemass-intra-abdominalmalignancycompressureterswithnobladderpalpablefemales-wherecausenotobviousManagingAKIIsyourpatientreallysick?GethelpVolumeassess+fluidchallengeU+Es+bloodgasUrinedipU/SabdoNephrologyreferralAKIQUESTIONTIMEHyperkalaemia-True/False1.CalciumgluconateactsbyreducingtheserumpotassiumT/F2.Insulin/dextroseinfusionrequires30minstoshiftpotassiumintocellsT/F3.Insulin/dextroseinfusioneffectslastfor24hoursT/F4.Salbutamol

nebulisershavethesameeffectasinsulin/dextroseinfusionT/F5.IVsodiumbicarbonatecanreducepotassiumT/F6.totreathyperkalemiayouwouldprescribe50unitsofactrapidin50ml50%dextroseT/F7.10mlof10%CalciumgluconateisthecorrectprescriptionforthetreatmentofhyperkalemiaT/F8.CalciumresoniumactswithinminutestoreduceserumKT/FHyperkalemiaK+>6.5-1st–repeatmeasureonVBG/ABG(takes5mins)-iftrue–ECG-iflifethreateningchangesCalciumgluconate10ml10%stat(throughbigvein–tissueburns)-thereafter10unitsactrapidin50mls50%glucoseover30mins.HyperkalemiaInsulin/dextrose–lasts4hoursonly-inmeantimecorrectcauseofhighK-RepeatABGat4hourstoseeifbetterIfK+stillhigh–DIALYSISMAYBEINDICATEDHyperkalemiaSalbutamolnebs(10-15mg)havesameactionasinsulin/dextroseandmaybeanoption-cautionincardiacdiseaseIVsodiumbicarbonate1.26%-usefulindehydratedpatientwhoisACIDOTIC-discusswithsenior,butconsiderifHCO3<18andneedsongoingfluidreplacement-worsenspulmonaryoedema++HyperkalemiaKeyistorecheckaftertreatmentCorrectunderlyingcauseConsiderdialysisPulmonaryoedemainAKIABCDEapproachOxygenGTNinfusionDiamorphineConsiderlargedosefurosemide250mgIVCPAPITU/ventilationCorrectcauseofrenalfailure(days)DialysisindicationsConsiderhaemodialysis/haemofiltrationif:Resistanthyperkalaemia>6.0FluidoverloadandnourineoutputPersistentacidosispH<7.2CallforseniorsupportinallcasesNephrologyreferralfordialysispatientsadmittedunderanyotherspecialtyWhentocallnephrologyAnyknowndialysispatientadmitte