Ep 151 AKI Half 2 – ED Administration
That is half 2 of our 2 half podcast sequence on AKI for the Emergency doctor. On this half Dr. Edward Etchells, Dr. Bourke Tillmann and Anton dig deeper into the easy 5-step ED method to AKI outlined partly 1, concentrating on the edematous affected person, and talk about the timing, quantity and IV crystalloid of selection in AKI sufferers in addition to dialysis indications and timing in gentle of the current STARRT-AKI trial. We reply the questions: are piperacillin and vancomycin together contraindicated in sufferers with extreme AKI? Is vasopressin most popular over norepinephrine in sufferers with AKI and septic shock? Is there a task for IV sodium bicarbonate in AKI? When ought to ACEi/ARBs be held in AKI sufferers? When, if ever, ought to NSAIDs be given in AKI sufferers, and in that case, how ought to the dose be modified? and lots of extra….
Podcast manufacturing, sound design & modifying by Anton Helman; voice modifying by Sheza Qayyum
Written Abstract and weblog publish by Anton Helman Jan, 2021
Cite this podcast as: Helman, A. Etchells, E. Tillmann, B. Episode AKI – ED Administration. Emergency Medication Instances. January, 2021. https://emergencymedicinecases.com/aki-ed-management. Accessed [date]
Administration of AKI within the ED: “Fluids & Foley” fixes most AKI
The vast majority of AKI may be mounted by “a bag of LR and a urethral catheter”… tincture of time could also be all that’s essential in lots of different instances. Someplace between 70-90% of AKI is pre-renal or post-renal in etiology, in order that fluid resuscitation and elimination of the obstruction (i.e. a urethral catheter) will in all probability resolve 70-90% of AKI. Nevertheless, a extra nuanced remedy algorithm needs to be thought-about in advanced instances.
5 step method to AKI within the ED
Step 1: Rule out the two quick life-threats
- Hyperkalemia – get ECG, electrolytes off the blood fuel
- Extreme acidosis – get blood fuel
Step 2: Assess for satisfactory perfusion – are they in shock?
Use your historical past, bodily examination and POCUS to evaluate for perfusion and deal with shock (hemorrhagic, vasodilatory, cardiogenic shock and so forth.) accordingly.
*the affected person in shock with acute coronary heart failure, pulmonary edema and AKI is particularly difficult, and should require norepinephrine to assist the blood stress and dobutamine to assist enhance cardiac ahead circulate, along with standard acute coronary heart failure administration; early session with an intensivist is advisable.
Step 3: Assess for each pulmonary and peripheral edema
Assess JVP and lungs with POCUS for pulmonary edema, look and palpate for peripheral edema (together with pre-tibial edema, sacral edema)
If there is no such thing as a proof of pulmonary or peripheral edema, give a fluid problem.
AKI with satisfactory perfusion, with pulmonary edema (with or with out peripheral edema)
- Give furosemide 1 mg/kg IV (or 1.5 mg/kg IV if on furosemide already)
- Take into consideration pulmonary renal syndromes apart from CHF (comparable to anti-GBM illness, ANCA related vasculitis, circulating immune advanced syndromes like lupus), and search for medical clues (inflammatory arthritis, purpura, Raynaud’s, mononeuritis multiplex, uveitis or Sicca syndrome?)
AKI with satisfactory perfusion, with peripheral edema however not pulmonary edema
- Give furosemide 1 mg/kg IV (or 1.5 mg/kg IV if on furosemide already)
- If no enchancment in renal operate take into consideration hypovolemia (“pre renal”) regardless of peripheral edema
o Low serum albumin – deal with underlying trigger, and think about hepatorenal syndrome which can require IV albumin
o Venous insufficiency and/or lymphedema – give crystalloid, think about compression remedy
o Drug induced edema – give crystalloid, reassess offending drug
o Extreme myxedema – give L-thyroxine and monitor
Step 4: The golden guidelines of AKI workup
- Measure a post-void residual (PVR) with bladder scan or urethral catheter
- Get a urine dip to search for blood and protein suggestive of nephritic syndrome
- Monitor urine output ideally with a urethral catheter
- Keep away from nephrotoxins (NSAIDs, ACEi, ARBs, gentamicin and so forth)
Step 5: Think about imaging for a small subset of post-renal AKI
Radiology division imaging needs to be reserved for these sufferers who:
- Don’t enhance with fluid problem (making pre-renal much less doubtless),
- Have a standard urine dip (making intra-renal much less doubtless),
- Have a post-void residual <100mL (making BPH much less doubtless)
- Have apparent bilateral hydronephrosis on POCUS
These sufferers warrant additional imaging as they could have a uncommon post-renal bilateral ureteric obstruction explanation for AKI comparable to obstructive metastatic most cancers, lymphoma or a kidney stone with a solitary kidney.
Think about a nephrology or inner drugs seek the advice of if any of:
- Insufficient urine output after 4 hours administration
- Unexplained blood and protein in urine required workup for intrinsic renal illness
- Creatinine rises regardless of preliminary administration
- Worsening pulmonary standing regardless of preliminary administration
IV crystalloid of selection, timing and quantity in sufferers with AKI
Fluid of selection and timing in AKI
Our specialists suggest a balanced fluid for resuscitation comparable to Ringer’s Lactate (RL) primarily based on SMART and SALT-ED trials, though the profit in AKI sufferers was primarily based on sub-group evaluation. SMART and a current examine taking a look at beginning balanced fluids within the ED vs ICU suggests a mortality profit if balanced options comparable to RL are began early versus ready till they’re within the ICU to modify over. RL is barely acidotic, much less so than NS, so monitoring pH is vital no matter which crystalloid is given. RL is much less wish to result in hyperkalemia in comparison with NS primarily based on proof from renal transplantation research the place anephric sufferers given NS had been extra prone to turn out to be hyperkalemic; do not forget that an acidotic setting results in potassium shifts which can result in life-threatening hyperkalemia.
Sufferers with end-stage liver cirrhosis or publish huge paracentesis needs to be quantity resuscitated with albumin relatively than crystalloid.
Quantity of fluid in AKI resuscitation
With the aim in thoughts of bettering cardiac output and tissue oxygenation while reaching acceptable urine output and imply arterial stress, our specialists suggest small, frequent crystalloid boluses of 3mL/kg with frequent medical assessments incorporating POCUS for proof of quantity overload. Within the affected person in NSR on a ventilator, think about using pulse stress variation to assist information fluid resuscitation.
AKI dialysis indications and timing
On the whole sufferers with the next circumstances needs to be thought-about for quick dialysis: extreme electrolyte derangements, particularly hyperkalemia, which can be leading to hemodynamic instability or arrhythmia and are refractory to pharmacologic remedy, life-threatening fluid overload resulting in respiratory or cardiac failure, uremia (presenting as pericarditis or altered psychological standing), extreme metabolic acidosis (pH <7.1), symptomatic ethylene glycol ingestion and extreme rhabdomyolysis.
AEIOU mnemonic for indications for emergent dialysis
Acidemia – pH<7.1 regardless of medical administration
Electrolyte abnormalities – hyperkalemia refractory to medical administration
Ingestion – nephrotoxic drug ingestion amenable to dialysis
Overload – quantity overload leading to respiratory failure
Uremia with bleeding, pericarditis or encephalopathy
Timing of dialysis in non-emergent AKI: STARRT-AKI trial
STARRT-AKI is the biggest trial up to now evaluating quick/early dialysis with delayed dialysis in AKI sufferers. It’s a multinational RCT of 3019 critically in poor health sufferers with AKI (principally with sepsis), evaluating an accelerated technique (median 6hrs to initiation of dialysis) vs customary technique dialysis (median 31hrs to initiation of dialysis) with a major final result of dying from any trigger at 90 days.
Major final result of dying related in each teams: Loss of life at 90 days occurred in 43.9% within the accelerated technique and 43.7% in the usual technique (RR, 1.00; 95% CI 0.93-1.09)
Hostile occasions extra widespread in early dialysis group: Hostile occasions occurred in 23% within the accelerated technique and 16.5% in the usual technique group (RR, 1.40;95% CI, 1.21 to 1.62), mostly hostile hypophosphatemia and hypotension.
Backside line: beginning dialysis early (6hrs) for sufferers with AKI and no true emergency indications in comparison with 31hrs, has no mortality profit and should incur some hurt.
Are piperacillin and vancomycin contraindicated in sufferers with extreme AKI?
The commonest motive to be admitted to an ICU with AKI is septic shock. Piperacillin-tazobactam and vancomycin are generally utilized in sufferers with septic shock. Some observational information counsel that these antibiotics could also be nephrotoxic when mixed, nevertheless no causation has been demonstrated and newer formulations are thought to include fewer nephrotoxic impurities. Our specialists don’t withhold these antibiotics in AKI sufferers when in any other case indicated, nevertheless different antibiotic choices needs to be thought-about in session with ICU or ID in sufferers with extreme AKI.
Aminoglycosides and amphotericin ought to usually be averted in sufferers with AKI.
Is vasopressin most popular over norepinephrine for sufferers with AKI and septic shock?
There’s blended proof for preferential use of vasopressin over norepinephrine because the preliminary vasopressor of selection in AKI sufferers with septic shock.
VANCS ll trial: no final result distinction with vasopressin in comparison with norepinephrine, no matter renal standing
VANISH trial: no distinction in creating AKI however much less dialysis in vasopressin group
VASST: slower development towards renal failure in vasopressin group in comparison with norepinephrine group in secondary evaluation
A 2019 metaanalysis of trials concluded that “Vasopressin remedy in septic shock had no impact on 28-day mortality though the arrogance intervals are extensive. It seems protected however with a unique aspect impact profile from norepinephrine. The discovering on diminished [dialysis] needs to be interpreted cautiously. Future trials ought to give attention to long-term outcomes in choose affected person teams in addition to incorporating value effectiveness analyses concerning doable diminished [dialysis] use.”
Backside Line: Our specialists proceed to make use of norepinephrine as their first line vasopressor in sufferers with AKI and septic shock.
Is there a task for giving sodium bicarb in AKI sufferers?
IV sodium bicarbonate is an inexpensive remedy in AKI sufferers with extreme metabolic acidosis as a temporizing measure, however shouldn’t preclude the seek for, and reversal of the underlying trigger.
BICAR-ICU was an RCT of 389 ICU sufferers with extreme metabolic acidemia (pH ≤7⋅20, PaCO ≤45 mm Hg, and bicarb ≤20 mmol/L), a complete Sequential Organ Failure Evaluation rating of 4 or extra or an arterial lactate focus of two mmol/L or extra who had been randomized to receiving 4.2% sodium bicarbonate to keep up a pH>7.3 or crystalloid.
Though there was no important distinction for the first final result (mortality at day 28 and the presence of organ failure at day 7), bicarbonate confirmed a development towards decreased want for dialysis, and within the subgroup of sufferers with AKI bicarbonate decreased mortality and vasopressor necessities. NNT=6 for requiring dialysis within the AKI subgroup.
Backside line: our specialists suggest giving bicarb in sufferers with AKI and refractory extreme acidosis.
Take House Factors for AKI ED Administration
- Before everything, rule out quick life threats – hyperkalemia and extreme acidosis
- Most sufferers with AKI merely require “fluids and a foley”, nevertheless a extra nuanced remedy algorithm needs to be thought-about in advanced instances
- Have respect for brand spanking new extreme hypertension within the setting of AKI as these sufferers might have an intrarenal trigger that requires pressing BP management and inner drugs session for additional workup
- Get assist from ICU for sufferers with AKI, pulmonary edema and cardiogenic shock as these sufferers are difficult to handle
- Not all sufferers with AKI require imaging; bilateral ureteric obstruction is a uncommon explanation for AKI
- Keep away from nephrotoxins in sufferers with AKI every time doable (NSAIDs, ACEi/ARBs, gentamicin, amphotericin)
- The resuscitation fluid of selection in AKI sufferers is Ringer’s Lactate in small boluses with frequent assessments of quantity standing
- Use AEIOU mnemonic for emergency indications for dialysis; for different AKI sufferers it’s usually protected to delay dialysis for 1-2 days
- IV bicarb is cheap in AKI sufferers with refractory extreme metabolic acidosis
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Drs. Helman, Etchells and Tillmann don’t have any conflicts of curiosity to declare