Presentation on theme: "NEUROLOGICAL INJURY and RENAL REPLACEMENT THERAPY Lina C"— Presentation transcript:
1 NEUROLOGICAL INJURY and RENAL REPLACEMENT THERAPY Lina C NEUROLOGICAL INJURY and RENAL REPLACEMENT THERAPY Lina C. Laxamana, FPCP, FPNA Neurocritical Care Unit October 8, 2010 NKTI Post Graduate Course
6 CASE M.B., 56/M, married, from Isabela Admitted due to sudden onset of R sided weakness and aphasia~11 hours PTASudden onset of R sided weakness, with aphasiaBrought to a local hospitalCranial CT requested
23 Imaging (day 2) Interval evolution to beginning subacute stage Without increase in volumeInterval progression of perilesional edemaMidline shift to the right has not significantly changed
24 Case Prepared for surgery Repeat PT 138% INR 0.88 PTT 31.1s Day 3 post ictus (915am)Prepared for surgeryRepeat PT 138% INR PTT 31.1sNa and K correctionMannitol continued at 60gms q4HemodialysisClearances requested
25 Case Day 3 post ictus (1110am) Elective intubation done (Anes) Day 3 post ictus (515pm)E2vtm5, more difficult to arouseBP 166/100 HR 90 O2sat 100%Pupils 2-3mm EBRTLAwaiting repeat labs post HD
26 Case Day 3 post ictus (10pm) K 4.35 Scheduled for surgery at 4am Day 4 post ictus (120am)E2vtm5BP 160/90 HR 88 O2sat 98%Pupils 2-3mm EBRTL
27 Case Day 4 post ictus (4am) OR Plan L frontal craniotomy, endoscopic evacuation of hematoma with intraparenchymal ICP monitor probe insertion
28 Case Goals for treatment Address the increased intracranial pressure from the hematomaEvacuate the capsuloganglionic hemorrhageLessen the need for osmotic diuretics in an ESRD patient
34 Renal Replacement Therapy and the Neurocritical Care Patient
35 Cerebral Blood FlowLang & Chestnut, Neurosurg Clin N Am 1994;5(4):
36 Cerebral Blood FlowBhardwaj A. Cerebral blood flow. In Suarez JI, Critical Care Neurologyand Neurosurgery, Humana Press, 2004 with permission
37 MAP = 2 (diastolic) + systolic 3CPP = MAP - ICPCBF = Cerebral Perfusion PressureCerebral Vascular Resistance=P x x r4 / 8 x L x (Hagen-Poiseuilleequation for movement of Newtonianfluids in large caliber vessels)Autoregulation: MAP mmHg
39 The other main compensatory defense mechanism comes from interstitial astrocytes, which not only regulate endothelial integrity, but also take up both water and plasma proteins that have passed into the brain tissue to try to maintain intracerebral osmostasis. In addition, these cells also take up such excitatory neurotransmitters as glutamate to help reduce cerebral neuronal activity and thus reduce oxygen demandIn the brain, the astrocytes play a key role in maintaining extracellular homeostasis. These cells respond to changes in extracellular ﬂuid tonicity by regulating Na/K ex- change, and by accumulating intracellular osmoles, not only urea but also other retained osmolytes, by producing glycine, glycerol, myoinositol, and sorbitols,5 which enable these cells to regulate cerebral extracellular volume.
44 IHD and ICPFrom: Davenport A. Hemod Internl 2008;12:307–312 with permission
45 MAP and CAPDFrom: Davenport A. Hemod Internl 2008;12:307–312 with permission
46 Effect of renal replacement on ICP From: Davenport A. Semin Dialysis, 2009;22:165–168 with permission
47 Serum osmolality following renal replacement From: Davenport A. Semin Dialysis, 2009;22:165–168 with permission
48 Modifications to standard hemodialysis prescription that may potentially reduce risk of further cerebral injury in patients with acute cererbal injuryFrom: Davenport A. Hemod Internl 2008;12:307–312 with permission
58 Statement CRRT is the preferred mode in ABI Previous studies did not show decrease in ICP but rather only stabilitypatient populationmode of CRRT usedmembrane biocompatibilityDavenport; Nephrol Dial Transplant. 1990;5:192–198Br Med J (Clin Res Ed). 1987;295:1028.
59 Osmotherapy If elevations in ICP are noted or cerebral edema: Treatment of ICP should continue as usual20% mannitol infusionsHypertonic saline with the dialysate to keep serum sodium mEq/L
60 Renal Failure and Neurosurgery Emergency surgical evacuationCorrect coagulopathy:Platelet transfusionDDAVPCorrect INRRRT as indicated above
61 Conclusions Renal failure is common in the ICU Less common in patients with neurological injuryAll risk factors should be correctedContinuous replacement therapies are preferredClose communication and team work with nephrologists are key
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