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NEUROLOGICAL INJURY and RENAL REPLACEMENT THERAPY Lina C

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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

2 Renal Replacement Therapy
Indications: Severe hyperkalemia Fluid overload Refractory acidosis Uremic symptoms: Serositis Encephalopathy Bleeding Objectives: Remove excess volume Remove solutes

3 Renal Replacement Therapy

4 Intensity of RRT and outcome in critically ill patients with ARF

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6 CASE M.B., 56/M, married, from Isabela
Admitted due to sudden onset of R sided weakness and aphasia ~11 hours PTA Sudden onset of R sided weakness, with aphasia Brought to a local hospital Cranial CT requested

7 Imaging ( 2 ½ hours)

8 Imaging (2 ½ hours)

9 Imaging (2 ½ hours)

10 Imaging (2 ½ hours)

11 Imaging (2 ½ hours) Intracerebral hematoma with an estimated volume of 30cc in the L capsuloganglionic region. With perilesional edema, mass effect and midline shift No IVE, HCP

12 Case PMHx With HPN, DM II, CAD
With ESRD requiring HD every 5th day through a L brachial AV fistula Maintained on Plavix 75mg/tab, ½ tab daily Denies allergies PSHx unremarkable

13 Pertinent examination
E4V2M6 Cranial nerves Pupils 2mm EBRTL R central facial palsy Good gag Tongue deviated to the R Motors UE R 0/5 L 5/ LE R 0/5 L 5/5

14 Case Pertinent labs CBC 13.3/44.1/11.1/N92/249 BT 4’ CT 5’
PTT 35.1s PT 85% INR 1.06 Na 127 K 5.89 BUN 34 Crea 6.77 Cranial CT repeated

15 Imaging (10 ½ hours)

16 Imaging (10 ½ hours)

17 Imaging (10 ½ hours) L capsuloganglionic acute intraparenchymal hematoma (42cc) Surrounding edema Compression of the ipsilateral ventricle and slight midline shift to the right

18 Case Admitted to NCCU Started on Mannitol 60gms q4
Neuro status quo: E4v2m6 Pupils 2mm EBRTL Slight headache Started on HD

19 Day 2 Day 3 post ictus (830am) E2v1m6, drowsier
BP 150/90 HR 90 O2sat 95% T 37.8C Pupils 1mm, equal Na 126 (124) K 5.89 (6.26) Stat CT scan requested NPO Additional Mannitol 30gms bolus given

20 Imaging (day 2)

21 Imaging (day 2)

22 Imaging (day 2)

23 Imaging (day 2) Interval evolution to beginning subacute stage
Without increase in volume Interval progression of perilesional edema Midline 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 surgery Repeat PT 138% INR PTT 31.1s Na and K correction Mannitol continued at 60gms q4 Hemodialysis Clearances requested

25 Case Day 3 post ictus (1110am) Elective intubation done (Anes)
Day 3 post ictus (515pm) E2vtm5, more difficult to arouse BP 166/100 HR 90 O2sat 100% Pupils 2-3mm EBRTL Awaiting repeat labs post HD

26 Case Day 3 post ictus (10pm) K 4.35 Scheduled for surgery at 4am
Day 4 post ictus (120am) E2vtm5 BP 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 hematoma Evacuate the capsuloganglionic hemorrhage Lessen the need for osmotic diuretics in an ESRD patient

29 Surgery

30 Surgery

31 Surgery

32 Surgery

33 4th day post-op

34 Renal Replacement Therapy and the Neurocritical Care Patient

35 Cerebral Blood Flow Lang & Chestnut, Neurosurg Clin N Am 1994;5(4):

36 Cerebral Blood Flow Bhardwaj A. Cerebral blood flow. In Suarez JI, Critical Care Neurology and Neurosurgery, Humana Press, 2004 with permission

37 MAP = 2 (diastolic) + systolic
3 CPP = MAP - ICP CBF = Cerebral Perfusion Pressure Cerebral Vascular Resistance =P x  x r4 / 8 x L x  (Hagen-Poiseuille equation for movement of Newtonian fluids in large caliber vessels) Autoregulation: MAP mmHg

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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.

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44 IHD and ICP From: Davenport A. Hemod Internl 2008;12:307–312 with permission

45 MAP and CAPD From: 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 injury From: Davenport A. Hemod Internl 2008;12:307–312 with permission

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55 Conclusion CRRT may have beneficial effects in patients with RIH
Further research may be warranted Fletcher et al, J Trauma, Critical Care ,2010

56 Has CRRT caused ICP reduction?
Unknown mechanism Removal of cytokines and myocardial depressants seen with ultrafiltration and membrane absorption Fletcher et al, J Trauma, Critical Care ,2010

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58 Statement CRRT is the preferred mode in ABI
Previous studies did not show decrease in ICP but rather only stability patient population mode of CRRT used membrane biocompatibility Davenport; Nephrol Dial Transplant. 1990;5:192–198 Br 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 usual 20% mannitol infusions Hypertonic saline with the dialysate to keep serum sodium mEq/L

60 Renal Failure and Neurosurgery
Emergency surgical evacuation Correct coagulopathy: Platelet transfusion DDAVP Correct INR RRT as indicated above

61 Conclusions Renal failure is common in the ICU
Less common in patients with neurological injury All risk factors should be corrected Continuous replacement therapies are preferred Close communication and team work with nephrologists are key

62 THANK YOU


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