Presentation is loading. Please wait.

Presentation is loading. Please wait.

NEUROLOGICAL INJURY and RENAL REPLACEMENT THERAPY Lina C. Laxamana, FPCP, FPNA Neurocritical Care Unit October 8, 2010 NKTI Post Graduate Course.

Similar presentations


Presentation on theme: "NEUROLOGICAL INJURY and RENAL REPLACEMENT THERAPY Lina C. Laxamana, FPCP, FPNA Neurocritical Care Unit October 8, 2010 NKTI Post Graduate Course."— Presentation transcript:

1 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

5

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

9

10

11 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 5 th 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 5/5 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

17 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

22

23 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 Day 3 post ictus (915am) – Prepared for surgery – Repeat PT 138% INR 0.88 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

31

32

33 4 th day post-op

34 Renal Replacement Therapy and the Neurocritical Care Patient

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

36 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 r 4 / 8 x L x (Hagen-Poiseuille equation for movement of Newtonian fluids in large caliber vessels) Autoregulation: MAP mmHg

38

39

40

41

42

43

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

49

50

51

52

53

54

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

57

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


Download ppt "NEUROLOGICAL INJURY and RENAL REPLACEMENT THERAPY Lina C. Laxamana, FPCP, FPNA Neurocritical Care Unit October 8, 2010 NKTI Post Graduate Course."

Similar presentations


Ads by Google