Nephrologic Emergencies Jeff Kaufhold MD FACP Nephrology Associates of Dayton July 2009

Case 1 81 y/o WF with poor responsiveness Family couldn’t wake her up Saw FP day before and felt OK Squad found her unresponsive Monitor in squad showed HR 30 Transcutaneous pacing initiated

Case 1 In ER, HR 20 without pacer Atropine given without improvement EKG with 3 rd degree AV Block Transvenous pacer placed Labs sent, foley placed Respiratory failure and intubated

EKG

Case 1- Past Medical History CKD with Cr 1.9 HTN Afib Cirrhosis- cause unknown Paracentesis this week for ascites

Case 1- Meds Cardizem CD 300mg QD Lasix 40mg QD Digoxin 0.125mg QD Enulose 15cc QD Remeron 30mg QD Aldactone 100mg QD* Neutraphos K 1 packet TID*

Case 1 BP dropped and dopamine initiated Labs: ABG 7.08/23/273/6.9 on vent CK 56, troponin 0.11 Na 131 K 8.3 Cl 100 CO2 9 AG 22 BUN 34 Cr 4.7 Dig 2.3 Phos 12.1 Mag 2.4

Case 1 Bicarb, D50, Insulin Albuterol 4 puffs Kayexalate 30 gm Digibind 1 vial Repeat K and ABG Nephrology contacted

Case 1 Family gave consent for hemodialysis Catheter placed, transferred to ICU Hemodialysis on 0 K bath x1 hr then 2 K During dialysis rhythm became Afib in 90’s TV Pacer turned off

EKG after treatment

EKG after HD started

Case 1 Admission day –0530 K 8.3 –0730 K 7.5 –1200 K 4.5 –1300 K 4.3 Next morning –0500 K 4.2

Case 1 Summary Renal function improved to Cr1.9 with hydration DC’d off neutraphos and aldactone Synthroid started for TSH Outpt followup for cirrhosis

Case 2 65 y/o WF found unresponsive Had been depressed due to poor health History of alcoholism requiring admissions Various bottles of alcohol at scene per squad

Case 2 In ER completely unresponsive Vitals stable but no gag Intubated for airway protection Physical exam unremarkable except –Thin, mildly malnourished –open ulcers on legs –Lungs scattered rhonci

Case 2 Past Medical History per niece –Diabetes mellitus –Chronic leg ulcers –HTN –Alcoholism –Tobacco abuse –Depression

Case 2- Meds Glucotrol XL 10 mg QD Altace 5mg QD Zoloft 50mg QD Recently finished antibiotic for leg ulcers Home remedy- rubbing alcohol for legs

Case 2- Labs ABG 7.29/32/365/17 Na 130 K 3.9 Cl 108 CO2 14 Glu 78 BUN 31 Cr 1.1 AG 8 Acetone neg Lactic acid 1.3

Case 2 DOA neg, ASA neg EtOH 0.86

Case 2 Why doesn’t this make sense? Metabolic (and respiratory) acidosis Nongapped with neg acetone, neg lactate Ethanol should give a gapped acidosis

Case 2 Calculated serum osmolality 275 2Na + Glu/18 + BUN/2.8 Measured serum osmolality 353 Osmolal gap 78 Normal osmolal gap <10

Case 2- Increased Osmolal Gap Ethanol Ethylene glycol Methanol Isopropyl alcohol All should have an increased anion gap also …except isopropyl

Case 2 Review of history- –Pt was found with various bottles of alcohol –Mostly vodka, some isopropyl –When sober, would wipe legs ulcers with isopropyl –When drunk, apparently would drink it

Case 2 Pt emergently dialyzed x 8 hrs Isopropyl, methanol, ethylene glycol levels “sent out”

Case 2- Summary Pt began to wake up at end of dialysis Extubated the following day No long term neurologic adverse effects Renal function remained stable Psych and crisis evaluations

Indications for Dialysis A acidosis E electrolyte abnormalities I intoxication/poisoning O fluid overload U uremia symptoms/complications

Dialysis for Intoxications T theophylline A aspirin B barbiturates L lithium E ethylene glycol, methanol M metformin

Case #3 68 y/o AAM sent in from chronic hemodialysis unit where staff noticed – a diffuse red rash/discoloration to skin of chest and face –Hypertension uncharacteristic for this patient did not respond to clonidine 0.2 mg) –Decreased mental staus

Case #3 PMH – ESRD, DM2, PVD, HTN, CAD PSH – b/l BKA, CABG, PTCA (8 months prior), Left UE A/V fistula, Penile implant All – NKDA Soc – married, no tobacco/EtoH, independent, high functioning

Case #3 Meds Phoslo 667 mg I TID meals Nephrocaps QD evening meal Accupril 10mg QD Atenolol 12.5 mg BID ECASA QD Glucotrol XL 2.5 mg qd Tylenol, Lomotil PRN Viagra 50 mg PRN

Case #3 Exam T-98, P-95, R-22, 170/63 –Skin – diffuse redness to face, chest, hands (palmar) no macules, papules, ecchymosis, discrete lesions –HEENT – lips swollen, poss periorbital edema –H – RRR, L – clear –Abd – soft, nontender, no hepatospleenomegaly, no rebound –Ext – L a/v fistula + thrill/bruit

Case #3 –ABG 7.43/43/54/29/88% on Room air –CBC WBC – 10.4 RBC – 1.21 Hgb – 7.0 HCT – 11.0 MCV – 86 PLT – 69,000 Sample is grossly hemolyzed

Case #3 –Na-139, K-3.8, Cl-102, HCO3-29 –BUN-38, Cr-6.0 –Glu 424 –CPK-545, CK-MB-22.8 (4%) –Troponin I 2.7

Case #3 Differential for Hemolysis –Liver disease –Hypersplenism –Infection (Clostridial sepsis, babesiosis, malaria, bartonella, E. coli O157) –Microangiopathies (TTP/HUS, Valvular prosthesis) –Autoimmune (warm/cold Ab) –Infusions – IVIg, Rhogam, Hypotonic saline, blood transfusion –Oxidant agents – dapsone, nitrites, snake bites –Hemoglobinopathies, Enzyme deficiencies, membrane deficiencies

Case #3 More lab results –Albumin – 3.1 –Total bilirubin – 13.9, indirect – 12.6 –Retic % 3.2 –AST-238, ALP-43, ALT-37, GGT<8 –LDH – 4591 –Haptoglobin – 36 (49-297) –Myoglobin

Case #3 Intravascular hemolysis, thrombocytopenia, altered mental status in a renal failure patient Thrombotic Thrombocytopenia Purpura Pt received therapuetic plasmapheresis (TPE) alternating with hemodialysis. Stabilized in 4-5 days. Suffered NQWMI day one

Case #4 62 y/o CM presents with confusion and altered mental status –Family states he was normal yesterday but has been unable to “clear the cobwebs” today. Seems as though he is getting progressively more sleepy as the day goes on. PMH – DM2 diet controlled, HTN PSH – Appy, L femur fx with internal fix All - NKDA

Case #4 Soc – retired school teacher, married, independent, Tobacco 60 pack-years, EtoH-social (daily) Meds –Accuretic 10/12.5 md QD –ASA QD

Case #4 Exam T-98.6 P-88 R /80 80kg –Neuro – sleepy, follows simple commands, poor historian, communications are incoherent. Pupils are 4 mm, equal and reactive. Neck supple. Reflexes brachial/patellar normal. –H-RRR, no JVD, L-slight expiratory wheeze left –Abd – soft nontender no HSM –Ext – no edema

Case #4 CT Head – normal ABG 7.41/40/98/25/99% on room air Na-108, K-3.2, CL-76, HCO3-23, BUN – 23, Cr-0.8 Glu-96 CXR – left upper lobe peripheral density Sosm – 226, Uosm – 560 mosm/kg

Case #4 Hyponatremia –Hypo-osmolar, Euvolemic, but this patient has neurologic manifestations Treatment –Restoration of serum sodium, goal 120Meq/L –Na deficit OR: –Free Water Excess –Monitor Na q2 hours, neuro checks –Investigate underlying cause

Case #4 Hyponatremia –Restoration of serum sodium, goal 120Meq/L –Na deficit: ( Meq/L)(0.6)(80kg) =576 Meq of sodium needed to correct One liter of 3% NaCl has 513 Meq Na Correct 0.5 Meq/L each hour (12 Meq/L over 24 hours) –Hang one liter NaCl 3% at 40 cc/hr through central line. –Monitor Na q2 hours, neuro checks –Investigate underlying cause

Case #4 Hyponatremia –Restoration of serum sodium, goal 120Meq/L –Free Water Excess: 108 mEq/L * 48 L = 120 mEq/L in X L (108*48)/120 = 43.2 L Excess = 4.8 L of free water to get rid of –Give NS to volume expand –Give Lasix to begin diuresis –Check urine vol, sodium hourly –Replace the sodium Eg: (40 mEq/L * 0.5 L) = 20 mEq or 39 cc of 3% –Keep track of the water lost.