renal pt

[sdadam]

so I had a pt this last shift that I still can't quite figure out, let me know what you all think:

moderate status medical call, 49yo Male PT weighing aprox. 120kg.

c/c: anuria x3 days

Initial impression; late-middle aged man sitting in a chair, supporting some weight with his upper body on a walker, abc's intact, in no apparent disstres.

His story: PT reported not having urinated in three days, while maintaining his normal intake of fluids. Claimed that he normally urinated without pain or difficulty several times a day. Stated that he had been diagnosed with renal failure (beginning stages) three weeks prior and was supposed to have a dialysis shunt placed and regular dialysis treatments begun, however he told us that there was some kind of administrative mixup and that he was unable to have the treatment started, and had not sought further attention since the administrative problems.

My assessment:

PT was breathing @ 18rpm full and effective, w/a mild amount of fine rails in only the lower left lobe, otherwise good/clear air movement. O2 sat 90% RA.

PT AOx4, answering questions appropriately and able to follow simple commands.

eyes PEARL @ 1.5mm PT is legaly blind in both eyes.

PT is able to MAE w/ full range of motion and no Px

PT denies SOB, CP, ABD Px, Pelvic Px, HA, NVD.

v/s : P: low 89, high 100.
R: 18 FE
Bp: 1) 58 / 30 2) 72 / 46 3) 68 / 38
E: PEARL 1.5mm
L: mild rails in lower left lobe only.
02: 90% RA
S: 140 pta, (bs taken pta, pt took 5 of insulin 5min pta)
S: Pale Warm Dry
Px: PT denies any px

Secondary Survey revealed no signs of trauma or acute injury, no JVD, no pedal or sacral edema. signs of peripheral perfusion were lacking: pedal and radial pulses were not palpable, cap-refil was absent, significant pallor was noted in the distal extremities.

NKDA

took hypertention meds, and insulin. (administered by a long time caregiveer at PT home, who was tehre and could attest to regular dosages and times for the day.)

PMHx Diabetes, Pacemaker.

Treatment:
O2 NC 4lpm, pt responded well w/02 sat increased to 98%

So:

Considering the renal failure and the lack of urine output I was focusing on the possibility of hypervolemia, but for the life of me I couldn't find where he was shunting any extra fluid that may have been in his body. All of my assessment was actualy pointing to him being hypovolemic (tachy, hypotensive, decreased peripheral perfusion, pallor, etc.l)

I figure he just wasn't drinking watter, and was dehydrated, allong with new onset renal failure equals no pee for three days.

anyone else have any thoughts?

 

[Ridryder911]

He is in acute renal failure (ARF) with septic shock. There may not be any urine produced due to the inability of the kidneys to produce any. Even if there was water, this does not always mean urine. Water and urine are not the same.. some patients excrete water, but the waste remains in them. The body becomes toxic.

As well, with the inability of not being able to excrete the urine/fluids he probably has a multitude of medical problems. From your assessment he is as well in CHF. ARF patients are easy to go into CHF from the increasing amount of fluid and with the history of diabetes and other pre-existing illnesses his chances of a poor compliant heart is great. Ammonia levels, as well as increased Blood Urea Nitrogen (BUN) which is basically waste is great, and then on top of that there is major electrolyte imbalances that occurs such as potassium, sodium, and magnesium (which can affect the electrical components of muscles (heart included). Not to exclude his pulmonary systems and his metabolic problems such as pH level and glucose (even though the level was okay).

What many people may foresee as a typical patient, in reality is a "ticking time bomb", and a internal medicine's nightmare.

 

[Ravamedic]

A renal pt is always a pucker factor of 10 - due to the numerous conditions that rid has so kindly pointed out!

My ears are always glued to the monitor's QRS complex "bleeeep" - so so so many of my renal pt transfer's have ended with me changing my destination from a A&E department to a morgue!

I know it doesn't answer your question as I think rid did that well already - but these pt's are an electrolytic nightmare.

 

[Onceamedic]

so, besides load and go, what would you do for treatment for this patient ; considering the complexity of the case ?

 

[knxemt1983]

so, besides load and go, what would you do for treatment for this patient ; considering the complexity of the case ?

I would also be interested in knowing what the correct treatment would be. Of course o2, witht eh hypovolemic state, but would some ns have helped the situation? I would be worried about flooding his lungs, since he may have been beginning chf

 

[Ravamedic]

There isn't really much to do.

My treatment would include O2 via non rebreather, IV access with nacl TKO and then continually monitor - intervene when necessary.

I would limit his fluids if lungs arnt clear it may indicate pulmonary oedema - if short of breath maybe some salbutamol and possibly some nitrates.

Cosely monitor for electolyte imbalances and treat appropriately - might be hyperkalemic due to a complication with his diabetes or from decreased output so maybe some sodium bicarbonate MAYBE.

Basically some O2 and rapid transport and extremely close monitoring, especially if electrolyte imbalances are evident. The time it takes from being imbalanced to being in arrest is very close with these patients and imbalances are quite common as their ability to handle fluids are quite reduced

 

[RedZone]

ABC's first. We all know this patient is in decompensated shock. His circulatory system is barely adequate to support life, and intervention is necessary.

I would put him on a non-rebreather, and get him onto my stretcher or use a scoop to remove him. I do not want him sitting upright. Vital signs need to be monitored often.

Since everyone's discussing ALS intervention: EKG monitoring (no time to do a 12 lead unless it is on the way to hospital). Intravenous access is required.

The dilemma here is, how to intervene? The intervention will be dictated by the provider's impression on what kind of shock this is: Cardiogenic vs septic vs hypovolemic are the possibilites.

Is the pump failing (cardiogenic)? If so, then medication to increase pump output is necessary.

Is the container size affected? Is the container empty? (septic, hypovolemic) If so, then treatment is thru fluid resuscitation.

Cardiogenic: I don't suspect cardiogenic as the CAUSE of shock, because there were no prior complaints of shortness of breath or chest pain. There is no pedal edema or JVD. Unless he had a sudden massive silent MI, I would have expected some evidence of progression into shock. Not to say that his heart is not failing, or will not fail very soon.

Septic: Very likely. The skin is dry even though we expect diaphoresis, and he has absolutely no urine output with a history of chronic renal failure. This means his kidney's have shut down (complete renal failure). And for the last three days, toxins and electrolytes have been building up. Anytime I notice warm skin on a hypoperfused patient... I strongly suspect septic shock.

Hypovolemic: Since you mentioned dehydration... that is unlikely. Generally, renal failure patients don't dehydrate. Even if you suspected 0 fluid intake, remember... there has also been 0 fluid output. No vomiting, no diarrhea. Whatever fluid was excreted through exhaling or feces was probably equal to the fluid from eating and breathing. We know he ate because the aid confirms he received insulin regularly, and he is not hypoglycemic.

BUT... I would still do an abdominal exam. Even though we have a likely cause AAA is still a possibility (elderly, hypertensive history, sudden onset of hypotension). GI Bleed is a more remote one... but complete the assessment and rule it out.

And there is also one other possibility too. Virtually all medications are metabolized and excreted by either the kidneys or the liver. If he cannot remove the medication from his system, it just circulates in an endless cycle... and he just adds more and more over the three days. You say he was on anti-hypertensive meds? Which ones?

Regardless of the cause, my treatment is going to be fluid. Yes, the rales and the renal failure means be careful. He only needs a systolic BP of 90 to keep his vital organs perfused, so I would titrate the fluid carefully to attempt to achieve that BP while checking to see if his rales worsen. Any delay or extended transport time, and I would be calling medical control for advice. Also, if at all possible, I would transport him to a facility capable of providing emergency dialysis.

 

[Flight-LP]

He's septic and he is in heart failure. His MAP is running in the 30's, way too low. He needs ALS and an ICU quickly. Only BLS interventions needed are O2 to maintain adequate oxygenation and skillful emergency driving. ALS wise, a 12 lead is essential. If he's not perfusing the body, chances are he isn't efficiently perfusing the heart either. Fluids are not needed and will probably kill him. He needs pressors, Dobutamine and Neo-Synephrine preferred. I'd avoid Epi unless its all you have and are out in the sticks. He needs CVP and preferably PA monitoring, along with immediate dialysis. So no band aid station hospitals for him, he needs a tertiary medical center. Not one around you, then stick him on a helicopter. Despite all of this, he is still looking at a high mortality rate...............

 

[knxemt1983]

wow, good reply, I wouldn't have even thought about the meds building up in his system but it makes since it has to go somewhere. Thanks for the info

 

[RedZone]

wow, good reply, I wouldn't have even thought about the meds building up in his system but it makes since it has to go somewhere. Thanks for the info

Yeah, actually, a strong clue for me is HR in the 90's. I would expect the patient to have a HR of about 140 in this scenario. Without knowing the rhythm, I can only make guesses as to why.

Medication overdose is one possible cause... but I would then expect the HR to be much lower (like, in the 50's). But his pacemaker would prevent that. But I wouldn't expect the pacemaker to be set for a rate in the 90's. Plus, I would then expect the rate to be very regular.. 89 first set, 100 second set.

Like I said, I need a rhythm.

If there is a strong suspicion of overdose, we use glucagon for beta blocker overdose and calcium chloride for calcium channel overdose. He's not yet under a nephrologist's care, so he could be on anything... and that might have caused the renal failure as well.

Side note: Keep in mind that complete renal failure is very important to take into consideration. For instance.... you wouldn't give Lasix here, but if you ever give Lasix to a hemodialysis patient, be sure to ask "Do you urinate?". If they have 0% kidney function (they wouldn't be able to pee at all), Lasix is toxic.

 

[RedZone]

I would also be interested in knowing what the correct treatment would be. Of course o2, witht eh hypovolemic state, but would some ns have helped the situation? I would be worried about flooding his lungs, since he may have been beginning chf

This is a very difficult call. I like what rid said: an internal medicine nightmare. An experienced ED doc would probably have a difficult time here too. I agree with Flight-LP in that this man will probably die no matter what you do. I think 3 organs failing is pretty much the equivalent of no chance. So we know the kidney's are gone and the heart is going. And the pecking order from shock is predictable. By the time the heart fails (I still believe the heart is failing because of the shock and not from congestion), the only organ left is the brain. How he is still conscious is a mystery.

Best weapon: Admit that you need help with this one, and call medical control.

I am not even sure if my choice is appropriate here, and I thought about it for quite some time before posting. Without that luxury of time, I'd call the doc.

I still think I'd go with fluids (carefully), but dopamine may be appropriate too. Honestly, you might as well get the intubation kit set up (sorry, not trained in CPAP) since arrest is only minutes away.

 

[knxemt1983]

This is a very difficult call. I like what rid said: an internal medicine nightmare. An experienced ED doc would probably have a difficult time here too. I agree with Flight-LP in that this man will probably die no matter what you do. I think 3 organs failing is pretty much the equivalent of no chance. So we know the kidney's are gone and the heart is going. And the pecking order from shock is predictable. By the time the heart fails (I still believe the heart is failing because of the shock and not from congestion), the only organ left is the brain. How he is still conscious is a mystery.

Best weapon: Admit that you need help with this one, and call medical control.

I am not even sure if my choice is appropriate here, and I thought about it for quite some time before posting. Without that luxury of time, I'd call the doc.

I still think I'd go with fluids (carefully), but dopamine may be appropriate too. Honestly, you might as well get the intubation kit set up (sorry, not trained in CPAP) since arrest is only minutes away.

well thats interesting. I to would have called med control, I was taught not to guess blind, sometimes we have to use educated guessing, or reasoning, but my instincts would say to call, I just wanted to hear what others had to say. I am not trained for anything beyond combitube (see #2 below).
My course would have been;
1. load and go
2. call doc or als unit (if not close to hosp)
3. iv (tko since I dont know what going on)
4.02
5. talk to the pt to see if there is anymore info he could give.
I would definitely talk to the doc about fluid rate, I would stay tko, unless the doc says otherwise.