Renal protective strategies in the ICU

Posted by e-Medical PPT Tuesday, February 28, 2012
Causes of ARF in the ICU
Primary disease activity
Shock states
Sepsis syndromes
Infections-malaria, scrub, leptospirosis
Nephrotoxic drugs
Contrast nephropathy
Vascular-anastomotic, athero and cholesterol embolisation

Renal protection - general
Ensure adequate renal perfusion
Avoid / minimize use of nephrotoxic drugs including radio contrast
Early recognition and aggressive management of sepsis

Adequate renal perfusion
Blood pressure
Intravascular volume
Cardiac output
Other markers of perfusion

Renal failure in sepsis
Shock
Cytokine damage
DIC
Drug induced

Scenarios
60 year old lady presented with urosepsis to the casualty. She had not passed urine for the last 6 hours. Blood pressure on arrival was 60mmHg systolic. She was catheterized and 50ml of urine was drained. 1 liter of crystalloids is rushed in and dopamine is started-BP picks up to 100/40mmHg. She reaches ICU after 2 hours. The MAP is 64mmHg. She is treated with 1 liter of Haesteril, and output increases to 45ml per hour for the next hour, and gradually trails off. Her creatinine is 1.5, and goes up to 3.2 the next day.

A 76 year old female undergoes a sigmoid colectomy for ruptured diverticulum. Her baseline blood pressure is 140/80, MAP 100mmHg. She requires multiple boluses of phenylephrine in the  operating room to support her blood pressure. On return to intensive care, the patient is mechanically ventilated. Her urinary output is 15ml in the first hour.
        She is treated with 1 litre of colloid, her CVP rises to 14cmH2O, she puts out little urine, and her blood pressure remains 90/50 mmHg (MAP 63). The registrar starts a noradrenaline infusion, targeted at a MAP of >80mmHg, and the patient’s urinary output increases to 70 to 100ml/hour. Over the next 48 hours, each time the vasopressor was weaned and the MAP fell below 75mmHg, so too did the urinary output. Eventually, the patients blood pressure recovers, and she is weaned from ventilation and vasopressors without further difficulty.

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