Nephrologic Emergencies

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 3rd 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

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 50.09

• 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

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 - 2017

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, Tobbaco 60 pack-years, EtoH-social (daily)

• Meds – Accuretic 10/12.5 md QD– ASA QD

Case #4

• Exam T-98.6 P-88 R 14 140/80 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: (120-108Meq/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