Episode 30 - Acute Kidney Injury in the SICU with kidney_boy Dr. Joel Topf
Oct 30, 2020
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Dr. Joel Topf, a board-certified nephrologist and clinical professor, shines a light on acute kidney injury (AKI) in critically ill patients. He emphasizes the importance of monitoring and managing AKI, especially in trauma cases. The discussion explores how traditional fluid management can impact kidney function and why balanced solutions are essential. Joel also tackles sodium correction challenges in trauma patients, highlighting the dangers of rapid treatments. His insights aim to transform approaches to kidney health in the surgical ICU.
Acute kidney injury (AKI) not only signifies immediate patient distress but also predicts long-term complications like chronic kidney disease and cardiovascular issues.
The KDIGO classification has emerged as the most reliable system for diagnosing AKI, focusing on serum creatinine and urine output to enhance clinician communication.
Using balanced intravenous solutions instead of normal saline during resuscitation significantly lowers the risk of acute kidney injury in critically ill patients.
Deep dives
The Impact of Acute Kidney Injury
Acute kidney injury (AKI) is increasingly understood as a significant marker for adverse outcomes in critically ill patients. The recognition of AKI has evolved, moving beyond immediate concerns to the long-term implications it holds for patient health. Research has shown that patients who experience AKI are at a heightened risk for chronic kidney disease and cardiovascular complications later on. This underscores the need for healthcare providers to be vigilant and monitor patients post-discharge for potential kidney-related issues, even if they initially appear stable.
Classification and Criteria for AKI
The approach to defining and classifying AKI has undergone refinements over the past several years, shifting towards standardized criteria that enhance communication among healthcare professionals. Previous classification systems, such as the RIFLE and AKIN criteria, laid the groundwork, but the KDIGO criteria have become the most widely adopted. These criteria focus on serum creatinine levels and urine output, staging AKI into three levels of severity. Although this system simplifies the identification of AKI, experts stress that creatinine levels alone can be misleading, particularly in trauma patients undergoing intensive fluid resuscitation.
Fluid Resuscitation and AKI Risk Factors
The selection of intravenous fluids during resuscitation plays a critical role in the development of AKI, particularly regarding the use of normal saline versus balanced solutions. Recent clinical trials indicate that using balanced solutions like Lactated Ringer's or Plasmalyte can reduce the incidence of major adverse kidney events compared to normal saline. These findings support the idea that high chloride content in normal saline can impair kidney function, raising concerns about its routine use in critically ill patients. As such, healthcare providers are encouraged to consider the electrolyte composition of fluids administered to patients at risk for renal complications.
Hyponatremia and Its Management
Hyponatremia is a common electrolyte disturbance in trauma patients that can pose serious health risks if left unaddressed. In cases of severe hyponatremia, careful management is essential to avoid complications such as osmotic demyelination syndrome. The administration of hypertonic saline can rapidly correct sodium levels, but great caution is required to avoid overly aggressive shifts. Guidelines recommend a more gradual adjustment of sodium levels, emphasizing the importance of maintaining clinician vigilance regarding underlying conditions that may contribute to lowered sodium levels.
Rhabdomyolysis and Its Immediate Treatment
Rhabdomyolysis can lead to acute kidney injury, especially when compounded by metabolic disturbances such as severe hyperkalemia and acidosis. In cases of significant rhabdomyolysis, immediate intervention is necessary to stabilize the patient, including fluids to promote kidney function and potential dialysis for high potassium levels. Continuous renal replacement therapy is often preferred due to its efficiency in managing hyperkalemia, although regular hemodialysis may be warranted depending on the patient's stability. Interprofessional collaboration is vital to effectively manage these complex cases, and nephrology consultation can enhance patient outcomes.
Dr. Joel Topf joins us on Rounds to discuss and review key concepts in the recognition and management of acute kidney injury (AKI) in the SICU. AKI is a common and morbid complication among hospitalized patients. Further, trauma and surgical patients, in particular, are at an increased risk for AKI due to the myriad of pre-, intra-, and postrenal insults that commonly occur at the time of injury, during resuscitation, surgery,, as well as from iatrogenic insults including IV contrast, NSAIDs, antibiotics (aminoglycosides and the infamous Pip/Tazo/Vanco ice cream sandwich).
From the use of a DDAVP clamp in patients with severe hyponatremia to the use of balanced solutions in critically ill patients, kidney_boy breaks it down for us as only a true salt whisperer can!
