Renal failure and Sepsis/hyperglycemia

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WyMedic

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Went on a call recently that made me start thinking about treating patients with renal failure. How would you guys treat a renal failure pt with sepsis and or hyperglycemia?


I had not even encountered this before, my initial thoughts would be to treat hypo-tension secondary to sepsis with pressors, but i;m not sure about hyperglycemia, I've read that even renal failure pt's can tolerate a fluid bolus as long as you are cautious of not overloading them.

any thoughts? any reasons not to treat the hypo-tension with pressors? would the pt's ability to metabolize a vasopressor be something to consider?
 
You don't withhold fluids in sepsis because of CKD (nor CHF).
The tank is low and the pipes are leaky. The patient needs preload! They need intravascular volume stat and will need more. Period.
Sepsis in CKD means you should want to have a very sensitive threshold for volume overload, but you don't want to withhold fluid from the hypotensive patient. Most of the time that decision point is in the ICU.
 
No reason to withhold IVF or vasopressors. In fact, treatment of pretty much any acute emergency is the same in the patient with ESRD.
 
Remi said:
No reason to withhold IVF or vasopressors. In fact, treatment of pretty much any acute emergency is the same in the patient with ESRD.
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Thanks! I feel like myself and probably other medics get a little apprehension when treating dialysis patients. I think knowing that the treatments are essentially the same helps me feel a little more confident
 
You've gotta try to protect the kidneys in any shock state; even more when theyre in any kind of renal failure. The old mantra "brain, heart, kidneys" still holds true, and probably always will.

Letting them become ischemic/lower GFR further is way more dangerous than "overloading" them, which probably won't happen anyway when most of it is leaking into the interstitium lol
 
Doczilla said:
You've gotta try to protect the kidneys in any shock state; even more when theyre in any kind of renal failure. The old mantra "brain, heart, kidneys" still holds true, and probably always will.

Letting them become ischemic/lower GFR further is way more dangerous than "overloading" them, which probably won't happen anyway when most of it is leaking into the interstitium lol
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That makes sense, I would imagine that the hypo-tension would be more detrimental to kidneys than the risk of overloading the pt with fluid.

So glad I came here to ask this, cleared things up for me! thanks everyone!
 
I'm sorry for reviving a necro thread, but I wonder how your story ended? Did you dig up any further info on this topic?
 
If someone is septic and symptomatic, we aren't withholding or limiting our fluids initially. The ER/ICU can always diurese them later if needed. Our protocols do state we need to re-assess every 250ml in the field.
 
ER isn't doing diuresis on CRF/sepsis. CRRT is done in the unit.
 
How would you guys treat a renal failure pt with sepsis and or hyperglycemia?

The same as any other septic or hyperglycemic patient, however, fluid administration is slightly different. Non-renal failure patients usually receive 30ml/kg LR or NS. Fluid sensitive patients recieve fluid over a longer period of time 126ml/hr. You wouldn't want to clamp down on empty pipes.

They're Kidneys are fried and most likely oliguric, so they can't be diuresed. They would need hemodialysis or CRRT if too unstable ( continously renal replacement therapy, basically a slower rate dialysis).

As an EMS provider giving small fluid blouses at a time 100-250ml and assessing for fluid responsiveness/ work of breathing would be a great start.
 
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Summit said:
ER isn't doing diuresis on CRF/sepsis. CRRT is done in the unit.
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I’m not talking about CRRT, I’m talking about lasix if u overload a little too much. Just saying we don’t do that, we’ll let the ER/ICU do that if we give them a bit too much
 
Summit said:
ER isn't doing diuresis on CRF/sepsis. CRRT is done in the unit.
Click to expand...
This is very much the case in my experience. I have never seen CRRT done in the ER. Emergent dialysis on patients that already have a port or shunt already in place, yes. WRT diuresis in CRF/sepsis patients, I have not seen that done in the ED either.

What I've seen with CRF/hyperglycemic patients is they're managed much like any other hyperglycemic patient. We might be a bit more judicious with fluid boluses but we usually don't have to do too much with them in the ED as long as they're not in DKA...
 
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