Renal failure and Sepsis/hyperglycemia

[WyMedic]

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?

 

[Summit]

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.

 

[Gurby]

I just read this article, it's a fantastic primer on patients with renal failure: http://www.emsworld.com/article/103...is-patients-what-the-ems-provider-should-know

 

[Carlos Danger]

No reason to withhold IVF or vasopressors. In fact, treatment of pretty much any acute emergency is the same in the patient with ESRD.

 

[WyMedic]

I just read this article, it's a fantastic primer on patients with renal failure

I read this shortly after the call, it is a great read!

 

[WyMedic]

No reason to withhold IVF or vasopressors. In fact, treatment of pretty much any acute emergency is the same in the patient with ESRD.

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

 

[Doczilla]

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

 

[WyMedic]

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

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!

 

[hannahchloe]

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?

 

[BobBarker]

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.

 

[Summit]

ER isn't doing diuresis on CRF/sepsis. CRRT is done in the unit.

 

[Comfort Care]

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.

 

[BobBarker]

I

ER isn't doing diuresis on CRF/sepsis. CRRT is done in the unit.

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

 

[silver]

Here's a summary of 2 recent papers looking at this topic.

Fluid Administration in End-Stage Renal Disease for Severe Sepsis and Septic Shock

 

[Akulahawk]

ER isn't doing diuresis on CRF/sepsis. CRRT is done in the unit.

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...