AKI Treatment: What Not to Do

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Questions and Answers

What is renal replacement syndrome?

An artificial method of solute clearance (correct)

A natural method of solute clearance

A type of medication to treat kidney disease

A type of surgery to remove the kidney

What is the usual indication for RRT?

Hemodynamic instability and heart failure

Metabolic acidosis and volume overload

Life-threatening hyperkalemia and respiratory failure

Volume overload, life-threatening hyperkalemia, and metabolic acidosis (correct)

How is blood withdrawn during acute hemodialysis?

Through a large-bore double-lumen catheter (correct)

Through a single-lumen catheter

Through a peripherally inserted central catheter

Through a surgically implanted arteriovenous fistula

What is the rate of blood flow during acute hemodialysis?

200-300 mL/min Signup and view all the answers

What is a characteristic of asthma?

Airway inflammation and increased airway responsiveness Signup and view all the answers

What is a characteristic of exacerbations of asthma?

Increased dyspnea, cough, wheeze, chest tightness, and decreased expiratory air flow Signup and view all the answers

What is the term for a severe asthma attack?

Status asthmaticus Signup and view all the answers

What is a potential outcome of underestimation of asthma severity?

Delayed and/or inadequate treatment, potentially leading to adverse outcomes Signup and view all the answers

What is a sign of severe asthma?

Pulsus paradoxus of >15 mmHg Signup and view all the answers

Why may patients with severe asthma be underdiagnosed?

They have diminished perception of dyspnea Signup and view all the answers

What is the goal of titrating oxygen therapy in acute severe asthma?

To achieve a SpO2 >90% Signup and view all the answers

What is the first-line bronchodilator therapy of choice for acute severe asthma?

Short-acting beta agonists Signup and view all the answers

What is the mechanism of action of beta agonists?

Stimulation of β2-receptors on airway smooth muscle Signup and view all the answers

What is the role of ipratropium bromide in acute severe asthma?

As an anticholinergic Signup and view all the answers

Why is salbutamol generally the agent of first choice among beta agonists?

It has relative β2-selectivity Signup and view all the answers

Why are long-acting beta agonists not used in status asthmaticus?

They have a slow onset of action Signup and view all the answers

What is a benefit of systemic steroids in asthma exacerbations?

Increased β-responsiveness of airway smooth muscle Signup and view all the answers

What is a common side-effect of aminophylline?

Headache Signup and view all the answers

What is a theoretical advantage of epinephrine over pure β2-agonists?

Additional α-agonist actions Signup and view all the answers

What is the mechanism of action of magnesium sulphate?

Blocking calcium channels Signup and view all the answers

What is the effect of helium: oxygen mixture on air-flow resistance?

Reduces gas density Signup and view all the answers

What is the minimum concentration of helium likely to provide benefit?

60% helium Signup and view all the answers

What is the effect of ketamine on airway smooth muscle?

Causes bronchodilatation Signup and view all the answers

What is not recommended to correct oliguria in AKI?

Giving furosemide Signup and view all the answers

What is the primary mechanism of iodinated contrast agents' damage to the kidneys?

Direct renal tubular toxicity Signup and view all the answers

What is a common side-effect of corticosteroids?

Both A and B Signup and view all the answers

What is the incidence of contrast-induced nephropathy (CIN)?

8-9% Signup and view all the answers

What is a predisposing condition for contrast-induced nephropathy (CIN)?

Diabetes Signup and view all the answers

What is the most effective preventive measure in high-risk patients to prevent CIN?

Intravenous hydration with isotonic saline Signup and view all the answers

What is the recommended hydration rate for high-risk patients to prevent CIN?

100-150 mL/hr Signup and view all the answers

What is the role of N-acetylcysteine (NAC) in preventing CIN?

As a protective agent with antioxidant actions Signup and view all the answers

What is the recommended duration of N-acetylcysteine (NAC) regimen for CIN prevention?

48 hours Signup and view all the answers

What is a contraindication to Non-Invasive Ventilation (NIV)?

Cardiac arrest Signup and view all the answers

What is the recommended initial pressure setting for NIV in acute respiratory failure?

5 cmH2O CPAP and 8-10 cmH2O pressure support Signup and view all the answers

What is a complication of Non-Invasive Ventilation (NIV)?

Nasal bridge ulceration Signup and view all the answers

In what type of asthma is the incidence of mechanical ventilation decreasing?

Acute severe asthma Signup and view all the answers

What is a characteristic of hyperacute asthma?

Marked hypercapnia Signup and view all the answers

What is a risk of institution of invasive ventilation with endotracheal intubation?

Inadvertent pulmonary hyperinflation Signup and view all the answers

In what type of asthma is the response to treatment often poor?

Asthma that has been progressing for days Signup and view all the answers

What is a potential consequence of dynamic hyperinflation in asthma?

Hypercapnia Signup and view all the answers

Study Notes

What Not to Do in AKI

Do not give furosemide to correct oliguria, as it does not improve renal function and can convert oliguric to non-oliguric renal failure.
Do not use low-dose dopamine to increase renal blood flow in AKI, as it does not improve renal function and can have deleterious effects.

Contrast-Induced Nephropathy (CIN)

CIN is a complication of iodinated contrast agents, which can damage the kidneys through direct renal tubular toxicity, renal vasoconstriction, and the generation of toxic oxygen metabolites.
The incidence of CIN is 8-9%.
CIN typically appears within 72 hours after the contrast study and most cases resolve within two weeks without renal replacement therapy.
Predisposing conditions for CIN include diabetes, dehydration, renal dysfunction, and the use of nephrotoxic drugs.
Prevention measures for CIN include intravenous hydration with isotonic saline and N-acetylcysteine (NAC) as a protective agent.

Renal Replacement Therapy (RRT)

RRT refers to artificial methods of solute clearance, including hemodialysis, hemofiltration, and hemodiafiltration.
The usual indications for RRT include volume overload, life-threatening hyperkalemia, and metabolic acidosis.

Acute Hemodialysis

A large-bore double-lumen catheter is inserted percutaneously into the internal jugular or femoral veins.
Venous blood is withdrawn through one lumen of the catheter by a pump in the dialysis machine.
The blood passes through the dialysis membrane and returns through the other lumen of the catheter.

Acute Severe Asthma

Acute severe asthma is a medical emergency associated with significant morbidity and mortality.
Clinical definition of asthma includes airway obstruction that is reversible, airway inflammation, and increased airway responsiveness to a variety of stimuli.
Exacerbations of asthma are characterized by increasing dyspnea, cough, wheeze, chest tightness, and decreased expiratory air flow.
Status asthmaticus has varying definitions, but a respiratory rate >30/min, pulse rate >120/min, and pulsus paradoxus of >15 mmHg are associated with severe asthma.

Management of Acute Severe Asthma

Established treatments include:
- Oxygen: Humidified supplemental oxygen should be titrated to achieve a SpO2 >90%.
- Beta agonists: Short-acting beta agonists, such as salbutamol, are the first-line bronchodilator therapy of choice.
- Anticholinergics: Ipratropium bromide is the most commonly used anticholinergic for asthma and is used in conjunction with beta-agonist therapy.
- Corticosteroids: Systemic steroids should be considered in all but mild exacerbations of asthma.
Non-established treatments include:
- Epinephrine: Has some theoretical advantages over pure β2-agonists in that its additional α-agonist actions may improve airway caliber.
- Magnesium sulphate: May block calcium channels and possibly acetylcholine release at the neuromuscular junction, leading to smooth muscle relaxation and bronchodilatation.
- Heliox: Inhalation of a helium: oxygen mixture reduces gas density and turbulence with reduced air-flow resistance.
- Anaesthetic agents: Ketamine has been used in severe asthma and may cause bronchodilatation by both sympathomimetic potentiation and a direct effect on airway smooth muscle.

Non-Invasive Ventilation (NIV)

Contraindications to NIV include cardiac or respiratory arrest, decreased conscious state, severe upper gastrointestinal bleeding, hemodynamic instability, facial trauma or surgery, and inability to protect the airway and clear secretions and high risk of aspiration.
NIV should be commenced with 5 cmH2O CPAP (expiratory positive airway pressure) and 8-10 cmH2O pressure support (inspiratory positive airway pressure).
Complications of NIV include nasal bridge ulceration, mask discomfort, nasal congestion, gastric insufflation, aspiration, hypotension, and pneumothorax.

Invasive Ventilation

Invasive mechanical ventilation in acute severe asthma may be lifesaving, but can be associated with significant morbidity and mortality.
The decision to intubate depends on both the clinical status of the patient and the natural history of the type of asthma present.

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Description

Learn what not to do in the treatment of Acute Kidney Injury (AKI), including when not to use furosemide and low-dose dopamine.