Ep 151 AKI Part 2 – ED Management

This is part 2 of our 2 part podcast series on AKI for the Emergency physician. In this part Dr. Edward Etchells, Dr. Bourke Tillmann and Anton dig deeper into the simple 5-step ED approach to AKI outlined in part 1, concentrating on the edematous patient, and discuss the timing, volume and IV crystalloid of choice in AKI patients as well as dialysis indications and timing in light of the recent STARRT-AKI trial. We answer the questions: are piperacillin and vancomycin in combination contraindicated in patients with severe AKI? Is vasopressin preferred over norepinephrine in patients with AKI and septic shock? Is there a role for IV sodium bicarbonate in AKI? When should ACEi/ARBs be held in AKI patients? When, if ever, should NSAIDs be given in AKI patients, and if so, how should the dose be modified? and many more.... Podcast production, sound design & editing by Anton Helman; voice editing by Sheza Qayyum Written Summary and blog post by Anton Helman Jan, 2021 Cite this podcast as: Helman, A. Etchells, E. Tillmann, B. Episode AKI - ED Management. Emergency Medicine Cases. January, 2021. https://emergencymedicinecases.com/aki-ed-management. Accessed [date] For part 1 of this series on AKI go to Episode 150 Acute Kidney Injury- A Simple Emergency Approach to AKI Management of AKI in the ED: "Fluids & Foley" fixes most AKI The majority of AKI can be fixed by “a bag of LR and a urethral catheter”… tincture of time may be all that’s necessary in many other cases. Somewhere between 70-90% of AKI is pre-renal or post-renal in etiology, so that fluid resuscitation and removal of the obstruction (i.e. a urethral catheter) will probably resolve 70-90% of AKI. However, a more nuanced treatment algorithm should be considered in complex cases. 5 step approach to AKI in the ED Step 1: Rule out the 2 immediate life-threats * Hyperkalemia – get ECG, electrolytes off the blood gas * Severe acidosis – get blood gas Step 2: Assess for adequate perfusion – are they in shock? Use your history, physical examination and POCUS to assess for perfusion and treat shock (hemorrhagic, vasodilatory, cardiogenic shock etc.) accordingly. *the patient in shock with acute heart failure, pulmonary edema and AKI is especially challenging, and may require norepinephrine to support the blood pressure and dobutamine to help improve cardiac forward flow, in addition to usual acute heart failure management; early consultation with an intensivist is recommended. Step 3: Assess for both pulmonary and peripheral edema Assess JVP and lungs with POCUS for pulmonary edema, look and palpate for peripheral edema (including pre-tibial edema, sacral edema) If there is no evidence of pulmonary or peripheral edema, give a fluid challenge. AKI with adequate perfusion, with pulmonary edema (with or without peripheral edema) * Give furosemide 1 mg/kg IV (or 1.5 mg/kg IV if on furosemide already) * Think about pulmonary renal syndromes other than CHF (such as anti-GBM disease, ANCA associated vasculitis, circulating immune complex syndromes like lupus), and look for clinical clues (inflammatory arthritis, purpura, Raynaud's, mononeuritis multiplex, uveitis or Sicca syndrome​?) AKI with adequate perfusion, with peripheral edema but not pulmonary edema * Give furosemide 1 mg/kg IV (or 1.5 mg/kg IV if on furosemide already)​