I would like for us to thank you professor for inviting me to be a part of this important isn’t forces and as i told he told me it is not the first time to be done in egypt it was done several times before and it’s really uh my pleasure and honor to be a part of this course this time uh i am professor yasser professor of nephrology and as some of you may
Know i am interested in critical care nephrology and like your kidney injury uh and in the coming few minutes i i will try to illustrate some important points that i met during my clinical practice regarding this important field of mythology and everyday practice we live in icu care of our patients first how to assess volume status and these are the measures
To assess volume mistakes clinical symptoms and signs of volume overload and of volume depletion you all know just x-ray doing researching for curly uh b lines the volume of congestion network type prop which are good negative tests and if they are positive in er need combination of other symptoms and signs to judge that this patient is having myocardial
Stretch of heart failure or volume overload what the point that i want to stress is the chest ultrasound detecting the b lines same b lines of chest x-ray symbionts detected in checks x-ray can be detected by bedside use of ultrasonography without the need to transfer your patient to uh radiology department or doing the chest x-ray in bedside wise simply you
Can do it by our ultrasonography machine which is nowadays mostly present in our icu detecting p lines by chest ultrasound and also predicting ibc diameter if it is increased diameter uh or normal diameter and the collapsibility of ivc also is important is it collapsing or not all of these signs and combining them with the use of chest ultrasound and the use of
Ivc diameter can judge that this patient is volume overloaded or not and really these two methods of using the ultrasonography machine that side in detecting chest ultrasound and ivc diameter give very useful tool to differentiate if the patient is congested or anything else such as for example infection while giving iv fluids especially in patients with acute
Kidney injury in sepsis as in success guidelines please use dynamic measures not static modes dynamic measures are used on the top of them is response to basically grains overflow poles what is the response of cvp january venous pressure and hemodynamic parameters if you raise the leg of your patient for a while and uh if you give a pay your patient if you would
Call it this is a very important item clinical item that you can do bedside to see if your patient is close depleted you will see a small response or no response to raise or no response to physicalism mostly no response to possibilities if there is no uh response if there is good response and the cvp increased after arising the regular exhibition or after giving a
Small police of ivory fluids this indicates that this patient is in no need for further fluid assessment and for satisfying for further fluid intake so please judge your patient after uh passively grades or after giving him a fluid bonus judge cvp and hemodynamic parameters no more space now for static parameters including cvp measurements ctp measurements alone
Has no place nowadays as most for example most of our patients having copd uh ascites uh tritaspin regards all of these patients having false readings of high school and you cannot judge what about this cbp and what does it mean in case of this abnormalities so please don’t depend on single measurement of cvp in assessment of your patient coming to the second
Point is the diuretic therapy in acute compensating failure this we use usually luke the heretics and please remember that furious is two to one oral as it is have five fifty percent availability while tourism and people tonight with the same orange is affected by food the same as people and i had what tourism is not affected by food indeed iv response is the
Is a big response but is of shorter duration while aura response is uh less than much less than iv but is a prolonged duration and that those needed in heart failure is more than that those needed in that in the same response in patient with healthy fast so to induce further dialysis in cases of iv intake of diuretics because of short duration you need to
Inject more frequently or to give it as a continuous intravenous inflation after a porous infusion and this is the point i want to stress your patient will mostly respond to iv infusion if you responded to a policy iv dose so give your patient a bonus iv those first if you responded this means that he will respond to iv infusion go with iv if no response it is
Questionable to respond to iv infusion for this patient these are the oral doses please remember that maximum single those in patients with normal kidney function is 18 for fluorosimide and a higher doses is needed with inferred kidney function theory is mine tell me tonight those might are all excreted inside that we need a larger those for these drugs to act
In cases of impairment of egfr as they and secreted inside a filter and act with a from within volume so a higher goal is needed as filtration rate is improved to attain the same effect towards the mind five to ten once in the moment up to 200 milligram wire up to two milligrams for iv infusion as i have said injecting loading those first to see the response
And this is the loading don’t 40 one for pimentonite and towards the mild 20 and see the response if good response go to iv infusion and in case of no serum creating more than 75 fusion i can be 10 milligram per hour while premature 9.5 and towards my 5. if this decreases by 50 you need double the those to attain the same effect higher doses are needed with
Improvement of kidney function with employment of gfr as it is filtered and with impermanent filtration we need the higher those to attain the same effect was much more impairment greater than clearance less than 25 fusion is increased and the dose is much is more double doubled once the ten become twenty and then the twenty becomes twelve t the two the point
Five become one and the one become true towards the mid four towards my five and 20. another important point that you usually use in my practice daily practice is the adding of mutualism to iv infusion if there is no favor of no substractive response he really it is of great benefit for these drugs to give a theoretical effect if you are not satisfied with
Your uh diuretic those and for your patient with this response to your diuretic dose add meter also five milligram dairy according to these illustrations uh of infusion if uh this is the dose of previous oral dose or previous infusion rate if there is no response at this rate at 10 milligram per hour at five if there is no response to this fuel furious fourth
Losing mind 20 at 50 at five five twice daily and 30 at five twice a day you will gain a uh more effect and you will gain a better and better theoretical effect for me my client can practice really i use this if i have a diuretic resistance and if my patient is not responding well to iv influence and these are reduces to use according to iv previous iv infusion
My third point is heart failure treatment and the rise of serum karyotyping and this is an important dilemma if we initiate diabetics and especially and specifically thus inhibitors in case of heart failure we’re having the effect of decreasing interstitial pressure decreasing ascites increased tubular blood flow and reduction of inflammation all of these are
Beneficial to the kidneys and to the heart these are important drugs for the heart these are not just simply injurious to the kidney in case of treatment of heart failure diuretics and specifically trust inhibitors are important drugs in spite of having the uh drawbacks of hypoperfusion and sympathetic nervous system activation with increase of serotonin so
This is the balance to treat the patient and we are to to get this benefit we are to pay for rise of creatine but uh the good news is that it is not an aki it is a worsening of real function it is called doors function because this is simply just the rise of it is not a complete syndrome of aki with its progression and the possibility of passing to chronic in
This stage it is simply a chemical uh finding of rise of serum it is defined as acute serum periodontal increase point three g for decrease by 25 which is equivalent to stage one right and the question is having a prognostic sign or not fortunately it is simply rise of serum caryatin don’t panic it is not that this complete syndrome of acute kidney injury simply
Arrives so deal with it smoothly to get the benefit for your patients the prognosis depends on severity and cardiovascular duration and residual congestion congestion is injurious by itself congestion is injurious for the heart and for the kingdom we need to resolve this dialogue patient needs to be treated by diuretics and virus inhibitors to improve the myocardial
Condition and to improve the renal condition also so pay for this by rising some rise of serum needs a proper judgment to continue these threats not to stop rapidly if we find the rise of cemeteries this simple algorithm for rust inhibitor with acute kidney injury in case of inhibitors if the patient is volume overloaded and all decomposited heart failure should
Receive dialects receive diuretics first the conjunction was diuretics with high dose or infusion in case of heart failure was reduced ejection fraction consider reducing or withholding grass inhibitors only have symptomatic hypotension or severe hypokalemia or progressive acute kidneys while preserving ejection fraction you can’t stop plus inhibitors as no prognose
Depends in case of hypotension or infection stop rust if no other cause are no prognostic signs such as uh heart failures preservation uh preservation if no other cause for hypotension you are to consider at this time uh stopping grass it is symptomatic hyper tension or hyperkalemia or progressive akin that’s it symptomatic or hyperkalemia resistant to treatment
Or a progressive these recommendations change in case of heart failure is preserved or reduced ejection production creatine increases less than 30 percent preserve reaction fraction consider stopping reduced continuum from 30 to 50 stop if a preserved ejection french consider reducing the dose not to stop if there is increased period reduce the dose and see the
Effect these are beneficial drugs more than 50 percent temporarily stop in case of heart failure with reduced ejection function and try to reinitiate again important drugs you can stop completely in preservative ejection fraction uh of course if there is a g if r less than 20 or remix symptoms and this time we are to stop the drugs and not to go further as the
Patient this is a progressive piece of acute kidney injury thank you very much and i hope i have stressed on some points that will be important for you in your clinical effects thank you very much
Transcribed from video
Clinical Tips in Critical Care Nephrology_Prof Yasser AbdelHamid By AHMED AKL
