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Clinical Cases and Images: ClinicalCases.org: Prerenal Acute Renal Failure due to Volume Depletion

This is a good practical case and very useful for new clinicians. For any clinician:No foley catheter unless oliguric, anuric, obstructed since any catheter is a foreign body and increases infection risk.Rehydrate if U/A has high spec gavity, mucous membranes dry, or if BUN is >30 times the creatinine as in this case. Even CHF pts get dry if not in heart failure. If in doubt, do CXR, BNPT, listen for crackles.Start with 250cc IVF if BNPT not less than 150 or give carefully while checking lung bases posteriorly after each bolus along with pulse ox, etc as above. Half of pts in acute renal failure are septic. Look for and eliminate source such as pneumonia, foreign body, pyelonephritis, joint infections. May be afebrile/ low temp or low WBCs with sepsis. Do cultures, check lactate ASAP to detect sepsis BEFORE the BP drops. Lactic acid "the troponin of sepsis." If septic, give a lot of fluids (up to 10 liters often) since capillary leak syndrome will lead to severe hypotension. If septic expect edema to develop with IV boluses yet be aware pt is intravascularly depleted. No pressors without fluids "pressors are not your friend" as per lecturers on Surviving Sepsis campaign.  
clinicalcases.org
about 6 years ago
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Prerenal Acute Renal Failure with High FENa (Fractional Excretion of Sodium)

Very good case in showing a frequently overlooked issue of diuretics. Remember, there is almost never a reason to give both fluids and diuretics...make up your mind. IV fluids are the #1 method to try in oliguric pts NOT Lasix.Do not agree with Foley cath placement if patient is able to urinate and can check creatinine to know pt is improving. Any catheter is a foreign body and increases infection risk.It is also very uncomfortable for patients.Not sure why U/S of kidney needed right away either unless the patient has chronic kidney disease or does not improve with fluids.Unnecessary tests add to the expense of healthcare which all of us pay for. This increases insurance costs, medicaid costs, etc so much it can put companies (and gov't in the future?) out of business.  
clinicalcases.org
about 6 years ago
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Replacing a peripheral venous catheter when clinically indicated versus routine replacement | Cochrane

Most hospital patients receive fluids or medications via an intravenous catheter at some time during their hospital stay. An intravenous catheter (also called an IV drip or intravenous cannula) is a short, hollow tube placed in the vein to allow administration of medications, fluids or nutrients directly into the bloodstream. These catheters are often replaced every three to four days to try to prevent irritation of the vein or infection of the blood. However, the procedure may cause discomfort to patients and is quite costly.  
cochrane.org
about 6 years ago