Medical Emergencies: Uraemic and Renal Emergencies

 

Uraemic and Renal Emergencies

 Decide whether the patient has acute renal failure or chronic renal failure. If chronic renal failure search for any acute reversible element of like sepsis., dehydration, uncontrolled hypertension, obstruction or nephrotoxic drugs; in other words, does the patient have ‘acute or chronic renal failure’?

Acute Renal Failure (ARF)

Causes:

1.       Hypoperfusion of kidney (Pre-renal Failure)

-          Shock, severe dehydration, blood loss, trauma

2.       Obstruction to flow of urine (post-renal failure)

-          Stones, enlarged prostate, carcinoma, slough papilla.

3.       Renal parenchymal disease

-          Acute vascular disorders: malignant hypertension, polyarteritis nodosa (PAN), vasculitis

-          Acute tubular necrosis (vasomotor nephropathy)

-          Leptospirosis

-          Drugs (gentamicin, amikacin, cephalosporins, streptomycin, neomycin)

-          Interstitial nephritis: leptospirosis, drugs, toxins

The patient with ARF is usually not anaemic (unless due to blood loss)

Search for “Reversible Treatable” Chronic Disease:

1.       Vesico-ureteric reflux, analgesic, renal tuberculosis

2.       Hypercalcemia, hypokalemia

3.       Drugs, chemicals

4.       Obstruction – stones, enlarged prostate.

Search for “Reversible Factors” – ‘Acute Elements’: -

1.       Urinary tract infection, sepsis elsewhere

2.       Dehydration salt depletion

3.       Uncontrolled hypertension

4.       Obstruction due to stones, papillary necrosis

5.       Drugs – non-steroidal anti-inflammatory drugs (NSAID), gentamicin, amikacin, cephalosporins, streptomycin, neomycin

KUB X-ray and ultrasound of kidney are helpful in distinguishing the patient with Acute Renal Failure vs Chronic Renal Failure

Management of Acute Renal Failure:

1.       Anuric Patient

Exclude obstruction: if confirmed, refer surgeon for cystoscopy and retrograde pyelogram or antegrade pyelogram to determine cause and site of obstruction. Percutaneous nephrostomy is a useful way to relieve obstruction. It allows time for the surgeon to plan an elective operation.

2.       Non-Oliguric Renal Failure

 

Look for pre-renal factor (dehydration, sepsis. Nephrotoxic drugs).

3.       Oliguric Phase of ARF

 

a)       Fluid and electrolyte balance – 500 ml / day. Check electrolyte, intake / output.

b)      No fruits and fruit juices

c)       Anemia – transfuse with packed cells to avoid fluid overload

d)      Treat infection – antibiotics (dose important) and avoid nephrotoxic agents.

e)      Treat hypertension, heart6 failure

f)        Dialysis – for uremic symptoms, hyperkalemia, severe acidosis, pulmonary edema

N, B. If using gentamicin or amikacin – monitor levels to avoid renal damage and ototoxicity.

Management of Chronic Renal Failure:

1.       Hyperkalemia (Se K+ 6 E/l or more)

a)       IV 10 units soluble insulin + 50 cc of 50% dextrose, bolus dose

b)      Commence oral Resonium A 15 gm., 8 hourly.

c)       If patient can’t take orally commence Resonium retention enema 30 gm, 8 hourly

d)      Also give IV calcium gluconate 10 cc slowly to combat effects of hyperkalemia on the heart.

e)      Repeat Se K+ 4 hour later, Repeat treatment if necessary.

f)        If K + still high, consider dialysis.

2.       Hyponatremia

If Dilutional Hyponatremia: (↑ JVP, edema, crepitation in lungs)

 

a)       Give large doses of Lasix 240 mg. t.d.s. or more(small doses of Lasix are inadequate in renal failure). Bumetamide oral or IV is a useful agent. It has 40 times the potency of Lasix.

b)      Restrict fluids to less than 500 mls / day.

If salt depletion – replace salt.

Sodium Deficit

If body weight less than 65 kg and Se Na+ 120 mE / L

Na” Deficit = 140 – 120 = 20 mE / L

Body water = 60 % pf BW

Hence Na + deficit = 65 x 60/100 x 20 = 780 mE = 5 liters of 0.9 NaCl

(1 litre 0.9 % NaCl = 154 mE or Na+

Oral 1 gm NaCl = 17 mE.

1 litre 3 % NaCl = 512 mE of Na+

Give ½ the calculated Na+ deficit in 24 hours. Repeat Se Na+ next day using the same calculation. See how much more Na+ is needed. Do not be in a hurry to correct as there is a risk of pontine myelinolysis.

3.       Hypertension

a)       If diastolic BP 120 mmHg or more, give 10 mg Nifedipine sublingually: repeat 4 hourly prn.

b)      Or use IV or IM hydralazine 25 mg or 50 mg 4 hourly.

 

At the same time, start Nifedipine 10 mg t.i.d. or if patient is not in congestive heart failure, start propranolol or atenolol and hydralazine or prazosin

4.       Uraemic Acidosis

Correct id Se bicarb less than 15 mE/ L. Formula:

One-third X BW (kg) x Bicarb deficit (25 – Se Bicarb) = x mls 8.4 % NaHCO

If patient is overloaded do not give NaHCO, as this will precipitate pulmonary edema. Dialysis is the safest and best way to correct acidosis. Steam bath may also be an alternative option.

5.       Anemia

 

No urgency to correct unless Hb less than 6 gm or patient has symptoms. Give 1 unit of packed cells. If patient is overloaded delay transfusion. Best time to give blood is during dialysis

 

6.       Uremic Fit

Give IV valium 10 mg.

Check Se Na+. Se calcium, blood glucose and correct if abnormal.

Indication for Dialysis:

1.       Uraemic symptoms, hyperkalaemia, pulmonary edema.

2.       Tide patient over while diagnosis is being made.

3.       Acute or chronic renal failure, tide patient over acute element.

4.       Patient being considered for dialysis or transplantation programme or plans uncertain.

 

The mode of Dialysis can be acute Peritoneal Dialysis (PD) or Acute Hemodialysis (HD)

Acute Peritoneal Dialysis:

1.       Acute Peritoneal Dialysis can be performed by the bedside in the ICU as an emergency procedure> It is important to observe asepsis to prevent peritonitis.

2.       Catheterize the urinary bladder in order to avoid accidental puncture of the bladder by the PD catheter.

3.       Clean the abdomen and create ascites by infusing 2 L dialysate.

4.       With the patient tensing the abdomen. Insert the PD catheter through the anesthetized area.

5.       The usual point of insertion is in the midline about 3 to 4 cm below the umbilicus.

6.       Creation of ascites is necessary to avoid puncture of the intestines.

7.       Avoid closed PD if patient has previous abdominal surgery, has bleeding tendency or thrombocytopenia.

8.       For difficult cases, the surgeon can always insert a Tenckhoff PD catheter via open insertion under the direct vision. Patients with bleeding tendency can have fresh frozen plasma or platelet transfusion prior to surgery.

Acute Hemodialysis

1.       An alternative to PD is Acute Hemodialysis

2.       This is quick and efficient but requires the support of a renal physician and the HD machine

3.       A subclavian catheter can be  introduced into the subclavian vein or a femoral catheter inserted into the femoral vein to allow vascular access for hemodialysis (heparin-free dialysis) if indicated.

AV Hemofiltration

1.       Patients with unstable hemodynamics e.g., Acute Pulmonary Edema / Septicemia Shock can be treated with continuous arterio-venous hemofiltration (CAVH).

2.       This provides an efficient method of rapid fluid removal for the patient in the ICU setting with unstable cardiovascular hemodynamics and low blood pressure but who is in severe  fluid overload in greater danger of dying from pulmonary odema.

3.       Hemofiltration is effected by means of a hemofilter and the necessary blood lines and a vascular access (subclavian or femoral catheterization). A hemodialysis machine is not needed.

Source / Reference / Further Reading:

1.       PH Feng, KM Fock. Philip Eng: Handbook of Acute Medicine

2.       David M. Cline, O. John Ma, Judith E. Tintinalli, Ernest Ruiz, Ronald L. Krome: Emergency Medicine: Companion Handbook

3.       Richard Robinson & Robin Stott: Medical Emergencies: Diagnosis and Management

4.       Sonke Mulle: Memorix Emergency Medicine

 

Life-Saving Drugs in Medical Emergency

 

I was just discussing with some doctors and with some of my ex-medical colleagues yesterday in our WhatsApp chat group that drug-based medicine fails miserably in managing most chronic diseases due to nutritional lifestyle, environmental exposures, occupational insults among other external and internal factors. Here's a comic illustration: 

 

I discussed with them drugs do not cure lifestyle diseases if we are unwilling to change the way we eat and live. Most patients take the easy path by swallowing pills than modifying their lifestyles such as managing their body weight, some are pathologically obese, others smoke and drink, yet others lead a sedentary life and is easily upset by the slightest stress among many other causative factors. They depend only on pills, tablets and surgery as a panacea for all their disorders and ills with each follow-up appointment their medication needed to be titrated to higher and higher dosage to the maximum only to be substituted by another as adjunct. 

 

Other medication needed to be added for other emerging linked diseases till they and all their drugs do them part into death. This is the sad scenario for most of the drug-dependent chronic disorders because they refuge to change the ways they live their lives, especially dietary and nutritional lifestyles. 

 

 

In medicine non-compliance by patients to take the prescribed medication is already one of the problems. This may be due to many reasons, such as social, cultural and economic reasons, taboos, belief systems, forgetfulness, too much medication to take especially by the elderly. These factors for non-compliance are mostly unknown or ignored by the clinician, let alone the much more difficult path to follow by changing or modifying patients' lifestyles to replace drugs.

 

However, there is a moderately long list of essential emergency drugs that are very life-saving and crucial in emergency situations that cannot be replaced by lifestyle changes or other alternative, complementary or traditional systems of medicine.

 

Let us have a very brief tour on some of these rapid-acting drugs used in emergency situations. Let us just very briefly run through the list. The emergency drugs are:

 

lignocaine, propranolol, verapamil, digoxin, inotropic agents such as adrenaline, aminophylline, atropine, diazepam, dopamine, flumazenil, glucose, isoprenaline. Other useful drugs are morphine sulphate, naloxone, nitro-glycerine, nitroprusside, pancuronium bromide, dobutamine, chlorpromazine, ipratropium, corticosteroids, phenytoin, potassium chloride.

 

Listing further are protamine sulphate, salbutamol, sodium bicarbonate, intravenous fluids such as 0.9 % normal saline, fluid expanders such as dextrose 3% with 0.3 saline, Hartmann’s solution, fluid expanding solution (e.g., Haemaccel, Gelofusin), including colloids for patients with hypovolaemic shock in association with crystalloid solutions.

 

Lignocaine for example is recommended for the treatment of ventricular fibrillation and ventricular tachycardia; atropine is used in the treatment of asystole and severe bradycardia. It acts to block the effects of the vagus nerve on the heart.

 

Sodium bicarbonate is used to treat the metabolic acidosis associated with cardiac arrest.

 

Our list can go on, but this short list will do as they are just examples. They will suffice for us to know how important, and lifesaving fast-acting drugs are in emergency situations.

 

But let us give ourselves just one example. Let us take a heart attack as the most common one even any lay person is aware of.

 

Let us say we are confronted by a cardiac emergency? A person has a heart attack or even a total cardiac arrest. What shall a doctor or even a well-trained and well qualified licensed paramedic with 4 -years of structured training in pre-hospital emergency care would do. We shall discuss this shortly.

 

Cardiac emergency is just one of the many types of medical crisis.  They can range from anything from cardiac arrest, hypertensive encephalopathy, eclampsia, phaeochromocytoma, aortic dissection.

 

Others are respiratory emergencies like acute ventilatory failure, spontaneous pneumothorax, primary and secondary pneumothorax, tension pneumothorax, haemothorax re-expansion pulmonary oedema, acute severe asthma, respiratory distress syndrome, massive haemoptysis, acute gastrointestinal emergencies such as GIT haemorrhage, variceal haemorrhage, hepatic encephalopathy, acute pancreatitis.

 

Listing further are metabolic emergencies to include diabetic comas, hypoglycaemia, diabetic ketoacidosis, hyperosmolar hyperglycaemic non-ketotic coma, hypernatremia, hypercalcemia, hypocalcemia, Addisonian crisis, hypomagnesemia, hypophosphatemia, lactic acidosis, uraemic crisis.

 

Then we also encounter neurological emergencies such as subarachnoid haemorrhage, head injuries, acute myelopathy, myasthenia gravis, to haematological emergencies such as severe anaemia, severe neutropenia, fat embolism syndrome, massive pulmonary embolism, acute limb ischaemia, acute mesenteric embolism.

 

Listing down other medical emergencies include, anaphylaxis, acute auto-immune emergencies such as cerebral lupus, down to acute poisoning from overdose of drugs, poisoning from swallowing detergents, bleaches, disinfectants, salicylate, barbiturates, organophosphate, carbamate, insecticide, paraquat, paracetamol, opium alkaloids and morphine, benzodiazepines, and methanol poisoning.

 

Other medical emergencies may include, but not limited to, are acute life-threatening infections like septicaemia and septic shock from streptococcal, gram-negative bacillus septicaemia, malaria, tetanus, dengue, melioidosis, all the way down to other medical crises from near drowning to heat disorders like heat cramps, heat exhaustion, heat stroke to snake bites, etc, etc.

 

There are other medical emergencies too besides what we have briefly listed here that need to be considered, and it is outside the scope of this very short article to even list them partially, let alone discuss their treatment using drugs and other adjunct therapies.

 

Let us now go back to what we mentioned earlier that the most known emergency event of all is a heart attack or myocardial infarction or even more serious a total cardiac arrest.

 

 Let us use only this example most lay people are aware of, and how drugs come in very useful and lifesaving, besides other non-pharmacological interventions such as CPR. Let us discuss only this emergency.

 

During a myocardial infarction, commonly called a heart attack there are three things we need to consider, namely: airways, breathing and circulation (ABC). If the heart stops beating or just quiver (fibrillating) we need to perform cardiopulmonary resuscitation (CPR) immediately besides maintaining patent airways with head tilt, chin lift.

 

We need to initiate mouth-to-mouth resuscitation with rescue breath in the prehospital environment, and in the hospital environment, ventilate with 100 % oxygen through air viva and intubate via oral route. Ventilate through downstroke at every 5^th chest compression, namely, 12 to 15 ventilation per minute.

 

Next, we need to establish circulation by external cardiac massage at the rate of 60 compressions per minute by transmitting heel of hand compression at sternum 2 fingerbreadths above the xiphisternum without pausing for ventilation.

 

Open cardiac massage may be considered if there is a cardiothoracic surgeon available.

 

Defibrillate if VT or VF serially with 200, 300, then 360 joules of shock. If no ECG rhythm gives blind DC shock since VF collapse rhythm is common. If cardiac rhythm is established after successful defibrillation, give lignocaine infusion to maintain.

 

All essential drugs should be given through the central line or through antecubital vein reserving intratracheal or intracardiac routes as the last option. Emergency drugs of choice for asystole is 1:10,000 adrenaline 10 ml given bolus, repeat every 5 minutes. This drug can cause fine VF to coarse VF more suitable for defibrillation.

 

Lignocaine is indicated for VT to be given at 50 to 100 mg bolus.

Giving Sodium bicarbonate is debatable and may not be suitable since acidosis may be reversed through adequate ventilation.

 

In acute myocardial infarction this should be differentially diagnosed from pneumothorax, aortic dissection, acute pulmonary embolism and pericarditis. Management includes total bed rest in CCU, intranasal oxygen at 2 litres per minute, maintaining IV access with slow infusion, IV morphine 3 -5 mg titrated to 10 – 15 mg for pain management.

 

Sedate with oral benzodiazepine such as diazepam at 6 mg tds. Antiplatelet agents such as aspirin (100- 300 mg) om may be indicated. Betablockade such as propranolol 40 mg tds may be considered. Other areas of intervention to be considered are diltiazem 30 mg tds for non-Q infraction.

 

Thrombolytic therapy with streptokinase 1.5 megaunit or rTPA 100 mg at 10 mg bolus, 50 mg first hour, 20 mg in 3^rd hour can be considered in define Q-wave infarction for age below 75 years, with no risk factor for bleeding, example recent surgery, prolonged CPR and no history of allergy or streptococcal infections.

 

These are just some examples where essential emergency drugs become very lifesaving. There is no other system of medicine that can match conventional pharmacological interventions in medical emergency events such as in a cardiac emergency.

 

We have very briefly outline in point form other medical emergencies where conventional drug-based medicine is beatable by other systems of medicine.

 

Unfortunately drug-based medicine fails badly in all other lifestyle and age-related diseases such as obesity, type 2 diabetes, high blood pressure, CVA (stroke), asthma and Chronic Obstructive Pulmonary Diseases (COPD), cancers, dental disease, heart, liver and renal failures, mental disease, osteoporosis, and other diseases due to dietary lifestyles and other unhealthy causative factors such as smoking, physical inactivity, stress, anger and personality disorders among others.

 

I hope we have high-lighted how certain drugs whose pharmacodynamics are very fast acting and clinically very efficient in managing very acute medical events that will open our eyes that no other medical system can replace.

 

Unfortunately, drugs are synthetic and most fail miserably in managing most other chronic and degenerative diseases of lifestyles where the root causes are never addressed, preventive medicine and health education are largely ignored by clinicians.

 

This is where other medical systems such as naturopathic medicine, nutritional medicine far surpassed conventional drug-based medicine, and that is where they take over to replace drug-based medicine effectively and permanently.

 

Health care is an integrated system not based only on monotherapy of an isolated modality. Nutrition and lifestyles take precedence over drugs for the prevention of chronic diseases. 

 

Hippocrates, the Father of Medicine said:

 

"Let food be thy medicine”. 

 

He has never said: Let medicine be thy food?? This was put into his mouth after he was long dead. 

 

I hope this is helpful to clinicians and medical doctors and also to practitioners of other systems of medicine.

 

 

jb lim