○Prerenal- give fluids and expand intravascular volume○Intrarenal - d/c nephrotoxic drugs, CRRT therapy○Postrenal - remove source of obstruction, renal ultrasound, KUB, check pt’s foley●Assessment and Diagnosis of Acute Kidney Injury○Urine changes - decreased?○Other changes■ABG’s--Metabolic acidosis●Due to decreased ability of kidneys to excrete acid metabolites (uric acid, ammonia)■BUN●BUN to creatinine ratio○More effective with pre-renal AKI ●Not a reliable tool to determine kidney problems (AKI)■Creatinine■Creatinine clearance●Over 24 hrs●Better indicator/tool for renal function and monitoring GFR●Most accurate, tells us about renal fx, adequate reflection of GFR ■K+●Dextrose w/ insulin – pulls K out of blood and into the cell ●Kayexalate (K excreted via stool) ●Diuretic vs oliguric stage? ■Calcium (Decreased GI absorption) and phospurus (Inverse relationship with Ca+)■Anemia●B/c can’t stimulate production of RBCs (decr. Renal fx) ●At-Risk Disease States and Acute Kidney Injury○Underlying chronic kidney disease (CKD)■How are we managing it?○Older age ■Less nephrons ■Hx – diabetic, HTN ○Heart failure - monitor BP and glucose ○Respiratory failure - vent can decrease level of perfusion b/c of positive pressure and blood flow, avoid too much PEEP ■Managing ARDS? ○Sepsis ■Causes most cases of AKI ■Need fluids ■No antibiotics – renal dose vs normal adult dose ■Prevent shock 63
○Trauma ■Rhabdomyolysis - need sodium bicarb ●Release of myoglobin and creatine (trauma of kidney, muscle break down) ●Life-threatening hyperkalemia (fastest way to get rid of excess K is dialysis) ●Metabolic acidosis – give bicarb ■Esp a crush injury (fall in elderly) ○Contrast-induced nephrotoxic (CIN) injury ■Radiopaque contrast – prefer without if possible ●“Use the least dose as possible” ■Promote hydration and avoid dehydration■Medications●Metformin stop day before, return 48 hrs after●Hemodynamic Monitoring and Fluid Balance and AKI○Pts in ICU- CVP, cardiac something, poomonary something■Someone help she went too fast■Pre-renal = low CVP ■MAP needs to be at least 60-65 ○Hemodynamic monitoring■I&O●In and out cath, foley, what did they have?