632 box 26 2 1 Prerenal Decreased renal blood flow Low cardiac output Causes

632 box 26 2 1 prerenal decreased renal blood flow

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3 Categories of Acute Kidney Injury p.632 box 26-2 1. Prerenal - Decreased renal blood flow, Low cardiac output Causes- shock, septic, dehydrated, burned, fluid volume loss, hemorrhage Decr. Kidney perfusion 2. Intrarenal - Direct damage in kidneys. NSAIDS, contrast dye, glomerular diseases [glomerulonephritis, lupus], acute tubular necrosis [ischemic (trauma, sepsis) and nephrotoxic agents (environmental-street drugs, gentamicin, acyclovir)] Antifungals, antivirals Street drugs – heroin, amphetamines Radiology procedures Glomerular dz – glomerular nephritis 3. Postrenal - obstruction of urine flow from kidneys kidney stones, prostate problems, BPH, renal tumor Management 62
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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
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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?
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