CHRONIC RENAL FAILURE WITH FLUID OVERLOAD PATHWAY O2 therapy

Urinary catheter if required

Investigations:
FBC--anaemia
PT/PTT, GXMfor dialysis, transfusion Treatment Orders:
U/E/Cr/HCO3/Glucoserenal fxn, DM 1. Diuresis with IV frusemide:
HbA1c if diabetic--DM 120-240 mg/8hrly (if serum Cr > 400 mol/L)
Ca/Phosphate/Magnesiumrenal osteodystrophy 80-120 mg/8hrly (if serum Cr < 400mol/L)
Fasting iPTHendocrine compx If no response, step up to maximum OR infusion at 30 mg/hr
LFT Urinary catheter if no urine output > 6hrs
Fasting lipids--hyperlipidaemia
2. Exclude cardiac event
ECG/CXR )
Check baseline ECG
ABG on room airmetab acidosis ) exclude AMI If pt has IHD, do CK/CKMB/Trop T
CK/CKMB ) Repeat ECG x3
UFEME, Urine c/s
3. Consider acute dialysis/filtration (if hypoxic, severe fluid overload, acidosis, or hyperkalaemia)
Day 2: PT/PTT, GXM
If Hb<11 g/dL: If for dialysis, trace Hep/HIV status.
Fe/TIBC If results > 6mths, order HBsAg, Anti-HCV, HIV
Ferritin 4. (Day 3) If anaemia workup negative, consider erythropoietin therapy refer pharmacist and inform
B12 / folate on cost
Stool OB x3
If Hb<6 g/dL 5. (Day 5) Review CXR: if clear, consider switching to oral frusemide. If well on oral frusemide,
Consider OGD, transfusion, thal workup etc consider discharge

6. Discharge plan:
Nutrition: Fluid restriction
Low salt
Nutritional restriction (decreased protein, potassium, phosphate, calories (if DM))
Low protein 0.8g/kg/day
When to seek medical help: skin turgor, pitting oedema, weakness, fatigue, muscle cramps,
Low phosphate N/V
Low potassium Skin care
DM 1500/1800/2000 kcal Identify primary physician, appointments, home care etc.

Fluids: Referral Plan (Day 2 onwards):

500ml/day (if serum Cr > 400 mol/L) If Cr > 400 mol/L
800ml/day (if serum Cr < 400mol/L) Assess ADL (toilet needs, dressing, feeding)
If cant do any one ADL, refer MSW
Assessment: If can do all, refer renal coordinator, vascular surgeon
Vital signs If Cr < 400 mol/L, refer renal coordinator, MSW, vascular surgeon as required
Height/weight Others: pharmacist, physiotherapist, psychologist etc.
Urine dipstick
Pruritus
Oedema sites and severity
Compliance with fluid restriction
I/O charting
IV plug

DGIM Last updated March 2005