Renal protective strategies in the ICU

Nov 2006

Kishore P. Critical care conference

Why renal protection?

Nov 2006

Kishore P. Critical care conference

RIFLE classification of ARF

Crit Care. 2004 Aug;8(4):R204-12

Acute renal failure

67% of ICU admissions Mortality
R-8.8% I-11.4%, hazard ratio 1.4 F-26.3%, hazard ratio 2.7

Cost Technology requirements

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Kishore P. Critical care conference

Prevention is better than cure

Desiderius Erasmus

Nov 2006

Kishore P. Critical care conference

Causes of ARF in the ICU

Primary disease activity Shock states Sepsis syndromes Infections-malaria, scrub, leptospirosis Nephrotoxic drugs Contrast nephropathy Vascular-anastomotic, athero and cholesterol embolisation
Kishore P. Critical care conference

Nov 2006

Renal protection - general

Ensure adequate renal perfusion Avoid / minimize use of nephrotoxic drugs including radio contrast Early recognition and aggressive management of sepsis

Nov 2006

Kishore P. Critical care conference

Adequate renal perfusion

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Kishore P. Critical care conference

Adequate renal perfusion

Blood pressure Intravascular volume Cardiac output Other markers of perfusion

Nov 2006

Kishore P. Critical care conference

Scenarios
1. 60 year old lady presented with urosepsis to the casualty. She had not passed urine for the last 6 hours. Blood pressure on arrival was 60mmHg systolic. She was catheterized and 50ml of urine was drained. 1 liter of crystalloids is rushed in and dopamine is started-BP picks up to 100/40mmHg. She reaches ICU after 2 hours. The MAP is 64mmHg. She is treated with 1 liter of Haesteril, and output increases to 45ml per hour for the next hour, and gradually trails off. Her creatinine is 1.5, and goes up to 3.2 the next day.
Nov 2006
Kishore P. Critical care conference

2.

A 76 year old female undergoes a sigmoid colectomy for ruptured diverticulum. Her baseline blood pressure is 140/80, MAP 100mmHg. She requires multiple boluses of phenylephrine in the operating room to support her blood pressure. On return to intensive care, the patient is mechanically ventilated. Her urinary output is 15ml in the first hour. She is treated with 1 litre of colloid, her CVP rises to 14cmH2O, she puts out little urine, and her blood pressure remains 90/50 mmHg (MAP 63). The registrar starts a noradrenaline infusion, targeted at a MAP of >80mmHg, and the patients urinary output increases to 70 to 100ml/hour. Over the next 48 hours, each time the vasopressor was weaned and the MAP fell below 75mmHg, so too did the urinary output. Eventually, the patients blood pressure recovers, and she is weaned from ventilation and vasopressors without further difficulty.
Kishore P. Critical care conference

Nov 2006

Renal Autoregulation Renal Medullary Hypoxia Tubuloglomerular Feedback

Nov 2006

Kishore P. Critical care conference

CCM tutorials.com

CCM tutorials.com

Blood pressure
Renal autoregulation suboptimal below 80 and lost below 60mmHg Renal success Vs renal failure

Nov 2006

Kishore P. Critical care conference

Blood pressure
Target MAP of 70mmHg normally in ICU 80mmHg in patients with oliguria, established renal failure, longstanding hypertensives and raised ICP

Nov 2006

Kishore P. Critical care conference

Intravascular volume
Target CVP of at least 14-16mmHg Fill till signs of overfill just manifest
CVP>16mmHg Drop in P/F ratio Bilateral crackles S3 Loss of stroke volume variation

Fill to targets, do not go by numbers!

Nov 2006
Kishore P. Critical care conference

CO and other markers of perfusion

Cardiac output assessment Urine output Base excess and lactate ScvO2

Nov 2006

Kishore P. Critical care conference

Sepsis syndromes

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Kishore P. Critical care conference

Renal failure in sepsis

Shock Cytokine damage DIC Drug induced

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 Principles of optimizing renal perfusion Specific measures

Low dose dopamine Fenoldopam Dopexamine Intensive insulin therapy Ischemic preconditioning

Nov 2006

Kishore P. Critical care conference

Low dose dopamine

Renal dose-2.5mcg/kg/min-renal vasodilation Meta-analysis: low-dose dopamine increases urine output but does not prevent renal dysfunction or death. Can actually worsen renal perfusion No role.
Ann Intern Med. 2005 Apr 5;142(7):510-24 Kidney Int. 2006 May;69(9):1669-74

Nov 2006

Kishore P. Critical care conference

Fenoldopam
Dopamine-1 receptor agonist Selective renal vasodilation Many small trials. Evidence inconclusive Recent RCT - did not show significant reduction in renal failure with Fenoldopam

Crit Care Med. 2005 Nov;33(11):2451-6

Nov 2006

Kishore P. Critical care conference

Dopexamine
Beta2 and dopamine agonist - inodilator Not useful

British Journal of Anaesthesia 2005 94(4):459-467

Nov 2006
Kishore P. Critical care conference

Intensive insulin therapy

Intensive insulin therapy in the SICU to maintain capillary sugars between 80100mg/dl reduced acute renal failure requiring dialysis or hemofiltration by 41 percent However subsequent study in the MICU did not support this. However new onset rise in creatinine was reduced (12.6 vs 8.3%). No difference in dialysis requirement. N Engl J Med. 2001 Nov 8;345(19):1359-67
N Engl J Med. 2006 Feb 2;354(5):449-61

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Kishore P. Critical care conference

Nephrotoxic drugs

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NSAIDs ACE inhibitors Aminoglycosides Last straw Consider alternatives Weigh risk vs benefit

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Kishore P. Critical care conference

Contrast
Incidence of contrast nephropathy 2% in noncritically ill patients Rise in s.creat. By 0.5mg% or a 25% increase from baseline 48-72 hours after contrast exposure Is contrast really necessary? Non ionic contrast Hydration N-acetyl cysteine NaHCO3 Fenoldopam Ascorbic acid, theophylline
Nov 2006
Kishore P. Critical care conference

Hydration
Most effective stand alone intervention 1000-2000 ml in the 12 hours prior to the procedure

Clin Nephrol. 2004 Jul;62(1):1-7

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Kishore P. Critical care conference

N-acetyl cysteine
RCTs show inconsistent results Meta-analyses show benefit 2gms over 6 hours

Clin Cardiol. 2004 Nov;27(11):607-10

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Kishore P. Critical care conference

Bicarbonate
Better than saline alone 3ml/kg/hr 1 hour before procedure followed by 1ml/kg/hr for 6 hrs after

JAMA. 2004 May 19;291(19):2328-34

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Kishore P. Critical care conference

 Hemodialysis and filtration in pre-existing renal failure

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Kishore P. Critical care conference

Specific situations
Rhabdomyolysis: 10% mannitol and hydration to maintain urine output 100ml/hr Cholesterol embolisation- care during cath procedures

Nov 2006

Kishore P. Critical care conference

Oliguria in the ICU

Rule out obstn, abdominal compartment syndrome BP, volume, CO target optimisation Diuretics only if all above fulfilled

Nov 2006

Kishore P. Critical care conference

Organ preference
Prefer the lung to the kidneys do not fill the kidneys and flood the lungs

Nov 2006

Kishore P. Critical care conference

The superior doctor prevents sickness; The mediocre doctor attends to impending sickness; The inferior doctor treats actual sickness;
Chinese proverb