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Renal Replacement Therapy

NEUROLOGICAL INJURY and RENAL REPLACEMENT THERAPY Lina C. Laxamana, FPCP, FPNA Neurocritical Care Unit October 8, 2010 NKTI Post Graduate Course. Renal Replacement Therapy. Indications: Severe hyperkalemia Fluid overload Refractory acidosis Uremic symptoms: Serositis Encephalopathy

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Renal Replacement Therapy

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  1. NEUROLOGICAL INJURY and RENAL REPLACEMENT THERAPYLina C. Laxamana, FPCP, FPNANeurocritical Care UnitOctober 8, 2010NKTI Post Graduate Course

  2. Renal Replacement Therapy • Indications: • Severe hyperkalemia • Fluid overload • Refractory acidosis • Uremic symptoms: • Serositis • Encephalopathy • Bleeding • Objectives: • Remove excess volume • Remove solutes

  3. Renal Replacement Therapy

  4. Intensity of RRT and outcome in critically ill patients with ARF

  5. CASE • M.B., 56/M, married, from Isabela • Admitted due to sudden onset of R sided weakness and aphasia • ~11 hours PTA • Sudden onset of R sided weakness, with aphasia • Brought to a local hospital • Cranial CT requested

  6. Imaging ( 2 ½ hours)

  7. Imaging (2 ½ hours)

  8. Imaging (2 ½ hours)

  9. Imaging (2 ½ hours)

  10. Imaging (2 ½ hours) • Intracerebral hematoma with an estimated volume of 30cc in the L capsuloganglionic region. • With perilesional edema, mass effect and midline shift • No IVE, HCP

  11. Case • PMHx • With HPN, DM II, CAD • With ESRD requiring HD every 5th day through a L brachial AV fistula • Maintained on Plavix 75mg/tab, ½ tab daily • Denies allergies • PSHx • unremarkable

  12. Pertinent examination • E4V2M6 • Cranial nerves • Pupils 2mm EBRTL • R central facial palsy • Good gag • Tongue deviated to the R • Motors UE R 0/5 L 5/5 LE R 0/5 L 5/5

  13. Case • Pertinent labs • CBC 13.3/44.1/11.1/N92/249 • BT 4’ CT 5’ • PTT 35.1s PT 85% INR 1.06 • Na 127 K 5.89 • BUN 34 Crea 6.77 • Cranial CT repeated

  14. Imaging (10 ½ hours)

  15. Imaging (10 ½ hours)

  16. Imaging (10 ½ hours) • L capsuloganglionic acute intraparenchymal hematoma (42cc) • Surrounding edema • Compression of the ipsilateral ventricle and slight midline shift to the right

  17. Case • Admitted to NCCU • Started on Mannitol 60gms q4 • Neuro status quo: E4v2m6 • Pupils 2mm EBRTL • Slight headache • Started on HD

  18. Day 2 • Day 3 post ictus (830am) • E2v1m6, drowsier • BP 150/90 HR 90 O2sat 95% T 37.8C • Pupils 1mm, equal • Na 126 (124) K 5.89 (6.26) • Stat CT scan requested • NPO • Additional Mannitol 30gms bolus given

  19. Imaging (day 2)

  20. Imaging (day 2)

  21. Imaging (day 2)

  22. Imaging (day 2) • Interval evolution to beginning subacute stage • Without increase in volume • Interval progression of perilesional edema • Midline shift to the right has not significantly changed

  23. Case • Day 3 post ictus (915am) • Prepared for surgery • Repeat PT 138% INR 0.88 PTT 31.1s • Na and K correction • Mannitol continued at 60gms q4 • Hemodialysis • Clearances requested

  24. Case • Day 3 post ictus (1110am) • Elective intubation done (Anes) • Day 3 post ictus (515pm) • E2vtm5, more difficult to arouse • BP 166/100 HR 90 O2sat 100% • Pupils 2-3mm EBRTL • Awaiting repeat labs post HD

  25. Case • Day 3 post ictus (10pm) • K 4.35 • Scheduled for surgery at 4am • Day 4 post ictus (120am) • E2vtm5 • BP 160/90 HR 88 O2sat 98% • Pupils 2-3mm EBRTL

  26. Case • Day 4 post ictus (4am) • OR • Plan • L frontal craniotomy, endoscopic evacuation of hematoma with intraparenchymal ICP monitor probe insertion

  27. Case • Goals for treatment • Address the increased intracranial pressure from the hematoma • Evacuate the capsuloganglionic hemorrhage • Lessen the need for osmotic diuretics in an ESRD patient

  28. Surgery

  29. Surgery

  30. Surgery

  31. Surgery

  32. 4th day post-op

  33. Renal Replacement Therapy and the Neurocritical Care Patient

  34. Cerebral Blood Flow Lang & Chestnut, Neurosurg Clin N Am 1994;5(4):573-605

  35. Cerebral Blood Flow Bhardwaj A. Cerebral blood flow. In Suarez JI, Critical Care Neurology and Neurosurgery, Humana Press, 2004 with permission

  36. MAP = 2 (diastolic) + systolic 3 • CPP = MAP - ICP • CBF = Cerebral Perfusion Pressure Cerebral Vascular Resistance =P x  x r4 / 8 x L x  (Hagen-Poiseuille equation for movement of Newtonian fluids in large caliber vessels) • Autoregulation: MAP 60-150 mmHg

  37. IHD and ICP From: Davenport A. Hemod Internl 2008;12:307–312 with permission

  38. MAP and CAPD From: Davenport A. Hemod Internl 2008;12:307–312 with permission

  39. Effect of renal replacement on ICP From: Davenport A. Semin Dialysis, 2009;22:165–168 with permission

  40. Serum osmolality following renal replacement From: Davenport A. Semin Dialysis, 2009;22:165–168 with permission

  41. Modifications to standard hemodialysis prescription that may potentially reduce risk of further cerebral injury in patients with acute cererbal injury From: Davenport A. Hemod Internl 2008;12:307–312 with permission

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