Quiz 2 - AKI, DKA, HHS, More Cardiac, and Cancer Still ****

AKI criteria

-↑ in SCr by ≧ 3mg/dL w/in 48hr

-↑ of SCr by x1.5 baseline w/in 7d

-urine output <0.5mg/kg/hr x 6hrs

AKI risk factors

≧65 y/o, diabetes, HTN, CKD, HF, liver failure, sepsis, IV contrast (esp right after cardiac surgery) or other nephrotoxic medications,

categories of AKI

-prerenal; problem with perfusion to kidneys

-intrarenal; damage directly to kidneys

-postrenal; obstruction downstream

prerenal AKI

-reduced renal blood flow

-causes; prolonged hypotension (sepsis, massive vasodilation), prolonged low CO (HF, cardiogenic shock), prolonged fluid deficit (dehydration, hemorrhage), thrombosis, NSAIDS -> afferent vasoconstriction

goal of care for prerenal AKI

restore normal perfusion

intrarenal AKI

-direct damage to the kidneys, esp nephrons

-causes; prolonged ischemia, Hgb release from hemolysis, myoglobin release from necrotic muscle (rhabdo), primary renal diseases (SLE and glomerlunonephritis), and nephrotoxic agents (aminoglycosides, IV contrast)

acute tubular necrosis (ATN)

-damage to the renal tubules

-most common cause of AKI

-causes; ischemia (MAP <50-70 x 25 min), nephrotoxic agents, sepsis

postrenal AKI

-mechanical obstruction in the outflow of urine

-causes; BPH, prostate cancer, calculi, trauma, extrarenal tumor

-if obstruction resolved w/in 48 hrs, GFR recovery

-if obstruction not resolved by 12 weeks, GFR recovery unlikely

phases of AKI

Oliguric/anuric, diuretic, recovery

oliguric/anuric phase of AKI signs and symptoms

-fluid retention; JVD, bounding pulse, edema, HTN, heart failure, pulmonary edema, pericarditis, pleural effusion

-metabolic acidosis; Kussmaul respirations, hyperkalemia -> weakness (ESP IN LEGS), peak T waves, wide QRS, ST depression

-hyponatremia/uremia; cerebral edema, fatigue, seizures, stupor, difficulty concentrating, coma

serum and urinary changes in oliguric/anuric phase of AKI

-urine; increased sodium with present sediment, RBCs, casts, and proteins, decreased Sp. gravity with prerenal, normal sp. gravity with intrarenal

-serum; hyponatremia, hyperkalemia, BUN >20 and Cr >1.2, decreased bicarbonate, increased nitrogenous waste products

diuretic phase of AKI

-renal tissue begins to recover; nephrons unable to concentrate urine but can excrete waste

-gradual increase in urine output but caution for hypovolemia and hypotension

-caution for electrolyte loss in urine

-Serum BUN and Cr still elevated but dropping

recovery phase of AKI

-most improvement in first 2 weeks, stable kidneys at 12 months

-GFR, BUN, Cr normal

lab testing for AKI

-Cr and creatinine clearance are best tests

-normal BUN:Cr :: 20:1; >20:1 = prerenal causes, <10:1=ATN

why is Sr Cr a better test of renal function than BUN?

Cr is more stable, BUN affected by catabolism, hemorrhage, and dehydration

AKI treatment

-ensure euvolemia and good CO; loop diuretics and osmotic diuretics to maintain

-strict I&Os; fluid restriction during oliguric = all losses for 24 hrs + 600 mL

-CRRT (criteria on another card)

-diet; mostly carbs and fats, just enough protein to prevent breakdown, restrict sodium, potassium, phosphate

treatment of hyperkalemia

-temp fix is insulin and sodium bicarb to move potassium into cells

-calcium gluconate to stabilize myocardium and decrease risk of dysrhythmias

-sodium polystyrene sulfonate (kayexalate) or patiromer or dialysis to remove potassium from body

indications for CRRT

volume overload, metabolic acidosis, hyperkalemia, BUN >120, significant altered mental status, pericarditis, pericardial effusion, cardiac tamponade

DKA precipitating factors

-Inadequate insulin intake; fear of weight gain, hypoglycemia, stress, non-adherence to plan of care

-Infection

-Infarction; MI, CVA, pancreatitis, other co-morbidities

-Intoxication

triad of DKA

hyperglycemia, ketonemia, metabolic acidosis

DKA pathophysiology

insulin deficiency -> gluconeogenesis and glycogenolysis -> decreased glucose uptake -> lipolysis -> increased fatty acids -> ketonemia and ketonuria -> metabolic acidosis

DKA s/sx

polyuria, polydipsia, tachycardia, dehydration, orthostatic hypotensio, lethargy, weakness, abdominal pain, anorexia, vomiting, acetone breath, Kussmaul respirations

DKA labs

glucose >250, pH <7.30, serum bicarb <15, ketonuria, ketonemia

HHS precipitating factors

-same as DKA

-infection of urinary tract, pneumonia, sepsis, dehydration

HHS labs

glucose >600, pH normal, absent/minimal ketonuria/ketonemia, increased serum osmolality

HHS s/sx

-DEHYDRATION; poor skin turgor, dry mucous membranes, sunken eyes, polyuria

-AMS, seizures, hemiparesis, aphasia

-tachycardia, tachypnea, hypotension

DKA/HHS treatment

-insulin drip at 0.1 u/kg/hr, when glucose is <200-250 -> 0.05 u/kg/hr, consider initial bolus of 7-10 units

-IVF; 1 liter NS first hour, when glucose is <200 -> D5 1/2 NS

-give potassium to prevent hypokalemia

-sodium bicarb ONLY FOR DKA if pH <7.0 or bicarb <5

goal of DKA/HHS treatment

-reduce blood glucose by 36-54 mg/dL per hour to avoid complications like cerebral edema

-treat precipitating factor

DKA/HHS monitoring

-mental status change = notify PCP STAT

-vitals, LoC, strict I&O, heart monitor

-breath sounds for fluid overload

-blood glucose hourly

-blood chemistry/ABGs q2-4 hrs

potassium dosing for DKA/HHS

-if >5.0, nothing

-if 4-5, add 20 mEq/L for each liter of fluids

-if 3-4, add 40 mEq/L for each liter of fluids

-if <3, HOLD INSULIN until >3.3, then add 40 mEq/L for each liter of fluids

oncologic emergencies

life-threatening complications associated with cancer or cancer treatment

superior vena cava syndrome

-tumor or thrombosis compresses the SVC -> impaired venous drainage from head, neck, shoulders, and arms

-associated with lung cancer, lymphomas, metastatic tumors, central venous catheter use, and mediastinal radiation

s/sx SVC syndrome

-neruo; headache, lightheadedness, dizziness, seizures

-resp; cough, dyspnea, dysphagia, tachypnea, hoarseness, choking sensation

-cardio; angina, JVD, venous distention of head and chest

-integumentary; edema to trunk and upper extremeties, redness in face

SVC syndrome diagnosis

CXR, CT, invasive contrast venography

SVC syndrome treatment

-oxygen, diuretics, steroids, anticoagulants

-decrease size of tumor; radiation or chemo

-maintain semi-fowlers

-avoid venipuncture/blood draws/NIBP measurements of upper extremities

-avoid straining

spinal cord compression

-tumor in epidural space compresses spinal cord -> neurological damage, vertebral collapse, and infarct

-associated w/ cancers prone to metastasis like breast, lung, prostate, GI, renal, melanoma, myeloma, nasopharynx

-neuro function prior to treatment indicates prognosis

spinal cord compression s/sx

-MSK; progressively worse back pain, weakness, paralysis

-sensory changes; useful for determining where compression is

-bladder and bowel dysfunction

diagnosis of spinal cord compression

MRI, CT-angio, bone scan, spinal XR, myelogram

treatment of spinal cord compression

-high dose corticosteroids, high dose radiation, surgery

-pain management, frequent neuro checks, activity limitation

metabolic oncologic emergencies

stem from either the tumor directly secreting hormones or from chemotherapy

SIADH

-excess ADH secretion -> free water retention and dilutional hyponatremia

-associated w/ oat or small cell lung cancer mostly, also Hodgkin's lymphoma and duodenal and pancreatic cancer

SIADH s/sx

oliguria, weight gain w/out edema, anorexia, nausea, vomiting, personality changes, seizures, coma, decreased DTRs, weakness

SIADH labs

serum sodium <130, serum osmolaliy <280, urine osmolality >330

SIADH treatment

-fluid restriction, weight BID, strict I&Os

-frequent neuro and respiratory checks

-seizure precautions

-increased sodium intake

-if sodium <114, IVF 3% NS + furosemide

-give samsca for free water elimination

hypercalcemia

-excess serum calcium (>12 = life threatening)

-associated w/ breast, lung, kidney cancers, bone metastasis, multiple myeloma, tamoxifen use

hypercalcemia s/sx mneumonic

STONES, THRONES, GROANS, BONES, PSYCHIATRIC OVERTONES!!..... cardiac :)

hypercalcemia s/sx

-neuro; fatigue, apathy, depression, fatigue, psychotic behavior, seizures

-MSK; bone pain and weakness

-cardio; dysrhythmias

-GI, anorexia, nausea, vomiting, constipation, ileus

-renal; insufficiency, stones, failure, polyuria, nocturia

corrected calcium formula

serum calcium + 0.8(4-serum albumin)

example: 10.5 + 0.8(4-2.1) = 12.02

hypercalcemia treatment

-resolve underlying cause

-decrease bone resorption via bisphosphonate

-urinary excretion via diuretics

-encourage ambulation

tumor lysis syndrome

-rapid destruction of large amount of tumor cells -> releases intracellular material into circulation (K+, phosphate, DNA, RNA) -> hyperkalemia, hyperphosphatemeia, hypocalcemia, hyperuricemia

-associated w/ radiation and chemo (1-5 days after treatment)

s/sx tumor lysis syndrome

-hypocalcemia; tetany, muscle cramps, seizures, Chvostek's and Trousseau's signs

-hyperkalemia; NVD, muscle weakness, dysrhythmias

-hyperphosphatemia, worsening renal function, oliguria

-hyperuricemia; AKI, anorexia

treatment of tumor lysis syndrome

-hyperkalemia; calcium gluconate, insulin + dextrose, and polystyrene sulfonate, restrict K+ intake

-hyperphosphatemeia; phosphate binders

-hyperuricemia; allopurinol, increase fluid intake

cardiac tamponade

-accumulation of fluid in the pericardial sac

-associated w/ lung and breast cancer, metastasis, and radiation

beck's triad

-indicative of cardiac tamponade

-hypotension, JVD, muffled heart sounds

s/sx cardiac tamponade

-becks triad; hypotension, JVD, muffled heart sounds

-retrosternal chest pain relieved by leaning forward, heavy feeling in chest

-tachycardia, decreased CO, dyspnea, SoB, hiccups, hoarseness, tachypnea

-anxiety, decreased LoC, dysphagia, nausea, vomiting, diaphoresis

treatment of cardiac tamponade

-HoB slightly elevated

-give oxygen, steroids, diuretics, IVF, vasopressors

-s/p of pericardiocentesis or pericardial window

purposes of cardiac surgery

revascularization, repair, or replacement

surgical revascularization

-intent is to increase myocardial perfusion

-types; CABG, MidCAB, robotic assist CABG, or off-pump

-uses grafts from saphenous vein (rare), internal mammary artery, or radial artery

consideration for cardiac surgery

it requires cardiopulmonary bypass, needing heparin, hemodilution, and hypothermia to fully empty heart of blood

complications of CABG

-DYSRHYTMIAS

-imapired contractility -> low CO, intra-operative MI, pericardial tamponade, respiratory insufficiency, pain, emobolus, stroke

heart transplant

-requires same ABO and weight

-transplant performed in 6 hrs of removal from donor

-heart denervated so not responsive to some meds, can't feel as much pain, HR ~100 BPM from loss of vagal stimulation

indications for chest tubes

-pneumothorax; open (wound ~ the size of a nickel) or closed (tension pneumothorax)

-hemothorax

-pleural thorax

steps for chest tube assessment

-check, dressing, drainage, bubbling, tidaling, level of water, and tubbing

-ensure no dependent loops, stripping, or milking

sternal pain

-localized, does not radiate, increases w/ coughing and deep breathing

-is different from anginal pain

pain effects on CO

decreases via SNS stimulation

aneurysm

ballooning of a weakened portion of an arterial wall

aortic dissection

-tearing of aorta

-type A is any involvement in Ascending Aorta and is emergency

-type B is in descending aorta and is non emergency

fusiform aneurysm

circular dilation involving whole circumference of aorta

saccular aneurysm

a sac-like bulge on one side of an artery

true aneurysms

-affect all three vessel layers

-is fusiform and saccular

false aneurysms

extravascular hematoma, partial disruption of arterial walls

aortic aneurysm risk factors

age, male, HTN, vascular disease, fam hx, tobacco use, trauma, connective tissue disorders, obesity, hypercholesterolemia

aortic dissection risk factors

age, women, HTN, vascular disease, fam hx, tobacco use, trauma, connective tissue disorders, illicit drug use, aortic disease, prior heart surgery, pregnancy d/t increased blood volume

thoracic aneurysm s/sx

-can be asymptomatic

-deep, diffuse chest pain, SVC syndrome, JVD, facial edema

-if in ascending and aortic arch; coronary artery ischemia -> angina, carotid artery occlusion -> TIA, coughing, SoB, hoarseness, dysphagia

abdominal aneurysm symptoms

- generally asymptomatic, often found coincidentally

-palpable, wide abd. aorta, bruits, abdominal or back pain, altered bowel function, mottled feet and pedal edema

aneurysm treatment

-PREVENT RUPTURE

-for small/stable; tobacco cessation, ACEi and BP management, control cholesterol and glucose, gradual increase in physical activity

-for large/unstable; surgery

signs of ruptured aortic aneurysm

severe back pain, hypovolemic shock, grey turner sign (bruising along flanks)

type A aortic dissection s/sx

severe chest pain, neurologic deficit, impaired coronary and upper extremity perfusion, hypotension

type B aortic dissection s/sx

back, abdominal, and leg pain, hypotension, impaired abdominal organ perfusion

complications of aortic dissection

cardiac tamponade, internal bleeding, organ ischemia and infarction, death

aortic dissection treatment

-surgery for emergent repair

-also BB/CCB for HR and BP control, morphine for pain

pre-op care for aortic dissection

HoB elevated, quiet environment, titrate anti-HTN to 60 BPM and SPB 100-120