AKI (Part V)

Question 1

Fluid administration in sepsis as per surviving sepsis guidelines?

Answer 1

At least 30ml/kg

Question 2

Risk & benefits of administration of normal saline?

Answer 2

• Hyperchloremic acidosis
• Beneficial in traumatic brain injury

Question 3

Action of Furosemide on the kidney?

Answer 3

• Renal protection by decreasing renal tubular oxygen demand
• Expedites renal function recovery by washing out necrotic debris blocking the tubule

Question 4

RBF ?

Answer 4

• It is constant due to autoregulation
• Dependent on arterial blood pressure

Question 5

Norad?

Answer 5

• Alpha and beta agonist effects
• Increases contractility

Question 6

Adrenaline?

Answer 6

• Increases CO & perfusion pressures

Question 7

Metabolic side effects of Adrenaline administration?

Answer 7

• Hyperglycaemia
• Acidosis
• Hyperlactataemia
• Deleterious effect on splanchnic circulation
• Proarrhythmogenic

Question 8

Dopamine?

Answer 8

• Dopaminergic effect - Direct renal vasodilation
• Stronger beta effect
• Not recommended in septic shock

Question 9

Phenylephrine ?

Answer 9

• Synthetic pure alpha agonist
• No beta effect
• Effect is dependent on preload status
• Induces increased venous resistance
• increases CO only

Question 10

Vasopressin?

Answer 10

• Potent vasopressor
• Action on the mesenteric compartment
• Pure vasoconstrictor w/o inotropic effect
• Useful in septic shock
• May prevent progression of AKI

Question 11

Vasopressin deficiency ?

Answer 11

• Septic shock induced reduced vascular tone

Question 12

Effects of various vasopressors?

Answer 12

See attached image

Question 13

Drugs to avoid in order to prevent AKI?

Answer 13

• NSAIDs
• ACE inhibitors
• ARBs
• Contrast agents
• Aminoglycosides

Question 14

What is the chemical name for statins ?

Answer 14

3-hydroxy-3-methylglutaryl-CoA reductase inhibitor

Question 15

Useful effects of statins?

Answer 15

• Anti-inflammatory
• Endothelial stabilizer

Question 16

What are the hallmarks of critical illness?

Answer 16

• Alteration in fluid status
• Absolute volume depletion (Hypovolaemic or haemorrhagic)
• Relative volume depletion ( page 9

Question 17

How does renal blood flow remain constant?

Answer 17

Autoregulation

Question 18

What does renal blood flow depend on ?

Answer 18

Arterial pressure

Question 19

What is the target MAP for patients with chronic HTN?

Answer 19

80-85mmHg as this is renal protective and reduces the need for RRT

Question 20

Are alpha-receptors present in the renal vessels?

Answer 20

Their density here is relatively high

Question 21

What occurs when the MAP is below the autoregulatory threshold ?

Answer 21

Increasing the MAP will directly increase Renal Blood Flow

Question 22

What does the threshold and slope of the autoregulatory curve depend on?

Answer 22

Comorbidities;
- HTN
- Vascular disease

Question 23

What is the target MAP for critically unwell patients?

Answer 23

This depends on the prior presence or absence of chronic HTN

Question 24

What are the effects of vasopressors on renal vasculature?

Answer 24

• Increases MAP & RBF
• Glomerular filtration - Effect on afferent & efferent arterioles

Question 25

Effects of vasoactive drugs

Answer 25

See attached image

Question 26

Effects of vasopressors?

Answer 26

See attached image

Question 27

What are the effects of Norepinephrine?

Answer 27

- Alpha-agonist - Beta-agonist - Increased contractility

Question 28

What are the effects of epinephrine?

Answer 28

- Increased CO & perfusion pressures

Question 29

What are the metabolic side-effects of epinephrine (Adrenaline)?

Answer 29

- Hyperglycaemia - Hyperlactataemia - Acidosis - Pro-arrhythmogenic - Impairment of splanchnic circulation

Question 30

Effect of low dose Dopamine?

Answer 30

- Direct renal vasodilation

Question 31

Properties of Dopamine ?

Answer 31

- Weak vasoconstrictor effect - Predominant Beta-effect - Not recommended for sepsis

Question 32

Properties of phenylephrine?

Answer 32

- Pure alpha-agonist - Effect depends on preload & LV function

Question 33

Characteristics of Vasopressin?

Answer 33

- Potent vasopressor - It is non-catecholamine - Pure vasoconstrictor - No inotropic effect - Prevents progression of AKI

Question 34

What is the relationship between septic shock and vasopressin?

Answer 34

- During septic shock there might be vasopressin deficiency - Decrease in vessel tone

Question 35

Review vasoactive drugs alongside their renal and systemic effects ?

Answer 35

See image attached

Question 36

Nephrotoxic drugs to avoid?

Answer 36

- NSAIDs - Contrast - ACEi / ARBs - Aminoglycosides

Question 37

What is the full name for statins?

Answer 37

3-Hydroxy-3-Methylglutaryl-CoA reductase inhibitor

Question 38

What are the effects of statins?

Answer 38

- Lowering cholesterol levels - Anti-inflammatory - Endothelial stabilization

Question 39

Major mechanisms of development of AKI?

Answer 39

- Inflammatory pathways - Endothelial dysfunction

Question 40

Characteristics of iodinated contrast agents ?

Answer 40

- Iso-osmolality - Reduced risk of AKI

Question 41

Alkaline phosphatase?

Answer 41

- Endogenous enzyme - Detoxifying effect - Renoprotective effect

Question 42

Nephrotoxicity can be caused by ?

Answer 42

- Hyperglycaemia

Question 43

Resuscitation using goal directed therapy ?

Answer 43

See image attached

Question 44

What are the absolute indications for RRT ?

Answer 44

- Hyperkalaemia - Metabolic acidosis - Pulmonary oedema - BUN > 140mg/dL - Pericarditis

Question 45

Furosemide stress test ?

Answer 45

- High sensitivity & specificity - Predicts progression of AKI

Question 46

Conditions potentiating the harmful effect of hyperkalemia?

Answer 46

- Acidosis - Hypocalcemia - Hyponatremia

Question 47

Systemic effects of hyperkalemia ?

Answer 47

- Muscle weakness - Shortened QT interval - Tall T-waves - Progressive lengthening of QRS & PR intervals - VF is a possibility

Question 48

What is the role of B2-Adrenergic agonist in Mx hyperkalemia ?

Answer 48

- Acts directly on Na/K-ATPase - Avoid in individuals with coronary disease

Question 48

What is the role of calcium chloride/gluconate in hyperkalemia?

Answer 48

- Antagonizes cardiac membrane excitability and onset of effect is within minutes. - Beneficial when ECG changes are present

Question 48

What is the role of insulin in hyperkalemia ?

Answer 48

- Stimulates Na/K-ATPase activity - Shift of potassium into the cell - Approx. 0.5-1.5mmol/L fall in potassium within 15 mins & peak effect observed in about 60 mins

Question 49

What is the typical ECG for hyperkalemia?

Answer 49

See image attached

Question 50

What are the causes of metabolic acidosis in AKI?

Answer 50

- Increased acid production - Increased acid retention - Decreased bicarbonate reabsorption

Question 51

Uraemic complications ?

Answer 51

- Observed in 10% of patients with ESRF - It is rarely encountered in AKI - Inflammation of visceral & parietal membrane of pericardial sac -

Question 52

What is the characteristic presentation of pericarditis in AKi?

Answer 52

- Fever - Pleuritic chest pain - Unable to lay flat - Pericardial rub

Question 53

What are the early clinical signs of uremic encephalopathy?

Answer 53

- Rambling speech - Disorientation - Lethargy - Irritability - Hallucination - Coma

Question 54

What are the commonly encountered signs of encephalopathy ?

Answer 54

- Tremors - Myoclonus - Asterixis