Discover and read the best of Twitter Threads about #akiconsultseries
Most recents (4)
#AKIConsultSeries:👨w T2DM➡️🏥 for fever, dysuria and CVA tenderness. On arrival: ⬇️BP, ⬆️Glucose, ⬆️AGMA. Dx UTI + DKA. Tx: Abx + Insulin Pump + 4 L Crystalloid + NE
After resus, pt still oliguric, Cr 3.2. NE 0.7 ug/kg/min,🧠confused, BP 85/62, HR 123, 2L O2. CRT 4 sec
1/12
After resus, pt still oliguric, Cr 3.2. NE 0.7 ug/kg/min,🧠confused, BP 85/62, HR 123, 2L O2. CRT 4 sec
1/12
Given DKA, giving additional fluids is tempting. But before we do this, its easy to do a quick assessment of fluid tolerance #POCUS
#LUS shows some B-lines (bilat)
#IVC plethoric w no respiratory collapse
#VExUS shows very pulsatile portal vein 🚨🤔
2/12
#LUS shows some B-lines (bilat)
#IVC plethoric w no respiratory collapse
#VExUS shows very pulsatile portal vein 🚨🤔
2/12
Pulse pressure is low (23!): This suggest a low cardiac output state!
Also, there are signs of fluid intolerance!
#EchoFirst: Window is suboptimal, but we see a Hyper-dynamic LV w small cavity and a turbulent flow (green color). There was no systolic RV failure
3/12
Also, there are signs of fluid intolerance!
#EchoFirst: Window is suboptimal, but we see a Hyper-dynamic LV w small cavity and a turbulent flow (green color). There was no systolic RV failure
3/12
#AKIConsultSeries Middle-aged male ➡️🏥 for painful knee and fever. Now in shock 🚨
📂Chart review: PMH EtOH Cirrhosis, right knee arthroplasty.
It is always a good practice review previous PACS images🩻: Nodular liver, colateral vessels and prosthetic right knee
1/11
📂Chart review: PMH EtOH Cirrhosis, right knee arthroplasty.
It is always a good practice review previous PACS images🩻: Nodular liver, colateral vessels and prosthetic right knee
1/11
On exam: BP 72/48, HR 82, O2Sat 95%.
CRT 7 sec, 🧠somnolent, confused. No edema, no obvious ascites.
Warm, swollen and erythematous knee: Tap with obvious purulent fluid🧫
Cr 2.8 mg/dl (baseline 0.5), K 6.7, Urine 🔬: hyaline casts, some urothelial cells
2/11
CRT 7 sec, 🧠somnolent, confused. No edema, no obvious ascites.
Warm, swollen and erythematous knee: Tap with obvious purulent fluid🧫
Cr 2.8 mg/dl (baseline 0.5), K 6.7, Urine 🔬: hyaline casts, some urothelial cells
2/11
Loos like hemodynamic AKI (AKA Pre-renal)
Usual causes in Cirrhosis:
🔷Distributive: Septic, "Hepatorenal physiology" 🔷Hypovolemic: Laxatives, vomiting, large volume paracentesis
🔷Congestive: Porto-pulmonary HTN, Co-existing cardiomyopathy
3/11
Usual causes in Cirrhosis:
🔷Distributive: Septic, "Hepatorenal physiology" 🔷Hypovolemic: Laxatives, vomiting, large volume paracentesis
🔷Congestive: Porto-pulmonary HTN, Co-existing cardiomyopathy
3/11
#AKIConsultSeries 👵➡️🏥 w necrotizing fasciitis s/p debridement. Significant 🩸 during surgery ➡️ intensive resuscitation (transfusions + crystalloid)
48 hrs later 💧📈 =+13 L, Edema +++, Hypoxemia, pleural effusion.
Now anuric unresponsive to high dose IV diuretics 1/10
48 hrs later 💧📈 =+13 L, Edema +++, Hypoxemia, pleural effusion.
Now anuric unresponsive to high dose IV diuretics 1/10
Cr 3.2, K 3.5, HCO3 25, Hb 8.9, WBC 26k, 95% PMN, Lactate 2.5
MAP 65 on NE (0.02 ucg/kg/min), HR 130, O2 sat 80-85 on 15 L NRB, RR 17 but w increased respiratory effort.🧠 drowsy, CRT >8 sec👇, JVP not elevated
Primary team consults for RRT initiation with ultrafiltration 2/10
MAP 65 on NE (0.02 ucg/kg/min), HR 130, O2 sat 80-85 on 15 L NRB, RR 17 but w increased respiratory effort.🧠 drowsy, CRT >8 sec👇, JVP not elevated
Primary team consults for RRT initiation with ultrafiltration 2/10
What would you do next? 3/10
#AKIConsultSeries
👴 w Advanced Cirrhosis, hemorrhagic portal hypertension and hx of a heart block (w pacemaker).
Came to the ED w diarrhea 2/2 severe C. Diff.
Now in shock...
Initial resus with Norepinephrine 0.3 ug/kg/min, Crystalloid and albumin. Cr 3.8
1/7
👴 w Advanced Cirrhosis, hemorrhagic portal hypertension and hx of a heart block (w pacemaker).
Came to the ED w diarrhea 2/2 severe C. Diff.
Now in shock...
Initial resus with Norepinephrine 0.3 ug/kg/min, Crystalloid and albumin. Cr 3.8
1/7
18 hrs later, no renal improvement + oliguria.
MABP 70, CRT 2 seconds. 🧠 confused, + asterixis. No ascites or edema
Workup: hemodynamic AKI (⬆️SG, ⬇️UNa, ⬆️BUN/Cr, bland sediment)
Team wants to continue fluids, albumin and antibiotics... Dr. Harris, do you concur?
2/7
MABP 70, CRT 2 seconds. 🧠 confused, + asterixis. No ascites or edema
Workup: hemodynamic AKI (⬆️SG, ⬇️UNa, ⬆️BUN/Cr, bland sediment)
Team wants to continue fluids, albumin and antibiotics... Dr. Harris, do you concur?
2/7
Obviously you are here for the #POCUS so here we go:
IVC: Plethoric (No subX window 2/2 intestinal air)
LV, RV: Relatively preserved systolic fx
Pacemaker lead seen causing important Tricuspid Regurgitation!
3/7
IVC: Plethoric (No subX window 2/2 intestinal air)
LV, RV: Relatively preserved systolic fx
Pacemaker lead seen causing important Tricuspid Regurgitation!
3/7
