Lessons from two weeks on the frontlines of Detroit as a #COVIDwarrior.
We are winning some of these battles. We are pushing ultrafiltration and diuretics to keep these people dry.
These x-rays are consistent with reductions in paCO2, FiO2 and PEEP.
When we go the other way, have patients consistently in positive balance, they do worse.
Over and over we are seeing people present in advanced AKI, with creatinines of 6, 8, 17 with no previous CKD. They show up with Cr of 8 and potassium of 7, and are like check-mate time for dialysis. I have never started so many people on dialysis on the day of admission.
This is not all over Detroit, talking to docs at other hospitals, they are seeing AKI on hospital day 7 or 8. I suspect this has more to do with social determinants of health than viral pathology.
Kidneys and Lungs seem to be the 2 organs most targeted. ‼️ Selection Bias‼️
Kidneys are not failing just as part of multi organ failure. This doesn’t feel like run of the mill septic ATN.
And yes we are seeing a ton of clotting. We are going through CRRT cartridges fast.
Here is a patient who has been in persistant positive balance
• • •
Missing some Tweet in this thread? You can try to
force a refresh
When we published our study <> of ODS and hyponatremia we were pummeled for including people at low risk of ODS because we included Na levels between 120 and 130. They said it is well known "that ODS is incredibly rare/non-existent at those levels." 1/4evidence.nejm.org/doi/10.1056/EV…
Of course one of the reasons it was thought to be incredibly rare was that no one looked for CPM in patients with Na from 120-130. We found a fair number (≤5 of 12). 2/4
Our findings are replicated in a study from Australia. The authors took a different approach to investigating ODS. Instead of starting w/ hyponatremia and working forward to ODS, they started with a dx of ODS and worked backwards
3/4ncbi.nlm.nih.gov/pubmed/35717664
Gadolinium in dialysis patients.
What's up with that?
#Tweetorial
1/11
Nephrogenic systemic fibrosis (NSF) is an iatrogenic disease that presents with hardening of the skin and other organs. It is often lethal. I treated 5 people with this condition (including one with AKI). Terrible.
2/11
The etiology of NSF was unknown and there were many theories. In 2006, Thomas Grobner published a small case series showing 5 patients developing NSF within weeks of receiving gadolinium contrast for MRI.
3/11pubmed.ncbi.nlm.nih.gov/16431890/
I just recently recommended the Renal Physiology book by Bruce Koeppen and Bruce Stanton. I thought it was a good medical student level text book: pbfluids.com/2023/08/ouwb-s…
But I came across this question in Chapter 8 Regulation of Acid Base. It is a straight forward question asking the learner to interpret simple acid-base cases.
But the question falls apart when you look at the answer...
Michael Emmett on electrolyte artifacts
Pre-analytical and analytical #NKFClinicals
Starting with pseudohyponatremia
These are real cases
The osmolality was 294, so there is a huge gap. 44ish
Implies Artifactual decrease in sodium
Her triglycerides were >6000 #NKFClinicals
Note the different between HCO3 and tCO2 should be closer than 19 and 9. #NKFClinicals