Thread by @ArgaizR

#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

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

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

What is the usual initial guideline-recommended treatment in this scenarios?

Cirrhosis + AKI: Albumin, fluids
Sepsis: Antibiotics, source control (prosthesis removal), fluids

¿Can we do better?

Yes, quick screen for fluid tolerance in 1 minute #POCUS: #IVC and #LUS

4/11

Lung Ultrasound (#LUS) looks ok, but IVC is plethoric 🚩🚩🚩

I have wrote about thus scenario before: criticalcarenow.com/albumin-for-vo…

Venous congestion needs further evaluation!

5/11

#Echofirst PLAx, PSAx, A4ch (RV view).

Good LV, Septal Shift (D-Sign), Dilated RV and RA, RV systolic disfunction and Severe Tricuspid regurgitation!

6/11

#Hemodynamics

#VExUS HV: S wave reversal, PV: Non pulsatile (Not reliable in Cirrhosis), IRVD: Monophasic.

RVOT Doppler: Notched Envelope

TRVMax: 2.8 m/sec (note triangular shape, because of severe TR, this can't be used to estimate sPAP)

LVOT VTI: 18 (not so bad)

7/11

This hemodynamic evaluation is compatible with pre-capillary pulmonary hypertension with severe venous congestion (monophasic IRVD)!

As previous echo (2 yrs ago) showed no evidence of PH, we got AngioCT: It ruled out PE

8/11

Working Dx: Septic arthritis with underlying Porto-pulmonary hypertension

#HemodynamicAKI: distributive + congestive

Fluids and albumin were 🛑

Vasopressin, NE, Levosimendan and Furosemide were started. Source was controlled

Despite MAP >80. Patient remained Oliguric

9/11

CRRT was initiated and a negative fluid balance of 3-4 L daily was obtained. After 48 hrs, pt started producing urine. We kept decongesting with diuretics.

Patient was fully decongested, AKI resolved.

Repeat #echofirst showed persistent severe PH and severe TR

10/11

Lessons:

1) AKI-Fluid reflex prevented by #POCUS (#IVC + #LUS to check for Fluid Tolerance)
2) In Cirrhosis, use intra-renal doppler for #VExUS (PV not reliable)
3) #VExUS can be used to monitor decongestion even in severe TR

POCUS Always

/END