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NEUROLOGICAL INJURY and RENAL REPLACEMENT
THERAPY
Lina C. Laxamana, FPCP, FPNANeurocritical Care Unit
October 8, 2010NKTI Post Graduate Course
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Renal Replacement Therapy• Indications:– Severe hyperkalemia– Fluid overload– Refractory acidosis– Uremic symptoms:• Serositis• Encephalopathy• Bleeding
• Objectives:– Remove excess volume– Remove solutes
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Renal Replacement Therapy
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Intensity of RRT and outcome in critically ill patients with ARF
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CASE
• M.B., 56/M, married, from Isabela • Admitted due to sudden onset of R sided
weakness and aphasia • ~11 hours PTA– Sudden onset of R sided weakness, with aphasia– Brought to a local hospital– Cranial CT requested
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Imaging ( 2 ½ hours)
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Imaging (2 ½ hours)
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Imaging (2 ½ hours)
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Imaging (2 ½ hours)
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Imaging (2 ½ hours)
• Intracerebral hematoma with an estimated volume of 30cc in the L capsuloganglionic region.
• With perilesional edema, mass effect and midline shift
• No IVE, HCP
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Case • PMHx–With HPN, DM II, CAD–With ESRD requiring HD every 5th day
through a L brachial AV fistula–Maintained on Plavix 75mg/tab, ½ tab daily–Denies allergies
• PSHx–unremarkable
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Pertinent examination • E4V2M6• Cranial nerves–Pupils 2mm EBRTL–R central facial palsy–Good gag– Tongue deviated to the R
• Motors UE R 0/5 L 5/5 LE R 0/5 L 5/5
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Case • Pertinent labs–CBC 13.3/44.1/11.1/N92/249–BT 4’ CT 5’–PTT 35.1s PT 85% INR 1.06–Na 127 K 5.89 –BUN 34 Crea 6.77
• Cranial CT repeated
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Imaging (10 ½ hours)
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Imaging (10 ½ hours)
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Imaging (10 ½ hours)
• L capsuloganglionic acute intraparenchymal hematoma (42cc)
• Surrounding edema
• Compression of the ipsilateral ventricle and slight midline shift to the right
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Case • Admitted to NCCU–Started on Mannitol 60gms q4–Neuro status quo: E4v2m6•Pupils 2mm EBRTL• Slight headache
–Started on HD
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Day 2 • Day 3 post ictus (830am)– E2v1m6, drowsier–BP 150/90 HR 90 O2sat 95% T 37.8C –Pupils 1mm, equal–Na 126 (124) K 5.89 (6.26)– Stat CT scan requested• NPO• Additional Mannitol 30gms bolus given
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Imaging (day 2)
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Imaging (day 2)
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Imaging (day 2)
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Imaging (day 2)
• Interval evolution to beginning subacute stage
• Without increase in volume
• Interval progression of perilesional edema
• Midline shift to the right has not significantly changed
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Case • Day 3 post ictus (915am)
–Prepared for surgery–Repeat PT 138% INR 0.88 PTT 31.1s –Na and K correction–Mannitol continued at 60gms q4–Hemodialysis–Clearances requested
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Case • Day 3 post ictus (1110am)– Elective intubation done (Anes)
• Day 3 post ictus (515pm)– E2vtm5, more difficult to arouse–BP 166/100 HR 90 O2sat 100%–Pupils 2-3mm EBRTL–Awaiting repeat labs post HD
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Case • Day 3 post ictus (10pm)–K 4.35– Scheduled for surgery at 4am
• Day 4 post ictus (120am)– E2vtm5–BP 160/90 HR 88 O2sat 98%–Pupils 2-3mm EBRTL
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Case • Day 4 post ictus (4am)–OR
• Plan– L frontal craniotomy, endoscopic
evacuation of hematoma with intraparenchymal ICP monitor probe insertion
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Case • Goals for treatment–Address the increased intracranial pressure
from the hematoma– Evacuate the capsuloganglionic hemorrhage– Lessen the need for osmotic diuretics in an
ESRD patient
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Surgery
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Surgery
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Surgery
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Surgery
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4th day post-op
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Renal Replacement Therapy and the
Neurocritical Care Patient
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Lang & Chestnut, Neurosurg Clin N Am 1994;5(4):573-605
Cerebral Blood Flow
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Cerebral Blood Flow
Bhardwaj A. Cerebral blood flow. In Suarez JI, Critical Care Neurology and Neurosurgery, Humana Press, 2004 with permission
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• MAP = 2 (diastolic) + systolic 3• CPP = MAP - ICP• CBF = Cerebral Perfusion Pressure Cerebral Vascular Resistance =P x x r4 / 8 x L x (Hagen-Poiseuille equation for movement of Newtonian fluids in large caliber vessels)• Autoregulation: MAP 60-150 mmHg
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IHD and ICP
From: Davenport A. Hemod Internl 2008;12:307–312 with permission
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MAP and CAPD
From: Davenport A. Hemod Internl 2008;12:307–312 with permission
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Effect of renal replacement on ICP
From: Davenport A. Semin Dialysis, 2009;22:165–168 with permission
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Serum osmolality following renal replacement
From: Davenport A. Semin Dialysis, 2009;22:165–168 with permission
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Modifications to standard hemodialysis prescription that may potentially reduce risk of further cerebral
injury in patients with acute cererbal injury
From: Davenport A. Hemod Internl 2008;12:307–312 with permission
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Conclusion
• CRRT may have beneficial effects in patients with RIH
• Further research may be warranted
Fletcher et al, J Trauma, Critical Care ,2010
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Has CRRT caused ICP reduction?
• Unknown mechanism• Removal of cytokines and myocardial
depressants seen with ultrafiltration and membrane absorption
Fletcher et al, J Trauma, Critical Care ,2010
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Statement
• CRRT is the preferred mode in ABI• Previous studies did not show decrease in ICP
but rather only stability• patient population• mode of CRRT used • membrane biocompatibility
Davenport; Nephrol Dial Transplant. 1990;5:192–198 Br Med J (Clin Res Ed). 1987;295:1028.
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Osmotherapy
• If elevations in ICP are noted or cerebral edema:– Treatment of ICP should continue as usual–20% mannitol infusions–Hypertonic saline with the dialysate to keep
serum sodium 150-155 mEq/L
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Renal Failure and Neurosurgery
• Emergency surgical evacuation• Correct coagulopathy:–Platelet transfusion–DDAVP–Correct INR
• RRT as indicated above
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Conclusions• Renal failure is common in the ICU• Less common in patients with neurological
injury• All risk factors should be corrected• Continuous replacement therapies are
preferred • Close communication and team work with
nephrologists are key
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THANK YOU