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Year 3 OSCE > Case 13- AKI and Sepsis > Flashcards

Case 13- AKI and Sepsis Flashcards

1
Q

Pre renal AKI causes

A

Dehydration
Sepsis
Hypotension
Shock
Severe heart failure

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2
Q

Renal AKI causes

A

NSAIDS, ACEI, ARBS
Gentamicin, amoxicillin
Glomerulonephritis
Interstitial nephritis
ATN
Contrast agent
Myeloma
Rhabdomyolysis

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3
Q

Post renal AKI causes

A

Prostate enlargement eg. BPH
Renal stones
Pelvis cancer

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4
Q

Investigations for suspected AKI

A

Urine output chart, observations, urinalysis and culture
Bloods- FBC, UE, LFT, CRP, blood cultures, VBG (lactate, oxygen)
CXR- infection (sepsis can cause the AKI)
ECG- if hyperkalaemia present
Renal tract USS
(Renal biopsy- unlikely)
Myeloma and nephritic screen

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5
Q

Medication that causes neutropenia

A

Clozapine
Methotrexate
Carbimazole
Quinine (malaria)
Rituximab

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6
Q

Hyperkalaemia causes

A

AKI, CKD, rhabdomyolysis, adrenal insufficiency, aldosterone antagonists, ACE-I, NSAIDS, DKA, Addison’s disease, burns, heparin

NB- thiazide diuretics cause hypokalaemia

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7
Q

Hyperkalaemia Sx

A

Tachycardia, irregular pulse, chest pain, weakness,palpitations, light headed ness

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8
Q

Investigations for suspected sepsis

A

Urine output chart, observations
ECG and Urinalysis, culture and sensitivities (MSU), sputum culture if applicable
Bloods- FBC UE LFT ABG (lactate) CRP Coagulation profile
CXR
Lumbar puncture- if meningitis

NB- get to HDU!! Involve seniors and preform QSOFA
NB- sepsis 6

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9
Q

Emergency management of hyperkalaemia

A

Insulin and dextrose
Calcium gluconate (stabilise cardiac muscle cells)

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10
Q

Dialysis indications in AKI

A

AEIOU (refractory)

Acidosis
Electrolyte abnormalities eg. Hyperkalaemia, hyponatraemia, hypercalcaemia (EXG changes)
Intoxicants- methanol, lithium, salicylate
Overload- acute pulmonary oedema
Uraemia- urea >60, ureamic pericarditis, encephalopathy

NB- CKD: dialysis required when eGFR below 15

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11
Q

Management of an AKI

A

Treat underlying cause (depends on pre, renal, or post)
Stop nephrotoxic drugs eg. NSAID ACE-I
Monitor and correct pH, fluid balance and electrolytes
Insert a catheter
Involve the renal team (may require dialysis)

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12
Q

Pre renal AKI/uraemia

A

Concentrated urine as the tubules are still working

High osmolality (500+)
Low NA (<20)
Good response to fluid
Raised urea:creatinine (100+)
Normal or bland sediment
Fractional sodium excretion (<1%)

NB- kidneys hold onto sodium to preserve volume (that’s why sodium is low)

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13
Q

Intrinsic AKI osmolarity/uraemia (ATN)

A

Tubules not working so dilute urine

Low osmolality (<350)
High urine NA (40+)
Poor response to fluid
Normal urea:creatinine
Muddy brow casts
Fractional sodium excretion (>1%)

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14
Q

Complications of an AKI

A

Hyperkalaemia
Fluid overload eg. Heart failure and pulmonary oedema
Metabolic acidosis
Uraemia can cause encephalopathy and pericarditis

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15
Q

Sepsis Sx

A

Tachypnoea, high or low temp, tachycardia, altered mental status (acute), low sats, hypotension, oliguria, poor cap refill, mottled skin, cyanosis, malaise, lethargy, nausea, vomiting

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16
Q

Sepsis differentials

A

MI
PE
Hyperthyroidism

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17
Q

Management of sepsis

A

Sepsis 6

Measure lactate, urine output, take 2 blood cultures from separate sites
Give oxygen (above 94), IV fluids, IV broad spectrum antibiotics

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18
Q

Neutropenic sepsis

A

Sepsis in a patient with a low neutrophil count of less than 1x10 (9)

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19
Q

ATN

A

Damage and necrosis to the epithelial cells of the renal tubules (most common cause of AKI)

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20
Q

Causes of ATN

A

Ischaemia- shock, sepsis, dehydration

Direct toxin damage- contrast dye, gentamicin, NSAID

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21
Q

Management of ATN

A

Same as AKI

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22
Q

ATN Investigations

A

Urinalysis- muddy brown casts or renal tubular epithelial cells in the urine

23
Q

Potassium requirement when prescribing fluids

A

1 mmol/kg/day

24
Q

Proteinuria and urine dip

A

Protein rules out a pre or post AKI cause (must be a renal cause)

25
Q

Glucose requirement when prescribing fluids

A

50-100g/day irrespective of weigh

26
Q

3 things to remember that cause intrinsic AKI

A

Glomerulonephritis (many specific causes- displaying nephritic and nephrotic syndromes)
ATN- most common cause of AKI, due to ischaemia or nephrotoxins
AIN- drug-induced AKI (hypersensitivity reaction)

27
Q

Hyperkalaemia- stabilisation of the cardiac membrane

A

IV calcium gluconate

28
Q

Hyperkalaemia- shift potassium to intra cellular fluid

A

Insulin/dextrose infusion
Nebulised salbutamol

29
Q

Hyperkalaemia- removal of potassium from body

A

Calcium resonium (rectal ie. enema)
Loop diuretics
Dialysis

30
Q

AKI definition

A

Urine output of less than 0.5ml/kg/hour for 6 hours (8 paeds)
Rise in creatinine of 26 or more in 48 hours
>50% rise in creatinine over 7 days

Paeds or young adults- 25% fall in eGFR in 7 days

31
Q

AKI stage 1

A

Increase in creatinine to 1.5-1.9x baseline (7 days)
Increase in creatinine 26.5 (48 hours)
Reduction in urine output to 0.5ml/kg/hour for 6 hours

32
Q

AKI stage 2

A

Increase in creatinine 2-2.9x baseline (7 days)
Reduction in urine output to 0.5ml/kg/hour for 12 hours

33
Q

AKI stage 3

A

Increase in creatinine 3x baseline (7 days)
Increase in creatinine to 353.6 (48 hours)
Reduction in urine output to 0.3ml/kg/hour for 24 hours or the commencement of RRT

34
Q

AKI referral to nephrology criteria

A

Renal transplant
No known cause
Vasculitis/glomerulonephritis/ myeoloma/tubulointerstitial nephritis
Inadequate response to treatment
Complications of an AKI
Stage 3 AKI
CKD stage 4 or 5
Qualify for RRT

35
Q

Haemolytic uraemic syndrome Sx

A

AKI
Haemolytic anaemia
Thrombocytopenia

36
Q

Causes of HUS

A

Primary- complement dysregulation

Secondary
Shiva toxin producing E. coli
Pneumococcal infection
HIV
SLE, drugs, cancer

37
Q

Investigations for HUS

A

Urinalysis
FBC, blood film, UE
Stool culture- OCR for shiva toxin

38
Q

Management of HUS

A

Supportive- fluids, dialysis etc.
No role for ABX
Eculuzumab (C5 inhibitor monoclonal antibody) has greater evidence than plasma exchange

39
Q

Staging of hyperkalaemia

A

Mild 5.5-5.9
Moderate 6.0-6.4
Severe 6.5+

40
Q

When to initiate emergency management of hyperkalaemia

A

Severe hyperkalaemia (6.5+) or ECG changes

41
Q

Further management of hyperkalameia after initial pharmacotherapy management

A

Stop exacerbating drugs eg ACE-I
Treat underlying cause
Lower total body potassium eg. Calcium resonium, loop diuretics, dialysis if needed

42
Q

Features of hypokalaemia

A

Muscle weakness, hypotonia

43
Q

Hypokalaemia and ECG changes

A

U waves
Small or absent T waves
Prolonged PR interval
ST depression

NB-In Hypokalaemia, U have no Pot and no T, but a long PR and a long QT

44
Q

Features of rhabdomyolysis

A

AKI with disproportionately raised creatinine
Elevated CK (10,000)
Myoglobinuria
Hypocalcaemia
Elevated phosphate
Hyperkalaemia
Metabolic acidosis

45
Q

Causes of rhabdomyolysis

A

Seizure
Collapse and subsequent time on floor
Ecstasy
Crush injury
Statins (esp. if with clarithromycin)

46
Q

Management

A

IV fluids
Urinary alkinisation

47
Q

Sterile pyuria

A

White cells in urine without presence of bacteria

48
Q

Causes of sterile pyuria

A

Partially treated UTI
Chlamydia infection (urethritis)
Renal stones
Appendicitis
Bladder/renal cancer
APKD

49
Q

Hyaline casts

A

Tamm horsfall protein
Normal urine, after exercise, during fever, loop diuretics use

50
Q

Red cell casts

A

Nephritic syndrome

51
Q

Rhabdomyolysis and AKI

A

Rhabdomyolysis would give a CK of >10,000 (if CK is raised but not this high, and the patient has been on the floor, think of dehydration as a cause of their AKI (unable to drink for many hours))

52
Q

Drugs to stop in an AKI

A

DAMN AKI

Diuretics
Aminoglycosides (eg. gent, neo and strep) and ACE inhibitors
Metformin
NSAIDs (except cardioprotective aspirin eg. 75mg)

NB- you would however use diuretics in AKI due to fluid overload

53
Q

AKI and pulmonary oedema

A

Start with IV furosemide

If medical management has failed to resolve the fluid
overload, then haemodialysis is indicated in order to lower the pulmonary arterial pressure and prevent further overload.

Year 3 OSCE (61 decks)

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