Renal

Question 1

Acute renal failure

Answer 1

Admission

• DAT
• Chart IO
• BW x1 then alt day
• Obs q4H
• Bld x CBC LRFT bone clotting RG
• Bld x ANCA, antiANA, anti-dsDNA, anti-GBM, C3/C5, HBsAg, anti-HCV, SPE, bence jonce, Ig pattern
• Save urine x inspection
• Urine x multistix, RM, C/S
• CXR
• ECG
• Post void bladder scan x1, if RU >350mL foley to BSB, UO q4H
• Urgent USG urinary system to RO obs cause
• IV NS 500mL q1H/q2H x1 then recheck RFT (fluid challenge if dry)
• Resume usual meds
• W/H NSAID, gentamycin, ACEI, metformin

Question 2

CAPD peritonitis

Answer 2

Admission
- Renal diet
- Obs q4H
- H’stix x1
- Cardiac monitor
- Bld x CBC LRFT clotting bone CRP VBG
- Bld C/S if fever >38
- PDF fluid C/S
- Resume usual meds
- Rapid flushing of PDF fluid 2L x3 + IP heparin 500-1000U/L
- Increase CAPD regimen to 4 bags/D (CMO decide)
- + IP heparin 500-1000U/L prn
- No fever: IP fortum (ceftazidime) 1g + cefazolin 1g stat, then daily x13days
&raquo_space;» no response: + gnetamycin on D3 (MO), switch fortum and cefazolin to vancomycin on D5
- Fever: IV fortum (ceftazidime) 1g + cefazolin 500mg stat then q24H

Ward complain

• PDF fluid x C/S
• Bld x C/S if fever >38
• Rapid flushing of PDF fluid 2L x3 + IP herparin 500-1000U/L
• No fever: IP fortum (ceftazidime) 1g + cefazolin 1g stat, then daily x 13 days
  &raquo_space;» no response: + gnetamycin on D3 (MO), switch fortum and cefazolin to vancomycin on D5
• Fever + chills/rigors: IV fortum (ceftazidime) 1g + cefazolin 500mg stat, then q24H

Question 3

CAPD output increase

Answer 3

Ward complain

• W/H CAPD if hypotnension
• IVF replacement/ encourage fluid intake

Question 4

CAPD output decrease

Answer 4

Ward complain

• Think peritonitis
• (laxatives)
• Fluid overload: CAPD 4.25% q2H x2

Question 5

Dysuria

Answer 5

Ward complain

• MSU x stix, C/S
• PO Pyridium (phenazopyridine) 200mg TDS prn
• +- PO augmentin 1g BD

Question 6

Fluid overload

Answer 6

Admission

• prop up
• renal low salt diet/ NPOEM if severe SOB
• FR 1.2L/D
• Cardiac monitor
• Chart IO, Foley to BSB if APO
• BW x1 then alt day
• O2 supplement to keep SaO2 >92%
• Bld x CBC LRFT bone clotting RG
• +- ABG (high flow O2/ COPD)
• ECG, TnI, CK q6H x3
• Bld x FG, FL mane
• Urine x multistix
• Sputum x C/S
• CXR
• ECG

If RRT,

• CAPD 4.25% 2L q2H x2
• HD see renal team

No RRT,
- IV lasix stat 40mg (severe SOB), then IV lasix 40mg q12H/q6H (increase freq> dosage)

• Resume usual meds (w/h betaloc if severe APO)

APO

• Foley to BSB
• IV lasix
• CPAP 10cm H2O, FiO2 1.0, then slowly wean off

High bp
- IV nitrocaine 30mg in 50mL NS, 4mL/H

• CVP insertion prn
• BiPAP if severe resp distress

Question 7

Hematuria

Answer 7

Admission

• DAT
• Obs q4H
• Bld x CBC LRFT bone clotting INR RG
• CXR, KUB
• Urine x inspection
• MSU x C/S, cytology x3
• EMU x AFB x3
• Resume usual meds
• Foley to BSB if massive hematuria
• Early USG abd for upper tract screening
• Consult uro if not subsided later

Question 8

HyperK

Answer 8

Admission
- Renal diet
- Obs q4H
- H’stix x1
- Cardiac monitor
- Bld x CBC LRFT clotting bone VBG
- ECG
- Resume usual meds (W/H ACEI, ARB, K supplement)
- DI drip: D50 50mL + actrapid 6-10U q30min x1
&raquo_space;» renal patients difficult excrete actrapid, caution hypoglc
- PO resonium A/C 15g q6H x3, recheck RFT + H’stix afterwards

• Persistent hyperK, temp HD

Question 9

No UO

Answer 9

Ward complain

• Aim 0.5mL/kg/H (50kg chinese ~25mL/H)
• Check hydration status, CVP, PR for melena
• +- UO q1H x4, if stable q4H
• Bladder scan +- foley insertion (flush if foley in place)
• Low BP: IV gelofusine 500mL FR x1
• Normal BP: IV NS 500mL q1H x1/ q2H x1
• Fluid overload + low BP: IV dopamine 200mg in 100mL NS, 5mL/H
• Fluid overload + normal BP: IV lasix 10mg stat x1, IV lasix 20mg stat x1 (lasix last 6H)
• Bld x RFT, KUB