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Critical care Nursing Acute Renal Failure


Critical care Nursing Acute Renal Failure Dr Naiema Gaber Complications of ARF Death (50%) Sepsis infection (leading cause of mortality) Hypertension exacerbated by ... – PowerPoint PPT presentation

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Title: Critical care Nursing Acute Renal Failure

Critical care NursingAcute Renal Failure
  • Dr Naiema Gaber

The Learning outcomes
  • 1- Define acute renal failure (ARF).
  • 2- Explain the causes of ARF.
  • 3- Differentiate between the three types of ARF.
  • 4- Identify the clinical stages of ATN.
  • 5- Discuss the clinical manifestations of ARF.
  • 6- List the complications of ARF.
  • 7- Develop a plan for managing ARF.

Acute Renal Failure (ARF)
  • Definition Sudden deterioration in the ability
    of the kidneys to function ( to maintain fluid,
    solute or electrolyte homeostasis). It occurs
    over hrs or few days.
  • It is Common in ICU patients (10-20) Why?

ARF Types, Causes and mortality
  • 1- Primary renal (intrarenal) disease 33
  • Hemolytic uremic syndrome 88
  • Obstructive uropathy
  • Renal vein/artery thrombosis
  • Primary glomerulonephritis (RPGN)
  • Overall mortality 6
  • Most primary renal diseases develop RF gradually
    and do not need emergent dialysis

2-Extra-renal causes of ARF 67 of total
  • Overall mortality 62!!

Data pooled from Ped. Nephrol. 7703, 8334,
6470, and 7434
ARF What are the Risk factors for mortality?
  • Multi-organ failure
  • Bacterial Sepsis
  • Fungal sepsis
  • Hypotension/ vasopressors
  • Ventilatory support
  • Initiation of dialysis late in hospital course
  • Oliguria /anuria with oliguric ARF, mortality is
    gt 50 compared to lt 20 with non-oliguric ARF

Risk factors cont.
  • Advanced age
  • Co morbid conditions (heart failure, liver or
    kidney failure, diabetes)
  • Contrast exposure (dehydrated, diabetic)
  • Nephrotoxic medications (aminoglycosides,
    angiotensin enzyme inhibitors)
  • Volume depletion (especially in diabetes)
  • Rhabdomyolysis surgery (cardiac surgery)

Types and causes of ARF
1- Prerenal
  • 2- Renal

1- Prerenal azotemia (failure)
  • Causes
  • Decreased circulatory volume
  • Hypovolemia
  • GI losses (V/D, ileostomy, NG drainage)
  • Hemorrhage (trauma, GI bleeding)
  • Cutaneous losses (burns)
  • Renal losses (diabetes insipidus or mellitus)
  • Loss of fluids from intravascular space
  • Third spacing
  • Septic (capillary leak) or anaphylactic shock.

Prerenal azotemia (failure) cont.
  • Decreased local blood flow to kidney
  • Renal artery stenosis or RVT
  • Drug-induced renal vasoconstriction
  • cyclosporin, tacrolimus
  • Hepatorenal syndrome
  • Diminished cardiac output
  • Congestive Heart Failure (CHF)
  • Arrhythmias, tamponade, etc.
  • Cardiovascular surgery

Prerenal azotemia
1-Decreased circulatory volume A-Hypovolemia B-
Loss of fluids
3- Diminished cardiac output A- (CHF) B-
Arrhythmias, tamponade, etc. C-
Cardiovascular surgery
2-Decreased local blood flow to kidney A- Renal
artery stenosis B- Drug C-
Hepatorenal syndrome
2-Postrenal Failure
  • Kidney stone (usually UVJ)
  • Ureteropelvic junction (UPJ) or UVJ obstruction
  • Bladder as neurogenic bladder or fungus ball
  • Urethra posterior urethral valve foreign body
  • Iatrogenic obstructed Foley narcotics

3- Intrinsic Acute Renal Failure
  • Acute tubular necrosis (ATN)
  • Prolonged Prerenal azotemia of any cause
  • Nephrotoxin-induced drugs (aminoglycosides
  • Primary Glomerular diseases
  • Hemolytic uremic syndrome
  • All other forms of glomerulonephritis
  • Intra-renal obstruction tumor lysis syndrome

Clinical course of Acute Tubular Necrosis (ATN)
  • I- Onset phase (initiating) begins with an
    initial insult and lasts until cell injury
    occurs. It lasts from hours to days, the clinical
    manifestations in this phase include
  • 1-decreased urine output
  • 2-increased serum Creatinine.
  • The major goal during this phase is to determine
    the cause

Clinical course of tubular Necrosis (ATN) cont
  • II- Oliguric phase or non oliguric phase (anuria)
    Oliguria lt400ml/24 hrs or lt20ml/hr
  • Anuria lt50ml/24 hrs
  • III- Diuretic phase lasts 1-2 weeks. There is
    gradual increase in urine output and may lead to
    volume deficits and electrolytes imbalance.
  • IV- Recovery phase lasts from months to years.
    Renal function return to its normality.

Diagnosis and Assessment of ARF
  • In history, seek clues regarding secondary causes
    - symptoms of CHF, liver disease, sepsis,
    systemic vacuitis, prodromal bloody diarrhea
    birth asphyxia
  • Check for symptoms of primary renal disease -
    UTI, gross hematuria, flank pain, Hx of strept
    infection, drug exposure ( aminoglycosides or
    narcotics) for bladder dysfunction

Assessment of ARF (Physical exam.) cont.
  • Subjective Dysuria, nausea, weakness, and
  • Tachycardia and/or a drop in HR gt15 b pm or
    drop in SBP gt15mmHg with orthostatics indicate
  • Decreased mental status decreased
  • Rales fluid overload, CHF
  • Abdominal pain and distension obstruction, UTI
  • Itching

Assessment of ARF cont.
  • During physical exam, look for secondary causes
  • Causes of decreased effective circulatory volume
    - CHF, ascites, edema, sepsis
  • Signs of systemic illness - (vasculitis, SLE)
    rash, arthritis, purpura
  • Signs of obstructive uropathy enlarged kidneys
    or bladder - CHECK FOLEY.

Assessment of ARF, Labs cont.
  • UA
  • High specific gravity dehydration
  • RBCs UTI, urolithiasis
  • WBCs, bacteria UTI
  • Casts RBC (glomerulonephritis), WBC
    (pyelonephritis), and epithelial cells and
    granular casts (ischemic damage)
  • Electrolytes to assess for metabolic d/o
  • Urine Na, Creatinine
  • ECG to look for peaked T waves, indicates

Assessment for ARF cont.
  • BUN, Cr CBC with platelets.
  • Urine Analysis hematuria, myoglobinuria,
    proteinuria, RBC casts, eosinophils
  • Urine indices (U-osm, U-CR, U-Na )
  • Renal Ultra Sound (with Doppler flow to rule out
    renal vein thrombosis)
  • Anti-DNA, ANA, renal biopsy

Nursing diagnosis for client having ARF
  • Fluid volume excess related to decreased function
  • Alteration in cardiac output decreased related
    to fluid volume excess.
  • Altered nutrition less than body requirements
    related to anorexia, nausea and vomiting.
  • Impairment of skin integrity related to poor
    nutritional status, immobility and edema

Nursing diagnosis for client having ARF cont
  • Anxiety related to unexpressed serious illness
    and current symptoms.
  • Activity intolerance related to fatigue, anemia,
    retention of waste products and dialysis
  • Sleep pattern disturbance related to decreased
    functioning of immune system.
  • Knowledge deficit, disease and it management

Anticipated problems
  • worsening the ARF
  • Adjust medicines for renal insufficiency
  • Avoid Nephrotoxins if possible
  • Avoid intravascular volume depletion (especially
    in third-spacing or edematous patients)

Management of ARF
  • Ventilation and oxygenation
  • Circulation / perfusion
  • Fluids /electrolytes
  • Mobility
  • Protection/safety
  • Skin integrity
  • Nutrition
  • Comfort/ pain control
  • Psychological support
  • teaching

NB Management of (ARF )To maintain Water
  • 1- Assess the Volume status
  • "Maintenance" is IRRELEVANT in ARF!!!
  • If euvolemic, give insensible losses UOP
  • If volume overloaded,
  • concentrate all meds limit oral intake
  • Need frequent check on weights and BP as well
    as accurate I/O
  • give insensible 30 cc/100 kcal or
  • If has any UOP, Lasix ordered drugs may be

Once ARF stabilizes, fluid replacement should be
equal to insensible losses (400) mL /day) plus
urinary or other drainage losses to avoid
Management of ARF General cont.
  • Discontinue/re-dose nephrotoxic drugs
  • Diet Eliminate potassium if serum level
    increased Oral and IV amino acids Provide
    nutrition with increased
  • carbohydrates to decrease
  • Total caloric intake of 35 to 50
  • kcal/kg/day should be
    maintained with
  • most calories provided by
  • (100 g/day).

Management of ARF General cont
  • Foley catheterization for accurate output
  • Daily weight, monitor BP, labs
  • Correct easy bleeding with DDAVP,
  • estrogen, and cryoprecipitate
  • Prednisone in acute interstitial nephritis may
  • Mannitol - alkaline diuresis in Rhabdomyolysis

Management Prerenal
  • Goal is to restore BP and intravascular volume
  • Fluid deficit
  • Fluid bolus with 500ml, recheck fluid status,
  • Monitor vital signs and electrolytes
  • Normal or increased fluid status
  • CHF monitor O2 status. Lasix 20-80mg IV.
  • Monitor diuresis, potassium status, daily weight

Management Postrenal
  • Place Foley, note residual. If gt400ml and
    discomfort is relieved, leave catheter in place.
  • If Foley in place, Fluds with 20-30ml saline
  • Consider stones or mass obstruction
  • Daily weights, strict I/O

Management Renal
  • Hyperkalemia
  • Continuous cardiac monitoring
  • Kayexalate 15 to 30g in 50-100ml 20 sorbitol PO
    q 3-4 hours or in 200ml 20 sorbitol PR q 4 hours
  • Dialysis for failed kidneys can remove 30-60
  • Contrast dye
  • Creatinine peaks within 72 hours with slow
    recovery over 7 to 14 days with appropriate
  • Aminoglycosides
  • higher risk elderly, volume depletion, gt5 days,
    large doses, preexisting liver disease, and
    preexisting renal insufficiency.
  • Correct preexisting volume depletion and monitor
    drug levels

Indications for renal replacement therapy
  • Volume overload
  • Pulmonary edema, CHF, refractory HTN
  • Hyperkalemia
  • Hyperphosphatemia
  • Uremic side-effects pericarditis, pleuritis
  • Metabolic acidosis
  • Mental changes

Modes of renal replacement therapy
  • Peritoneal dialysis - also gentle and don't need
    heparinization but slow and catheter may leak or
    not work.
  • Hemodialysis - very fast, but need big lines and
    systemic heparinization causes hemodynamic
    instability and uremic dysequilibrium symptoms

Complications of ARF
  • Death (50)
  • Sepsis infection (leading cause of mortality)
  • Hypertension exacerbated by fluid overload Use
    antihypertensive that do not decrease renal blood

Complications of ARF cont.
  • Anemia is common, caused by increased red blood
    cell (RBC) loss and decreased RBC production.
  • Platelet dysfunction may occur secondary to the
    uremia and present as gastrointestinal (GI)

Special Cases
  • Elderly
  • Elderly more susceptible to ARF (3.5 X more
  • Creatinine clearance dependent on age
  • Evolution to acute tubular necrosis more common
  • Pregnancy
  • Infected uterus
  • Toxemia and related obstetric complications.
  • Pregnant patients only group with a sharp drop in
    ARF mortality (1.7)
  • Pediatric Congenital anomalies (e.g.,urethral
    valves, etc)

Review questions
  • 1-Intrarenal acute renal failure can be due to
  • a- dehydration and increased cardiac output
  • b- calculi in the ureters and hypovolimic shock
  • c- antibiotics and radiocontrst dye
  • d-obstructed Foley catheter and prostate
  • (c)

  • 2-During which phase of acute tubular necrosis
    (ATN) are Hyperkalemia, gastrointestinal
    bleeding, infection, and vascular volume overload
    major potential problems
  • a-onset
  • b-oliguric
  • c-diuretic
  • d-recovery

  • 3- Decreased erythropoietin production in renal
    failure results in
  • a- decreased RBC survival
  • b-impaired white blood cell function
  • c- decreased red blood cell production
  • d-an inability of platelets to function properly

Clinical Case 1
  • Ali is a 15 year old male who presented with URI
    (upper Respiratory Infection) symptoms, then
    headache, vomiting, abdominal pain, knee pain,
    edema, and a purpuric rash on his legs. He had
    not voided for 24 hours.
  • What is the diagnosis?
  • ARF? What the lab. Investigations that confirm
    the diagnosis?

Physical exam and labs
  • BP was 152/94. Heart and lung exams were normal.
  • hypertension
  • A urinalysis revealed hematuria and proteinuria.
    BUN and Creatinine were 76 and 8.0. Albumin was
    3.1 indicate
  • ARF

Fluid management in ARF (Clinical Case 1)
  • This kid weighs 70 kg. What percent
    maintenance should you run his IV at?
  • NO FLUIDS - Hes fluid overloaded and
    hypertensive he doesnt need any fluid
  • How were the maintenance calculations derived?
    What goes into the formula?
  • Insensible UOP maintenance400 cc only

Fluid management in ARF (Clinical Case 1) cont.
  • If this kid had an albumin of 1.0 and mucus
    membranes were very dry, what fluids would you
    give him?
  • Bolus of NS like any other dehydrated kid but
  • Now you have the kid euvolemic by exam but still
    has no UOP. Hes NPO though, so what fluid rate
    should you run now?
  • Insensible loss 400 cc UOP maintenance
  • 400 cc

2-Hypertension management(Clinical Case 1)
  • High blood pressure could be from volume overload
    or from intrinsic renal disease
  • If has volume overload, need to directly
    vasodilate (calcium channel blockers, clonidine,,
    nitropruside, etc
  • Goal is to prevent stroke or congestive heart

Back to Ali (Clinical case 1)
  • K 6.5,
  • Bicarb. 14
  • Calcium 5.8, Phosphorus 9.3
  • Hematocrit 30.3, Platelets 280K
  • Interpret this results.
  • low bicarb. Metabolic Acidosis

3-Acidosis management (Clinical case 1)
  • Correct bicarbonate which is lt 15
  • Acidosis makes the kids feel terrible
  • watch
  • -sodium and fluid overload
  • -lowering ionized calcium levels (by increasing
    binding of calcium to albumin)

4-Anemia and uremic bleeding management (Clinical
Case 1 )
  • Anemia results from lack of renal erythropoietin
    production increased loss
  • Underlying disorder may also cause hemolysis or
    decreased RBC production (sepsis, leukemia)
  • Uremic PLT's do not function well, so have
    increased bleeding treatment will causes
    transient improvement in PLT function.

Clinical Case 2
  • Samira. is a 10 year-old with acute lymphocytic
    leukemia receiving chemotherapy
  • Has fever, neutropenia and thrombocytopenia
  • UOP (Urinary output) is 1.2 cc/kg/hour
  • On clinical exam she has very moist mucus
  • BUN and Creatinine are 110 and 0.7.
  • Albumin is 3.5

Assessment of clinical case 2
  • Is she in renal failure?
  • Creatinine is normal, so NO!
  • Why is BUN so high?

Use of plasma BUN Cr ratio
  • In pre-renal BUN Cr gt 20 usually
  • However, BUN may be increased disproportionately
    with blood products, excess amino acids in
    bleeding increased catabolism as in case of
    treatment with steroids, fever.

Mr. salem hasnt peed all night long! How is UO
measured? a-By shift b- by hour c- Foley
d- urinating on own? For more information
write three more questions 1-What is the trend
over last 2-3 hours vs. last 24 hours? Oliguria
lt400ml/24 hrs or lt20ml/hr Anuria lt50ml/24
hrs 2- does he has Recent surgery? 3- are therre
any Other symptoms 4- is there any changes in
vital signs?
Any questions???