Dialysis: 7binking Cntically
A 60-year-old gentleman was admitted through the emergency department following the onset of severe abdominal and back pain. On arrival, his blood pressure was 80/60 mm Hg, and pulse was 120 beats/min and regular. He was slightly dyspnek. His abdomen was large and rigid, and bowd. sounds were absent. Within an hour, he received 1500 mL of normal saline and 1200 mL of albumin. When his blood pressure did not respond to the fluid challenge, he was placed on a norepinephrine infusion. A urinary catheter was placed with return of only 35 mL of urine output After a CT scan, he was t:ikcn to the OR for repair of a ruptured aortic aneurysm. Estimated blood loss was 12,000 mL, with replacement of 11,000 mL of whole blood, 600 mL of fu:sh frozen plasma, and 1250 mL of normal saline. When he was admitted to the critical care unit following surgery, he had no urine output.
His BP continued to be low (80/60 mm Hg) and passive leg raise indicated the need for further fluid resuscitation. While his BP was gradually increased using fluids and dopamine, he continued to have a rocky course. By his third postoperative day, he still had a low urine output. His creatinine had climbed quickly to 7.5 mg/dL and BUN to 90 mg/dL. His potassium was 6.4 mEq/L. Hemodialysis was instituted.
After 2 weeks on dialysis, his urine output began to gradually increase. His wound bleeding stopped, and he became hemodynamically more stable. He had been started on cnteral nutrition, which was stopped as soon as he started eating an adequate diet. Seven weeks after the rupture, he was ready for discharge. His urine output was averaging 1200 mUday; BUN and creatinine were 28 and 1.9 mg/dL, respectively.
Would initiation of a diuretic be appropriate?
What type of fluid therapy i1 best for thi1 patient?
What special considerations need to be made for his medication therapy while he is being treated with dialysis?
What intervention will help meet his increased caloric demanda?