Acute HD

[Old_School]

Hey WR . . . got a patient with ARF on dialysis. He has pancreatitis and a fatty liver. Got 30#s of ascites in his abdomen. No peripheral edema. Just how effective is giving 25%albumin and mannitol during HD to get that ascites off. We got about 5 litres off today and the belly hasn't changed a bit.

O_S

[WRRN]

If he has chrosis (sp) of the liver. You may never get that fluid. Better to tap him.. Hemodialysis takes fluid out of the blood.. And yes as you take fluid out of the blood other fluid from tissues will cross into the blood. You really shouldn't take fluid to vigorously from such an acutely ill patient. The body compensates and you have to take off fluid slowly. He should be dialyzed daily or you might suggest CVVH.. If you even have access to that modality.


WR,,, three commas for Becca.

Were you using the mannitol for B/P support? If so I'm not a fan of it. If B/P wasn't dropping no need to use Mannitol.

[Old_School]

The guy doesn't have cirrhosis. Some gall stones but the LFTs are elevated. Biggest problem is the pancreatitis. I've never seen that much ascites w/pancreatitis. Thought the alb and the mannitol would kick up the intravascular osmotic gradient to get the fluid moving out of the belly. But in retrospect, w/o a shunt of some kind its pretty futile. Guys HR in the 140s from all the pressure on the IVC. Bp pretty stable 130 sys.

[WRRN]

Neither have I.. Does he have small extremeties?


WR,,, three commas for Becca

[Old_School]

Not much peripheral edema yet, but its starting.

[WRRN]

Portal hypertension causes the fluid to "back up" and usually the extremeties look like concentration camp victims. Sorta like the bellies of the malnourished children you see on TV.

Is he being treated appropriately for pancreatitis?


WR,,, three commas for Becca

[Old_School]

I know what you mean but no he doesn't have those features.

The amyl/lip are almost down to normal. They were up in the 4-digit range on adm. The GI is talking naso-jejunal feeding tube. He's currently on TPN. Which isn't helping either the BS nor the pancreatitis. You ought to see that N-J tube. What a piece of work that is. Put in with endoscopy.

[WRRN]

TPN is the way to go.. Gotta rest that GI tract. Did they remove the stones????


WR,,, three commas for Becca

[Old_School]

F/U MRCP did not show stones. GI says cholestasis. Rec. ERCP in future. Re: TPN. I thought so too until I saw a study that pts. w/pancreatitis do better w/jejunal alimentation over TPN. We got this guy on a RegInsulin drip at 10 units/hr to keep his BS 150. Hence the N-J tube.

[Old_School]

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