Potassium disorders in pediatric emergency department: Clinical spectrum and management.

INTRODUCTION: Potassium abnormalities are frequent in intensive care but their incidence in the emergency department is unknown. AIM: We describe the spectrum of potassium abnormalities in our tertiary-level pediatric emergency department. METHODS: Retrospective case-control study of all the patients admitted to a single-center tertiary emergency department over a 2.5-year period. We compared patients with hypokalemia (<3.0mEq/L) and patients with hyperkalemia (>6.0mEq/L) against a normal randomized population recruited on a 3:1 ratio with potassium levels between 3.5 and 5mEq/L. RESULTS: Between January 1, 2013 and August 31, 2016 we admitted 108,209 patients to our emergency department. A total of 9342 blood samples were tested and the following potassium measurements were found: 60 cases of hypokalemia (2.8±0.2mEq/L) and 55 cases of hyperkalemia (6.4±0.6mEq/L). In total, 200 patients with normokalemia were recruited (4.1±0.3mEq/L). The main causes of the disorders were non-specific: lower respiratory tract infection (23%) and fracture (15%) for hypokalemia, lower respiratory tract (21.8%) and ear-nose-throat infections (20.0%) for hyperkalemia. Patients with hyperkalemia had an elevated creatinine level (0.72±1.6 vs. 0.40±0.16mg/dL, P<0.0001) with lower bicarbonate (19.4±3.8 vs. 21.8±2.8mmol/L, P=0.0001) and higher phosphorus levels (1.95±0.6 vs. 1.42±0.27mg/dL, P=0.0001). Patients with hypokalemia had an elevated creatinine level (0.66±0.71 vs. 0.40±0.16mg/dL, P<0.0001) and a lower phosphorus level (1.12±0.31 vs. 1.42±0.27mg/dL, P=0.0001). We did not observe significant differences in pH, PCO2, base excess and lactate, or in the mean duration of hospitalization in general wards and pediatric intensive care units according to the PIM and PRISM scores. DISCUSSION: Dyskalemia is rare in emergency department patients: 0.64% for hypokalemia and 0.58% for hyperkalemia. This condition could be explained by a degree of renal failure due to transient volume disturbance. The main mechanism is dehydration due to digestive losses, polypnea in young patients, and poor intake. In the case of hypokalemia, poor intake and digestive losses could be the main explanation. These disorders resolve easily with feeding or perfusion and do not impair development. CONCLUSION: Dyskalemia is rare in emergency department patients and is easily resolved with feeding or perfusion. A plausible etiological mechanism is a transient volume disturbance. Dyskalemia is not predictive of poor development in the emergency pediatric population.

Treatment of patients with cardiac surgery associated-acute kidney injury.

Members of the Acute Dialysis Quality Initiative (ADQI) participated in a 3-day conference in Vicenza in May 2007 to evaluate the available literature on this topic and draft consensus recommendations for research studies in this area. This report summarizes the available evidence and describes the key questions that will need to be addressed with the goal of standardizing the care of patients with cardiac surgery-associated acute kidney injury (CSA-AKI) and improving outcomes.

Patient and kidney survival by dialysis modality in critically ill patients with acute kidney injury.

Using a large, international cohort, we sought to determine the effect of initial technique of renal replacement therapy (RRT) on the outcome of acute renal failure (ARF) in the intensive care unit (ICU). We enrolled 1218 patients treated with continuous RRT (CRRT) or intermittent RRT (IRRT) for ARF in 54 ICUs in 23 countries. We obtained demographic, biochemical and clinical data and followed patients to either death or hospital discharge. Information was analyzed to assess the independent impact of treatment choice on survival and renal recovery. Patients treated first with CRRT (N=1006, 82.6%) required vasopressor drugs and mechanical ventilation more frequently compared to those receiving IRRT (N=212, 17.4%), (p<0.0001). Unadjusted hospital survival was lower (35.8% vs. 51.9%, p<0.0001). However, unadjusted dialysis-independence at hospital discharge was higher after CRRT (85.5% vs. 66.2%, p<0.0001). Multivariable logistic regression showed that choice of CRRT was not an independent predictor of hospital survival or dialysis-free hospital survival. However, the choice of CRRT was a predictor of dialysis independence at hospital discharge among survivors (OR: 3.333, 95% CI: 1.845 - 6.024, p<0.0001). Further adjustment using a propensity score did not significantly change these results. We conclude that worldwide, the choice of CRRT as initial therapy is not a predictor of hospital survival or dialysis-free hospital survival but is an independent predictor of renal recovery among survivors.

Simplified citrate anticoagulation for continuous renal replacement therapy.

BACKGROUND: Regional anticoagulation with trisodium citrate is an effective form of anticoagulation for continuous renal replacement therapy (CRRT) for patients with contraindications to heparin. However, because of the metabolic complications of trisodium citrate, it is a complicated technique requiring specialized dialysis solutions. We have designed a simplified protocol for citrate regional anticoagulation for CRRT. METHODS: Two percent trisodium citrate was delivered at 250 mL/h via the prefilter port of a COBE PRISMA device, with the rate adjusted to maintain a postfilter ionized calcium (iCa++) <0.5 mmol/L. A central calcium gluconate infusion was used to maintain a systemic iCa++ at 1.1 mmol/L. A standard dialysate solution consisting of 0.9% saline, KCl 3 mmol/L, and MgSO4 1 mmol/L was delivered at 1000 mL/h. We retrospectively reviewed the outcomes and complications associated with this protoco1 in 29 patients treated from July 1999 to October 1999, evaluating the frequency of clotting of the dialyzer, bleeding complications, citrate toxicity, and patient mortality. RESULTS: The Kaplan-Meier curve for dialyzer survival demonstrated a 61% survival rate at 48 hours. There were no episodes of significant bleeding or citrate toxicity. Seventy-two percent of patients died for reasons unrelated to CRRT. CONCLUSIONS: A CRRT protocol using regional 2% trisodium citrate anticoagulation is not associated with significant bleeding complications or citrate toxicity, and represents a simplified approach compared with previous applications using 4% trisodium citrate.

Dilative cardiomyopathy leading to congestive heart failure in a male squirrel monkey (Saimiri sciureus).

A 17-year-old, 1-kg, colony-housed, male squirrel monkey (Samiri sciureus) developed clinical signs of congestive heart failure. The monkey presented with lethargy, increased heart and respiratory rates, and mild abdominal distention. The clinical history, laboratory analysis, and radiographic findings were consistent with heart failure due to dilative cardiomyopathy. Gross and microscopic examination of the heart confirmed a dilative cardiomyopathy. This is the first report describing congestive heart failure caused by dilative cardiomyopathy in a squirrel monkey. Spontaneous dilative cardiomyopathy may be infrequently observed in the squirrel monkeys because they are not routinely housed in the research environment during their advancing years.

Predictors of adequacy of arteriovenous fistulas in hemodialysis patients.

BACKGROUND: Dialysis access procedures and complications represent a major cause of morbidity, hospitalization, and cost for chronic dialysis patients. To improve the outcomes of hemodialysis access procedures, recent clinical guidelines have encouraged attempts to place an arteriovenous (A-V) fistula, rather than an A-V graft, whenever possible in hemodialysis patients. There is little information, however, about the success rate of following such an aggressive strategy in the prevalent dialysis population. METHODS: We evaluated the adequacy of all A-V fistulas placed in University of Alabama at Birmingham dialysis patients during a two-year period. A fistula was considered adequate if it supported a blood flow of >/=350 ml/min on at least six dialysis sessions in one month. Fistula adequacy was correlated with clinical and demographic factors. RESULTS: The adequacy could be determined for 101 fistulas; only 47 fistulas (46.5%) developed sufficiently to be used for dialysis. The adequacy rate was lower in older (age >/= 65) versus younger (age < 65) patients (30.0 vs. 53.5%, P = 0.03). It was also marginally lower in diabetics versus nondiabetics (35.0 vs. 54.1%, P = 0.061) and in overweight (BMI >/= 27 kg/m2) versus nonoverweight patients (34.5 vs. 55.2%, P = 0.07). The adequacy rate was not affected by patient race, smoking status, surgeon, serum albumin, or serum parathyroid hormone. The adequacy rate was substantially lower for forearm versus upper arm fistulas (34.0 vs. 58.9%, P = 0.012). The adequacy of forearm fistulas was particularly poor in women (7%), patients age 65 or older (12%), and diabetics (21%). In contrast, upper arm fistulas were adequate in 56% of women, 54% of older patients, and 48% of diabetics. CONCLUSIONS: An aggressive approach to the placement of fistulas in dialysis patients results in a less than 50% early adequacy rate, which is considerably lower than that reported in the past. Moreover, the success rate of fistulas is even lower for certain patient subsets. To achieve an optimal outcome with A-V fistulas, we recommend that they be constructed preferentially in the upper arm in female, diabetic, and older hemodialysis patients.