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Case Study

Question:

Discuss About The Operation Surgical Procedure Was Performed?

The paper deals with the case study of the Mrs Nancy Andrews. She is 77-year-old female. The patient was initially admitted for the endovascular repair of a 6 cm infra renal abdominal aortic aneurysm. On the third day after operation, the patient had intense abdominal pain. On the fourth day post operation second surgical procedure was performed. After the surgical procedure the patient was diagnosed with Acute Kidney Injury or AKI.  Currently, she is prescribed Continuous Veno-Venous Hemo Dialysis. In response to the case study, the paper discusses acute kidney injury and explains the criteria, in this patient that is suggestive of acute kidney injury. The choice of therapy prescribed for the patient is critically evaluated.

Acute kidney injury can be defined as a decrease in the kidney function abruptly that results in the dysregulation of the extracellular volume and electrolytes, and the retention of nitrogenous waste products and the urea (Zuk and Bonventre 2016).

The criterion for the patient that is suggestive of AKI is the endovascular aneurysm repair or EVAR. Since acute kidney injury is characterised by the decrease in the glomerular filtration rate and increase in the serum creatinine and urea nitrogen. The same was observed in the case of Mrs Andrews. Her creatinine was 310 instead of 50-100. Her urea concentration was 22 instead of 2.7 – 8. Decreased haemoglobin was indicative of increased fluid volume and acute kidney failure. Mrs Andrews’s haemoglobin was 87 instead of 115-155. AKI could also occur due to increase in infection, which in case of Mrs Andrews is evident from WCC  of 18.2 instead of 4-11. The cause of infection could be the Arterial and CVP line were inserted during the procedure in her (Saratzis et al. 2015).

According to Bang et al. (2014), the patients who underwent the complex EVAR procedure are at risk of AKI. Further, the emergence of AKI after EVAR is documented in various studies.  Age is the  major risk factor for the AKI. For patients older than 70 years aneurysm and AKI are highly prominent (Saratzis et al. 2013). Mrs Andrews is 77 year old and was highly susceptible to the AKI after EVAR. Long time of operation is also found to increase the risk of AKI, in this case this may have also caused the AKI in the patient (Bang et al. 2014).  According to Ronco et al. (2015), severe cardiac disease, hypercholesterolemia and large abdominal aortic aneurysm diameter increases the surgical intervention and associated complications. Among the complication, the main one is the AKI. In this case study the patient has endovascular repair of a 6 cm infra renal abdominal aortic aneurysm. Further, the patient also has the history of the coronary artery disease, hyperlipidaemia which, is suggestive of AKI in this case.  In addition, the angiography results showing the renal perfusion defects indicate the risk of AKI. However, in the case Mrs Andrews, the angiography at the completion of the procedure revealed no graft or endovascular leaks. The other physiological data suggests of AKI.

Definition of Acute Kidney Injury

CVVHD is the appropriate treatment for the AKI. This process involves the use of a pump-driven venovenous circuit. This method works on the principle of both diffusion and ultra-filtration. In this technique a dialysate solution is run at a low rate counter-current t the flow of the blood. This technique maximises the diffusion based solution removal. It permits blood flows better than that provided by the arteriovenous circuit. The blood flow is more constant and higher. In addition, it eliminates the need of a large-bore arterial catheter. This eliminates the risks of arterial thrombosis and arterial bleeding associated with it. The benefits of the therapy include good clearance of small solutes urea, water, creatinine and electrolytes. Due to continuous haemodialysis, it is efficient in removing the low molecular weight solutes. It is thus used clinically for regulating the serum concentration of the small solutes (Symons 2017).

 It helps to maintain the stable hemodynamic status and the nutritional requirements of the patients. It is useful to eliminate the large amount of plasma ammonia (Pistolesi et al. 2016). Currently the status of the patient shows that the urine output is 0-2 mls per hour. Her renal ultrasound 1800 reveals adequate flow through renal arteries. The medical events of Mrs Andrews in ICU show that she has periods of hypotension. Using the therapy of CVVHD, the chance of hypotension can be removed as ultrafiltration can be done at slow rate. Even if the hypotensive episodes are brief, there is high probability that kidney may be further damaged. Recovery from AKI is slowed by multiple hypotensive episodes, in patients who are critically ill. Thus, this method is appropriate for Mrs Andrews considering her present condition.  Mrs Andrews is meeting the criteria for the haemodialysis therapy. Fluid resuscitations are performed on her with infusions of crystalloid packed cells and colloids. Infusions of Dobutamine and Noradrenaline are commenced. A pulmonary artery catheter is inserted at 0400 hours for hemodynamic monitoring. Her initial blood glucose level is 12.1

According to Kakajiwala et al. (2016), it is effective to prevent the kidney problems by providing the patient with lots of fluid and salts or bicarbonates. The alternative therapy could be the Continuous Veno-Venous Hemofiltration (CVVH) is the short-term treatment for the patients in ICU. It is the therapy used when the patient is unable to tolerate the haemodialysis or is having the low blood pressure (Liu et al. 2016). McLaughlin et al. (2017) argued on the basis of the retrospective review that CVVH is not effective in reducing mortality or the length of stay in hospital when compared to the CVVHD. Evidences from other studies showed that when compared to CVVH, CVVHD is effective in terms of diffusion- based principle as it results in greater solute removal. 

Suggestive Criteria of AKI

According to Eyler et al. (2014) patients who have undergone the abdominal aortic aneurysm and have been diagnosed with the complication of AKI is also susceptible to the also susceptible to protein calorie malnutrition. In this patients, it is necessary to balance the protein levels by administering a lot of fluids and proteins.  Unlike the intermittent haemodialysis, CVVHD addresses the need of the critically ill patients by helping with slow and continuous removal of the toxins and fluids. In the intermittent method the patients fluid and protein intake is limited between the treatments. This helps to prevent the toxic levels of nitrogen and fluid overload. By removing the fluids continuously, the advantage is that the therapy mimics the native kidney. Further, there is no build up of the protein and toxins the patients can receive as much of them to get the optimal nutrition. In the current condition, Mrs Andrews is a critically ill patient, she may not be able to tolerate the intermittent dialysis. The same is evident from the prescription of fluid removal prescribed at at 100 mls/hr. It is commenced with 2 liter exchanges and a blood flow rate at 200 mls/hr. She require large amount of fluid for various reasons. If there is no hemodynamic compromise, the patient will not be able to tolerate the rapid fluid and electrolyte shifts (RENAL Replacement Therapy Study Investigators 2009). 

Conclusion

In conclusion, the assignment has comprehensively discussed the, criteria in-patient that is suggestive of AKI. The choice of therapy is critically analysed and is concluded that the CVVHD is the appropriate therapy for Mrs. Andrews.

References

Bang, J.Y., Lee, J.B., Yoon, Y., Seo, H.S., Song, J.G. and Hwang, G.S., 2014. Acute kidney injury after infrarenal abdominal aortic aneurysm surgery: a comparison of AKIN and RIFLE criteria for risk prediction. British journal of anaesthesia, 113(6), pp.993-1000.

Eyler, R.F., Vilay, A.M., Nader, A.M., Heung, M., Pleva, M., Sowinski, K.M., DePestel, D.D., Sörgel, F., Kinzig, M. and Mueller, B.A., 2014. Pharmacokinetics of ertapenem in critically ill patients receiving continuous venovenous hemodialysis or hemodiafiltration. Antimicrobial agents and chemotherapy, 58(3), pp.1320-1326.

Kakajiwala, A.K., Ferguson, M.A. and Fitzgerald, J.C., 2016. Acute Kidney Injury 11. Fundamentals of Pediatric Surgery, p.75.

Liu, D.L., Huang, L.F., Ma, W.L., Ding, Q., Han, Y., Zheng, Y. and Li, W.X., 2016. Determinants of Calcium Infusion Rate During Continuous Veno-venous Hemofiltration with Regional Citrate Anticoagulation in Critically Ill Patients with Acute Kidney Injury. Chinese medical journal, 129(14), p.1682.

McLaughlin, M.M., Masic, I. and Gerzenshtein, L., 2017. Evaluation of nucleoside reverse transcriptase inhibitor dosing during continuous veno-venous hemofiltration. International journal of clinical pharmacy, 39(1), pp.37-40.

Pistolesi, V., Di Napoli, A., Fiaccadori, E., Zeppilli, L., Polistena, F., Sacco, M.I., Regolisti, G., Tritapepe, L., Pierucci, A. and Morabito, S., 2016. Severe acute kidney injury following cardiac surgery: short-term outcomes in patients undergoing continuous renal replacement therapy (CRRT). Journal of nephrology, 29(2), pp.229-239.

RENAL Replacement Therapy Study Investigators, 2009. Intensity of continuous renal-replacement therapy in critically ill patients. N Engl j Med, 2009(361), pp.1627-1638.

Ronco, C., Ricci, Z., De Backer, D., Kellum, J.A., Taccone, F.S., Joannidis, M., Pickkers, P., Cantaluppi, V., Turani, F., Saudan, P. and Bellomo, R., 2015. Renal replacement therapy in acute kidney injury: controversy and consensus. Critical Care, 19(1), p.146.

Saratzis, A., Melas, N., Mahmood, A. and Sarafidis, P., 2015. Incidence of acute kidney injury (AKI) after endovascular abdominal aortic aneurysm repair (EVAR) and impact on outcome. European Journal of Vascular and Endovascular Surgery, 49(5), pp.534-540.

Saratzis, A.N., Goodyear, S., Sur, H., Saedon, M., Imray, C. and Mahmood, A., 2013. Acute kidney injury after endovascular repair of abdominal aortic aneurysm. Journal of Endovascular Therapy, 20(3), pp.315-330.

Symons, J.M., 2017. Continuous Renal Replacement Therapy (CRRT) and Acute Kidney Injury (AKI). In Pediatric Dialysis Case Studies (pp. 271-278). Springer, Cham.

Zuk, A. and Bonventre, J.V., 2016. Acute kidney injury. Annual review of medicine, 67, pp.293-307.

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