All of the following are indications for dialysis in methanol poisoning, EXCEPT:
The correct answer for the AKI Quiz of 10/10/11 is C. He should be rapidly volume repleted with normal saline.
A 22-year old white male is seen in the emergency room at midnight for evaluation of acute renal failure. He explains that he finished running the Boston marathon 8 hrs previously. He complains of severe leg cramps. He tells you that he has had no urine output. No significant past medical history. No medications. Denies recent alcohol consumption. PE: BP 120/80 mmHg, HR110 bpm, afebrile. JVP is 2-3 cm. Clear lungs, normal cardiovascular and abdominal examination. No edema. Skin turgor reduced. Urinalysis: SG of 1020, pH 5.0, 4+ blood, rest negative.
What is the next step in management:
–A.) He should be assured that this presentation is common in marathon runners and he will improve with bed-rest
–B.) He should be treated with high dose ibuprofen (800 mg TID until his leg cramps resolve).
–C.) He should be rapidly volume repleted with normal saline
–D.) He should be immediately administered 10 g mannitol IV
–E.) Furosemide 120 mg IV should be given immediately
Explanation
Rhabdomyolisis - Clinical Features
A.) Methanol level >50 mg/dL
B.) Visual, fundoscopic, or mental status changes
C.) Severe acidosis
D.) Serum formic acid levels elevated
E.) Consumption of the equivalent of more than 5
mL of pure methanol
_____________ The correct answer for the AKI Quiz of 10/10/11 is C. He should be rapidly volume repleted with normal saline.
A 22-year old white male is seen in the emergency room at midnight for evaluation of acute renal failure. He explains that he finished running the Boston marathon 8 hrs previously. He complains of severe leg cramps. He tells you that he has had no urine output. No significant past medical history. No medications. Denies recent alcohol consumption. PE: BP 120/80 mmHg, HR110 bpm, afebrile. JVP is 2-3 cm. Clear lungs, normal cardiovascular and abdominal examination. No edema. Skin turgor reduced. Urinalysis: SG of 1020, pH 5.0, 4+ blood, rest negative.
What is the next step in management:
–A.) He should be assured that this presentation is common in marathon runners and he will improve with bed-rest
–B.) He should be treated with high dose ibuprofen (800 mg TID until his leg cramps resolve).
–C.) He should be rapidly volume repleted with normal saline
–D.) He should be immediately administered 10 g mannitol IV
–E.) Furosemide 120 mg IV should be given immediately
Explanation
Rhabdomyolisis - Clinical Features
- Classic description of acute renal failure associated with crush injury occurred in London Blitz in 1940 (Bywaters)
- All of the patients were buried for 3-4 hours
- All of the patients had hyperkalemia early and this led to early deaths Muscle pain and dark urine
- “Coca-Cola” color Orthotoludine-positive urine without RBCs
- Electrolyte disorder occurs within 2 hours
- Hyperkalemia, Hypocalcemia, Hypo- or Hyper phosphatemia, Hyperuricemia, Metabolic acidosis, Rapid increase in serum creatinine Elevated CPK and myoglobin
- Massive uptake of ECF by swollen muscles upto 14 L within hours - profound volume depletion
- Release of nephrotoxins: Phosphate, Purines, Myoglobin AKI from: heme casts in distal tubules, ATN (Renal ischemia + tubular toxins)
- Excessive muscle activity –seizures, delerium tremens, sport
- Direct of ischemic muscle injury trauma, compression syndrome, vascular occlusion
- Metabolic disorders hypokalemia, hyponatremia, hypophosphatemia
- Drugs or toxins ethanol, isopropyl alcohol, heroin, methadone
- Infections tetanus, legionaires, influenza
- Early massive volume repletion
- Saline should be given a 1 Liter /hour
- Urine flow should be maintained at 8 L/day
- Total amount of fluid required to maintain this rate is usually 12 liters day Bicarbonate infusion should be given once patient is in a monitored setting 200-300 mEq for the first day but can be highly variable 1 amp= 50 mEq, needs to be infused in D5W or 1/2 NS
- Maintain urine pH above 6.5
- Mannitol should not be given to a patient who has established anuria
- If patient is anuric after initial volume resuscitation, some may give one time bolus of 20 g mannitol with Lasix 120mg
- Once urinary flow is established, Mannitol can be added at 20% solution at rate of 1-2 g/kg over 4 hours.
- Usually given as 1/2 NS with 10g mannitol and 40mEq bicarbonate, alternating with normal saline
- Maximum dose should not exceed 200g/24hrs
