Question

Mr. C. is 42 years of age and was admitted to the critical care unit from the emergency department with the admitting diagnosis of diabetic ketoacidosis (DKA). He was brought to the emergency department by his wife, who reported that her husband had progressively become more ill with complaints of shortness of breath, abdominal pain, and excessive urination. She became concerned when he started displaying confusion. She reported that the patient fell off a 5-foot ladder 1 weck ago. Ecchymosis was noted around the umbilical area. According to his wife, Mr. C. did not have any health problems before this admission and was not taking any medications except for an occasional dose of acetaminophen or ibuprofen for knee pain. Admission weight was 161 kg Abdominal and head computed tomography scans without contrast were performed and were within normal limits The following laboratory data supported the initial diagnosis of DKA: glucose, 975 mg/dL; arterial pH, 6.81; serum lactate, 8.4 mmol/L. His blood pressure remained below 90 mm Hg systolic despite a 9-L fluid resuscitation. A triple-lumen catheter was placed in the right internal jugular for central venous pressure- guided fluid management. A norepinephrine infusion was initiated to maintain the systolic blood pressure above 90 mm Hg. The patient was intubated and received mechanical ventilation including positive end-expiratory pressure (PEEP). Chest radiography identified a pleural effusion in the left lung and findings consistent with pneumonia. An insulin infusion was titrated to manage hyperglycemia. The urine output was 400 mL during the first 24 hours. Elevations in white blood cells and temperature and persistent hemodynamic instability supported the diagnosis of severe sepsis. Cultures were obtained, and antibiotic therapywas initiated. Over the next 72 hours, the patient's serum creatinine level increased from 3.45-8.48 mg/dL. Urine output remained less than 400 mL in 24 hours. Hyperglycemia resolved after 72 hours of intravenous insulin titration. Mechanical ventilation and norepinephrine titration for blood pressure continued. Continuous venovenous hemofiltration was initiated on the third day for management of fluid overload, metabolic acidosis, and uremia. 1. What factors predispose Mr. C. for the development of AKI? 2. What laboratory studies assisted in the diagnosis of AKI for this patient? 3. On the third day, a dialysis catheter was placed in the right internal jugular vein Why is this the preferred site for placement?

Answer 1

1. The predisposing factors for acute kidney injury in the patient is the uncontrolled blood sugar level which is very high .A very high blood glucose level affects the kidney function and eliminating the blood glucose via renal system ,burdening the kidney overtime and causing an acute kidney injury.

2.The laboratory studies which assisted in diagnosis of AKI is the elevated creatinine level.The normal ranges from 0.5 to 1.5mg/dL. The steady raise from 3.45 to 8.48 ,with decrease in urine output (<400ml) sudesbin the diagnosis.

3.The main and preferred reason for selecting this site is because it has a direct end or connection to the right atrium where deoxygenated or impure blood drains and to be purified.

It can also prevent the central venous stenosis

Reduces the risk of thrombosis

It is a blind site confirmatory because the superior venacava end ps in right atrium