A 55-year-old male with history of diabetes mellitus, hypertension, and ESRD has been admitted to the ICU following a polytrauma. He suffered a mild concussion of his brain and multiple orthopedic injuries including a fractured pelvis and pelvic bleeding which required coiling in the interventional radiology suite. He is protecting his airway and has been hemodynamically stable for the past 24 hours. He is being started on IHD, as his blood urea nitrogen (BUN) is 180 mg/dL and creatinine is 8 mg/dL. Following IHD, he develops nausea, vomiting, and altered mental status concerning for dialysis disequilibrium syndrome.
Which of the following interventions if used is MOST likely to prevent the occurrence of this syndrome?
A. Use of CRRT with slow removal of fluids and solutesCorrect Answer: A
Dialysis disequilibrium syndrome can occur when using aggressive/rapid RRT in a severely uremic patient. The shift of water into brain tissue due to the abrupt lowering of plasma tonicity during IHD may lead to an acute increase in intracranial pressure and cerebral hypoperfusion. Caution should be exercised in patients who are at risk of cerebral edema prior to initiation of RRT. To avoid brain edema caused by large variations in osmolality, several preventative measures can be employed. They include targeting a reduction in the plasma urea nitrogen of 40% at the most, reducing blood and dialysate flow, using a small dialyzer, and limiting the length of treatment. The use of a sodiumenriched dialysate may further reduce the risk. Dialysis disequilibrium syndrome is a significant risk with rapid clearance in severe azotemia when instituting RRT.
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