Dialy-trauma in RRT – Questions – Nephro Critical Care Society

🩸💥 When CRRT Heals… but Slowly Hurts—Will You Notice the Dialy-Trauma? 💥🩸

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Q1. A 62-year-old trauma patient on CRRT for rhabdomyolysis-associated AKI has normal serum phosphate (2.6 mg/dL), worsening respiratory acidosis, and diaphragmatic excursion on POCUS. You are already giving 1.5 g/kg/day protein via EN. What’s the most appropriate response?

A. Add enteral phosphate supplementation

B. Increase CRRT dose to accelerate acid removal

C. Switch to phosphate-containing replacement fluid

D. Administer IV sodium glycerophosphate bolus twice daily

Q2. A 45-year-old with recovering septic shock on CRRT and broad-spectrum antimicrobials shows rising creatinine kinase and prealbumin decline. You are delivering 1.2 g/kg/day of protein, and enteral nutrition is 75% goal. The effluent nitrogen loss is high. What should you do next?

A. Increase enteral protein to 2.0 g/kg/day cautiously

B. Add supplemental parenteral nutrition to offset losses

C. Reduce CRRT dose to preserve amino acids

D. Accept current losses and target nutrition on recovery

Q3. A patient with vasoplegic shock on CRRT is being considered for switch to SLED. He is on norepinephrine 0.06 µg/kg/min with a MAP of 67 mmHg. ScvO₂ is 58%, and perfusion indices are borderline. What should guide your next step?

A. Proceed with SLED; vasopressor dose is acceptable

B. Delay transition; borderline perfusion suggests unresolved shock

C. Switch to intermittent HD to accelerate fluid clearance

D. Initiate low-dose SLED with higher dialysate temperature

Q4. A CRRT patient shows persistent mild hypothermia (35.2°C), normal lactate, and stable hemodynamics. You’re already using a warming blanket. Nursing raises concerns about continuing ultrafiltration. What is your best approach?

A. Stop ultrafiltration until patient rewarms

B. Add in-line fluid warmer to CRRT circuit

C. Reduce CRRT blood flow rate to 80 mL/min

D. Accept mild hypothermia as physiologically adaptive

Q5. A 68-year-old cirrhotic patient with ACLF on CRRT shows total calcium 10.8 mg/dL, iCa 0.9 mmol/L, and a pH of 7.53. You suspect citrate accumulation. The current calcium infusion rate is 3 mL/h. What’s your next step?

A. Increase calcium infusion to normalize iCa

B. Decrease citrate infusion and monitor Ca total/iCa ratio

C. Switch to heparin anticoagulation

D. Add bicarbonate to correct alkalosis

Q6. A 50-year-old burns patient on high-dose CRRT (35 mL/kg/h) develops persistent hypoglycemia and elevated lactate despite adequate feeding. There are no signs of sepsis or insulin overdose. What’s the most plausible intervention?

A. Increase caloric density of feeds

B. Add dextrose to dialysate

C. Administer IV thiamine

D. Switch to parenteral nutrition

Q7. A CRRT patient in negative fluid balance develops cold extremities, prolonged CRT, and borderline MAP despite unchanged vasopressors. Dynamic fluid tests are unreliable due to arrhythmia. What’s your best approach?

A. Reduce UF to zero and reassess over 6 hours

B. Administer 250 mL crystalloid bolus and assess CRT/lactate

C. Increase vasopressor support and continue current UF

D. Continue ultrafiltration to target net 500 mL/day

Q8. Despite 2.2 g/kg/day protein delivery and preserved gut function, a CRRT patient continues to have a fall in prealbumin and muscle wasting. CRRT dose is 30 mL/kg/h. What’s the most plausible contributor?

A. Inadequate energy delivery

B. Unrecognized amino acid loss in effluent

C. Gut mucosal atrophy reducing nutrient absorption

D. CRRT-associated myopathy from filter shear forces

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🩸💥 When CRRT Heals… but Slowly Hurts—Will You Notice the Dialy-Trauma? 💥🩸

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