Case Scenario 01
A 54-year-old male (weight 85 kg, height 175 cm) with a medical history of Type 2 diabetes mellitus, essential hypertension, chronic kidney disease (Stage 5), ischaemic heart disease, and heart failure with reduced ejection fraction (HFrEF) was admitted to the ICU with septic shock secondary to pneumonia. Currently he is on broad-spectrum antibiotics, vasopressors, and mechanical ventilation. His hemodynamic parameters and lab investigations are as follows:
Hemodynamics:
Blood Pressure: 90/50 mmHg (on norepinephrine at 0.1 mcg/kg/min)
Heart Rate: 110 bpm
Central Venous Pressure (CVP): 12 mmHg
Cardiac Output: 4 L/min
Urine output of 20 to 25 ml/hr
Labs:
Haemoglobin: 9.5 g/dL
WBC: 15,000 /µL
Platelets: 120,000 /µL
Serum creatinine: 6.5 mg/dL
Blood Urea Nitrogen (BUN): 70 mg/dL
Potassium: 5.8 mEq/L
Arterial Blood Gas (ABG): pH 7.25, PaCO2 30 mmHg, PaO2 75 mmHg, HCO3- 16 mEq/L
He was initiated on intermittent hemodialysis (IHD) for acute kidney injury and severe metabolic acidosis.
Initial settings: Blood flow rate 300 mL/min, Dialysate flow rate 500 mL/min, Ultrafiltration goal 2 litres over 4 hours.
1 hour into dialysis, his blood pressure dropped to 80/45 mmHg, and heart rate 120 bpm. His norepinephrine infusion rate increased to 0.2 mcg/kg/min; 500 mL of normal saline bolus was administered.
A review of the dialysis solution composition shows the following:
Base: bicarbonate 25 mM
Sodium: 130 mM
Potassium: 3.5 mM
Calcium: 1.5 mM (3.0 mEq/L)
Magnesium: 0.375 mM (0.75 mEq/L)
Dextrose: 5.5 mM (100 mg/dL)
Phosphate: none
Dialysis solution temperature: 33°C
At this point, to improve the hemodynamic tolerance of the ongoing intermittent hemodialysis session, the following changes are recommended, except:
