Question 29

Pathophysiological change

Management implications

Respiratory:

Prone to pulmonary oedema 

Fluid restriction/ positive pressure ventilation as needed

Cardiovascular:

Hypertension 

Dyslipidaemia, Atherosclerosis, 

Pericarditis 

Appropriate drug therapy, aim higher MAP

targets based on baseline BP Monitor for pericardial effusion

Neurological:

Dialysis   disequilibrium      Polyneuropathy myopathy

and

Low dose dialysis to prevent rapid shifts

Renal:

Low/no urine output 

Fluid prescribing/restriction, nutrition depends on dialysis plan

Metabolic:

Hyperkalaemia

Metabolic acidosis

K⁺ restriction, Caution with K-sparing drugs

(ARBs, ACE-Is, Spironolactone)

May be worsened by critical illness

Mineral & Bone disorders:

Secondary             hyperparathyroidism,

Hyperphosphataemia, Hypocalcaemia

Phosphate restriction/binders,

Calcitriol and calcium supplementation, Care to prevent fractures

Gastrointestinal:

Impaired gastrointestinal motility

Peptic ulceration & bleeding

Malnutrition

Aspiration risk, enteral feeding difficulty

Stress ulcer prophylaxis

Early feeding

Skin:

Fragile skin 

Meticulous pressure area care

Haematological:

Anaemia

Platelet dysfunction (uraemic)

Appropriate transfusion, EPO

Bleeding risk, DDAVP may have a role

Immunological:

Increased risk of infection 

Antimicrobial        prophylaxis/therapy           as appropriate

Endocrine:

Thyroid dysfunction

Difficult to interpret TFTs during critical illness

Pharmacological:

Altered   clearance               of            renally    excreted medications 

Dose adjustment based on GFR, dialysis regime

Vascular access:

and arterial access

Consider choice of site avoiding site of fistula, Monitor fistula function during critical illness