Acute kidney failure

        You have just started your night shift when you get a new admission from the ED. Bill Grates, a 47-year-old man, arrives to your unit, handcuffed to the gurney with a police escort, after an MVA in which he suffered a fractured left femur. The ED nurse tells you that Mr. Grates states that he “has a few beers at night.” The nurse reports that his blood alcohol level was 374 upon arrival at the ED. An abdominal CT scan performed in the ED revealed no abnormalities. Dr. Orcutt plans an ORIF the next morning and admits Mr. Grates with the following orders: NPO after midnight CBC and BMP in am CIWA protocol Ativan per CIWA protocol Banana bag X1 at 250 mL/hr NS after banana bag at 100 mL/hr When you come on shift the following night, Mr. Grates’s CIWA is 51, his vital signs are: B/P 85/40 P 120 R 32 O₂ 85% on room air T 38.5°C Height 6’ 1” Weight 95.5 kg A STAT ABG is ordered with the following results: pH 7.19 PaO₂ 77 mm Hg PaCO₂ 29 mm Hg HCO₃ 16 mEq/L Mr. Grates is intubated for acute respiratory distress syndrome (ARDS) and transferred to the ICU. Prone positioning and pressure control are initiated for the management of hypoxemia. Mr. Grates requires repeated fluid boluses and the titration of vasopressors to achieve and maintain hemodynamic stability. During the first 48 hours of admission to the ICU, his urine output ranges from 10 to 20 mL per hour. His serum potassium level is 6.6 mEq/L, and his serum creatinine level has risen from 0.9 mg/dL at admission to 3.9 mg/dL. Dr. Orcutt requests a consult from Dr. Hansen, the nephrologist, to manage acute kidney injury. Continuous venous hemofiltration was initiated for five days. On day 14, Mr. Grates was extubated. He was transferred to the step-down unit on day 20, at which time Mr. Grates complained of abdominal pain and bloating. Dr. Orcutt orders an additional CT scan of the abdomen. How many mL per hour must Mr. Grates have for adequate urine output? Why is this important? Based on labs, what level of kidney dysfunction does Mr. Grates experience? What is the classification of Mr. Grates’s acute kidney injury, prerenal, intrarenal, or postrenal? What is your rationale for this classification? What are the pros and cons of using continuous venous hemofiltration? What precautions need to be considered before Mr. Grates has his second CT scan to prevent or minimize further kidney injury?