CKD

 50 yr old male working as carpenter resident of oligonda , married 30 yrs ago having 3 children ,elder daughter got married and other younger son and daughter are studying.

His wife also works as daily labourer.

Since past one year pt is not doing manual labour work and is just supervising contract based carpentry work and is at home most of the times ,as he is feeling weak .

So their daily needs are met by her wife and younger son who started working since past year .

Pt is a chronic smoker since 20 years - 10 vlbeedis /day

Chronic alocholic since 20 yrs - wife doesn't know exactly the amount of alcohol.

Since dialysis was started in 2019 around diwali time..pt stopped drinking and smoking.

Not a k/c/o HTN,DM,TB,ASTHMA,CAD,CVA.

No previous history of allergies/surgeries.

H/o NSAID abuse present whenever pt did lot of manual work.

In 2019 around diwali time pt noticed bilateral pedal edema extending upto knees and decreased urine output, but patient neglected the symptoms..went to local rmp .

He visited Hyderabad to his sons place for diwali . One month after diwali in 2019 ,one day pt developed sob ,pedal edema increased amd abdominal distension increased.

Pt got admitted in NIMS where he was told he developed renal failure and requires hemodialysis.

10 sessions of hemodialysis was done there Around jan 2020 , pt wanted to come back to his village ,so they discharged him on medications and adviced to follow up locally. Pt felt weak ,loss of appetite after dialysis .They used medications for one month and then stopped using it as they were not having sob , decreased urine output.

Pedal edema was present ,but patient dint give much attention to it.

Patient dint get checked up nor used any medications since past one year.

He dint visit any hospital as he had fear of COVID19 , he would be infected..by coming to hospital. So he stayed at home .

Since past one month pt noticed bilateral pedal edema increased with Abdominal distension and facial puffiness. He visited to nephrology opd here where he was advised investigations. But pt dint come for review.

Since one week Sob increased and urine output markedly reduced , so he got admitted .

Day 1: 

Yesterday evening pt was tachypneic , altered sensorium and was shifted to icu where abg showed severe metabolic acidosis (ph =6.9) .

O/E :

Pt is in altered sensorium .

GCS - E2V1M3 

BP - 110/70 mmHg ; Pr - 72bpm

RR - 38/MIN  ; SPO2 -70%on RA .

CVS - S1S2 PRESENT.

RS - BILATERAL FINE CREPITAIONS PRESENT Over ISA,IAA,MA ,SSA ,inter sacpular areas.

Pupils - Mid dilated and not reacting to light 

ABG :  yesterday night 

ph =6.9 

pco2=16.2

po2=114

so2=93

hco3=3.6

CBP :

HB = 3.8 g/dl

Tlc= 12000

platelet= 1lakh

RFT : UREA = 249

creat =12.3

Na -.140   ;  k-5; cl- 108

Pt was given 100 meq bicarbonate correction and Inj Lasix 80mg immediately and then intubated in view of falling saturation and respiratory distress .

Central line was placed and took for hemodialysis immediately ,and one PRBC transfued.

Cxr after intubation and hemodialysis : 

Ecg : 

Pt was put on ACMV -VC mode overnight .

with peep -6cm of h20 ; VT - 360ML 

RR - 16 ; Fio2 - intially 100 % and then tapered according to sats.

Post dialysis abg : 

Ph= 7.18 ;pco2- 37.5 ; po2- 191 ; hco3-13.5

Diagnosis - CKD ON MHD 

CARDIOGENIC PULMONARY EDEMA.

Severe metabolic acidosis ( resolving).

 Treatment given : 

1) FLUID RESTRICTION UPTO 1.5 LIT PER DAY 

2) PROPPED UP POSTURE / AIR WATER BED

3) INJ LASIX 40 MG IV TID 

4) Inj PANTOP 40MG IV OD 

5) INJ ZOFER 4MG IV TID 

6) INJ MONOCEF 1G IV BD 

7) INJ MIDAZOLAM 2CC IV SOS 

8) Nebulization with duolin and budecort 12 th hrly

9) RT FEEDS MILK PLUS PROTEIN POWDER AND FREE WATER 100ML 4 TH HRLY 

9) BP/PR/SPO2 /GRBS charting.

DAY 2- 

Pt on mechanical ventilator CPAP - VC mode 

pressure support - 12

fio2-60%

Peep -5cm of h20.

Morning reports:

Cbp : HB - 6.2 ; TLC - 15,600 , PLATELETS - 94,000

RFT - UREA - 201 ; CREAT - 8.6 ; NA-144 ; K - 4 ;CL- 106.

ABG - ph - 7.099 ;pco2 - 51.6 ; po2- 194 ; hco3-15.3

Day 2 Cxr : 

PT was shifted for one more session of hemodialysis around 4pm .

At 6pm - BP - 110/70 mmhg

PR -78bpm

SPO2- 96 %

DAY 3 : 

Pt on mechanical ventilator day 3 - ACMV mode :

RR - 14 b/min 

Peep - 6cmof h20

Fio2- 75%

Vt- 340ml

Bp- 100/70mmhg; Pr - 72bpm spo2- 94%

O/e : GCS -E2VTM3 

pupils - bilateral mid dilated not reacting to light.

Corneal and conjuctival reflex present.

Bilateral pedal edema and raised jvp present.

-Cvs - s1s2 heard 

RS - Decreased air entry on left side .

Bilateral fine crepts present IAA (L>R).

2 sessions of hemodialysis done . Yesterday evening one HD done with one PRBC transfusion.

Cbp - HB - 6.2--7.2

TLC-15,600----3,400

PLT -94000----60,000

Rft : 

Urea - 201--146

Creat -8.6--5.6

Na-144--145

K-4---3.5

CL- 106--102

ABG (8am)- PH - 7.38

pco2-24.5

Po2-136

Hco3- 14.2

DAY 4 : 

8 am update - Pt drowsy 

GCS - E2VTM4

BP - 110/70MMHG (on nor adrenaline 4ml/hr ) - Tapered from 12ml/hr.

PR - 110bpm

Grbs - 102 mg/dl

I/O - 1000ml /350ml 

CVS - S1S2 present.

RS - Decreased air entry on left IAA,,MA .

Fine crepts present on Left ma ,IAA 

Right side - Fine crepts present in IAA.

P/A - Soft ,bowel sounds sluggish.

CNS - Pt drowsy , Responding to painful stimulus.

Corneal and conjunctival reflex present.

Gag reflex - Present

Plantars - Flexion bilateral 

Pupils - bilateral mid dialted , Sluggishly Reacting to light.

Pt was maintaining on CPAP VC mode so shifted to T Piece on 5 lit of oxygen.

Spo2- 98%.

Plan - One session of hemodialysis today.

-And if pt consciousness improves , planning to extubate.

- Dint pass stools since 2 days - soap water enema is to be given.

As patient Was shifted to hemodialysis , his Bp was 70/50 mmHg on nor adrenaline 10ml/hr . Dialysis was stopped and he was started additionally on Dobutamine 5ml/hr .

BP was monitored .

Triple lumen catheter was placed for giving drugs as patient was having generalized anasarca , peripheral IV cannula couldn't be placed.

Around 10pm - As Bp stabilised ,he was shifted on inotropes to hemodialysis with UF 700ml slowly over 4 hours with one unit prbc transfusion .( HEPARIN FREE HD was done in view of thrombocytopenia). 

Pt was put on cpap -VC mode overnight and saturations were monitored. Next day early morning was put on T piece.

DAY 5 : 

Pt drowsy , irritable 

GCS -E4VTM5

Pt on T piece with 6 lit of oxygen.

BP - 100/60mmhg (on nor ad 2 ml/hr and dobutamine 3ml/hr - tapered dose )

PR -82bpm

Spo2- 96% 

Cvs - S1S2 present

RS -BAE present 

 crepts present in Left Ma, IAA.

And right IAA 

I/O - 1250/250ml 

4 hrs of heparin free hemodialysis was taken yesterday night .

Plan - To extubate the patient .

Continue hemodialysis.

7:30 am abg - ph - 7.23

Pco2- 40.2

Pco2-161

Hco3- 18

Rft - 

Urea -155 ,creat -3.8 ,na -145,k-3.2,cl-103

As patient was conscious and obeying commands ,and maintaining saturations .(GCS -E4VTM6)

Abg was showing mild metabolic acidosis.

Gag reflex was present .

INJ HYDROCORTISONE 100mg Iv STAT was given and NEBULIZATION with budecort and duolin was given 4 th hrly ,since morning along with chest physiotherapy .

PT was extubated around 4pm . 

Post Extubation , nebulization with budecort and chest physiotherapy was continued and pt was put on oxygen mask -8lit /min

Saturations were maintaining.

Post Extubation abg : 

Ph - 7.24 , pco2 - 47 mmHg ,po2 - 92mmhg ,so2- 90%

Hco3- 21.