Pediatric emergency medicine trisk 2889 2889
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with frequent assessment of fluid status and urine flow. If the etiology is
unclear and the patient is hemodynamically stable, gentle IV fluid bolus
therapy starting at 10 mL/kg may be initiated with reassessment to
determine if further resuscitation is indicated. Though prerenal physiology
should be corrected, prevention of fluid overload should be emphasized.
This balance is most challenging in those patients who present critically ill
with sepsis associated with capillary leak and in those with heart failure and
ineffective circulating volume. Potassium supplementation should be
withheld until urine flow is established and results of serum electrolytes are
available. Electrolyte and acid–base disturbances should be addressed as
previously reviewed.
If AKI is associated with oligouria or anuria, the child may present in a
state of volume excess. If severe, hypertension and pulmonary edema may
be present and would warrant a trial of loop diuretic therapy. Intravenous
furosemide given at an initial dose of 0.5 to 1 mg/kg should be provided
and repeated as necessary every 6 hours if volume overload is causing
cardiopulmonary compromise. If an adequate dose of a loop diuretic does
not lead to a diuretic response, this therapy should be discontinued.
Hypertension may be treated with either oral or IV agents. Oral calcium
channel blockers and hydralazine, an arterial vasodilator, are well tolerated
and do not further impair renal function like ACE inhibitors and ARB
medications. If IV agents are required, intermittent doses of hydralazine or
labetalol are often effective. If the child remains oligouric or anuric despite
diuretic challenge and has clinical evidence of volume excess, a pediatric
nephrologist should be consulted given the potential need for RRT and
ultrafiltration. Indications for dialysis include progressive azotemia,
clinically significant volume overload, and severe electrolyte abnormalities
such as hyperkalemia or acidosis that is refractory to conservative medical
therapy. If medications such as antibiotics are indicated, dose adjustment
based on decreased renal function must be considered. Indications for
admission include hypertension and impaired renal function causing fluid or
electrolyte abnormalities.
INTRINSIC CAUSES OF AKI
AKI may be caused by a wide variety of both acute and chronic processes.
It may be due to a primary renal disorder or be related to a systemic disease.
