Fenoldopam and prevention of PO-ARF.

[sevoflurane]

Is anyone aware of any evidence in the literature regarding fenoldopam truly being renal protective? I've read that it increases renal blood Q, but I don't know if it makes any difference in the prevention of post-op ARF. It functions at the level of D-1 receptors much like Dopamine, although 6 times more potent... and we all know about "renal dose dopamine".

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[militarymd]

Nope, I think only N-acetycysteine and HCO3 infusions have been shown to do much.

 

[undecided05]

but we all know that mucomyst and bicarb are mostly hand waving and abracadabra as well...

 

[militarymd]

but we all know that mucomyst and bicarb are mostly hand waving and abracadabra as well...

perhaps mucomyst, but there is grade B data supporting bicarb.

 

[Idiopathic]

but we all know that mucomyst and bicarb are mostly hand waving and abracadabra as well...

No. Bicarb has support. Mucomyst is just to make people feel better about themselves as doctors.

 

[sevoflurane]

At least in the setting of Rhabdo, bicarb to "alkalinize the urine (ph>6.5)" has not shown to be useful. I think the New England Journal put out a paper on this a couple of months ago.

Back to Fenlodopam.... I've seen it used only once, and this was in the ICU setting, and at the time was used to appease academic curiosity. Urine output did pick up, but the patient was 3 days out of surgery and due to fluid shifts u/o was likely going to pick up anyways.

How about in the OR? say in the setting of necessary surgery with blood pressures trending toward malignant HTN with renal compromise (cr of 2.0 > 4.0). Would you forget about the theorized renal protection of fenlodopam?... ie bolus 20mg of labetalol with a nitroprusside drip running in the background titrated to effect? Up to date suggests that in the setting of renal insufficiency/failure, fenlodopam may be particularly useful... I just never seen it used and up to date doesn't really have any data to back that statement up. Also, I never hear of anybody talking about fenlodopam in the OR... it seems more like a closet drug that is never used.

 

[Idiopathic]

Hydration with bicarb/D5W is more efficacious than hydration with normal saline at preventing contrast nephropathy in CRF individuals.

As far as rhabdo or post-op in other cases, Im not sure. But bicarb is a winner.

 

[militarymd]

I/We use bicarb in cases where contrast will be used....fenoldapam just does not have data yet.

 

[undecided05]

Hydration with bicarb/D5W is more efficacious than hydration with normal saline at preventing contrast nephropathy in CRF individuals.

As far as rhabdo or post-op in other cases, Im not sure. But bicarb is a winner.

I don't mean to be an arse, but can you provide one study or a link to anywhere that has EBM to prove this??

As far as I can tell it's done mostly because it's been done in the past (with some theoretical reasoning of why it should work).

Not sure if this is even correct, but the only time I've seen an indication for bicarb is with ph<7.15 b/c at that low, pressors don't tend to work as well.

That being said, I'm going to con't to give my peeps with CRF bicarb prior to their contrast load & onc patients that are about to lyse a bunch of cancer cells.

 

[militarymd]

http://jama.ama-assn.org/cgi/content/short/291/19/2328

 

[undecided05]

thanks

 

[f_w]

fenoldapam, a drug in search of an application.

It is my understanding that it didn't do a lot of good in contrast induced nephropathy. The initial studies seemed to indicate that it works, but in broader application the hassle and complication of its use seems to outweigh the slim benefit.

I just came back from the meeting on endovascular therapy. A company hawked a special arterial catheter to be placed into both renal arteries for a low-dose infusion of fenoldapam during cardiac or peripheral vascular interventions. (http://www.flowmedica.com/solutions/benephit.html) Considering the challenge and potential danger to kidney function from selecting the renal arteries during renal artery stenting, I don't think it is a great idea to put anything in there if you don't have to.

Thanks for the link to the bicarb article. These days it is routine practice to use it in any patient with impaired Cr clearance and stable electrolytes. I do have an issue with the common definition of contrast nephropathy though. A temporary bump in Crea has no disease value to me unless the patient has either clinical evidence of renal failure or evidence of permanent damage to his renal function. (So far the study only proves that you can avoid the bump in creatinine, I am not aware that there is strong evidence to suggest that it reduces the rate of patients going on to kidney replacement therapy).

 

[s204367]

I use fenoldopam on all my AAA that have a Cr over 2.0. As well as RBF, it is a great for dropping pressure after clamp. I'll start it up 10 min or so prior to clamp time. Have yet to have a pt go into post op renal failure. Almost as fast as SNP for dropping pressure. I'm not convinced yet, and I await more literature.

 

[jetproppilot]

I use fenoldopam on all my AAA that have a Cr over 2.0. As well as RBF, it is a great for dropping pressure after clamp. I'll start it up 10 min or so prior to clamp time. Have yet to have a pt go into post op renal failure. Almost as fast as SNP for dropping pressure. I'm not convinced yet, and I await more literature.

If you're working with a great vascular surgeon who rarely gets into bleeding problems, dexmetatomidine is a great drug for keeping railroad-track-like hemodynamics during AAAs. And carotids/CABGs too.