Kidney Failure

[skatertudoroga]

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Lets say someone arrives at ER with acute renal failure. What would be the extent of ER Doctor's treatment of the patient versus an icu specialist or some other specialist. That is tell me what an ER Doctor would do in these situations versus Critical Care or Nephrologist,etc:
1) bacteria-pyelonephritis or something.
2) poisoning that damages either only kidneys or 2.1-multiple organs
3) complication of diabetes
4) kidney stone
5) trauma--i.e. severe blood loss, shock, but the trauma itself is not that bad, i.e. a cut artery
6) sepsis from pneumonia or something else.
Thanks.

And a question as to when ER hands it over to some other doctor how much does he know about further management and outcome for the patient?

 

[Rendar5]

Generally ED medicine is about identification and stabilization of the acute problem and handing it off, whether to an inpatient team or an outpatient team. Most kidney issues are not dealt with by critical care doctors, and the majority are treated with IV Fluids. You cite so many different issues that anything I tell you may or may not be how someone would deal with the issue. I can tell you how my hospital handles stuff, but it's not the only way to do so.

Pyelo is an infection. we give antibiotics and depending on how sick the patient is either admit them or not. If we admit, then usually a hospitalist or internal medicine doctor treats it. otherwise their primary doctor.

kidney stones only cause kidney damage after being there for extended periods of time. Our goal is to realize the problem is kidney stones and pain control. Unless it meets certain criteria, like infected stones or extremely swollen kidneys with stones unlikely to pass, they get sent home with a referal to a urologist. If they're admitted, usually it's to a urology service.

If there's trauma and someone is bleeding internally from damage to the kidney or arteries/veins, we get them seen by a trauma surgeon or whichever surgeon is handling it.

Sepsis with end-organ dysfunction tends to get admitted to intensive care units. ED's role is initial stabilization of BP (not always possible in sepsis, which is why it's a very high mortality disease), antibiotic initiation, and the rest of early goal directed therapy, and admission for a critical disease doctor to handle.

Poisons is just waaaay too broad a topic and everything depends on the poison.

Kidney disease from long-standing diabetes is a chronic issue, not an emergency one, and is best handled by the person's primary doctor. Diabetes does not cause acture renal failure, it causes chronic real failure. ED may treat patients for complications of long-standing kidney dysfunction, but we tend not to handle diseases themselves that are managed over decades long before and long after they're seen in the ED for 6 hours.

 

[BADMD]

Lets say someone arrives at ER with acute renal failure. What would be the extent of ER Doctor's treatment of the patient versus an icu specialist or some other specialist. That is tell me what an ER Doctor would do in these situations versus Critical Care or Nephrologist,etc:

For most acute renal failure issue, optimization of the patient's hemodynamics is going to be the treatment of choice; appropriate resuscitation, antibiotics, vasopressors, inotropes, etc. Whatever is appropriate to optimize renal perfusion. In that regard, there is very little that is going to differ in how the patient is managed from specialty to specialty (assuming everyone is doing their job). If you look at my procedural credentials versus an Intensivist's credentials, there isn't much that is different. As far as I can tell, I'm not credentialed to perform bronchoscopy, but that is about the extent of it.

The relationship between the Emergency Physician and the patient has to end at some time. Typically that is 4-8 hours. The big thing the intensivist has is a bunch of beds that are dedicated to critical care and nursing ratios that are more ideally suited to critical care. The other thing that the intensivist has is training for the next steps. I can manage a vented patient for 24 hours in fashion fairly similar to an intensivist. After 24 hours, I start to run out of knowledge and experience for how to manage a patient that is continuing to decline or won't wean.

Nephrologist prescribe dialysis and can often perform renal biopsies. Neither EPs nor ICU docs can provide that. They are best suited for chronic renal issues that go beyond hemodynamic management. They are also good at treating issues like Lupus, which have more complex issues surround renal injury.

If you go back to your list, 1, 5, and 6 are treated by fixing hemodynamics. 3 is really treated by good glucose/blood pressure control and is an outpatient issue. ICU, ED and nephro all treat #4 the same way; call someone else. That patient needs someone to unobstruct the flow of urine, either urology for a stent or radiology for a nephrostomy tube. As above, 2 is too broad, although many nephrotoxins are treated by optimization of hemodynamics.

And a question as to when ER hands it over to some other doctor how much does he know about further management and outcome for the patient?

It strongly depends. At most hospitals it isn't all that hard to follow up on your patients. It is requirement of EM residency programs, in fact.

 

[skatertudoroga]

Thank you! Very informative responses.