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Case report Crit Care Shock (2021) 24:125-129

Restrictive fluid and fluid removal approach in diabetic with septic AKI: A case report

Elvia AS1, Mayang Indah Lestari2, Yohannes WH George3

Abstract to the intensive care unit. Aggressive fluid re- is a life-threatening com- suscitation carries potential adverse effects such plication that requires a rapid restoration of as hyperchloremic metabolic , intersti- intravascular volume usually with aggressive tial multi-organ , and increased incidence administration of intravenous fluid with 0.9% of . The first day of ICU sodium chloride as recommended by the Ameri- treatment, positive cumulative can Diabetes Association. We report a 50-year- occurred and fluid removal was indicated. Fluid old obese female patient with a history of diabe- removal using or ultrafiltration is a tes mellitus (DM) since 20 years ago and rou- part of the treatment of organ congestion and tinely using insulin. She experienced dyspnea fluid overload after the initial phase of shock and presumably was caused by diabetic ketoac- resuscitation to achieve negative fluid balance. idosis. The patient was given fluid resuscitation This case showed that restricted fluid and fluid with normal , but the dyspnea did not re- removal improve the patient outcome, especially solve and the work of breathing increased fur- in diabetic ketoacidosis and septic AKI patients. ther, so the patient was intubated and admitted . Key words: Diabetic ketoacidosis, septic AKI, restricted fluid, fluid removal, negative cumulative balance.

Introduction (1) Recent guidelines from American Diabetes As- Diabetic ketoacidosis (DKA) is a life-threatening sociation (ADA) recommend fluid resuscitation complication that can occur in patients with diabe- using normal saline 15-20 ml/kg/hour (1-1.5 liter) tes mellitus. Diabetic ketoacidosis patients with in the first one hour and continue with 250-500 another condition such as acute kidney injury ml/hour as maintenance. This approach is still con- (AKI) and sepsis are considered critically ill and troversial because this type of fluid overload could require treatment in an intensive care unit (ICU). induce hyperchloremic . (2) Pos- . itive fluid balance and vein congestion may worsen critically ill patients’ outcomes and induce multiple organ failures such as lungs, renal, liver, and gas- 1. Trainee of Intensive Care Fellowship Program, Universitas trointestinal. (3) Active fluid removal using diuret- Indonesia, Cipto Mangunkusumo Hospital Jakarta, Indonesia ic and ultrafiltration could be used to treat organ 2. Universitas Sriwijaya, Mohammad Hoesin Hospital, Palem- congestion and fluid overload after initial resusci- bang, Indonesia 3. Department of Anesthesiology and Intensive Care, Universi- tation. We present a DKA with septic AKI case tas Indonesia, Jakarta. Emergency and Intensive Care Unit with a restricted fluid approach and active fluid Pondok Indah Hospital, Jakarta, Indonesia removal which improved patient outcomes.

Address for correspondence: Case presentation Yohanes WH George We report a 50-year-old obese female patient with Department of Anesthesiology and Intensive Care, Universitas a history of diabetes mellitus (DM) since 20 years Indonesia, Jakarta ago and routinely using insulin. First, she had my- Emergency and Intensive Care Unit Pondok Indah Hospital, Jakarta, Indonesia algia, nausea, and vomitus during the first day in Tel: +628121032069 the general ward. The patient had normal vital Email: [email protected] signs, leukocytosis, high blood glucose (358 .

Crit Care Shock 2021 Vol. 24 No. 3 125 mg/dl), normal urea-creatinine, normal chest X- 2009 is the administration of 1000-1500 ml of ini- ray, and normal electrocardiography (ECG). On tial normal saline for the first hour. Excessive ad- the second day of treatment, she experienced dysp- ministration of normal saline has the potential to nea, tachypnea, increased blood pressure (193/79 cause hyperchloremic metabolic acidosis. (2) A mmHg), tachycardia 142 beats/min, and presuma- recent study suggested that administering a bal- bly caused by diabetic ketoacidosis. The patient anced electrolyte solution can prevent hyperchlo- was given fluid resuscitation with normal saline remic metabolic acidosis. (5) 1500 ml and further consulted with the cardiolo- KAD is an acute inflammatory condition and may gist. The cardiologist performed echocardiography, promote further increase in inflammatory media- found there were no abnormalities, then gave diu- tors. Patients who are free from the shock phase retic (furosemide), nitrate, and antihypertensive will experience inflammatory mediator homeosta- agent to treat for the possibility of pulmonary ede- sis within three days, characterized by hemody- ma. One hour later, the dyspnea did not resolve namic stabilization and restoration of plasma on- and the work of breathing increased, so the patient cotic pressure, , mobilization of extravas- was intubated and admitted to the intensive care cular fluid, and negative fluid balance, which is unit (ICU). known as the flow phase. Contrary to usual in- In the ICU, the patient got mechanical ventilation flammatory patients, this patient developes persis- and a central venous catheter was inserted. During tent systemic inflammation, plasma leakage, and treatment, the patient tended to have tachycardia flow phase fails to be reached, so that fluid accu- (120-140 beats/min), fever, and elevated blood mulation increases, results in positive cumulative pressure (120-160 mmHg), so the patient was giv- fluid balance. Cordeman, et al introduced the term en nicardipine in titrated dose. Central venous global increased permeability syndrome (GIPS), pressure (CVP) was maintained around 6-8 mmHg. which denotes the third hit of shock after injury Additional examination showed the patient had an and multi-organ dysfunction syndrome (MODS). increased level of ketones and creatinine, leukocy- GIPS can be caused by hypervolemia and can be tosis, metabolic acidosis, but ECG and chest X-ray implemented as , lung edema, kid- did not show anything abnormal. The working di- ney edema, intestinal edema, and peripheral ede- agnosis was diabetic ketoacidosis with septic acute ma. (6) At the time of admission to the ICU, this kidney injury (AKI). patient had entered the third hit phase and GIPS On the first day in the ICU, this patient had posi- already occurred, which was marked by positive tive fluid balance and was indicated for fluid re- cumulative fluid balance. moval. On the third day, the patient got continuous Fluid removal was performed with to veno-venous hemofiltration (CVVH) and on the achieve negative fluid balance. Fluid removal us- fourth day negative cumulative fluid balance ing diuretic or ultrafiltration is a part of the treat- reached, the vital sign was stable (CVP around 0-6 ment of organ congestion and fluid overload after mmHg), and the level of creatinine and ketones the initial phase of shock resuscitation to achieve were significantly decreased. The CVVH was per- negative cumulative fluid balance. In addition to formed until the sixth day to maintain negative diuretics, ultrafiltration was also performed in or- fluid balance. Finally, on the seventh day, the pa- der to remove the cytokines and also the fluid. Ini- tient got extubation and transferred into the general tial CVP monitoring ranged from 8-12 mmHg and ward with a cumulative fluid balance of -5172 ml. reached 0-4 mmHg when the negative cumulative fluid balance was achieved. Legran, et al found Discussion there was a linear relationship between CVP val- Diabetic ketoacidosis is defined by the triad of hy- ues, and the risk of AKI. This suggests a role for perglycemia, metabolic acidosis, and ketonemia. venous congestion in the pathophysiology of AKI Hyperglycemia and ketones may induce osmotic in sepsis. (3) Multicenter observational studies diuresis, leading to and decreased found the use of diuretics was associated with bet- glomerular filtration rate (GFR). Progressive vol- ter survival in critically ill patients with AKI. (7) In ume depletion caused a decrease in GFR, and a 2017 European Society of Intensive Medicine rec- further decrease in clearance of glucose and ketone ommended the use of diuretics to control and pre- resulting in subsequent hyperglycemia, hyperos- vent fluid overload in patients who were respon- molality, and metabolic acidosis. (2) Patients with sive to diuretics. The use of diuretics can improve ketoacidosis also have a tendency to experience AKI including tubular obstruction, reducing me- sepsis and AKI. (4) dullar oxygen consumption, and increasing renal Fluid resuscitation protocol according to ADA in blood flow, reducing fluid overload, and venous . .

126 Crit Care Shock 2021 Vol. 24 No. 3 congestion. Although there is no single parameter In addition to fluid removal, ultrafiltration is also for fluid overload, increased CVP, peripheral ede- useful for eliminating cytokines. Patients with ma, and increased intra-abdominal pressure can be DKA may experience increased plasma levels of used as surrogates. (8) Negative fluid balance has a glucose, fatty acids, proinflammatory mediators, linear correlation with mean CVP and creatinine and oxidative stress. In uncontrolled diabetic pa- value, where the more negative fluid balance re- tients, there is an increase in interleukin (IL)-6, IL- sults in the lower mean CVP and creatinine value 1B, IL-8, tumor necrosis factor (TNF)-α, and also (Figure 1). the counter-regulating hormones so that ketoacido- Based on Guyton’s approach, the cardiovascular sis can occur. (10) The patient’s ketone value im- hemodynamic system depends on cardiac output proved on the second day and the creatinine value (CO) and venous return. Venous return is deter- increased on the third day but normalized after mined by the difference between the venous stress CVVH. The patient was extubated and moved to volume creating the mean circulatory filling pres- the general ward after the seventh day of treatment sure (MCFP) and CVP. Therefore, MCFP is one of in the ICU. the major contributors to the hemodynamic system. Normal MCFP level ranges from 8-10 mmHg Conclusion while normal values for CVP are 0-2 mmHg. (9) This case highlights the importance of fluid re- When the CVP value is too high, the pressure gra- striction and fluid removal in critically ill patients dient difference between MCFP and CVP will de- especially those with diabetic ketoacidosis and sep- crease, which can decrease venous return and CO. tic AKI. Fluid resuscitation in diabetic ketoacidosis This patient was given diuretic and CVVH to must be monitored cautiously to prevent GIPS. achieve a negative cumulative fluid balance, re- Fluid removal using diuretic and ultrafiltration may duce CVP levels, and increase MCFP coherent improve hemodynamic status and patient outcome. with improvement in hemodynamic status.

Crit Care Shock 2021 Vol. 24 No. 3 127 Figure 1. Cumulative fluid balance, CVP, and creatinine relationship

Legend: CVP=central venous pressure.

128 Crit Care Shock 2021 Vol. 24 No. 3 References

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