-Consider fluid challenge (to rule out pre-renal azotemia if not fluid overloaded) with 500-1000 mL NS IV over 30 min. In acute renal failure, inputs and outputs catheterize and check postvoid residual to rule out obstruction.
-Furosemide (Lasix) 80-320 mg IV bolus over 10-60 min, double the dose if no response after 2 hours to total max 1000 mg/24h, or furosemide 1000 mg in 250 mL D5W at 20-40 mg/hr continuous IV infusion OR -Torsemide (Demadex) 20-40 mg IV bolus over 5-10 min, double the dose up to max 200 mg/day. -Bumetanide (Bumex) 1-2 mg IV bolus over 1-20 min; double the dose if no response in 1-2 h to total max 10 mg/day. -Metolazone (Zaroxolyn) 5-10 mg PO (max 20 mg/24h) 30 min before a loop diuretic.
-Dopamine (Intropin) 1-3 mcg/kg per minute IV.
-Hyperkalemia is treated with sodium polystyrene sulfonate (Kayexalate), 1530 g PO/NG/PR q4-6h. -Hyperphosphatemia is controlled with calcium acetate (Phoslo), 2-3 tabs with meals.
-Metabolic acidosis is treated with sodium bicarbonate to maintain the serum pH >7.2 and the bicarbonate level >20 mEq/L. 1-2 amps (50-100 mEq) IV push, followed by infusion of 2-3 amps in 1000 mL of D5W at 150 mL/hr. -Adjust all medications to creatinine clearance, and remove potassium phosphate and magnesium from IV. Avoid NSAIDs and nephrotoxic drugs.
11. Extras: CXR, ECG, renal ultrasound, nephrology and dietetics consults.
12. Labs: CBC, platelets, SMA 7&12, creatinine, BUN, potassium, magnesium, phosphate, calcium, uric acid, osmolality, ESR, INR/PTT, ANA. Urine specific gravity, UA with micro, urine C&S; 1st AM spot urine electrolytes, creatinine, pH, osmolality; Wright's stain, urine electrophoresis. 24h urine protein, creatinine, sodium.
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