When to intubate in GCS?

GCS ≤ 8 requires intubation for airway protection. The patient cannot protect their own airway at this level of consciousness. Motor score is the most prognostically important component.

What is the best initial fluid for sepsis resuscitation?

Lactated Ringer's (LR) is the preferred resuscitation fluid. The SMART trial (2018) showed balanced crystalloids reduced death, new renal failure, and persistent renal dysfunction compared to normal saline.

When to start vasopressors in septic shock?

Start norepinephrine (first-line vasopressor) if MAP remains < 65 mmHg after initial 30 mL/kg crystalloid resuscitation, or earlier if patient is profoundly hypotensive. Do not delay pressors to complete full fluid resuscitation.

Why can serum uric acid be normal during acute gout?

During acute inflammation, IL-6 increases renal urate excretion and redistributes urate from plasma to tissues. Up to 40% of acute gout flares have normal serum uric acid. Joint aspiration with polarized microscopy is needed for definitive diagnosis.

How do you distinguish lupus flare from infection in SLE?

Key clues: CRP is low/normal in flare but elevated in infection. Complement (C3/C4) drops in flare but is normal/elevated in infection. Procalcitonin is elevated in bacterial infection but normal in flare. Anti-dsDNA rises in flare, stable in infection.

What is the difference between DKA and HHS?

DKA features acidosis (pH 600), hyperosmolality (> 320), and minimal ketosis -typically in Type 2 DM. DKA requires insulin drip; HHS requires aggressive fluid resuscitation first.

When to give tPA in acute ischemic stroke?

IV alteplase (tPA) can be given within 4.5 hours of last known well time in eligible patients. CT head must rule out hemorrhage first. For large vessel occlusion, mechanical thrombectomy can be performed up to 24 hours with favorable imaging.

What antibiotics for community-acquired pneumonia?

Inpatient non-ICU: ceftriaxone + azithromycin. ICU: ceftriaxone + azithromycin (add vancomycin if MRSA risk). Outpatient healthy: amoxicillin. Outpatient with comorbidities: augmentin + azithromycin or respiratory fluoroquinolone. Duration: 5 days if clinically stable for 48 hours.

How to interpret iron studies?

Iron deficiency: low ferritin (< 30), high TIBC, low iron, low transferrin saturation (< 20%). Anemia of chronic disease: normal/high ferritin (acute phase reactant), low TIBC, low iron. A ferritin of 50-100 in an inflamed patient may still represent iron deficiency.

What is the correction rate for hyponatremia?

Correct sodium no more than 8 mEq/L in 24 hours to avoid osmotic demyelination syndrome (ODS). For symptomatic severe hyponatremia with seizures, give 3% hypertonic saline 100-150 mL bolus over 10-20 minutes. If overcorrected, use D5W + DDAVP rescue protocol.

When to start antibiotics in meningitis?

Within 30-60 minutes. Do NOT delay antibiotics for LP or CT. Draw blood cultures, start empiric antibiotics (vancomycin + ceftriaxone ± ampicillin if > 50 or immunocompromised), then perform LP when possible. Dexamethasone should be given before or with the first antibiotic dose.

DOACs vs warfarin in antiphospholipid syndrome?

DOACs are contraindicated in APS. The TRAPS trial (2018) showed rivaroxaban was inferior to warfarin with more thrombotic events in triple-positive APS patients. Warfarin with INR target 2-3 is the standard for APS, indefinitely.

How to manage scleroderma renal crisis?

ACE inhibitors (captopril) are life-saving -start immediately and titrate aggressively. Do NOT hold for rising creatinine. Steroids > 15 mg prednisone per day precipitate scleroderma renal crisis. ARBs are NOT a substitute -evidence is only for ACEi.

What are the 4 pillars of heart failure treatment?

Guideline-directed medical therapy (GDMT) for HFrEF: (1) ARNI or ACEi/ARB, (2) beta-blocker (carvedilol, metoprolol succinate, or bisoprolol), (3) MRA (spironolactone or eplerenone), (4) SGLT2 inhibitor (dapagliflozin or empagliflozin). All four should be initiated and titrated to target doses.

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EmergentNephrology

Dialysis Indications

Know when to call nephrology emergently (AEIOU) and the differences between HD, CRRT, and PD. The decision to start emergent dialysis is clinical, not based on a single lab value.

🔍 Emergent Indications -AEIOU

AEIOU -Emergent dialysis indications (refractory to medical management):

Letter	Indication	Details
A	Acidosis	Severe metabolic acidosis (pH < 7.1) refractory to bicarb. Especially toxic ingestions (methanol, ethylene glycol -dialysis removes the toxin AND corrects acidosis).
E	Electrolytes	Refractory hyperkalemia not responding to medical management (calcium, insulin/glucose, albuterol, bicarb). K⁺ > 6.5 with ECG changes + anuric patient → emergent HD.
I	Ingestion	Toxic alcohols (methanol, ethylene glycol), lithium, salicylate, theophylline, metformin (with severe lactic acidosis). Dialysis removes the toxin directly.
O	Overload (volume)	Pulmonary edema refractory to diuretics. Anuric patient with flash pulmonary edema → emergent ultrafiltration/HD.
U	Uremia	Uremic symptoms: encephalopathy (AMS, asterixis), pericarditis (friction rub → can progress to tamponade), uremic bleeding (platelet dysfunction), intractable nausea/vomiting. Uremic pericarditis = absolute indication -can cause fatal tamponade.

There is no specific BUN or Cr threshold for starting dialysis. IDEAL, 2010: early initiation (GFR 10–14) showed no survival benefit over late initiation (GFR 5–7) in CKD. The decision is based on clinical symptoms and refractory complications, not a single lab value. A patient with BUN 150 and no symptoms doesn't need dialysis. A patient with BUN 80 and uremic pericarditis does.

🔧 Modalities

HD vs CRRT vs PD

Feature	Intermittent HD	CRRT	PD
Setting	Outpatient dialysis center, inpatient	ICU only	Home (chronic) or inpatient
Access	AV fistula, AV graft, or dialysis catheter (IJ preferred)	Dialysis catheter (large bore, dual lumen)	PD catheter (Tenckhoff, peritoneal)
Duration	3–4 hours, 3×/week	Continuous (24/7)	Overnight (APD) or 4× daily exchanges (CAPD)
Hemodynamic stability	Rapid fluid/solute shifts → hypotension risk	Gentler -preferred for hemodynamically unstable patients (septic shock, cardiogenic shock)	Gentle, minimal hemodynamic effects
Solute clearance	Fast, efficient for small molecules	Slower per hour but continuous → equivalent over 24h	Less efficient for small molecules
Best for	Outpatient ESKD, emergent dialysis (fast K⁺ removal), toxin removal	ICU patients who are hemodynamically unstable. AKI in shock. Cerebral edema (slower osmolar shifts).	Chronic CKD/ESKD who want home-based therapy. Preserve residual renal function longer.

CRRT Modes

Mode	Mechanism	Use
CVVH (Continuous VenoVenous Hemofiltration)	Convection (hydrostatic pressure pushes fluid + solutes across membrane, replaced with clean fluid)	Volume overload, middle-molecule clearance
CVVHD (Continuous VenoVenous Hemodialysis)	Diffusion (solute moves down concentration gradient across membrane via dialysate)	Small molecule clearance (urea, K⁺, toxins)
CVVHDF (Continuous VenoVenous Hemodiafiltration)	Both convection + diffusion	Most commonly used in ICU. Combines benefits of both. Best overall solute + fluid clearance.

Vascular Access

AV fistula -gold standard for chronic HD. Lowest infection rate, longest patency. Place when eGFR ~20 (needs 2–3 months to mature). Radiocephalic (wrist) → brachiocephalic (upper arm).
AV graft -synthetic conduit. Can use in 2–3 weeks. Higher infection and thrombosis rate than fistula.
Tunneled dialysis catheter (Permacath) -for patients awaiting fistula maturation or not candidates for fistula. Highest infection rate. Right IJ preferred (straightest path to RA).
Non-tunneled temporary catheter -emergent dialysis only. IJ or femoral. Should be replaced within 1–2 weeks.

Preserve arm veins: avoid blood draws and IVs in the non-dominant arm of any patient with CKD stage 3+ or approaching dialysis. That arm may be needed for a fistula. Never use a dialysis catheter for non-dialysis purposes (blood draws, meds, fluids) unless absolute emergency -infection risk.

🧪 Workup

Workup

BMP -K⁺, BUN, Cr, bicarb
ABG -acidosis severity
CXR -pulmonary edema
ECG -hyperK changes
Tox levels if ingestion
Access assessment

🚨 Management

Management

AEIOU: Acidosis pH<7.1, Electrolytes (K⁺ refractory), Ingestion, Overload, Uremia
HD: stable patients, 3-4h sessions
CRRT: hemodynamically unstable ICU
IDH prevention: slow UF, cool dialysate 35.5°C, midodrine, hold antihypertensives HD days

💊 Medications

Medications -Dialysis

Drug (Brand)	Dose	Route	Indication	Notes
CIRCUIT ANTICOAGULATION
Heparin	Per protocol (bolus + infusion)	IV	HD circuit anticoagulation	Standard for intermittent HD. Monitor aPTT. Hold if active bleeding -run without anticoag.
Citrate (regional)	Per CRRT protocol	IV	CRRT anticoagulation	Preferred for CRRT -chelates calcium in circuit. Monitor ionized calcium closely (systemic and circuit). Risk: metabolic alkalosis, hypocalcemia.
CKD-MBD MANAGEMENT
Sevelamer (Renvela)	800–1600 mg with meals	PO	Phosphate binder	Non-calcium binder -preferred to avoid vascular calcification. Take with every meal.
Calcium acetate (PhosLo)	667 mg (1–2 tabs) with meals	PO	Phosphate binder	Calcium-based binder. Avoid if hypercalcemic or high Ca x PO4 product.
Cinacalcet (Sensipar)	30–180 mg PO daily	PO	Secondary hyperparathyroidism	Calcimimetic -activates CaSR on parathyroid → suppresses PTH. GI side effects common. For dialysis patients with refractory hyperPTH.
Calcitriol (Rocaltrol)	0.25–0.5 mcg PO daily	PO	Active vitamin D	For secondary hyperPTH. Monitor calcium (risk of hypercalcemia). Alternative: paricalcitol (Zemplar).
ANEMIA MANAGEMENT
Epoetin alfa (Procrit)	50–300 units/kg 3x/week	IV/SQ	Anemia of CKD/ESKD	Iron-replete first (ferritin > 200, TSAT > 20%). Target Hgb 10–11.5. Never > 13.
Darbepoetin (Aranesp)	0.45 mcg/kg q2 weeks or monthly	IV/SQ	Anemia of CKD/ESKD	Long-acting ESA -less frequent dosing. Same Hgb target.
Iron sucrose (Venofer)	100–200 mg IV per HD session	IV	Iron deficiency on dialysis	Given during HD sessions. Target ferritin 200–500, TSAT 20–30%. Must replete iron before starting ESA.

📋 On Rounds

When do you choose CRRT over intermittent HD in the ICU?

Hemodynamic instability is the primary indication for CRRT over HD. Intermittent HD removes fluid and solutes rapidly over 3–4 hours → large intravascular volume shifts → hypotension (especially in patients already on vasopressors). CRRT removes the same total fluid/solutes but continuously over 24 hours → gentler osmolar and volume shifts → better tolerated hemodynamically.

Why is uremic pericarditis an absolute dialysis indication?

Uremic pericarditis is a fibrinous/hemorrhagic pericarditis caused by uremic toxin accumulation irritating the pericardium. Unlike viral pericarditis, it can rapidly progress to hemorrhagic pericardial effusion → tamponade because uremic patients have concurrent platelet dysfunction (uremic bleeding). The pericarditis responds to intensive dialysis (daily HD for 1–2 weeks), not to NSAIDs or colchicine (which treat viral pericarditis).

A patient on HD has hypotension during the session. What do you do?

Intradialytic hypotension (IDH) -the most common HD complication (~20-30% of sessions). Immediate management: (1) Passive leg raise (Trendelenburg has no evidence), (2) Reduce UF rate or stop UF (keep dialysis running for clearance), (3) NS 100-250 mL bolus, (4) If persistent → stop dialysis.

What is the difference between intermittent HD and CRRT, and when do you choose each?

Intermittent HD: 3-4h sessions, high solute clearance, significant fluid shifts. Use for: stable patients, urgent indications (hyperK, toxic ingestions -high clearance needed fast), outpatient maintenance. CRRT (continuous renal replacement therapy): runs 24/7, slower gentle fluid/solute removal.

Clinical Examples

📋 Case 1, Emergent Dialysis for Hyperkalemia

Patient: 58M with ESKD on MWF HD (missed 2 sessions). K⁺ 7.2, peaked T waves → widened QRS on ECG. Cr 14.2, BUN 128. Bilateral crackles, JVD.

Key findings: Life-threatening hyperkalemia with ECG changes + volume overload from missed dialysis. AEIOU indications met: Electrolytes (refractory K⁺) + Overload (pulmonary edema).

Management:

Calcium gluconate 3g IV over 5 min (membrane stabilizer, buys time, does NOT lower K⁺)
Insulin 10 units IV + D50 1 amp (shifts K⁺ intracellularly, onset 15 min, lasts 4-6h)
Emergent hemodialysis, call nephrology and dialysis nurse STAT. Most effective K⁺ removal
Albuterol 10-20 mg nebulized (shifts K⁺, additive to insulin)
Kayexalate is NOT emergent therapy (onset 6-12h, causes GI necrosis risk)

Teaching point: The order matters: stabilize the membrane (calcium) → shift K⁺ (insulin/albuterol) → remove K⁺ (dialysis). Calcium gluconate does not lower potassium, it prevents cardiac arrest while you arrange definitive removal.

📋 Case 2, CRRT in ICU for Septic Shock + AKI

Patient: 67F in ICU with septic shock on norepinephrine 0.25 mcg/kg/min. Oliguric AKI (Cr 1.1 → 5.8 in 3 days). K⁺ 5.9, pH 7.18, HCO₃ 12. Volume overloaded (6L positive).

Key findings: AKI with multiple dialysis indications (acidosis, hyperkalemia, volume overload) but hemodynamically unstable, cannot tolerate intermittent HD (rapid fluid shifts → hypotension).

Management:

CRRT (continuous venovenous hemodiafiltration, CVVHDF) rather than intermittent HD
CRRT advantages in shock: slow continuous fluid removal (50-100 mL/hr net UF), hemodynamically gentle
Dialysis catheter: temporary non-tunneled in right IJ (preferred site for flow)
Anticoagulation for CRRT circuit: citrate regional anticoagulation (preferred) or heparin
Monitor ionized calcium closely if using citrate (citrate chelates calcium → hypocalcemia risk)

Teaching point: CRRT is not "better" than intermittent HD, it's gentler. The AKIKI trial showed no mortality benefit for early vs delayed RRT initiation in ICU. Start CRRT for absolute indications (AEIOU), not prophylactically.

📋 Case 3, Dialysis Access Complications

Patient: 52M on HD via left brachiocephalic AV fistula × 3 years. Presents with left arm swelling, difficulty cannulating the fistula, and prolonged bleeding after last HD session. Thrill diminished on exam.

Key findings: AV fistula stenosis with signs of access failure: diminished thrill (should be palpable), prolonged bleeding (elevated venous pressure), difficult cannulation, arm edema (central venous stenosis).

Management:

Duplex ultrasound of fistula to confirm stenosis location and degree
Fistulogram (contrast venography) with angioplasty if stenosis > 50% with clinical symptoms
If angioplasty fails: surgical revision or new access creation
Temporary dialysis catheter if fistula nonfunctional and dialysis cannot wait
AV fistula hierarchy: radiocephalic (wrist) → brachiocephalic → brachiobasilic transposition → AV graft → tunneled catheter (last resort)

Teaching point: AV fistula is the gold standard for HD access (lowest infection rate, longest patency). Fistula first, always plan access early (6 months before anticipated HD start for fistula maturation). Catheters should be a bridge, not permanent.

📣 Sample Presentation

One-Liner

"Mrs. White is a 62-year-old with ESKD on HD (MWF via LUE AV fistula) who missed 2 sessions, presenting with dyspnea, bilateral crackles, K⁺ 6.8, and BUN 112."

Key Points to Cover on Rounds

Missed dialysis ×2 → volume overload + hyperkalemia + uremia. K⁺ 6.8 with peaked T waves → calcium gluconate, insulin/D50, albuterol given. Nephrology emergently contacted -urgent HD session arranged. Access: LUE fistula with good thrill and bruit. Fluid overloaded: JVP 14 cm, crackles bilaterally, 3+ LE edema. UF goal 4L for this session. Plan: resume regular MWF HD, social work to address barriers to sessions.

Monitoring -Dialysis

Parameter	Frequency	Target / Action
Pre/post BUN, K+, bicarb, Ca, PO4	Each HD session (or daily for CRRT)	Assess clearance adequacy. Post-HD K+ should be 3.5–5.0. Bicarb > 22. PO4 3.5–5.5.
Weight (dry weight target)	Pre/post each HD session	Fluid removal goal = pre-HD weight minus dry weight. Reassess dry weight monthly -clinical exam (edema, JVP, BP) guides adjustment.
Access assessment (AV fistula)	Every HD session	Check thrill and bruit -absence suggests thrombosis or stenosis. Inspect for signs of infection, aneurysm, steal syndrome (cold/pale hand).
Kt/V	Monthly	Dialysis adequacy: target Kt/V ≥ 1.4 (single-pool) for thrice-weekly HD. URR (urea reduction ratio) > 65% is alternative measure.
Hgb / iron studies	Monthly	Hgb target 10–11.5 g/dL. Ferritin 200–500, TSAT 20–30%. Replete iron before adjusting ESA dose.
PTH	Every 3 months	Target 2–9x upper limit of normal for dialysis patients. Rising PTH → increase phosphate binders, add cinacalcet or calcitriol.

Access is lifeline. Protect AV fistulas -no blood draws, no BPs, no IVs in the fistula arm. Never use a dialysis catheter for non-dialysis purposes unless absolute emergency.

⚡ Summary

Summary

Emergent Indications

AEIOU: Acidosis (pH < 7.1), Electrolytes (refractory K⁺ > 6.5), Ingestion (toxic alcohols), Overload (pulmonary edema), Uremia (pericarditis, encephalopathy, bleeding).

HD vs CRRT

HD: 3-4h sessions, stable patients, high clearance. CRRT: continuous, hemodynamically unstable ICU patients, cerebral edema risk.

Access

AV fistula (best long-term, 3-6 months to mature) > AV graft (2-4 weeks) > tunneled catheter (immediate but highest infection risk).

IDH Prevention

Slow UF rate, cool dialysate (35.5°C), midodrine pre-session, hold antihypertensives on dialysis days, extend session time.

Peritoneal Dialysis

Home-based, daily. Good for: independent patients, residual renal function preservation. Risk: peritonitis (cloudy effluate → culture + empiric abx).

Complications

Dialysis disequilibrium (cerebral edema with first session), air embolism, catheter infection, steal syndrome (fistula).

📄 One Pager

Nephrology · One Pager

Dialysis -HD & CRRT

AEIOU for emergent dialysis. HD for stable patients. CRRT for hemodynamically unstable ICU patients. Access: fistula > graft > catheter.

🧪 Emergent Indications -AEIOU

Acidosis (pH < 7.1, refractory). Electrolytes (hyperK refractory). Ingestion (toxic alcohols, salicylates). Overload (pulmonary edema refractory to diuretics). Uremia (pericarditis, encephalopathy, bleeding).

🚨 HD vs CRRT

HD: 3-4h sessions, high clearance, stable patients, outpatient. CRRT: continuous 24/7, gentle fluid removal, hemodynamically unstable ICU patients, cerebral edema risk.

💊 Access

AV fistula (best -refer at eGFR ~20, needs 3-6 months to mature). AV graft (2-4 weeks). Tunneled catheter (immediate, highest infection risk). Peritoneal catheter (home dialysis).

💊 Key Drugs

Calcium gluconateHyperkalemia bridge to HD

HeparinAnticoag for HD circuit

CitrateRegional anticoag for CRRT

EPOAnemia management on HD

⚠️ Pitfalls

Late fistula referral (needs months to mature)
IDH from aggressive UF rate (slow down, cool dialysate)
Dialysis disequilibrium in first session (cerebral edema)
Not adjusting medications for HD clearance