Appropriate Therapy for Mrs. Andrews

The assignment discusses the case of Mrs. Andrews, a critically ill patient in ICU who is experiencing acute kidney injury (AKI). The case presents several challenges, including hypotension and fluid resuscitation needs. The assignment concludes that Continuous Veno-Venous Hemofiltration with Diffusion (CVVHD) is the most appropriate therapy for Mrs. Andrews due to its ability to provide slow and continuous removal of toxins and fluids, which is essential for critically ill patients who require large amounts of fluids. CVVHD also helps to maintain stable hemodynamic status and nutritional requirements.

Running Head: Nursing assignment
Nursing assignment
Name of the Student
Name of the University
Author Note

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Introduction
The paper deals with the case study of the Mrs Nancy Andrews. She is 77-year-old
female. The patient was initially admitted for the endovascular repair of a 6 cm infra renal
abdominal aortic aneurysm. On the third day after operation, the patient had intense abdominal
pain. On the fourth day post operation second surgical procedure was performed. After the
surgical procedure the patient was diagnosed with Acute Kidney Injury or AKI. Currently, she is
prescribed Continuous Veno-Venous Hemo Dialysis. In response to the case study, the paper
discusses acute kidney injury and explains the criteria, in this patient that is suggestive of acute
kidney injury. The choice of therapy prescribed for the patient is critically evaluated.
Acute Kidney Injury
Acute kidney injury can be defined as a decrease in the kidney function abruptly that
results in the dysregulation of the extracellular volume and electrolytes, and the retention of
nitrogenous waste products and the urea (Zuk and Bonventre 2016).
Criteria in patient that is suggestive of AKI
The criterion for the patient that is suggestive of AKI is the endovascular aneurysm repair
or EVAR. Since acute kidney injury is characterised by the decrease in the glomerular filtration
rate and increase in the serum creatinine and urea nitrogen. The same was observed in the case of
Mrs Andrews. Her creatinine was 310 instead of 50-100. Her urea concentration was 22 instead
of 2.7 – 8. Decreased haemoglobin was indicative of increased fluid volume and acute kidney
failure. Mrs Andrews’s haemoglobin was 87 instead of 115-155. AKI could also occur due to
increase in infection, which in case of Mrs Andrews is evident from WCC of 18.2 instead of 4-

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11. The cause of infection could be the Arterial and CVP line were inserted during the procedure
in her (Saratzis et al. 2015).
According to Bang et al. (2014), the patients who underwent the complex EVAR
procedure are at risk of AKI. Further, the emergence of AKI after EVAR is documented in
various studies. Age is the major risk factor for the AKI. For patients older than 70 years
aneurysm and AKI are highly prominent (Saratzis et al. 2013). Mrs Andrews is 77 year old and
was highly susceptible to the AKI after EVAR. Long time of operation is also found to increase
the risk of AKI, in this case this may have also caused the AKI in the patient (Bang et al. 2014).
According to Ronco et al. (2015), severe cardiac disease, hypercholesterolemia and large
abdominal aortic aneurysm diameter increases the surgical intervention and associated
complications. Among the complication, the main one is the AKI. In this case study the patient
has endovascular repair of a 6 cm infra renal abdominal aortic aneurysm. Further, the patient also
has the history of the coronary artery disease, hyperlipidaemia which, is suggestive of AKI in
this case. In addition, the angiography results showing the renal perfusion defects indicate the
risk of AKI. However, in the case Mrs Andrews, the angiography at the completion of the
procedure revealed no graft or endovascular leaks. The other physiological data suggests of AKI.
Choice of therapy for this patient
CVVHD is the appropriate treatment for the AKI. This process involves the use of a
pump-driven venovenous circuit. This method works on the principle of both diffusion and ultra-
filtration. In this technique a dialysate solution is run at a low rate counter-current t the flow of
the blood. This technique maximises the diffusion based solution removal. It permits blood flows
better than that provided by the arteriovenous circuit. The blood flow is more constant and

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higher. In addition, it eliminates the need of a large-bore arterial catheter. This eliminates the
risks of arterial thrombosis and arterial bleeding associated with it. The benefits of the therapy
include good clearance of small solutes urea, water, creatinine and electrolytes. Due to
continuous haemodialysis, it is efficient in removing the low molecular weight solutes. It is thus
used clinically for regulating the serum concentration of the small solutes (Symons 2017).
It helps to maintain the stable hemodynamic status and the nutritional requirements of
the patients. It is useful to eliminate the large amount of plasma ammonia (Pistolesi et al. 2016).
Currently the status of the patient shows that the urine output is 0-2 mls per hour. Her renal
ultrasound 1800 reveals adequate flow through renal arteries. The medical events of Mrs
Andrews in ICU show that she has periods of hypotension. Using the therapy of CVVHD, the
chance of hypotension can be removed as ultrafiltration can be done at slow rate. Even if the
hypotensive episodes are brief, there is high probability that kidney may be further damaged.
Recovery from AKI is slowed by multiple hypotensive episodes, in patients who are critically ill.
Thus, this method is appropriate for Mrs Andrews considering her present condition. Mrs
Andrews is meeting the criteria for the haemodialysis therapy. Fluid resuscitations are performed
on her with infusions of crystalloid packed cells and colloids. Infusions of Dobutamine and
Noradrenaline are commenced. A pulmonary artery catheter is inserted at 0400 hours for
hemodynamic monitoring. Her initial blood glucose level is 12.1
According to Kakajiwala et al. (2016), it is effective to prevent the kidney problems by
providing the patient with lots of fluid and salts or bicarbonates. The alternative therapy could be
the Continuous Veno-Venous Hemofiltration (CVVH) is the short-term treatment for the patients
in ICU. It is the therapy used when the patient is unable to tolerate the haemodialysis or is having
the low blood pressure (Liu et al. 2016). McLaughlin et al. (2017) argued on the basis of the

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retrospective review that CVVH is not effective in reducing mortality or the length of stay in
hospital when compared to the CVVHD. Evidences from other studies showed that when
compared to CVVH, CVVHD is effective in terms of diffusion- based principle as it results in
greater solute removal.
According to Eyler et al. (2014) patients who have undergone the abdominal aortic
aneurysm and have been diagnosed with the complication of AKI is also susceptible to the also
susceptible to protein calorie malnutrition. In this patients, it is necessary to balance the protein
levels by administering a lot of fluids and proteins. Unlike the intermittent haemodialysis,
CVVHD addresses the need of the critically ill patients by helping with slow and continuous
removal of the toxins and fluids. In the intermittent method the patients fluid and protein intake
is limited between the treatments. This helps to prevent the toxic levels of nitrogen and fluid
overload. By removing the fluids continuously, the advantage is that the therapy mimics the
native kidney. Further, there is no build up of the protein and toxins the patients can receive as
much of them to get the optimal nutrition. In the current condition, Mrs Andrews is a critically ill
patient, she may not be able to tolerate the intermittent dialysis. The same is evident from the
prescription of fluid removal prescribed at at 100 mls/hr. It is commenced with 2 liter exchanges
and a blood flow rate at 200 mls/hr. She require large amount of fluid for various reasons. If
there is no hemodynamic compromise, the patient will not be able to tolerate the rapid fluid and
electrolyte shifts (RENAL Replacement Therapy Study Investigators 2009).

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Conclusion
In conclusion, the assignment has comprehensively discussed the, criteria in-patient that
is suggestive of AKI. The choice of therapy is critically analysed and is concluded that the
CVVHD is the appropriate therapy for Mrs. Andrews.

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References
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