>>Volume status. In most cases, these patients will be hypervolemic.
You’ll want to know by how much. This is tracked in the medical
record as ins and outs (i.e., I/O, or “Is and Os”). It’s conveyed in
liters and balanced against volume loss from urine output, blood
loss, etc. You’ll typically hear it reported as “the patient is 4. 5 L
positive.” Any patient presumably symptomatic from volume overload should be administered fluid only when absolutely necessary.
>>Baseline electrolytes and arterial blood gas. Although there’s no
evidence that clearly lays out any type of a schedule for how often
a patient’s electrolytes should be monitored while suffering from an
AKI, 10 I’m very cautious with an AKI patient who has any known
electrolyte derangements or issues with hemodynamic stability. Pay
close attention to electrolytes and blood gasses if there have been
any treatments to correct an imbalance, such as the administration
of calcium, bicarbonate, hypertonic saline, etc. For the purposes of
transport, a complete metabolic panel and an arterial blood gas should
be no less than eight hours old. If there’s been any gross changes in
hemodynamics, those test results should be no more than four hours
old—especially if the transport time is more than an hour.
>> Trends in pulmonary/cardiovascular status. Patients with a critical
illness that’s superimposed by an AKI can have a very tenuous course.
Their hemodynamic status can swing wildly from one hour to the
next. It’s imperative to know how the patient’s heart and lungs have
been responding to the illness at hand. This information will help
you be prepared for the future. If you’re told that a patient’s SpO2 was
100% eight hours ago, and it’s now 90% on 100% oxygen, there’s a
very high likelihood that this patient may continue to have problems
with oxygenation. The same is true of blood pressure and heart rate.
>> Previous treatments and response. The way a patient responded
to therapies previously will help you as you begin to formulate your
treatment plan. It’s important to know whether dialysis was sat-tempted. For instance, it’s not uncommon to hear that a patient is
being transferred for CRRT. It’s important to note that the referring facility tried traditional RRT twice already, but the patient
became too hemodynamically unstable several hours into or after
the treatment. This is likely due to the delayed fluid shift that happens from the removal of solutes. Don’t let these little details slip
past you; they’re especially important if the last RRT attempt was
several hours prior to your arrival.
Monitoring these patients during transport is fairly straightforward.
However, providers must pay close attention to trends in heart rate,
respiration, blood pressure and oxygenation status. Any trends that
suggest hemodynamic instability need to be immediately appreciated,
and a plan for how to correct for these issues should be formulated.
When confronted with the complexity and frailty of these patients,
most providers will quickly realize the limits of their expertise. Our physician colleagues should be contacted early and often in these instances.
Obtaining medical direction to help guide your therapies shouldn’t be a
last resort. Effective collaboration can mean life or death for these patients.
AKI poses a substantial risk to critically ill patients. The impact on mortality and morbidity is great, as is the resource-intense nature of the illness.
As healthcare begins to become more efficient, EMS providers need to
be adequately prepared to safely and expertly transport these critically
ill patients to the tertiary and quaternary care facilities they need. JEMS
Robert P. Girardeau, MSM-HCA, NRP, FP-C, is a manager and critical care/flight paramedic
with Jefferson Health’s critical care transport and flight program, JeffS TAT. He’s also an educator
and field provider in the greater Philadelphia area. He can be reached at firstname.lastname@example.org.
Learn more from Robert Girardeau at EMS Today: The JEMS Conference
& Exposition, February 21–23, in Charlotte, N.C. Visit EMSToday.com
for additional information.
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During transport of AKI patients, providers must pay close attention trends in
heart rate, blood pressure and oxygenation status. Photo A.J. Heightman