A 74-year-old woman is brought to the emergency department with fever, chills, and shortness of breath. Two days ago, she choked while having tea and doughnuts and almost lost consciousness. Her son performed the Heimlich maneuver. The patient has advanced Alzheimer dementia, and her son is her health care proxy and primary caregiver; her 73-year-old husband also participates in her care. Her other medical problems include hypertension, hyperlipidemia, coronary heart disease, ischemic stroke with mild residual right hemiparesis, history of heme-positive stools, and urine incontinence. She is allergic to penicillin (anaphylaxis) . Her temperature is 38.9 C (102 F) , blood pressure is 120/80 mm Hg, pulse is 92/min, and respirations are 24/min. Pulse oxymetry shows 89% on room air and 94% on 40% facemask oxygen. Auscultation of the chest shows crackles at the right lung base. The heart sounds are regular. There is no jugular venous distension. The abdomen is soft, nontender, and nondistended. There is no peripheral edema. Laboratory results are as follows: A portable chest x-ray shows a right lower-lobe infiltrate.
During the last 4 days of hospitalization, the patient has received 6 L of 0.9% saline. Her urine output has been 400 mL in the last 24 hours. She has been afebrile for the past 2 days. Her blood cultures are negative, and her urine culture grew budding yeast. The patient is currently receiving 150 mL/hr of 0.9% saline, nasogastric tube feedings, and antibiotics. Her temperature is 36.7 C (98 F) , blood pressure is 140/70 mm Hg, pulse is 82/min, respirations are 18/min, and oxygen saturation is 96% on 2 L O₂ by nasal cannula. Her mucous membranes are moist. The lungs still have crackles at the right base. There is no pericardial rub, peripheral edema, or asterixis. The results of her recent basic metabolic panel are as follows:
An ECG shows no abnormal intervals and no peaked T waves.
What is the most appropriate course of action at this time?

Question

A 74-year-old woman is brought to the emergency department with fever, chills, and shortness of breath. Two days ago, she choked while having tea and doughnuts and almost lost consciousness. Her son performed the Heimlich maneuver. The patient has advanced Alzheimer dementia, and her son is her health care proxy and primary caregiver; her 73-year-old husband also participates in her care. Her other medical problems include hypertension, hyperlipidemia, coronary heart disease, ischemic stroke with mild residual right hemiparesis, history of heme-positive stools, and urine incontinence. She is allergic to penicillin (anaphylaxis) . Her temperature is 38.9 C (102 F) , blood pressure is 120/80 mm Hg, pulse is 92/min, and respirations are 24/min. Pulse oxymetry shows 89% on room air and 94% on 40% facemask oxygen. Auscultation of the chest shows crackles at the right lung base. The heart sounds are regular. There is no jugular venous distension. The abdomen is soft, nontender, and nondistended. There is no peripheral edema. Laboratory results are as follows:

A portable chest x-ray shows a right lower-lobe infiltrate.
During the last 4 days of hospitalization, the patient has received 6 L of 0.9% saline. Her urine output has been 400 mL in the last 24 hours. She has been afebrile for the past 2 days. Her blood cultures are negative, and her urine culture grew budding yeast. The patient is currently receiving 150 mL/hr of 0.9% saline, nasogastric tube feedings, and antibiotics. Her temperature is 36.7 C (98 F) , blood pressure is 140/70 mm Hg, pulse is 82/min, respirations are 18/min, and oxygen saturation is 96% on 2 L O₂ by nasal cannula. Her mucous membranes are moist. The lungs still have crackles at the right base. There is no pericardial rub, peripheral edema, or asterixis. The results of her recent basic metabolic panel are as follows:

An ECG shows no abnormal intervals and no peaked T waves.
What is the most appropriate course of action at this time?

Quizplus · Accepted Answer

Explanation: Although the patient seems to be improving clinically, she continues to be oliguric despite intravenous fluids. Her physical examination findings do not indicate hypovolemia, and she has no ongoing volume losses. Therefore, there is no indication for volume expansion with intravenous saline. Excess saline infusion can worsen her clinical status by causing volume overload (pulmonary edema) and hyperchloremic non-anion gap metabolic acidosis (in addition to her existing anion gap acidosis from her kidney failure). Her tube feeds should compensate for daily obligatory fluid losses. In a patient with acute kidney injury (AKI), the goals of care include maintaining adequate renal perfusion (intravenous saline or vasopressors), avoiding nephrotoxic agents, and close monitoring of volume status and any acid-base and electrolyte disturbances. (Choice A) In some patients with AKI, dialysis is indicated for intractable hyperkalemia, hypervolemia, severe metabolic acidosis (eg, pH <7.1), and marked uremic symptoms. This patient might require dialysis if her acidosis worsens, or if she develops significant hyperkalemia or progressive volume overload. She has none of these urgent indications at this time, and it is possible she may soon recover from AKI as her volume status (and renal perfusion) is adequate and her sepsis has resolved. (Choice B) Loop diuretics may improve urine output in a patient with AKI; however, they do not hasten recovery of renal function. A trial of loop diuretics is generally indicated if there is evidence of fluid overload (such as pulmonary edema). The doses required to achieve diuresis in AKI are usually high. (Choice C) Patients with indwelling urinary catheters may grow Candida on urine culture, but they do not require treatment with antifungals unless there is evidence of a systemic infection or tissue invasion. (Choice E) Intravenous colloids (albumin) can expand intravascular volume. Clinical trials have demonstrated no clinical or survival benefit of colloids over crystalloids. Intravenous albumin is used for volume expansion in cirrhotic patients with hepatorenal syndrome or spontaneous bacterial peritonitis, as they are at risk for third spacing of fluid. Educational objective: Fluid overload can occur in patients who are oliguric or anuric. Indications for dialysis include uremia, intractable hyperkalemia, hypervolemia, and metabolic acidosis. References: Fluid management in adults and children: core curriculum 2014. (http://www.ncbi.nlm.nih.gov/pubmed/24332766) Bicarbonate therapy in severe metabolic acidosis. (http://www.ncbi.nlm.nih.gov/pubmed/18322160)

A 74-Year-Old Woman Is Brought to the Emergency Department with Fever