Acute Kidney Injury When Vasopressors and Fluids Fail to Restore Haemodynamic and Renal Targets
Clinical scenario
This protocol addresses acute kidney injury in the context of vasomotor shock where vasopressors, given alongside continued fluid resuscitation, have not been sufficient to achieve the required haemodynamic and renal recovery benchmarks within the expected window.
Previous treatment — targets not achieved
The prior step — adding vasopressors in conjunction with continued fluids — did not meet the following goals:
- Mean arterial pressure returned to at least 65 mm Hg
- Central venous pressure 8–12 mm Hg
- Central venous oxygen saturation at least 70%
- Urine output at least 0.5 ml/kg/h within 6 hours
Non-achievement of these targets is the clinical trigger for escalation to this next-line protocol.
Next-line approach (partial overview)
The structured next step centres on initiating renal replacement therapy (RRT), with the anticoagulation strategy during RRT determined by individual patient factors — the full modality-specific algorithm is available in the complete protocol.
References
DOI: 10.1159/000339789
- Initiate RRT emergently when life-threatening changes in fluid, electrolyte, and acid-base balance exist.
- We recommend using anticoagulation during RRT in AKI if a patient does not have an increased bleeding risk or impaired coagulation and is not already receiving systemic anticoagulation.
- For anticoagulation in intermittent RRT, we recommend using either unfractionated or low-molecular-weight heparin, rather than other anticoagulants.
- For anticoagulation in CRRT, we suggest using regional citrate anticoagulation rather than heparin in patients who do not have contraindications for citrate.
View source ↗