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Nephrology

Subject:

Guidelines for the Management of Pulmonary Oedema in Patients


with Kidney Failure. 2nd Edition

Objective:

To standardize and improve the management of pulmonary oedema


in patients with kidney failure. For trust-wide use after discussion with
on call nephrology team

Prepared by:

Dr Craig Gradden, Consultant Nephrologist Contact: ext. 8797

Consultation:

None

Approved by:

Clinical Standards Group, July 2010

Evidence Base:

Rank: B

Original Issue Date:


Date of Issue:

Sept 2005
August 2010

Review Date: August 2013

Introduction/Background
Pulmonary oedema is a life-threatening condition that can be particularly difficult to
manage in patients who have co-existing kidney failure. Failure to identify and manage
such patients appropriately and in a timely fashion can and will increase the risk to the
patient, including the risk of death.
Management of patients with cardiogenic pulmonary oedema without renal/kidney failure
does not fall under the guidance of this document.
ONLY IF A PATIENT HAS RENAL FAILURE (AS DEMONSTRATED BY SERUM UREA
AND CREATININE LEVELS) AND HAS SEVERE FLUID OVERLOAD OR PULMONARY
OEDEMA SHOULD THIS GUIDELINE BE FOLLOWED

Renal Pulmonary Oedema Guidelines


Valid from: Aug 10 to Aug 13
Intranet location: Clinical Subjects-Nephrology

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GuidelinesfortheManagementofPulmonaryOedemainPatientswith
KidneyFailure
Patient has Renal Failure and evidence of
significant fluid overload and/or pulmonary oedema

Stop all iv fluids, restrict oral fluid intake, nurse in upright position, administer
100 % oxygen, use oxygen saturation monitor, monitor hourly urine output
Contact the on-call Nephrology Consultant
for advice, and consider discussing with
Intensive Care.
[100%O2, CPAP (if available), IV nitrate
infusion, IV diamorph or morphine and
loop diuretics (due to venodilatory effects)
can buy some time, but the definitive
treatment is usually dialysis]

YES
Patient is anuric and/or in respiratory

distress and/or is a known dialysis patient?

NO
Patient previously on loop diuretics?
YES
NO

Give iv furosemide 100mg. Double dose every 60


minutes to a maximum of 400mg as per clinical
response and as allowed by cardiovascular status

Give iv furosemide 40mg. Double dose


every 60 minutes to a maximum of 320mg
as per clinical response and as allowed by
cardiovascular status

Patient responds to treatment: (reduced shortness of breath, and diuresis >30ml/hr)?


YES
Discuss case with Medical SpR and/or
Nephrologist on-call to establish most
appropriate ward for ongoing care

NO
1. Give iv nitrates (isoket 0.05% starting at
1ml/hr) if cardiovascular status allows
(avoid if systolic BP<100mmHg, and/or
HR>120/min)
2. If BP>100mmHg, then give iv diamorphine
or morphine

Patient responds to treatment: (reduced shortness of breath, and diuresis >30ml/hr)?


YES

NO

1. Review hourly to consider further iv diuretics.


2. Discuss case with Medical SpR and/or Nephrologist oncall to establish most appropriate ward for ongoing care

Contact on-call Nephrology


Consultant and/or Intensive Care
for further advice

Beware of ototoxicity with rapid infusions of large doses of loop diuretics: give at
a maximum rate recommended in BNF (4mg/min for furosemide)
Renal Pulmonary Oedema Guidelines
Valid from: Aug 10 to Aug 13
Intranet location: Clinical Subjects-Nephrology

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Duties and responsibilities


The attending doctor must either implement the management plan themselves and review
the patient regularly (at least every 15 minutes for the first hour), or ensure that the
appropriate handover has taken place to provide safe continuity of care for the patient.
The attending doctor must ensure that the nursing staff are aware of the management
plan, and any trigger factors that they must make someone aware of (e.g. what level of
blood pressure should be a cause of concern for any specific patient).
The attending doctor should seek advice from the Medical SpR on-call, who in turn should
consider discussing the case with the on-call Consultant Nephrologist. The attending
doctor may contact the on-call Consultant Nephrologist directly if they are unable to
contact the SpR. All anuric patients with renal failure must be discussed with the
Consultant Nephrologist on-call.
The Nursing staff must ensure that they are aware of the management plan for the patient,
frequency of relevant observations, and escalation plan for management.

Monitoring effectiveness
Episodes of pulmonary oedema/severe fluid overload are inevitable in some patients with
Acute Kidney Injury. This guideline will not prevent such episodes, but should facilitate
timely management of such episodes.
Annual audits of the management of AKI will be undertaken as part of the response to the
NCEPOD report on AKI. We will include in these audits the details of the acute
management of the fluid balance in patients with Renal Failure.

References
Rose D. Diuretics. Kidney Int 1991;39:336
Brater DC. et al. Use of diuretics in patients with renal disease. Contemporary issues in
Nephrology. Phamacotherapy of Renal Disease and Hypertension and Hypertension, vol
17, Bennett WM, McCarron DA (eds), Churchill Livingstone, New York 1987
Agostoni P. et al. Sustained improvement in functional capacity after removal of body fluid
with isolated ultrafiltration in chronic cardiac insufficiency: failure of furosemide to provide
the same result. Am J Med 1994;96:191

Renal Pulmonary Oedema Guidelines


Valid from: Aug 10 to Aug 13
Intranet location: Clinical Subjects-Nephrology

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