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Renal Pulmonary Oedema Guidelines Page 1 of 3Valid from: Aug 10
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Subject: Guidelines for the Management of Pulmonary Oedema in
Patientswith Kidney Failure. 2ndEdition
Objective: To standardize and improve the management of
pulmonary oedema
in patients with kidney failure. For trust-wide use after
discussion withon 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: Sept 2005Date of Issue: August 2010
Review Date:August 2013
Introduction/Background
Pulmonary oedema is a life-threatening condition that can be
particularly difficult tomanage in patients who have co-existing
kidney failure. Failure to identify and managesuch patients
appropriately and in a timely fashion can and will increase the
risk to thepatient, including the risk of death.
Management of patients with cardiogenic pulmonary oedema without
renal/kidney failuredoes not fall under the guidance of this
document.
ONLY IF A PATIENT HAS RENAL FAILURE (AS DEMONSTRATED BY SERUM
UREAAND CREATININE LEVELS) AND HAS SEVERE FLUID OVERLOAD OR
PULMONARY
OEDEMA SHOULD THIS GUIDELINE BE FOLLOWED
Nephrology
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GuidelinesfortheManagementofPulmonaryOedemainPatientswith
Kidney
Failure
YES
NO
YES NO
YES NO
YES NO
Patient has Renal Failure and evidence ofsignificant fluid
overload and/or pulmonary oedema
Stop all iv fluids, restrict oral fluid intake, nurse in upright
position, administer100 % oxygen, use oxygen saturation monitor,
monitor hourly urine output
Patient is anuric and/or in respiratorydistress and/or is a
known dialysis patient?
Contact the on-call Nephrology Consultantfor advice, and
consider discussing with
Intensive Care.[100%O2, CPAP (if available), IV nitrateinfusion,
IV diamorph or morphine and
loop diuretics (due to venodilatory effects)can buy some time,
but the definitive
treatment is usually dialysis]Patient previously on loop
diuretics?
Patient responds to treatment: (reduced shortness of breath, and
diuresis >30ml/hr)?
Give iv furosemide 100mg. Double dose every 60minutes to a
maximum of 400mg as per clinical
response and as allowed by cardiovascular status
Give iv furosemide 40mg. Double doseevery 60 minutes to a
maximum of 320mgas per clinical response and as allowed by
cardiovascular status
Discuss case with Medical SpR and/or
Nephrologist on-call to establish mostappropriate ward for
ongoing care
1. Review hourly to consider further iv diuretics.
2. Discuss case with Medical SpR and/or Nephrologist on-call to
establish most appropriate ward for ongoing care
1. Give iv nitrates (isoket 0.05% starting at
1ml/hr) if cardiovascular status allows(avoid if systolic
BP120/min)
2. If BP>100mmHg, then give iv diamorphineor morphine
Patient responds to treatment: (reduced shortness of breath, and
diuresis >30ml/hr)?
Contact on-call NephrologyConsultant and/or Intensive Care
for further advice
Beware of ototoxicity with rapid infusions of large doses of
loop diuretics: give ata maximum rate recommended in BNF (4mg/min
for furosemide)
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Duties and responsibilities
The attending doctor must either implement the management plan
themselves and reviewthe patient regularly (at least every 15
minutes for the first hour), or ensure that theappropriate 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 managementplan, 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 shouldconsider discussing the case with the
on-call Consultant Nephrologist. The attendingdoctor may contact
the on-call Consultant Nephrologist directly if they are unable
tocontact the SpR. All anuric patients with renal failure must be
discussed with theConsultant 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 withAcute Kidney Injury. This guideline
will not prevent such episodes, but should facilitatetimely
management of such episodes.
Annual audits of the management of AKI will be undertaken as
part of the response to theNCEPOD report on AKI. We will include in
these audits the details of the acutemanagement 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 inNephrology. Phamacotherapy of Renal
Disease and Hypertension and Hypertension, vol17, Bennett WM,
McCarron DA (eds), Churchill Livingstone, New York 1987
Agostoni P. et al. Sustained improvement in functional capacity
after removal of body fluidwith isolated ultrafiltration in chronic
cardiac insufficiency: failure of furosemide to providethe same
result. Am J Med 1994;96:191
