Hyperkalemia and Dialysis in the Deployed Setting

Abstract

Acute kidney injury is a recognized complication of combat trauma. The complications associated with acute kidney injury, such as life-threatening hyperkalemia, are usually delayed in onset. In the recent conflicts, rapid evacuation of U.S. and coalition personnel generally resulted in these complications occurring at higher echelons of care where renal replacement therapies were available. In the future however, deployed providers may not have this luxury and should be prepared to temporize patients while they await transport. In this clinical practice guideline, recommendations are made for the management of patients with, or at risk for, acute kidney injury and hyperkalemia in the austere, deployed environment.

US Navy Ship-Based Disaster Response: Lessons Learned

“…Field hospitals and austere role 1 and role 2 platforms should attempt to prevent pre-renal acute kidney injury with appropriate blood based or isotonic intravenous (IV) crystalloid resuscitation as indicated. Solutions containing potassium such as Lactated Ringers should be avoided particularly if giving prophylactic crystalloid without knowing blood electrolyte data [ 21 , 29 , 30 ]. Patients should be monitored for the development of compartment syndrome, and prompt surgical treatment initiated when identified.…”

“…The Joint Trauma System, “Hyperkalemia and Dialysis in the Deployed Setting” clinical practice guideline describes the indications for acute PD in austere deployed environments, the repurposing supplies for PD catheter use and creating field-expedient PD fluids from both Normal Saline and Lactate Ringers. [ 21 ] Often, the length of disaster relief missions can be unpredictable, being prepared to provide PD may be necessary. Surgeons providing disaster relief are integral to the provision of PD and should be prepared for this contingency depending on the platform and mission.…”

“…The USNS Comfort internal medicine and critical care team had to stretch their dialysis capabilities for the influx of crush injuries with renal failure that presented during phase 1 and phase 2. The team prioritized dialysis for patients with oliguric renal failure and stabilized hyperkalemia using bicarbonate-based intravenous fluids and standard medical management [ 20 , 21 ]. Due to a limited supply of dual-lumen catheters, 2 separate central venous sheaths were used for the inflow and outflow, respectively [ 20 ].…”

K+ontrol rapidly and efficiently reduces potassium in donor blood during ex vivo circulation

“…3 These therapies have also been used in combat conditions since the Korean War 12 and, most recently, during Operation Iraqi Freedom and Operation Enduring Freedom. 12 However, specialized expertise and a significant amount of dialysate and replacement fluid (1-3 L/h, 20-40 L/day) [13][14][15] are required, which may not be available in a remote or austere environment outside of a hospital or dialysis center. 16 These logistical challenges limit HD and CKRT to specialized Military Treatment Facilities.…”