Dialysis in a Disaster Setting?
By Amesh A. Adalja, MD, April 15, 2011
During the response to the 2010 earthquake in Haiti, many patients were trapped under rubble for several days. The ensuing crush injury and development of myoglobinuria precipitated acute renal failure in a subset of patients. As the experience in Haiti demonstrates, without access to dialysis, injured patients who might otherwise be able to survive may die from renal failure and hyperkalemia.
The Israel Defense Force Medical Corps recently published a report of their experience with crush injury in their field hospital during the aftermath of the Haiti earthquake. Dialysis was not available for the first 10 days after the earthquake.
Crush Injuries in 11% of Field Hospital Patients
Of the 1,111 patients seen at the Israeli field hospital, 126 (11%) had sustained a crush injury. During the first 3 days of operation, 8 patients developed oligoanuric renal failure. A full report of their clinical course can be found in the paper by Bartal and colleagues; salient features include the following:
Most patients had limb involvement
Average time under rubble was 31 hours
All patients had creatinine levels greater than 7 mg/dL and BUN levels greater than 200 mg/dL
Creatinine phosphokinase levels ranged from 6,500 to 15,000 U/L
Potassium levels ranged from 6.2 to 8.5 mEq/L
Conservative Treatment as First Line Therapy
In the absence of dialysis, conservative therapy was initiated on all patients. Interventions included volume resuscitation with normal saline, intravenous bicarbonate administration, and high dose furosemide treatment. Hyperkalemia was treated with calcium, insulin/glucose, and albuterol. All patients received antimicrobial treatment.
Three patients developed compartment syndrome requiring fasciotomy, and 2 patients underwent amputation.
If no therapeutic response was evident by 48 hours, the patients were transferred to a local hospital for supportive care. Of the 8 patients reported, 2 recovered within 48 hours. Of those who did not improve, 4 died, and 2 were transferred to a local hospital for palliation.
Proposed Treatment Algorithm
Drawing on their experience, the authors propose a 3-phase algorithm for management of crush injury- associated acute renal failure in similar scenarios:
Phase I (0-24 hours): 5-7 L of normal saline infusion, intravenous sodium bicarbonate infusions, hyperkalemia treatment, and antimicrobial treatment. This treatment would be coupled with any required surgical interventions (ie, amputation, fasciotomy)
Phase II (24-48 hours): High dose furosemide continuous infusion (120-240 mg/24 hours)
Phase III (>48 hours): Renal replacement therapy (peritoneal dialysis or hemodialysis)
Is Dialysis Feasible in Disaster Settings?
While it may not be appropriate in a disaster setting to provide dialysis to patients with end stage renal disease in chronic need of dialysis, the use of delimited dialysis for acute renal failure secondary to crush injury is a separate consideration.
In normal circumstances, dialysis is performed in strictly aseptic and sanitary conditions that cannot be replicated in a disaster field hospital. Hemodialysis would also be constrained by a possible lack of running water, although portable hemodialysis machines exist. In such austere settings, peritoneal dialysis may be a possible alternative, as was the case after an earthquake in Turkey in 1999. However, both forms of dialysis would render patients prone to infectious complications.
Despite these caveats, studying and testing the feasibility and effectiveness of both peritoneal dialysis and hemodialysis (using portable dialysis machines) in disaster settings is warranted. Additionally, inclusion of more nephrologists in disaster planning and on disaster medical teams would augment implementation of this potentially life-saving intervention.
Modern disaster planning, in order to have the biggest impact, should be informed by research from past disasters. The Israeli experience with acute renal failure in earthquake victims in Haiti is an example of real-time research that has the potential to influence policy decisions regarding medical management of victims of crush injury after a disaster.
Bartal C, Zeller L, Miskin I, et al. Crush syndrome: saving more lives in disasters. Arch Int Med 2011; 171:694-696.