Initial Management of Sepsis with Hyponatremia and Acute Kidney Injury

Initial Resuscitation and Hemodynamic Management

The American College of Critical Care Medicine recommends initiating immediate protocolized resuscitation with at least 30 mL/kg of isotonic crystalloids within the first 3 hours for sepsis-induced hypoperfusion, targeting mean arterial pressure (MAP) ≥65 mmHg using vasopressors if needed after initial fluid resuscitation, and monitoring urine output targeting ≥0.5 mL/kg/hr as part of resuscitation goals 1, 3, 4
The Society of Critical Care Medicine suggests using dynamic over static variables to predict fluid responsiveness when available, and considering further hemodynamic assessment if clinical examination does not lead to clear diagnosis 5

The American Journal of Kidney Diseases recommends avoiding nephrotoxic medications when possible, and not using diuretics to treat AKI except in the management of volume overload 2
The European Renal Association suggests considering renal replacement therapy (RRT) for management of fluid balance in hemodynamically unstable septic patients, severe metabolic acidosis, uremic complications, but not solely for increase in creatinine or oliguria without other definitive indications 1, 6

The Surviving Sepsis Campaign recommends implementing protocolized blood glucose management, starting insulin when two consecutive blood glucose levels are >180 mg/dL, targeting an upper limit of ≤180 mg/dL, and monitoring blood glucose every 1-2 hours until stable, then every 4 hours 1, 6
The American College of Critical Care Medicine suggests avoiding sodium bicarbonate therapy to improve hemodynamics or reduce vasopressor requirements if pH ≥7.15 1, 6

The American Journal of Kidney Diseases recommends providing 20-30 kcal/kg/day total energy intake in patients with AKI, avoiding protein restriction, and administering 0.8-1.0 g/kg/day in noncatabolic AKI patients without need for dialysis, and 1.0-1.5 g/kg/day in patients on RRT 2
The National Institute of Diabetes and Digestive and Kidney Diseases suggests providing nutrition preferentially via the enteral route 2

The American Journal of Kidney Diseases recommends using albumin for volume expansion in patients with liver disease and hyponatremia 2