vasodilator effects. There is little and inconsistent data supporting the use
dopamine in infants and children. [31] A recent meta-analysis including 17
randomized clinical trials indicated that low dose dopamine did not prevent
mortality, onset of ARF or need for dialysis. [29]
Holmes et al demonstrated that the effects of low dopamine in the critically ill
patient have deleterious effects in the GI, endocrine, immunologic and respiratory
systems and its use is no longer justified in ARF. [32]
- Adequate oxygenation
Adequate oxygen supplementation helps minimize the effects of organ
hypoperfusion, including the kidney. High metabolic demands of the renal
medulla, which is by nature a poorly perfused zone, are only met with high
oxygen supply to prevent hypoxic injury (oxygen extraction of renal medulla
approaches 90%).
- Correction of hyperkalemia
Hyperkalemia (K >4.7 mEq/L in children) is the result of decreased
excretion of potassium in the distal and collecting cortical tubules, mostly
under the influence of aldosterone and kinases.
Elevation of K leads to muscle weakness, respiratory failure, and cardiac
conduction abnormalities such as bradycardia, ventricular fibrillation and
asystole. Classic electrocardiographic signs include peaked T waves, ST
depression, loss of P wave and widening of the QRS.
Once identified, parenteral potassium must be stopped and extracellular
potassium should be forced into the intracellular compartment with glucose
and insulin infusions. Glucose loading at a rate of 0.5 g/kg/h in children is
enough since these have an increased endogenous insulin production in
response to glucose. Insulin at a rate 0.05 u/kg/h should be added if blood
glucose levels reach 10 mmol/l. [35]