A 68-year-old man became acutely breathless following admission with a 2-
week history of nausea, vomiting and diarrhoea. Despite fluid resuscitation, he
had remained anuric 6 hours after admission.
On examination, his blood pressure was 104/63 mmHg, his jugular venous
pressure was 10 cm above the sternal angle and his respiratory rate was 32
breaths per minute. He had bibasal respiratory crackles and pitting oedema in
serum sodium 138 mmol/L (137–144)
serum potassium 5.6 mmol/L (3.5–4.9)
serum bicarbonate 12 mmol/L (20–28)
serum urea 29.0 mmol/L (2.5–7.0)
serum creatinine 640 µmol/L (60–110)
What is the most appropriate next step in management?
A: dopamine at renal dose
D: insulin and glucose 5%
E: sodium bicarbonate
Correct answer: C
Haemodialysis is the right answer as he is already fluid overloaded. Furosemide
will not work in this situation to cause a diuresis, and the other options are not
feasible or have no therapeutic value given his pulmonary oedema.