What Role Did Nephrologists Play in The Earthquake Relief?

In the past month, there have been frequent earthquakes around the world. On February 6, a magnitude 7.8 earthquake occurred in Turkey, on February 14, a magnitude 4.3 earthquake occurred in Mangya City, Qinghai Province, China, and a magnitude 3.6 earthquake occurred in East Wuzhumuqin Banner, Inner Mongolia1. In these earthquake disasters, nephrologists are inseparable from rescue teams and rear support hospitals. So what kind of important role did nephrologists play in earthquake relief?

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By searching Chinese and English literature, it was found that during earthquakes, patients with crush syndrome often appear, and nephrologists are required to prevent and treat acute kidney injury (AKI). In addition, for patients with chronic kidney disease (CKD) or end-stage kidney disease (ESKD) who require dialysis, nephrologists are needed to help manage the transition phase, giving necessary emergency dialysis support2-4.

patient with crush syndrome

01 Etiology and mechanism

An earthquake is a powerful natural disaster that can cause houses to collapse. Some victims will be squeezed by heavy objects for a long time or forced to fix in a certain position for a long time, which will cause ischemic necrosis of muscle tissue, swelling, numbness, or paralysis of the compressed part. After being rescued (no longer being oppressed), due to muscle ischemic necrosis or ischemia-reperfusion injury, muscle edema, increased volume, prone to rhabdomyolysis, and exudation of macromolecular plasma proteins, the pressure in the fascial compartment increases significantly, and compress blood vessels, resulting in muscle hypoxia 2.

Muscles can be regarded as the "water reservoir" and "potassium reservoir" of the human body. When the compression is relieved, myoglobin, potassium, magnesium, acidic metabolites, vasoactive substances, and tissue toxins in the muscle tissue will be released into the circulating blood, causing a series of systemic reactions. Clinical manifestations include hypotension, shock, hyperkalemia, acidosis, etc., and acute kidney injury (AKI) may also occur2-4.

02 Prevention of AKI

The main cause of casualties in earthquakes is severe trauma or suffocation, but crush syndrome is an important cause of death for those rescued. Timely diagnosis of crush syndrome and prevention of AKI are important methods to reduce the mortality of rescued persons. The diagnosis of rhabdomyolysis may be missed, especially in the early stage of muscle reperfusion, and clinical symptoms such as muscle pain, swelling, and tenderness may not be obvious. However, timely fluid rehydration at this time is an important means to prevent AKI. Of note, the clinical diagnosis of rhabdomyolysis is based on laboratory testing, which may not be readily available after the earthquake. Therefore, all personnel involved in the rescue, especially the medical staff, should pay attention to the above clinical symptoms of the patient and provide fluid infusion in time. Moreover, if the patient is not fully rescued (for example, half-buried), he can still receive fluid infusion therapy3-4.

The specific precautions for AKI prevention and fluid rehydration are as follows 9 3-4:

① If laboratory test results cannot be used to confirm the diagnosis, the daily fluid volume should be between 3 and 6 L;

②Ambient temperature needs to be considered. If the ambient temperature is low, the amount of rehydration will be less;

③Isotonic solution is the first choice for supplementary liquid, and does not contain potassium salt;

④ The time of burial should be considered. For patients who have been buried for a long time, more fluid can be added. However, for patients who have been buried for several days, it is necessary to determine whether AKI, anuria, and blood volume are too high. Taking the Marmara earthquake in Turkey (1999) as an example, many patients required dialysis after receiving fluid replacement because patients had already developed AKI and had high blood volume when receiving fluid replacement;

⑤ Rescue time needs to be considered, the rescue time for the trapped wounded ranges from a few minutes to several hours. If the patient needs to be rescued for a long time, rehydration should be started while the patient is still buried in the rubble. In this case, the optimal initial rehydration rate is 1000ml/h, which should be reduced to less than 50% of the initial rehydration rate after 2 hours;

⑥ It is necessary to consider the individual situation of the patient, such as the elderly, children, lightweight or minimally invasive patients, the amount of fluid replacement should be reduced;

⑦ Patients with hypotension, hemorrhage, and urine should receive more fluids, while patients with anuria and hypertension should receive fewer fluids;

⑧ Arterial tourniquet should only be used when the patient's life is in danger, and arterial tourniquet cannot prevent AKI or crush syndrome;

⑨Fasciotomy can prevent AKI, but compared with AKI, the complications of fasciotomy are also more difficult, so only based on clear clinical indications (such as limbs cannot be salvaged) or cardiovascular examination results, to perform fasciotomy.

03 Dialysis

Compared with AKI caused by other causes, crush syndrome is more prone to complications such as acidosis, hyperkalemia, and hypervolemia, so patients need more urgent initiation of dialysis. Studies have shown that the mortality rate of patients with traumatic AKI is higher than that of patients with non-traumatic AKI, which needs to be paid attention to by doctors. Patients with crush syndrome should undergo at least one or more dialysis sessions per day to control serum potassium. Nephrologists should especially consider which patients should receive dialysis and the appropriate single dialysis time (which may be lower than the ideal dialysis time) in the case of limited post-earthquake dialysis conditions2-4.

Currently, most patients with post-earthquake crush syndrome receive intermittent hemodialysis as the mode of dialysis, and fewer patients receive peritoneal dialysis and continuous hemodialysis. Intermittent hemodialysis offers medical and logistical advantages. If able to treat multiple patients on one dialysis machine, receive anticoagulation therapy minimally. In addition, the water supply may not be guaranteed after the earthquake, so the dialysis team may need to contact the government, fire protection, and other departments to obtain suitable dialysis water supply3-4.

Finally, the timing of cessation of dialysis is related to the patient's condition, such as serum myoglobin and creatine kinase levels returning to normal; water-electrolyte and acid-base balance disorders being corrected; urine output > 1500ml/d3-4.

2. Survivors requiring continuous dialysis

Major natural disasters are a huge challenge for survivors who need continuous dialysis. Whether it is an earthquake or a hurricane, they may damage dialysis equipment and dialysis centers, making it impossible for survivors to complete dialysis on time and in volume.

Usually, these survivors who need continuous dialysis will be transferred to other cities or dialysis centers for dialysis treatment, but there may be some days without dialysis or less dialysis during the transfer process. They should be managed by a nephrologist and, if necessary, diet restriction and potassium-lowering drugs such as potassium-lowering resins should be administered. At this time, if the telematics service is available, nephrologists in the receiving unit can also be involved in the diet and drug management of these patients. However, in most cases, communication interruption is a common condition in large-scale natural disasters, so the medical team involved in disaster relief needs to be equipped with nephrologists3-4.

The transfer of dialysis patients can place enormous pressure on receiving facilities, for example, after Hurricane Katrin, Los Angeles received 1,000 dialysis patients and New Orleans received 700 patients. This is a huge challenge for some dialysis centers and institutions. Therefore, the medical team needs to have good docking with the dialysis center before transferring the dialysis patients to avoid confusion3-4.

Finally, residents in earthquake zones and areas prone to other natural disasters should receive relevant rescue training, because many initial rescue actions were carried out spontaneously by residents without professional rescue teams involved. Failure to receive relevant rescue training is likely to delay the optimal treatment of crush syndrome, resulting in the death of survivors4.

In summary, nephrologists play an essential role in earthquake relief and other natural disasters and are closely related to survivors of crush syndrome and those who require continuous dialysis. Nephrologists can help crush syndrome patients and Survivors requiring continuous dialysis have increased odds of survival and reduced risk of long-term mortality. This is the main reason why nephrologists can always be seen in earthquake relief work.

for more information: Ali.ma@wecistanche.com