Best Case Ever 59 Management of Acute Renal Failure with Volume Overload

Sometimes our renal failure patients present short of breath with volume overload and we don’t have immediate access to dialysis. What then? Dr. Mike Betzner, EM doc and medical director of STARS air ambulance service and collaborator on EM Cases CritCases blog tells his Best Case Ever and his approach to this challenging clinical situation. He offers two commonly used solutions: nitroglycerin and BiPAP as well as two not so common solutions: phlebotomy and rotating BP cuffs blown to above SBP…


Podcast  production, sound design and editing by Anton Helman, June 2017

Four considerations in management of acute renal failure with volume overload




Rotating BP cuffs q20-30mins blown to above systolic (with ketamine or fentanyl for pain control)


Drs. Helman and Betzner have no conflicts of interest to declare

Sign up for our Newsletter 

About the Author:

Dr. Anton Helman is an Emergency Physician at North York General in Toronto. He is an Assistant Professor at the University of Toronto, Division of Emergency Medicine and the Education Innovation Lead at the Schwartz-Reisman Emergency Medicine Instititute. He is the founder, editor-in-chief and host of Emergency Medicine Cases.


  1. Peter Bonadonna June 30, 2017 at 1:38 pm - Reply

    I’m curious why you would inflate the blood pressure cuff’s over systolic. I started my career in the late 70s when we routinely used rotating tourniquets for pulmonary edema and we always set the pressure to diastolic so that blood would be pumped into the extremity but wouldn’t leave there by reducing circulating volume. By pumping blood pressure cuffs above systolic it wouldn’t allow for the vascular beds in the extremities to expand to take the extra blood. In addition, complete vascular closure would burden the heart. With the older technique, blood flow still filled the extremities and pain was uncommon even if we set the machine to rotate in 30 minutes. (Yes we had machines that did this). What is the new rationale?

    • Anton Helman July 4, 2017 at 3:40 pm - Reply

      Great point Peter. Your argument sounds very sound to me and Dr. Betzner. He used SBP which seemed to work, but if we are in this situation again we will take your advice and use DBP. Thanks for commenting.

  2. skhan July 4, 2017 at 6:22 pm - Reply

    Dr. Helman,

    Great case, Is there a cut off HB that you would not do the plebotomy? I was thinking 80-90? Any advice? And is 250ml the highest that you would normally remove?

  3. Hamish July 4, 2017 at 7:56 pm - Reply

    Loved this podcast. As a rural Doc in Australia, I often use GTN patches, as with only 1 nurse its hard to set up and manage GTN infusions. This is the first time I have come across it being mentioned by a retrieval Dr. Whenever I speak to retrieval doctors in Australia, they just look at you like you are crazy and say , you should use an infusion…

Leave A Comment