Transcript Slide 1

Acute Kidney Injury
at Dorset County Hospital renal unit
Prospective audit October 2011-October 2012
Dominic Taylor
ST4 Nephrology
Dorset County Hospital
NCEPOD: Adding insult to Injury (2009)
 Only 50% of AKI care considered good
 Poor assessment of risk factors
 Appropriate investigations (Ultrasound, urine
dip) not always performed
 Senior review within 12 hours recommended
 Renal referrals were delayed in 20%
 Timely, appropriate specialist advice and transfer
needed.
Dorset County Hospital Nephrology
service
 Large geographical area, population >850,000
 ‘Outreach’ service and clinics at YDH, RBH and PGH
Aims
 Assess adequacy of care from Nephrology and non-
Nephrology teams.
 Aim to implement guidelines to alter management and
continuous re-audit.
Inclusion criteria
 October 2011- October 2012
 Patients transferred to renal ward at DCH from other ward
or hospital, with a diagnosis of AKI.
 Electronic and written notes review.
Demographics
26 Male
51 patients
25 Female
18
16
Median age 72 years
12
Frequency
Mean age at presentation 68 years
(22-90)
14
10
8
6
4
2
0
20
30
40
50
60
70
Age at admission
80
90
Referrals
26(51%) from
within DCH
32(63%) from
medical teams
25 transferred
from other
hospitals
9(18%) surgical
10(20%) ITU
Referrer
DCH
YDH
RBH
PGH
Salis
TOTAL
medical
surgical
17
3
5
6
1
32
ITU
5
0
4
0
0
9
4
1
5
0
0
10
TOTAL
26
4
14
6
1
51
Length of stay
Mean Length of
stay 17 days
20
Mean LoS 7.5
days for medical
patients at DCH
18
18
15
16
Frequency
14
12
10
10
8
6
3
4
3
2
2
0
0
10
20
30
40
Total Length of Stay
50
60
Risk Factors
CKD
Angina
MI
CABG
Hypertension
DM1
DM2
PVD
Malignancy
0
10
20
30
40
Percentage of AKI patients audited
50
60
%
70
Aetiology
Pre-renal'
Renal'
Post-renal'
sepsis
D&V/GI upset
post-op
GI bleed
cardiorenal
Glomerulonephritis
Systemic disease
Iatrogenic
Ingestion
metabolic
‘Pre-renal'
14
4
3
1
1
ANCA vasc
Interstitial nephritis
other vasculitis
haemolysis/blackwater fever
Myeloma
Post angio/contrast
Vanc/Gent
ACEi toxicity
NSAIDS
Ethylene Glycol
Rhabdomyolysis
Hypercalcaemia
0
‘Renal'
7
2
1
1
3
2
2
2
2
1
4
1
RPF/malignancy
Retention
Calculus
10
20
‘Post-renal'
5
2
2
30
40
50
60
70
Referring team management
Electrolytes checked on admission
Urine dip on admission
Consultant review within 12 hours of admission?
Nephrotoxins stopped within 24 hours of renal
decline?
"Adequate" fluid resus
0
10
20
30
40
50
60
70
80
90
100
Timing of Imaging
2
33
<24 hours
46
24-48 hours
>48 hours
not at all
17
Referral and response
Renal referral within
24 hours of AKI?
%
69
Advice or
review within
24 hours of
referral?
100
Transfer to renal unit
within 48 hours of
referral?
72(85 excluding ITU on
support)
Outcomes
Dialysis
Death
34 received
haemodialysis
acutely
In-hospital death: 5
(10%)
11 of these
haemofiltered
on ITU
Death within 3
months: 10 (20%)
Baseline eGFR <60 significantly increased risk of
permanent RRT (χ2=0.00035)
7 (14%) needed
permanent
RRT (all HD)
Baseline eGFR <60 significantly increased risk of
death within 3 months (χ2= 0.0004)
Summary
 Acute on CRF most common cause of AKI with poorer





outcomes (death or long-term dialysis)
54% did not have renal tract imaging within 24 hours
20% patients did not have adequate fluid resuscitation
22% patients did not have nephrotoxic drugs discontinued
26% patients did not have consultant review within 12 hours
of admission
29% patients did not have urine dip
DCH AKI Checklist
 Quick checklist to guide initial management for junior teams
 Applies to non medical teams and AKI occurring after
admission
 Aim to pilot in DCH and re-audit for effectiveness.
CHECKLIST FOR AKI PATIENTS
ATTACH TO NOTES. TICK BOXES.
MANAGEMENT PLAN IS NOT EXHAUSTIVE.
Check U&Es on every newly admitted patient
In suspected AKI, find last recorded U&Es if available
AKI DEFINITION
If AKI:
(Creatinine increased >26µmol/L in 48 hours
Assess fluid status and replace fluid iv
Creatinine >1.5x known reference value or
UOP <0.5ml/kg/hr last 6 hours)
(Aim to restore blood pressure with saline. Plasmalyte contains potassium, avoid if ↑K+)
Examine for distended bladder
(Especially in men; Bladder scan also useful; Catheterise if retention suspected)
Perform urine dipstick
(Nurses to record in medical proforma even if negative, nurses also to record patient weight)
Stop nephrotoxic drugs
(Specifically ACE inhibitors or ARBs, diuretics, other antihypertensives, NSAIDs)
Check K+ and treat medically if indicated
(Check ABG; IV calcium gluconate 10 ml 10% followed by insulin-dextrose; do not use salbutamol)
Monitor urine output
(Catheter not always needed)
Senior review asap; Consultant review within 12 hours
Organise ultrasound to exclude obstruction
(Within 24 hours)
Try to establish the cause.
Treat sepsis as per established guidelines. Escalate care if needed.
Avoid iv contrast. If nephrotoxic antibiotics (Gentamicin) necessary, monitor carefully (see protocol)
Refer to renal unit or discuss early. VTE prophylaxis with Clexane 20mg od if indicated.
Acknowlegements
 Dr Jo Taylor, Consultant Nephrologist DCH
 Nephrology team, DCH