Welcome to Renal- Redwood and Beech Ward! A Junior Doctors Guide

Transcription

1 Welcome to Renal- Redwood and Beech Ward! A Junior Doctors Guide

2 Contents Contents E rror! Bookmark not defined. Introduction..3 The Team 3 The Typical Week and investigations. 4 Clinics. 5 Renal investigations. 6

3 Introduction Welcome to the Renal Unit of Darent Valley Hospital! The Unit shares beds on Redwood ward ( mainly AKI, Dialysis and transplant patients) and on Beech ward ( mainly Aki, general medicine patients). We share Redwood with our Urology colleagues and Beech with our Diabetes and Endocrinology colleagues. This guide will hopefully give you all the essential information and tools you need in order for you to have a great time and learning experience with us. The Team Dr Nihil Chitalia - Consultant Nephrologist Dr Andrew Coutinho - Consultant Nephrologist Dr Noshaba Khiljee- Consultant in Acute Medicine and Nephrology Dr Jonathan Kwan - Consultant Nephrologist Dr Nang Aye- Renal specialist CT level doctor Foundation Year doctor x 2

4 The Typical Week It is advisable that when coming in everyday to liaise with the nurse in charge to identify: 1. New patients 2. Patients needing review 3. Patients that could potentially go home Beech Ward rounds Monday am Full Ward round. On rare occasions this may be conducted in the afternoon if the Consultant is in clinic that morning. Tuesday am SHO/HO ward round Wednesday pm SHO/HO ward round Thursday am Full Ward round Friday SHO/HO ward round Redwood Ward Rounds Monday Consultant led round AKI and referral rounds 12:30- Renal debrief and MDT Tuesday :15- Alternate week Radiology MDT Junior led ward rounds AKI and referral rounds 12:00-13:00- Renal Histology MDT with Guys and St.Thomas Hospital and Kings College Hospital Wednesday Consultant Led Ward Rounds AKI and referral rounds Thursday Junior led ward rounds AKI and referral rounds 12:30-14:00 Grand Round

5 Friday Consultant Led Ward Rounds AKI and referral rounds Any day can have procedures performed- temporary line, tunnelled line insertions and renal biopsies. You are encouraged to attend our ward rounds or meetings on the Main dialysis satellite unit as well. Juniors are encouraged to partake in audit and Mortality and Morbidity meetings (every 3 months) Currently the audits running- AKI stage 3 Audit Contrast prophylaxis audit Hyper-kalemia audit IV fluids audit Renal Anaemia audit Renal Clinics Monday Am- DVH Monday PM- Sidcup Tuesday AM- Kings College Hospital alternate week Tuesday PM- DVH and Erith Wednesday AM- Kings College Hospital alternate week and Gravesend weekly Wednesday PM- DVH Thursday AM- Gravesend Thursday PM- Sidcup Friday AM- DVH These clinics are staffed by the Consultants on a rota basis, but we would encourage you to attend and observe or see a few patients if you are interested in Renal Medicine.

6 Teaching You will have Monday afternoon teaching that is conducted jointly with the Respiratory department from 13:00 to 14:00 hrs weekly. You also have your designated FY, CT level teaching and Grand Round, which is counted as an hour of teaching. You are encouraged to attend all these during the week EDNs (Electronic Discharge Notice, aka TTOs/Discharge Summaries) This is a document which is completed electronically which serves as an official discharge letter for the patient. It also serves a few other important purposes: 1. Information for the patient regarding their diagnosis and advice on the future management of their condition i.e. medications, alarm symptoms etc. 2. The GP will usually be sent a copy of the EDN via and so therefore this document serves as an important communication tool between the hospital team and the GP. If any further investigations are required, tests need or follow up appointments etc., it is usually under Instructions for GP within the EDN. To give examples, the most common instructions for the GP would are to arrange repeat U+Es if started on new medications, outpatient referrals and warfarin checks. 3. Pharmacy it important that the medications is filled in correctly specifying which medications are new, which are old and which have been changed. Liaise with the ward pharmacist who would be more than happy to help! 4. Consultant follow up The Renal consultant will usually make a decision on this on the ward round. To summarise if all these main points are implemented on EDNs you find that this document becomes very useful for AE, on call team and importantly your team! Tip: Try and have the patient s medical history in category of diagnosis filled out in the diagnosis section of the EDN and any investigations, ECHOs, CXRs/CTPAs, etc. fill out in the procedure section of the EDN for easy access of the reader.

7 Investigations in Renal Patients Generally these are the same as for any group of patients. However, patients with acute kidney injury should receive a thorough assessment including: 1. Urine dipstick test on arrival on Beech Ward and Urine Microscopy (MSU) 2. Renal tract ultrasound within 24 hours 3. Serum electrophoresis, serum free light chains and urine Bence - Jones protein (urine electrophoresis) on all patients with unexplained AKI or CKD. 4. ANCA, Anti GBM, C3/C4, Immunoglobulins and auto-antibody screen IF urine dipstick is positive for blood and protein 5. Urine for Protein: Creatinine ratio (plain white top container, early morning sample), for quantification of proteinuria if protein on dipstick 6. Renal Unit Profile to be requested rather than Electrolytes as this gives Calcium, phosphate and also bicarbonate 7. Ferritin / B12 and folate in patients with anaemia 8. PTH level in anyone with significant renal impairment (GFR <30) needs doing once during admission 9. Further specific tests e.g. nuclear medicine scans, should only be done after discussion with the consultants

8 Important Contact details Emma Ross (Renal secretary) Laura Jarvis (Renal secretary) King s Dartford satellite dialysis unit 8855/8861 Dr Chitalia/Coutinho/Kwan office 8696 William Harvey Hospital, Ashford Immunology dept (for urgent ANCA, anti-gbm and auto-antibodies) Tacrolimus results (immunosuppressant levels) Here are a few Guidelines that have been attached to assist you, but you will find a lot of information on ADAGIO as well.

9 The linked image cannot be displayed. The file may have been moved, renamed, or deleted. Verify that the link points to the correct file and location. Patient Name: Hospital Number: DOB: NHS Number: AKI Bundle checklist This patient has been identified as having Acute Kidney Injury - AKI Please ensure the following steps have been taken AKI Serum creatinine criteria Urine output criteria STAGE 1 Increase in serum creatinine of 26 mcrmol/l or more within 48 hours OR Less than 0.5 ml/kg/hour for more 1.5 to 2-fold increase from baseline than 6 hours 2 Increase in serum creatinine to more than 2 to 3-fold from baseline Less than 0.5 ml/kg/hour for more than 12 hours 3 Increase in serum creatinine to more than 3-fold from baseline OR Less than 0.3 ml/kg/hour for 24 hours or anuria for 12 hours Serum creatinine more than 354 mcrmol/l with an acute increase of at least 44 mcrmol/ L Actions Required Fluid Balance - Check for signs of dehydration - Prescribe IV fluid if indicated Low Blood - Withhold anti-hypertensive if SBP<110, and monitor Pressure - Bolus 250 ml N/Saline if hypovolemic unless systolic BP evidence of symptomatic heart failure and re-assess (<110 mm of Hg) Urine - Catheterise if: palpable bladder/ urinary retention OR Oliguric AKI stage 2/3 Imaging - Request urgent renal US scan if suspected obstruction/ no clear cause of AKI Drugs - Review Medication - Stop /withhold nephrotoxins Sepsis - Assess for signs of sepsis. Urgent Rx of any infection (Speak with Microbiology if indicated) Tick when done Cause of AKI: Obstructive Uropathy: (document likely cause) yes/ no Refer to Nephrology if indicated (see flowchart) Renal screen * if clinically indicated (active urinary sediment/clinical suspicion) Daily U & E s Relevant investigations Discharge summary to have AKI section filled

10 The linked image cannot be displayed. The file may have been moved, renamed, or deleted. Verify that the link points to the correct file and location. Patient Name: Hospital Number: DOB: NHS Number: New Diagnosis of AKI Stage 1 / Stage 2 / Stage 3 Alert on ipath and telepath system- Look at these systems for AKI stage Ward team to review patient and confirm Alert (Exclude patients on dialysis or stable CKD) Confirmed AKI- Necessary steps to be initiated by parent team o o o o o o Fluid Balance- Check for dehydration and treat, requires frequent assessment, too much fluid can be harmful (IV fluid, Input/output charts) Low BP- withhold anti-hypertensives (If angina present continue beta blockers but consider reduced dose/review) Urine dipstick test and microscopy (urinary catheterisation if obstruction suspected) Imaging- Urgent renal ultrasound if obstruction suspected or AKI has no identifiable cause Drugs and Toxins- Stop NSAIDS, Withhold ACE inhibitors and AR2B s, review use of metformin, trimethoprim and avoid gentamicin / aminoglycosides, Judiciously use radio-contrast agent. See Contrast Induced Nephrotoxicity guidance on ADAGIO Sepsis- Look for sepsis and treat accordingly, see trust sepsis guidelines Diagnose and treat other acute illness contributing to AKI Mandatory review by senior member of team (Registrar/Consultant) Critical care team referral in appropriate cases (i.e. hypotension not responding to fluids, multi organ failure) Daily U&E s Referral to Renal team AKI stage 1, AKI stage 2- if progression, no renal recovery or suspected glomerular cause or vasculitis AKI stage 3- Urgent renal referral Refer urgently if any complications of AKI or, need for RRT (Hyperkalemia, pulmonary oedema, severe metabolic acidosis, ph <7.2, Uraemic pericarditis / encephalopathy) Inform Renal team of all Dialysis and Kidney transplant patients admitted to your ward *Renal Screen: Urine MSSU, Urine Protein:Creatinine ratio, Urine Bence-Jones protein, ANCA, Anti-GBM antibody, ANA, C3, C4, serum electrophoresis, serum free light chains See ADAGIO- AKI link for management of Hyperkalemia, Contrast Induced nephropathy guidance and other advice

11 Fluids Adult Maintenance Fluids Adult Resuscitation or Replacement Fluids Baseline Requirements mmol sodium, 40-80mol potassium and L water per 24 hours Oral, enteral or parenteral route Adjust estimated requirements according to changes in sensible or insensible losses Sensible Losses (measurable) Surgical drains Vomiting Diarrhoea Urine (variable amounts of electrolytes) Insensible Losses Respiration Perspiration Metabolism Increase in pyrexia or tachypnoea (Mainly water) Regular assessment of volume and hydration status Daily weights Fluid charts Measured electrolytes Available parenteral solutions (if required) Hartmans solution/ringer s lactate Normal Saline 5% dextrose 0.4%/0.18% dextrose/saline Potassium usually added additionally Give According to Clinical Scenario General Volume Replacement or Expansion Give balanced crystalloid solutions (Hartman s solution/ringer s lactate) These contain small amounts of potassium. Avoid in hyperkalaemia. If AKI only use these if close (HDU) monitoring of potassium or Colloids Avoid high molecular weight (>200kDa starches in severe sepsis due to risk of AKI Assess vital signs, postural blood pressure, capillary refill, JVP and consider invasive or non-invasive measurement using flow-based technology Haemorrhage Give blood and blood products Balanced crystalloid or colloid may be given while blood awaited Clinical assessment as above Severe Free Water Losses (hypernatraemia) 5% dextrose or 4%/0.18% dextrose/saline Hypochloraemia (vomiting, NG drainage) Give normal saline (Potassium repletion usually also required) website: info@londonaki.net

12 Contrast Induced Nephropathy (CIN) Prophylaxis Assess Risk High volume (>100mls) iodinated contrast procedure and CKD with egfr<60 (particularly diabetic nephropathy) or AKI Other risk factors dehydration, heart failure, severe sepsis, cirrhosis, nephrotoxins (NSAIDS, aminoglycosides). Risk factors are multiplicative. Is Contrast Procedure Necessary? Yes Resuscitate to Euvolaemia Give Prophylaxis if High Risk Volume expansion (unless hypervolaemic) with normal saline or or 1.26% bicarbonate Sample regimens IV Na bicarbonate 1.26% 3mls/Kg/hr for 1 hour pre-procedure and 6 hours post-procedure or IV 0.9% normal saline 1ml/kg/hr 12 hours pre and 12 hours post procedure Minimise contrast, use low or iso-osmolar contrast Monitor Function To 72 Hours in High Risk Cases If oliguria or rising creatinine early referral to local renal team. NB there is no-proven role for N-Acetyl cysteine, post-contrast dialysis/cvvh or routine cessation of metformin or ACE inbitors. website: info@londonaki.net

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