Acute Kidney Injury shared guidance

Transcription

1 Acute Kidney Injury shared guidance

2 Acute Kidney Injury (AKI) Fluid balance assessment (NICE CG 169) Assess the patient s likely fluid and electrolyte needs 1.History previous limited intake, thirst, abnormal losses, comorbidities. 2.Clinical examination pulse BP capillary refill JVP oedema (peripheral/pulmonary) postural hypotension 3.Clinical monitoring NEWS fluid balance charts weight 4.Laboratory assessments FBC, urea, creatinine and electrolytes

3 Acute Kidney Injury (AKI) Prescribing intravenous fluids 1. Complete fluid balance assessment 2. Decide what is the purpose of fluid prescription Resuscitation, Routine maintenance, Replacement (fluid losses or redistribution) 3. Reassess the patient evidence/cg174-intravenous-fluid-therapy-in-adultsin-hospital-guideline2

4 NICE CG 169 Algorithms for IV fluid therapy

5 Acute Kidney Injury (AKI) Imaging Indications for urinary tract ultrasound (USS) Clinical suspicion of infected AND obstructed kidney[s] Perform USS within 6 hours OR If patient is at risk of urinary tract obstruction If no cause of AKI is identified Perform USS within 24 hours

6 AKI: contrast media In preparation

7 Acute Kidney Injury (AKI) Medication Review- Care Bundle AKI is a medical emergency. All patients with AKI should have their medications reviewed. Initial review can be performed by a pharmacist or doctor at ST3 or above. ALL PATIENTS WITH AKI AND HEART FAILURE SHOULD BE DISCUSSED WITH CARDIOLOGY A) Is a drug causing AKI or contributing to metabolic derangements associated with AKI? In all cases of AKI stop the following drugs ACE inhibitors angiotensin receptor antagonists non-steroidal anti-inflammatory drugs potassium sparing diuretics metformin If BP < 130/80 other antihypertensive drugs should be withheld. If drugs with antihypertensive effect are being used for anti-anginal prophylaxis or AF rate control discuss with senior of cardiology SpR on call B) Do drugs need dose adjustment because of alteration in renal function? Antibiotics The dosing of penicillins, cephalosporins, aminoglycosides, teicoplanin, vancomycin, quinolones+ macrolides needs review Opiate analgesia: opiates & their active metabolites can accumulate in patients with renal impairment C) Do drugs need to be stopped until renal function recovers because they will accumulate or have dangerous effects? Low molecular weight heparin- Do not use in patients with acute kidney injury D) Do any drugs need therapeutic drug monitoring? Aminoglycosides, glycopeptide antibiotics, digoxin and lithium need careful monitoring in patients with abnormal renal function Patient Name.. Hospital #... Initial Medication Review Date and time Name Role Formal pharmacy review and medicines reconciliation Date and time Name Role Pre-discharge pharmacy review + confirmation of plan to reinstate some or all pre-admission drugs Date and time Name Role

8 Acute Kidney Injury (AKI) Referral Discuss with Critical Care: Patients with AKI who are critically ill (NEWS scores, observations) Discuss with the local Renal Service: Patients with AKI AND protein and/or blood on dipstick symptoms or signs suggestive vasculitis, tubulointerstitial nephritis or myeloma Patients with AKI with no clear cause Patients with AKI that is not improving Patients with AKI Stage 3 acute kidney injury (AKI 3) Patients with AKI with a renal transplant Patients with AKI with pre-existing CKD 4 or 5 Discuss with the local Urology Service: All Patients with AKI with pelvi-calyceal dilatation on USS or CT Patients with AKI with bladder outflow obstruction

9 Acute Kidney Injury (AKI) Transfer of Patients AKI with other organ failure may require local intensive care stabilisation prior to transfer to tertiary renal unit. Safe transfer GUIDED by the following criteria: Metabolic K+ <6.5mmol/L with no ECG changes, potentially sustained by bicarbonate / haemofiltration (but not transiently with Insulin / Dextrose or salbutamol) ph >7.2 Lactate <4 Neurological Alert on AVPU scale Respiratory RR >11 and <26/min SpO 2 >94% on 35% O 2 or less Circulatory HR >50 and <120/min Systolic BP >100, MAP >65 mmhg

10 AKI : actions after discharge In preparation