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Recognition of Acute Kidney Injury in Elective Patients Pathway

Elective Surgical Patient

Risk assess for AKI by Anaesthetic and Surgical
teams in pre-assessment clinic or ward

AKI Risk Factors:

  • Age 65 yrs or more
  • Adult having iodinated contrast agents
  • CKD
  • Cardiac Failure
  • Liver Disease
  • Diabetes
  • Vascular disease
  • Nephrotoxic Medications
  • Nephrotoxic Pigments (bilirubin, myoglobin)

 

Pre-Op Management

  • Consider pre-optimisation in ward or critical care area and scheduled post-operative admission to critical care.
  • Discontinue or avoid nephrotoxic drugs if possible.
  • If risk of long-term renal insufficiency (e.g. nephrectomy in CKD discuss with nephrology team).
  • Optimise circulation and oxygenation during surgery.

Postoperative AKI Risk Assessment

As per pre-op assessment. Assess surgery undertaken, blood loss, perioperative
haemodynamic stability, perioperative oxygenation and perioperative oliguria.

Base Line Observations

Set and record targets for BP, HR, SpO2, temp, RR, conscious level and urine
output (if catheterised) and frequency of observations

Monitor

  • Full set of physiological observations (at least 4 hourly)
  • Fluid balance (at least 4 hourly)
  • Take admission bloods (U&Es, FBC. ABG if patient condition requires)

Review of admission blood tests <3 hours
Raised creatinine, acidosis, hypokalaemia?
Pathology alert flag for acute kidney injury

If Yes follow below.

If No Continue to monitor and recheck bloods daily

Manage the acute illness/event

  • Review observations
  • Review monitoring frequency
  • Review ABCDE interventions
  • Consider urine catheter

Assess severity of Acute Kidney Injury

Stage 1

Serum creatinine:
Increase of serum
creatinine ≥ 26 μmol/L
OR increase from
baseline of
150-200%

Urine Output: <0.5ml/
kg/hr for 6 hours

Acute Kidney Injury not requiring
immediate Renal support

Follow Management of Acute Kidney Injury Pathway

Stage 2

Serum creatinine:
Increase of serum
creatinine from
baseline of
200-300%

Urine Output:
<0.5ml/kg/hr for 12
hours

Acute Kidney Injury not requiring
immediate Renal support

Follow Management of Acute Kidney Injury Pathway

 

Stage 3

  • Review observations
  • Review monitoring frequency
  • Review ABCDE interventions
  • Consider urine catheter

Serum creatinine: Increase of serum creatinine > 400 μmol/L OR
increase of >300% from baseline


Urine Output: <0.3ml/kg/hr for 12 hours OR anuric > 6 hrs

Is the patient single (renal) organ failure?

Yes

Immediately discuss the following patients with Renal Care at LTHTr
(01772 716565):

Creatinine >400 μmol/L or >3x baseline

Hyperkalaemia (>6.0mmol/L)

  • No ECG changes.
  • If K lowered to <6.0 after presentation this must be potentially sustained (e.g bicarbonate
    therapy or dialysis/CVVH) not transient therapy (insulin and dextrose).

Renal Acidosis

  • pH <7.2.
  • Venous bicarbonate <12 mmol/L.
  • Lactate > 4 mmol/L.

Respiratory

  • Respiratory rate >11 and < 26/min.
  • Oxygen saturations <94% on not more than 45% oxygen.
  • If patient required acute CPAP must have been independent of this treatment for 24 hrs.
Circulatory
  • Heart rate > 50/min and < 120/min.
  • Blood pressure > 100mmHg systolic.
  • MAP > 65MMHg. - Lactate < 4mmol/L.
    (lower BP values may be accepted if it has been firmly established these are pre-morbid).
Neurological
  • Alert on AVPU score or GCS >12.

No

Refer to Critical Care (Bleep 703) patients that meet risk criteria but are physiologically unstable:

  • Hyperkalaemia
  • Acidosis
  • Requiring >45% face mask oxygen
    to maintain Spo2
    >94
  • Hypotensive after fluid resuscitation
  • Reduced Conscious Level