Using GFR and Hydration Protocol? How does your dept handle it?

Not ignoring you, Dutch, just gotta get those ducks in a row in order to post semi-intelligently.

We require BUN/creat (actually, Chem 7, CBC w/o diff and coags) results within a month on all heart cath pts.
Our clientele is *usually* men in their 50's - 80's (as a VA facility, we deal with adults only).
If creat. is >1.5 and/or eGFR is <60, we use Visipaque, otherwise everyone gets Omnipaque.
All pts are prehydrated but the Cardiologists differ in their opinion on what this means.
One insists each pt receive a 500ml NS bolus before coming into the Lab.
The others are happy if the pt has an IV hanging when s/he enters the room, don't question the rate.
We nurses are still trying to educate the "floor" nurses and the residents to hydrate the pts, that just a saline lock overnight is not enough if the pt is NPO to receive contrast for a cath the next day. (banging head against wall here)

I always speed up the IV to 150ml/hr (or more, depending on the EF - if known - --- if EF=20% or less, I consult with the Cardiologist for the IV rate, which is rarely below 50ml/hr) when the pt enters the room I don't leave the IV on a pump or depend on a Dial-A-Flow, as I want to be able to open it up at will and immediately, if I need to.

N-acetylcysteine (2 doses, 600ml/(po) dose pre-cath, and one dose post-cath) is given if Visipaque is used (same lab criteria).

Our Vascular surgeons' protocol is different:
NS @ 75ml/hr for all pts.
N-acetylcysteine for creat >1.1.
NaHCO3- 150mEq in D5/W 850ml = 1000ml, TRA 3ml/kg/hr X 1hr, then maintain at 1ml/kg/hr during case and X 12 hr post-case.
Visipaque for ALL pts.

Our IR Dept. requires labs within three months of pt (all pts; there is no age limit) having, say, a contrast CT exam.
I don't know what their protocol is for prehydration, mucomyst, etc.

(makes me think we need to get together and standardize it for the hospital, but then again, one would be dealing with so many strong personalities w/their difft opinions . . interesting thought, though )


Below are some reference articles that may be helpful.
These discuss prehydration (how much and when to give).
Also, interestingly (and in keeping with your policy of who gets labs drawn), the consensus is that all pts don't need labs drawn before receiving contrast. (I like to know, on the off chance . . )


http://www.aafp.org/afp/20021001/1229.html

http://www.medscape.com/viewarticle/494060_6

http://ndt.oxfordjournals.org/cgi/co...ull/14/12/2830

http://jama.ama-assn.org/cgi/content/full/295/23/2765

These address the use of N-acetylcysteine before contrast admin, to reduce the risk of RCIN:

http://content.nejm.org/cgi/content/...ct/354/26/2773

http://www.medscape.com/viewarticle/551142

This one is a good general information article answering questions about when to draw, and what labs to draw before contrast admin.:

http://radiographics.rsnajnls.org/cg.../24/suppl_1/S3

Check out: AJN Article September 2007, 107:9



CE Preventing Contrast Medium-Induced Nephropathy.
Cindy Kohtz, EdD, RN, CNE; Maren Thompson, PharmD
This condition, marked by an acute decline in renal function after the administration of contrast media, can progress to irreversible renal dysfunction. But it is preventable in many cases.