Acute renal failure alert?

[Chisca, RN]

I was on call this weekend and was paged at midnight for a patient who needed emergent dialysis. Septic, acidotic and on 90 mcgs of levophed. The patient had been in the hospital for 5 days and on admission serum creatinine was 0.97. Each day it rose to 1.16, 2.99, 3.19 and 3.94. Nephrology was not consulted until it was 3.19 and by that time the patients kidneys were in failure. RIFLE criteria for staging acute kidney injury has been around since 2004 but this is not the first patient I have seen where the kidney doctor is consulted after the horse has left the barn. We have sepsis alerts where based on labs and vital signs nurses and doctors are forced to address changes in a patient's condition. Shouldn't we have renal failure alerts? I can't help but think this patient's renal failure could have been avoided. If RIFLE criteria would have been used the nephrology consult would have been placed on day 3 instead of day 4 and it might have changed the outcome.

[Chisca, RN]

Showed my post to one of the nephrologists and his response? The serum creatinine IS the renal failure alert. Then why do so many doctors and nurses miss this?

[Penelope_Pitstop, BSN, RN]

I don't know about your facility, but at some institutions, some or many of the attendings refuse to consult anyone until it's too late.

I'm assuming this patient was in an ICU area because he or she was on Levophed (um, three times the popular maximum for Levophed).

Sometimes intensivists do not feel the need to consult anyone else. I know a lot of places allow only nephrologists to write dialysis orders, so it's possible nephrology was consulted only for the dialysis orders in this instance.

Just curious, was this HD or CRRT? The patient doesn't sound hemodynamically stable enough for HD.

[Chisca, RN]

HD. K+7.3. HCO3 13. No fluid removal but the nephrologist wanted to address the acidosis as rapidly as possible. CRRT wasn't even an option as this hospital hasn't trained any of the ICU nurses to manage that therapy.

[Penelope_Pitstop, BSN, RN]

How did the patient do? Those numbers are fairly incompatible with life!

Also, what access was being used for the HD?

[Chisca, RN]

6 hours after the dialysis treatment the patient coded and died. Their first and last dialysis treatment.

[chare]

If RIFLE criteria would have been used the nephrology consult would have been placed on day 3 instead of day 4 and it might have changed the outcome.

Good question. If he had been dialyzed on day 4 when nephrology was initially consulted, rather than day 5, might that have changed the outcome as well?

[core0]

Good question. If he had been dialyzed on day 4 when nephrology was initially consulted, rather than day 5, might that have changed the outcome as well?

Probably not. The real answer is that when the patient had an indication for dialysis (hyperkalemia, acidosis, or volume overload) they should have been transferred to a center capable of doing CVVH. In answer to the OPs question, in the ICU RIFLE isn't really used. In sepsis almost all patients are in some degree of renal failure. We call nephrology when the patient is moving toward dialysis. The problem is when providers don't recognize the patient is moving toward dialysis and wait until its too late. Fundamentally a hospital without CVVH shouldn't be trying to treat patients with septic shock and renal failure.

[Chisca, RN]

[h=1]Acute kidney injury: highlights from the ERA-EDTA Congress in London , 28–31 May 2015[/h][h=2]AUTOMATED ELECTRONIC ALERTS

(E-ALERTS) FOR AKI[/h]At the London Congress, there were two oral presentations and two lectures on e-alerts. In this review, snapshots from Mark Devonald's (UK) and P. Wilson's (US) presentations will be presented.

Electronic alerts automatically and systematically identify all AKI episodes based on changes in serum creatinine and notify especially non-nephrologists about patients with AKI. The main aim of these alerts is to facilitate earlier recognition and treatment of AKI [10]. This system may stratify the patients using KDIGO, AKIN or RIFLE criteria and may also be used in combination with other tools, such as hospital-wide intranet AKI guidelines, an educational programmes and also an AKI care bundle, which may further optimize the treatment.

For assessment of the first serum creatinine (SCr) on admission, a comparison is made against the lowest SCr on record from 7 to 365 days prior to admission. When no SCr is available in this particular period, a comparison is made against a ‘theoretical' SCr, calculated from the MDRD equation, assuming normal estimated glomerular filtration rate (eGFR) of 75 mL/min [11].

This alert can be conveyed to a clinician by a simple message alerting him/her about ‘high' serum creatinine: this may be a passive alert (i.e., a page or an e-mail message), or a more active alert (i.e. a telephone call), or alternatively, an interruptive element, where the clinician is forced to take some kind of action [12].

Theoretically, the system may have benefits, which include obtaining detailed statistics on AKI, triggering rapid diagnosis and correct treatment, thus achieving improved outcomes and training of non-nephrologists in the treatment of AKI. However, the procedure is not devoid of drawbacks. This system may (i) increase interventions (including more renal consultations and dialysis), (ii) trigger application of unnecessary medications, (iv) result in ‘alert fatigue' (providers become less likely to respond to an alert the more often they are exposed to it) and (v) use resources and time without any obvious clinical benefit [13–15].

There are controversial reports about the usefulness of e-alerts. Although some studies have noted a beneficial effect [12–14], according to a recent major randomized controlled trial (RCT), which included ∼1200 adults in each arm of the study, composite relative maximum change in serum creatinine, dialysis, and death at 7 days did not differ between the alert and the usual care group. It was concluded that e-alerts did not improve clinical outcomes among hospitalized patients with AKI [16]. In brief, for the time being, it is unclear whether e-alerts are useful or useless or even harmful (by triggering unnecessary interventions); however, it is clear that the pros and cons of e-alerts will continue to be discussed for a long time.

[Chisca, RN]

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[TD=width: 86%][h=1]Acute Kidney Injury Electronic Alert for Nephrologist: Reactive vers[/h][/TD]

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Acute kidney injury electronic alert for nephrologists.

http://www.karger.com/Article/FullText/450722

[Guttercat, ASN, RN]

Was just looking for this thread about a month ago. Thanks, Chisca.

[Chisca, RN]

My favorite internet nephrologist is not impressed by alerts for acute kidney injury.

Precious Bodily Fluids: When a non-clinician tells you AKI is simple, prepare for disappointment.