Appendix 1 All process of care indicators
Prevention and Early Identification of AKI after major surgery (12)
Obtain a serum creatinine before surgery
Use isotonic crystalloids to expand intravascular volume during surgery
Monitor serum creatinine daily to identify AKI after surgery
Monitor urine output daily to identify AKI after surgery
Monitor fluid balance daily after surgery
In the absence of volume overload, provide maintenance IV fluids after surgery
Administer aminoglycosides using single daily dosing in patients at risk of AKI
Discontinue non-steroidal anti-inflammatory drugs prior to surgery
Avoid repeated exposure to iodinated contrast after surgery
Monitor serum creatinine after prescribing a nephrotoxic drug
Avoid hydroxy-ethyl starch for volume expansion in patients with reduced kidney function
Flag patients at high risk of perioperative acute kidney injury in the medical record
Obtain a urinalysis before surgery
Discontinue aminoglycosides prior to surgery
Discontinue ACE inhibitors/angiotensin receptor clockers (ARBs) prior to surgery
Discontinue diuretics prior to surgery
Discontinue calcineurin-inhibitors prior to surgery
Monitor serum urea daily to identify volume depletion prior to a rise in serum creatinine
Monitor intra-abdominal pressure after complex intra-abdominal surgery
Early Management of AKI After major surgery (12)
Perform a urinalysis for investigation of the cause of AKI
Determine the severity of AKI by monitoring serum creatinine daily after the onset of AKI
Determine the severity of AKI by monitoring urine output daily after the onset of AKI
Monitor fluid balance daily after the onset of AKI
Monitor for acid–base disturbances after the onset of AKI
Monitor for hyperkalemia after the onset of AKI
Provide intravenous crystalloids to optimize hemodynamic status and restore effective circulating volume and blood pressure in patients with AKI and signs of volume depletion
Avoid non-steroidal anti-inflammatory drugs after the onset of AKI
Avoid aminoglycosides after the onset of AKI unless no other antibiotics are available
Provide vasopressors/inotropes to patients with AKI and vasomotor shock that does not respond to IV fluids
Review current medications to identify those that are nephrotoxic or require dose adjustment after the onset of AKI
Avoid diuretics in the absence of volume overload after the onset of AKI
Avoid angiotensin converting enzyme inhibotors/angiotensin receptor blocking drugs after the onset of AKI
Weigh patients daily after the onset of AKI
Recommendations for Prevention of Contrast-induced AKI (5)
Obtain a serum creatinine before a contrast imaging procedure
Use isotonic crystalloids for prevention in patients at high risk of CI-AKI
Use the lowest possible dose of iso-osmolar or low-osmolar iodinated contrast media in patients at high risk of CI-AKI
Withhold NSAIDs and diuretics before contrast administration
Use an imaging test that doesn’t require iodinated contrast administration in patients with AKI
Obtain a urinalysis before a contrast imaging procedure
Administer acetylcysteine to patients at high risk of CI-AKI
Criteria for Nephrologist Consultation (7)
An unclear etiology or cause other than pre-renal or acute tubular necrosis is suspected
Hyperkalemia refractory to medical therapy
AKI that is unresponsive to treatment or worsening
Respiratory compromise due to volume overload in anuric patients
Severe AKI (i.e., KDIGO Stage 3, 3-fold increase in serum creatinine or increase in Scr>350 μmol/L)
Signs or symptoms of uremia
A patient that may require renal replacement therapy
Hyperkalemia
Metabolic acidosis
All cases of AKI (i.e., always consult Nephrology)
Pre-existing kidney disease
Volume overload
Anuria not reversing with intravenous fluid
Criteria for Critical Care Consultation (4)
AKI with hemodynamic instability not responding to fluid resuscitation
Need for renal replacement therapy in hemodynamically unstable patient
Need for intubation or ventilatory support
Need for vasopressors or inotropes