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Table 2 Process of care quality indicators identified as having a high degree of validity in the prevention, identification, and management of acute kidney injury (AKI) after major surgery*

From: A modified Delphi process to identify process of care indicators for the identification, prevention and management of acute kidney injury after major surgery

  Number (%) who scored indicator ≥6/7
Prevention and Early Identification of AKI after major surgery  
Obtain a serum creatinine before surgery 30 (100)
Use isotonic crystalloids to expand intravascular volume during surgery 29 (97)
Monitor serum creatinine daily to identify AKI after surgery 26 (87)
Monitor urine output daily to identify AKI after surgery 29 (97)
Monitor fluid balance daily after surgery 26 (87)
In the absence of volume overload, provide maintenance IV fluids after surgery 30 (100)
Administer aminoglycosides using single daily dosing in patients at risk of AKI 25 (83)
Discontinue non-steroidal anti-inflammatory drugs prior to surgery 28 (93)
Avoid repeated exposure to iodinated contrast after surgery 26 (87)
Monitor serum creatinine after prescribing a nephrotoxic drug 29 (97)
Avoid hydroxy-ethyl starch for volume expansion in patients with reduced kidney function 26 (87)
Flag patients at high risk of perioperative acute kidney injury in the medical record 28 (93)
Early Management of AKI After major surgery:  
Perform a urinalysis for investigation of the cause of AKI 29 (97)
Determine the severity of AKI by monitoring serum creatinine daily after the onset of AKI 30 (100)
Determine the severity of AKI by monitoring urine output daily after the onset of AKI 30 (100)
Monitor fluid balance daily after the onset of AKI 30 (100)
Monitor for acid–base disturbances after the onset of AKI 29 (97)
Monitor for hyperkalemia after the onset of AKI 30 (100)
Provide intravenous crystalloids to optimize hemodynamic status and restore effective circulating volume and blood pressure in patients with AKI and signs of volume depletion 30 (100)
Avoid non-steroidal anti-inflammatory drugs after the onset of AKI 30 (100)
Avoid aminoglycosides after the onset of AKI unless no other antibiotics are available 27 (90)
Provide vasopressors/inotropes to patients with AKI and vasomotor shock that does not respond to IV fluids 29 (97)
Review current medications to identify those that are nephrotoxic or require dose adjustment after the onset of AKI 30 (100)
Avoid diuretics in the absence of volume overload after the onset of AKI 30 (100)
Recommendations for Prevention of Contrast-induced AKI:  
Obtain a serum creatinine before a contrast imaging procedure 27 (90)
Use isotonic crystalloids for prevention in patients at high risk of CI-AKI 30 (100)
Use the lowest possible dose of iso-osmolar or low-osmolar iodinated contrast media in patients at high risk of CI-AKI 30 (100)
Withhold NSAIDs and diuretics before contrast administration 27 (90)
Use an imaging test that doesn’t require iodinated contrast administration in patients with AKI 28 (93)
Criteria for Nephrologist Consultation:  
An unclear etiology or cause other than pre-renal or acute tubular necrosis is suspected 30 (100)
Hyperkalemia refractory to medical therapy 29 (97)
AKI that is unresponsive to treatment or worsening 28 (93)
Respiratory compromise due to volume overload in anuric patients 28 (93)
Severe AKI (i.e., KDIGO Stage 3, 3-fold increase in serum creatinine or increase in Scr > 350 μmol/L) 26 (87)
Signs or symptoms of uremia 29 (97)
A patient that may require renal replacement therapy 27 (90)
Criteria for Critical Care Consultation  
AKI with hemodynamic instability not responding to fluid resuscitation 30 (100)
Need for renal replacement therapy in hemodynamically unstable patient 28 (93)
Need for intubation or ventilatory support 30 (100)
Need for vasopressors or inotropes 30 (100)
  1. *All indicators listed in this table achieved high scores for validity based on a mean score >6 on a 7-point Likert scale.
  2. The number (%) of panelists who scored each indicator ≥ 6 is shown in the column on the right, with the 16 high consensus indicators, for which no panelists assigned a score <6, highlighted in bold.
  3. Applicable to all patients since hydroxyl-ethyl starches shown to increase the risk of AKI and renal replacement therapy in all populations (Mutter TC, Ruth CA, Dart AB. Hydroxyethyl starch (HES) versus other fluid therapies: effects on kidney function. Cochrane Database Syst Rev. 2013 Jul 23;7).