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*
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) |