Therapeutic Handbook - GGC Prescribing

Assessment / MonitoringAKI stage I• Obtain clinical history. Check for risk factors (see box 1 on previous page), any pointers towardsaetiology and review medication (see examples in box 2).• Clinical examination:- Check patient’s obs,- Fluid status (assess peripheral perfusion, JVP (central venous pressure, CVP), oedema, 3 rdspacing) and urine output (UO).• Investigations:- U&Es, urinalysis, MSSU, CXR, ECG.- Consider renal ultrasound (US), sepsis screenAKI stage IIAs for Stage I but renal US within 24 hours and sepsis screen.AKI stage III• As for stage II. Look for multi-organ failure and chase renal US report.• Mandatory blood tests are: U&Es and HCO 3-, CRP, creatine kinase, LFTs, Ca 2+ , FBC, coagulationfactors.• Consider: amylase level, urine PCR if proteinuria, autoantibody screen if haematuria orproteinuria, microscopy if haematuria, myeloma screen, abdominal US.AKI complications include: sepsis, acidosis, hyperkalaemia, multi-organ failure, oedema, respiratoryfailure, encephalopathy, serositis, haemorrhage.Resuscitation and AnaphylaxisManagementAKI stage I• Stop nephrotoxins (see box 2 on previous page)• Optimise fluid status.- Correct hypovolaemia, hydrate, optimise haemodynamics, keep accurate fluid balance chart.- Fluid challenge unless there is evidence of fluid overload.Aim for a mean arterial pressure > 65 or SBP > 100 mmHg.- Consider: vasoactive agents if hypotensive and not volume depleted.- Assess response and repeat U&Es. Aim for UO of 0.5 ml/kg/hour.• Treat infection if present (see Infection Management Guidelines pages 211-254).• Manage any contributing risk factors.• Consider: inserting urinary catheter, seeking senior review, assessing CVP, reviewing medicationand adjusting doses.• Relieve obstruction if present with mandatory decompression, also request urgent urology reviewand/or discussion with interventional radiologist.Continues on next pagePage 33