99: Guidelines on acute kidney injury in ICU, IV push antibiotics in sepsis, and a workflow diagram resource

In this episode I’ll:

1. Discuss a new guideline on Acute kidney injury in ICU patients.
2. Answer the drug information question “What do you think about IV push antibiotics in sepsis?”
3. Share a resource for creating workflow diagrams.
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Article

Acute kidney injury in the perioperative period and in intensive care units (excluding renal replacement therapies)

Lead author: Carole Ichai
Published April 2016 in Anaesthesia Critical Care & Pain Medicine

French critical care and nephrology societies have published recommendations for acute kidney injury in the perioperative period and in intensive care units. These guidelines use the GRADE method to rate the strength of the recommendations.

I’ve selected the recommendations that involve medications for discussion in this episode.

How to establish the diagnosis of acute kidney injury (AKI) and its severity

R1.1 – We recommend to use the KDIGO criteria (stage 1) to define AKI based on the presence of at least one of these 3 following diagnostic criteria: (1) an increase in serum creatinine ≥ 0.3 mg/dL within 48 hours; (2) an increase in serum creatinine ≥ 1.5-fold from baseline value within the last 7 days; (3) urine output < 0.5 mL/kg/h for 6 hours.

(Expert opinion) strong agreement

 

R1.3 – To estimate glomerular filtration rate (GFR), we do not recommend the use of formulas (Cockroft-Gault, MDRD, CKD-EPI) in critically ill patients or in the postoperative period.

(Grade 1–) strong agreement

 

R1.4 – To estimate GFR, we suggest calculation of creatinine clearance using the following formula: measured creatinine clearance with the UV/P creatinine formula.

(Grade 2+) strong agreement

In this formula, U is the urinary creatinine concentration in μmol/L, V is the urinary volume expressed in ml per unit time, and P is the serum creatinine concentration in μmol/L. This technique requires the collection of at least 1 hour’s worth of urine and is also known as a “flash creatinine clearance”.

Nephrotoxic medications

The guideline authors summarized the major nephrotoxic agents that are most frequently used in ICUs and during the perioperative period:

Radiocontrast agents
Aminoglycosides
Amphotericin
Non-steroidal anti-inflammatory agents
ß-lactams (interstitial nephropathies)
Sulfonamides
Acyclovir, methotrexate, cisplatin
Cyclosporin, tacrolimus
Angiotensin converting enzyme inhibitors (ACE)

I was curious why the authors omitted vancomycin, since in the US it would seem vancomycin would have a place on this list. So I did what I always do when I have a question about a published article – I emailed the corresponding author.

I got a prompt response to my question from Dr. Carole Ichai.  She stated that the guideline group was not impressed with the available data proving that vancomycin was nephrotoxic, and that vancomycin is no longer commonly used in Europe.  Additionally the nephrotoxic effects of vancomycin are limited given proper administration and monitoring.

Non-specific strategies to prevent AKI

R4.4 – We recommend maintaining a minimal level of mean arterial pressure (MAP) between 60 and 70 mmHg to prevent and treat AKI.

(Grade 1+) strong agreement

 

R4.5 – We suggest considering that patients with chronic arterial hypertension require a MAP target > 70 mmHg.

(Grade 2+) strong agreement

 

R4.9 – We suggest using noradrenaline as a first line treatment for maintaining MAP goals if a vasopressor drug is required.

(Grade 2+) strong agreement

 

R4.10 – We suggest not delaying any additional exams or potentially nephrotoxic agent administration if they are needed to manage the patient.

(Experts opinion) strong agreement

Managing nephrotoxic agents

R5.1 – We suggest optimizing hydration using crystalloids to prevent contrast-induced nephropathy, ideally before contrast media infusion and to continue this therapy within 6 to 12 hours after this infusion.

(Grade 2+) strong agreement

 

R5.2 – We suggest not using N-Acetylcysteine and/or sodium bicarbonate to prevent contrast-induced nephropathy.

(Grade 2–) strong agreement

 

R5.3 – We suggest administering aminoglycosides when necessary with respect to the following rules:

1. Administer them with single dosing per day
2. Monitor their residual level in case of more than a single infusion
3. Administer them for a maximum of 3 days whenever possible

(Grade 2+) strong agreement

 

R5.4 – We suggest not using non-steroidal antiinflammatory drugs (NSAIs), converting enzyme inhibitors (CEIs), and angiotensin 2 receptor antagonists in patients at risk of AKI.

(Experts opinion) strong agreement

Pharmacological strategies for the preventive and curative treatment of AKI

R6.1 – We recommend not using diuretics in order to prevent or treat AKI; we suggest using them for treating fluid overload.

(Grade 1–) strong agreement

 

R6.2 – We suggest not using sodium bicarbonate to prevent or treat AKI.

(Grade 2–) strong agreement

 

R6.3 – We recommend not using the following treatments to prevent or treat AKI: mannitol, dopamine, fenoldopam, atrial natriuretic factor, N-acetylcysteine, insulin-like growth factor-1, erythropoietin, adenosine receptor antagonists.

(Grade 1–) strong agreement

The full text of the guidelines is available for free here:

Drug information question

Shout out to “Nurse Shannon” who contacted me on LinkedIn with this question:

Q: What do you think about IV push antibiotics in sepsis?
A: I like the idea, although only beta-lactams have safety data to support this.

There is no sense re-inventing the wheel – Adam Spaulding, PharmD BCPS at Academic Life in Emergency Medicine has an excellent post on the use of IV push beta-lactam antibiotics in sepsis.

It seems most beta-lactam antibiotics can be given IV push over a few minutes (including cefepime and meropenem). Getting everyone educated and on board with the idea of IV push antibiotics should be done before they are ordered for the first time.

Resource

The resource for this episode is the website draw.io. The website is free online diagram software for making flowcharts, process diagrams, org charts, UML, ER and network diagrams. I used it to create a critical care rotation workflow diagram for my new PGY-1 Residents. I’ll be including this workflow diagram in the next episode – 100!

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If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.

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