PROPUESTA DE MEJORAMIENTO EDUCATIVO 1 TÍTULO:

 A prospective study that was carried out over a period of 16 months.

 All consecutive patients aged 18 and above meeting the criteria for ICU admission were recruited for the study and monitored over a period of at least 6 weeks. .

 Presence of AKI in these ICU patients and those patients on the open wards was determined using the RIFLE (Table 1) and AKIN (Table 2) criteria.

 Within 24 hours of admission of these patients, their respective death risk and severity index score was determined using APACHE IV (Appendix 1) scoring system.

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 APACHE foundation software generated a list of scores which represented the actual versus the predicted hospital mortality and ICU length of stay for the 100 patients recruited from the ICU. A standardized mortality ratio (SMR) was also generated for all the patients. This represented the ratio between the actual hospital mortality value and the patient’s actual ICU length of stay compared to the predicted mortality value and predicted ICU length of stay. A SMR ratio of 1.0 indicated a match between actual and predicted values. Ratio above 1.0 represented actual mortality rates above predicted, and ratio below 1.0 represented rate below predicted. A ratio of 1.0 indicates a precise match between actual and predicted values.

 Every patient in this study was stratified using RIFLE and AKIN criteria, to determine the pattern, severity and outcomes of AKI in them.

 The RIFLE criteria (classify AKI into 3 categories of severity – Risk; Injury;

and Failure, and 2 clinical outcome- Loss and End stage kidney disease). The AKIN classify AKI into 3 stages of severity.

 The actual length of stay of patients in ICU and their outcome along each stages of RIFLE and AKIN criteria was noted and compared to other ICU patients who did not developed AKI.

 Baseline Scr values for each patients was estimated by the Modified Diet in Renal Disease (MDRD) equation as recommended by the ADQI working group ( assuming a lower limit of normal baseline GFR of 75ml/min).^34,127.

 All patients recruited into this study were taken through a comprehensive evaluation of clinical history (through their relatives) using a proforma (Appendix IV), physical examination, and laboratory investigation as outlined below.

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(a) Socio-demographic data- Age, Sex, Occupation.

(b) Clinical data-Presenting symptoms and duration, duration of admission, causes of ICU admission,

(c) Underlying disease (relevant past medical history to exclude pre-existing chronic kidney disease).

(d) Other aetiological factors such as comorbid condition, organ failures development during ICU admission, history of trauma, sepsis, surgical operation/procedures that patient undergone, duration/type of surgery, anaesthetic medications administered during surgery, problems encountered during surgery especially hypotension, and cardiac arrest was noted.

(e) Aetiological factors responsible for patients’ admission were categorized into either medical, surgical, obstetrics and gyneacological, and others.

(f) Clinical history of oliguria, anuria, and evidence of ureamia like hiccups, vomiting, nausea, bleeding was noted.

 Physical examination was done to assess the general clinical status of our patients on 24 to 48 hourly bases in order to identify the cause or evidence of renal impairment such as acute body fluid loss e.g. rapid thread pulse, cold clammy extremities, loss of skin tugor, sunken eye balls and hypotension.

 Major Burns is defined as thermal injury involving complete full thickness of the skin characterized by eschar formation and complete loss of sensation.

 A general assessment of the organ system for presence of organ system failure using clinicopathological parameters as presence of one or more organ failure apart from kidneys as defined by Knaus and Wagner (Appendix IV).

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 Laboratory investigations such as venous blood sample for full blood count, white blood cell count and differentials, reticulocyte count, erythrocyte sedimentation rate were done. Blood group and genotype, glucose-6-phosphate dehydrogenase status (where applicable) were determined.

Furthermore, serum electrolytes, blood urea nitrogen and serum creatinine were determined using flame emission spectrophotometry, enzymatic method and modified Jaffe’s reaction respectively. However, serial serum creatinine was done at admission, at 48hourly basis.

 Blood, wound swab, urine and stool culture were carried out (where applicable) to determine the infective agents.

 Sepsis was defined as a microbiologically proven focus of infection (such as urine, blood, catheter, wound site and endotracheal tubes and others) and deterioration of the clinical state evidenced by at least one of the following⁷: temperature >39⁰C on 2 or more occasions, leucocytes >10 x 10⁹/L, positive blood culture.

 Other investigations such as chest x-ray, abdomino-pelvic ultrasound scan, and electrocardiography were done where applicable.

 Patients with severe AKI as per the following criteria were offered heamodialysis viz: Symptomatic ureamia, severe hyperkaleamia (serum potassium>6.5 mmol/L) Ureamic pericarditis, acute pulmonary oedema especially in the setting of anuria or oliguria, intractable acidosis especially with serum bicarbonate <12mmol/L ; azotemia with serum creatinine > 600µ mol/L and serum urea > 25mmol/L. Hypercatabolic state defined as daily rise in serum urea > 10mmol/L, Scr 100µmol/L, serum potassium >1mmol/L.

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 Heamodialysis was done through femoral vein cannulation using a single lumen femoral catheter with indwelling life span of not more than 48hours.

Such patients were treated as emergency cases and received some sessions of heamodialysis with one or two days interval. The conventional intermittent heamodialysis with low blood flow rate of 150ml/min, with heparin anticoagulation was used. Great attention was paid to their blood pressure during heamodialysis sessions and the use of low ultrafiltration and occasional vasopressor support was administered when necessary

 Conservative management in form of our unit protocol of practice required for use included attempts at reversing the underlying cause and corresponding fluid and electrolytes abnormalities. The fluid intake was restricted to 500ml to 1 litre in oliguric patients to match measurable plus insensible losses. The protein intake was restricted to 0.6g/kg/day of high biological value and calories of at least 35cal/kg. Energy supplementation for patients with severe

vomiting included the administration of 50% glucose boluses.

 Broad spectrum and potent antibiotics in renal adjusted doses was prescribed for infections. A combination of clavulanic acid/aminopenicillin and metronidazole either in reduced doses or increased dosing interval was instituted. Cephalosporins were prescribed in reduced doses in severe infections.¹⁰⁹ However, nephritoxic drugs such as aminoglycosides, e.t.c were avoided.

 Mechanical ventilation was given by the ICU specialists to some critically ill patients who require some form of assisted respiration.

 Clinical outcomes of all patients were determined by the following: (i) mortality {death from ureamia, death not due to ureamia or other condition

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(but from the primary condition)}, (ii) need for commencement on RRT, (iii) patients survival (steady reduction of Scr, and electrolyte to normal or near

normal levels.