Acute_Kidney_Injury

The aim of the assignment is to critically analyse, evaluate the interventions and approaches relevant to the author’s work place in order to deepen knowledge, demonstrate understanding of the main issues and theoretical underpinnings. Furthermore, the assignment will explore relevant perspectives, demonstrate personal development and propose reasoned, practical responses to the work place. The author works in National Health Service in Intensive Care Unit - often referred to as the ICU or ITU - is a place where the sickest hospital patients are nursed. They may be classified as ICU when requiring the highest level of technical and nursing care or High Dependency when requiring more attentive care than can be provided in a general ward. Whilst the length of a patients’ stay within these units varies according to their precise condition and rate of recovery, typical durations are three to seven days for ICU and two to three days for HDU. Staff members working in ICU provide the highest possible standards of patient care. Our nursing philosophy is patient and relative centered and we wish to provide maximum support to patients and their visitors, in what can be an extremely stressful time. The Nursing and Midwifery Council Code of Conduct (2010) states, that a nurse is accountable for an action, ©2011 CyberEssays.com Latest ActivityTerms of ServicePrivacy PolicyDMCA Ipromotes clients interests and their dignity irrespective of gender, age, race, ability, culture, sexuality, status, religion or political beliefs. In intensive care unit, the prevalence of acute kidney injury is approximately 50-60%, with 15-20% of patients requiring renal replacement therapy (RRT). In majority of the cases the pathology of AKI is acute tubular necrosis because of hypoxic tubular injury, associated with severe systemic disease. AKI is potential reversed following appropriate and timely intervention. Such as early recognition and treatment of imminent AKI is important as hospital high mortality rate. In contrast, patients presenting with AKI and multiorgan failure have been reported to have mortality rates of over 50%. If renal replacement therapy is required the mortality rate rises further to as high as 80%. Furthermore, evidence based practice in Acute Injury is a transparent process, that provides practitioners with powerful tools to deal with important questions of prognosis, diagnosis and etiology. However, evidence based practice can also alert professionals, if they have gaps in their knowledge or are not sufficiently trained to evaluate literature. According to Hatcher et al (2005) evidence based practice does not provide easy answers, because each patient problem is unique. Therefore, in the ward, available resources, patients’ values and circumstances are taken into consideration. Evidence Based Practice (EBP) can be further viewed as the bringing together of individual expertise with the best external evidence, which can be benefited from the ongoing and systematic research. Evidence practice proved quite topical as it underpinned and determined the best ways of providing particular services within the National Health Service (NHS). It is enshrined in the National Service Frameworks and is part of the National Institute for Clinical Excellence (NICE), Robinson (2000). Acute Kidney Injury (AKI) is as an abrupt decline in kidney function. Although simple to define conceptually, there has long been no consensus on an operational definition of ARF. As reported in a recent survey, more than 35 definitions have been used so far (Kellum and Levin N 2009). Depending on the definitions used, ARF has been shown to affect from1% to 25% of intensive care unit (ICU) patients and has led to mortality rates from 15% to 60%. In order to evaluate the research on Acute Kidney Injury, a comprehensive review of published literature was necessary. The following data base were accesed Science direct, CINAHL, Pubmed, Medline and the Cumulative Index to Nursing and Allied Literature. The following key words were used to search the database; renal function, RRT, dialysis, acute kidney injury together with intensive care, intensive therapy and critical care. The author included only studies in English from 2001 to 2011 and from these identified and included additional publication, The 14 most relevant publication are referenced in this review. Acute kidney injury (AKI) has now replaced the term acute renal failure and an universal definition and staging system has been proposed to allow earlier detection and management of AKI (Bagshaw 2006). The new terminology enables healthcare professionals to consider the disease as a spectrum of injury. This spectrum extends from less severe forms of injury to more advanced injury when acute kidney failure may require renal replacement therapy (RRT). There have previously been many different definitions of AKI used in the literature which has made it difficult to determine the epidemiology and outcomes of AKI. Over recent years there has been increasing recognition that relatively small rises in serum creatinine in a variety of clinical settings are associated with worse outcomes (Sumnall 2007) To address the lack of an universal definition for AKI a collaborative network of international experts representing nephrology and intensive care societies established the Acute Dialysis Quality Initiative (ADQI) and devised the Risk, Injury, Failure, Loss of Kidney Function, and End-stage Kidney Disease (RIFLE), in order to have a uniform standard for diagnosing and classifying AKI . The standard defines three grades of severity – risk (Class R), injury (Class I) and failure (Class F) and two outcome classes loss of kidney function and end-stage kidney disease. This classification system includes separate criteria for creatinine and urine output. A patient can fulfill the criteria through changes in serum creatinine or changes in urine output, or both. Class R is considered if there is an increase of serum creatinine X1.5 or an urinary output < 0.5 ml/kg/hour for 6 hours; Class I is considered if there is an increase of serum creatinine X2 or an urinary output < 0.5 ml/kg/hour for 12 hours; and Class F is considered if there is an increase of serum creatinine X3, or in patients with serum creatinine >4 mg/dl if there is an acute rise in serum creatinine of at least 0.5 mg/dl, or a urinary output < 0.3 ml/kg/hour for 24 hours, or anuria for 12 hours (Sterner 2008). Acute Kidney Injury Network (AKIN) group modified the RIFLE staging system to reflect the clinical significance of relatively small rises in serum creatinine. The main differences between AKIN and RIFLE classifications are as follows: a smaller change in serum creatinine used to identify patients with stage 1 AKI analogous to RIFLE-Risk, a time constraint of 48 hrs for the diagnosis of AKI, and any patient receiving RRT classified as stage 3 AKI. However, compared to RIFLE criteria, there is currently no evidence that AKIN criteria improve the sensitivity, robustness and predictive ability of the definition and classification of AKI in the ICU. This is consistent research finding that maximum renal dysfunction during the ICU stay was reached within a two-day period in most patients. Furthermore, classifying any patients receiving RRT as stage 3 is questionable and may introduce bias due to the lack of uniform recommendations regarding the timing and modalities of RRT Several studies have demonstrated that the RIFLE criteria have clinical relevance for the diagnosis of AKI, classifying the severity of AKI and for monitoring the progression of AKI, as well as having predictive ability for mortality in hospitalized patients in general, and patients in the intensive care unit (ICU) setting. Nevertheless, a more recent classification for AKI based on the RIFLE system has been proposed by the Acute Kidney Injury Network (AKIN). This new staging system differs from the RIFLE classification as follows: it reduces the need for baseline creatinine but does require at least two creatinine values within 48 hours; AKI is defined as an abrupt reduction in kidney function, currently defined as an absolute increase in serum creatinine ≥0.3 mg/dl (≥26.4 μmol/l), a percentage increase in serum creatinine ≥50%, or a reduction in urine output documented oliguria < 0.5 ml/kg/hour for > 6 hours; risk maps to Stage 1, but it also considers an increase in serum creatinine ≥0.3 mg/dl (≥26.4 μmol/l); injury and failure map to Stages 2 and 3, respectively; Stage 3 also includes patients who need renal replacement therapy irrespective of the stage they are in at the time of renal replacement therapy; and the two outcome classes loss and end-stage kidney disease have been removed (Lopes 2007). AKI can be managed in some patients by nondialysis interventions such as fluid challenge and loop diuretics furosemide and bumetanide. AKIN recommend that appropriate prescription of intravenous fluid should be carefully considered following assessment of the patient's volume status. Thereafter the patient’s clinical response should be monitored closely. Recently research, of the effects of diuretics in critically ill patients with AKI has been questioned. Shilliday et al (2002) found that the use of diuretics in critically ill patients with ARF was associated with an increased risk of death and non recovery of renal function. Appropriate management of intravenous fluid replacement is a key aspect of the treatment of AKI. In patients with acute glomerulonephritis and other intrinsic renal diseases, there is little clinical dispute that sodium and water restriction is beneficial in the setting of impaired renal excretory function. Conversely, in patients with AKI complicating systemic illness, supplemental intravenous fluids are considered an essential element of treatment (O’reill and Tolwani 2005). These acquired forms of AKI usually have a multifactorial etiology and, in such cases, fluid therapy aims to mitigate the effects of hemodynamic and nephrotoxic renal insults that might cause tubular injury. On the other hand, the adverse effects of fluid overload may be most pronounced in situations such as systemic sepsis, major surgery, or trauma, which predispose to acquired AKI. In this Review, the author focus on the dilemmas of fluid management in acquired AKI, which seeks a balance between the competing needs of adequate fluid resuscitation, the avoidance of progressively positive fluid balances with extracellular volume expansion and organ edema, and the possibility of overzealous fluid removal with the attendant risk of hypovolemic AKI (Mehta 2002). Intravenous fluids are widely administered to patients who have, or are at risk of AKI. However, deleterious consequences of overzealous fluid therapy are increasingly being recognized. Salt and water overload can predispose to organ dysfunction, impaired wound healing and nosocomial infection, particularly in patients with AKI, in who fluid challenges are frequent and excretion is impaired (Brar 2008). It can cause interstitial edema can further delay renal recovery and why conservative fluid strategies are now being advocated. Applying these strategies in critical illness is challenging. Although volume resuscitation is needed to restore cardiac output, it often leads to tissue edema, thereby contributing to on-going organ dysfunction (Star 1998). Conservative strategies of fluid management mandate a switch towards neutral balance and then negative balance once hemodynamic stabilization is achieved. In patients with AKI, this strategy might require renal replacement therapy to be given earlier than when more-liberal fluid management is used (Webb 2004). However, hypovolemic and renal hypo perfusion can occur in patients with AKI if excessive fluid removal is pursued with diuretics or extracorporeal therapy (Brar et al 2008). Accurate assessment of fluid status and careful definition of targets are needed at all stages to improve clinical outcomes. A conservative strategy of fluid management was recently tested and found to be effective in a large, randomized, controlled trial in patients with acute lung injury (Cleaver 2004). The decision to start RRT often varies in our unit depending on clinical condition. On our unit we recommend management strategy for patient with severe AKI. In the absence of evidence demonstrating clear superiority on one strategy over another, recommendations have been guided by economic and practical considerations. Evidence-based management strategies for persons with severe AKI are not currently available; for example, the optimal timing, modality, dose and frequency of hemodialysis are unknown. Unnecessary or too early a commencement RRT may subject to additional risk associated with the treatment itself. However clinical studies have not demonstrated a worse outcome in groups of patients where RRT was initiated early compared with patients where was commenced later. The most accepted indications for CRRT in patients with AKI generally include refractory fluid overload, Hyperkalemia (plasma potassium concentration >6.5) or rapidly rising potassium levels, signs of uremia, such as pericarditis, neuropathy, or an otherwise unexplained decline in mental status, metabolic acidosis (pH less than 7.1) and certain alcohol and drug intoxications The National Service Framework Part 1: Dialysis and Transplantation has stressed the need for a patient-centered approach in the planning and provision of renal replacement therapy with an emphasis on patient education and choice as well as the provision of adequate resources for elective access surgery, dialysis. It also identified that a small proportion of patients after counseling may opt for optimal conservative medical therapy without planning to initiate dialysis. The decision to initiate hemodialysis in patient with severe AKI requires consideration of multiple factors, including assessment of intravascular volume, electrolyte and acid base status, uremia nutritional requirement, urine output, hemodynamic status and the evolving clinical course of each patient. Potential advantages of earlier hemodialysis initiation must be set against the hypothetical risks of treatment induced kidney injury, bleeding due to anticoagulation and mechanical and infectious complications associated with central venous access (Bashaw 2006). Innovations and changes in hemodailysis practice have seldom been underpinned by adequately powered randomised trials. Nevertheless, day-to-day clinical decisions on hemodialysis are required and standards need to be set on the best available evidence. Consequently clinical practice guidelines for hemodialysis have been developed in Australasia, Canada, Europe and the USA as well as the UK. These guidelines serve to identify and promote best practice in the delivery of hemodialysis and have set clinical standards to allow comparative audit of the key aspects of the hemodialysis prescription, laboratory data and patient outcomes. The reports of the UK Renal Registry, Scottish Renal Registry and NHS Quality Improvement Scotland have demonstrated the benefits of performing regular audit to improve clinical standards in hemodialysis.As the search for better treatments for AKI continues, research findings are indicating that the technique and timing as well as the type of renal replacement therapy used may affect patients’ survival and recovery of renal function (Swartz, Bustanmi, Dailey 2005). The most common types of Continuous renal replacement therapy (CRRT) in acutely ill patients are, Continuous venovenous haemofiltration (CVVH), Continuous venovenous hemodialysis (CVVHD), Continuous venovenous haemodaiafiltration (CVVHDF) and Slow continuous ultrafiltration (SCUF). Dialysis is clearance of solutes and plasma water a semi permeable membrane down to a concentration gradient. Filtration is achieved across a semi-permeable membrane down a pressure gradient. The dialysate and effluent ultrafiltrate are discarded and substituted with replacement fluid before being returned to the patient together with the cleared blood. The author will only explain two most common types used in ICU which is CVVH and CVVHDF. According to research CVVH and CVVHDF are most commonly used and modern technology has led to increase safety and ease of use. CVVH is the most frequently used modality of CRRT in ICU. In our unit we used mainly CVVH in 90% of our patients. CVVH is defined as "a venovenous technique where the ultrafiltrate produced during membrane transit is replaced in part or completely with appropriate replacement solutions to achieve blood purification and volume control. The main difference from dialysis is the presence of pressure gradient across the semipermeable membrane and the transmembrane pressure gradient. This is achieved by a positive hydrostatic pressure in the blood compartment side of the filter and negative pressure on the dialysate side. Convective therapies appear to have advantages over other continuous therapies because of the ability to remove a wider range of solutes with the ultra-filtrate, including some cytokines (Faber and Klien 2009). Increasing the volume of ultrafiltrate produced in CVVH by increasing the infusion of replacement fluid increases clearance of both small- and middle-molecular-weight substances by solute drag. CVVHDF this combines the advantages of hemodialysis and CVVH, combines the advantages of hemodialysis and CVVH, obtaining solute clearance rates and biochemical control comparable to dialysis with the haemodynamic stability and filtration rates of CVVH. Most patients undergoing CRRT are oliguric, anuric, and possibly volume overloaded. The volume of hourly ultrafiltrate removed depends on an hourly fluid-balance calculation and an assessment of the patient’s volume status. Fluid management in CRRT typically involves hourly calculation of the patient’s non-RRT system intake plus fluid loss ordered by the doctor minus non-CRRT system output eg, urine, drainage fluid, blood loss. Excess fluid volume to be removed in a patient with fluid overload and is ordered by a doctor. Before starting CRRT, the tubing and filter should be primed with 0.9% saline containing 5000 i.u heparin. Priming of the circuit serves to remove air and detect any leaks before treatment is started (Brar et al. 2008). After the system is primed and brought to the bedside and before the connection with the patient is established, the circuit should be checked to ensure that all air has been removed. It is imperative to verify that the arterial or access side of the access tubing is securely connected to the catheter and, even more important, that the venous or return side of the tubing is securely attached to the catheter. If the venous side of the blood tubing is not connected securely to the catheter, an air embolism can occur because the blood will have traveled past the machine’s air detector. Nurses must continually assess the circuit tubing for the presence of air. Hypothermia is a complication of CRRT, the typical blood circuit can contain anywhere from 110 mL to 200 mL or more of blood outside the body at any time, a situation that contributes to cooling of the patient. Solutions such as replacement fluid and dialysate are used at room temperature. Infusion rates of 2 to 5 L/h or more provide a more efficient treatment than do slower rates; however, such large volumes of fluid can quickly lower a patient’s temperature if the fluids are not warmed. Effects of hypothermia include dysfunction of clotting factors and platelets, activation of fibrinolysis, and cardiac dysrhythmias (Lameire 2005 ). Some CRRT manufacturers offer a blood warmer for the blood in the circuit. In our unit our machine have plate or convective warmer for warming the therapy fluids, temperature can be adjusted up to 39 degree’s. Nursing tasks include monitoring the patient’s temperature, implementing warming interventions if needed, and monitoring for signs and symptoms of infection because the patient’s temperature is masked by the cooling effect of the circuit. Minimizing blood loss in patients receiving CRRT is always a priority. Prompt attention to alarms and knowledge of troubleshooting can prevent loss of blood in the circuit. Nurses caring for a patient receiving CRRT should know how to perform an automatic or manual return of the patient’s blood when CRRT is discontinued or the circuit is clotted. Ongoing blood loss due to failure to rinse the blood back to the patient or to an inability to detect signs of clotting in the hemofilter is detrimental to the patient and may affect the patient’s safety (Mehta at el 2004 ). Author suggest Nurses’ yearly competency testing should include a review of rinsing patients’ blood back in addition to a review of machine alarms. Predicting successful weaning from CRRT is difficult, spontaneous urine output more than 400mls a day us relatively reliable (Gibney et al 2008). In general most of our patient’s treatment is stepped down or intermittently pause once the patient clinical condition improves and the requirement for additional supportive therapy is decreasing. Although widely used of dopamine and furosemide have not bee shown to favorably affect the outcome of AKI. However, therapeutically forced urine production may ameliorate overall fluid balance and reduced dependence of RRT during recovery from the disease. Studies to date have indicated that mortality does not differ between patients who have had CRRT and patients who have had intermittent hemodialysis, but critically ill patients may experience other benefits from CRRT that are not possible with intermittent hemodialysis. Although CRRT has many benefits, like any other therapy, it does not guarantee survival. Patients requiring CRRT are often in a tenuous situation, and once CRRT is started, the therapy may or may not be discontinued without resulting in death. The decision to initiate CRRT requires clear and explicit understanding by patients and their families about the indications for the therapy and the potential that the therapy may or may not affect recovery (Thaker 2005). Critical care nurses have a responsibility to advocate for patients and patients’ families, encourage questions, and participate in education of patients and patients’ families about CRRT. Recent research indicating treatment with larger volumes of fluids each hour to provide a more adequate therapy may affect how CRRT continues to be used in critical care units. Our unit have set standards for care of patients receiving CRRT that require a ratio of 1 nurse to 1 patient, not only because of the severity of illness of patients receiving CRRT but also because of the additional burden of managing multiple liters of fluid volumes each hour and monitoring an extracorporeal blood circuit. This paradigm shift may contribute to an increased nursing workload if containers of therapy fluid and ultrafiltrate require replacement and disposal several times a shift or per hour. If the practice of using higher volumes of fluids increases, the issue of nursing time required to replace multiple liters of fluids for therapy and dispose of larger volumes of ultrafiltrate more frequently will have to be addressed. Currently, mortality associated with AKI remains high, and CRRT is becoming the therapy of choice for the treatment of AKI in critically ill patients. CRRT has many benefits for patients in the critical care unit, including improved hemodynamic stability, excellent fluid and solute removal, and possibly other benefits such as enhanced cytokine removal and prevention of sepsis. The use of CRRT in a multicenter trial may be necessary to validate its efficacy in the treatment of AKI. The use of CRRT for nonrenal indications and in conjunction with a bioartificial kidney will require further research and may offer promise for patients in whom AKI develops in the critical care unit (Drum et al 2005). The author has learnt that delivery of renal replacement therapy is now a core competency of intensive care nursing. The safe and effective delivery of this form of therapy is a quality issue for intensive care, requiring an understanding of the principles underlying therapy and the functioning of machines used. Although these machines conceal complexity behind a user-friendly interface, it remains important that nurses have sufficient knowledge for their use and the ability to compare and contrast circuit setups and functions for optimal and efficient treatment AKI support in the intensive care unit (ICU) is commonly provided by continuous treatment and managed by the ICU nurse. Regardless of the machine, safe and effective delivery of the various therapies requires a sound knowledge base and practical skill set beginning with appropriate education programs and supervision of practice. The knowledge base and clinical skills required of nurse to deliver this therapy have been defined and the importance of education and training and a collaborative practice model identified (Lameire 2005 ). A fundamental aspect of the safe and effective delivery of CRRT to manage AKI is an understanding of principles underlying therapy and functioning of the equipment used. The author can now compare and contrast the various modes of therapy in terms of solute clearance, delivery of treatment dose, and efficiency of solute clearance. Therefore, concepts of solute clearance and a consideration of the relative differences of the various modes of therapy. In conclusion the incidence of AKI is high and climbing, according to a presenter at the Society for Critical Care Medicine 2011 annual meeting. Bagshaw (2011) stressed the importance of early identification of at-risk patients and of primary and secondary prevention to head off the 50-60% mortality rate associated with AKI in critical illness.