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ASSESSMENT OF AKI IN ER.pptx
1. Patient Assessment with AKI in ER
BASMAH AL MUSALAM
RN,BSN,TOT CERTIFIED ,ICU CLINICAL INSTRUCTOR
2. Clinical Objectives
By the end of this lecture the audience will be able to:
Taking history from the patient for kidney function
Discuss the assessment of fluids and electrolytes
Differentiate pitting edema scale
Assess patient for orthostatic hypotension
Explain the needed lab test to assess kidney function
Discuss the 5 step approach to AKI in the ED
4. Introduction
• Acute kidney injury (AKI), formerly known as acute renal failure (ARF)
• It is a sudden and often reversible reduction in kidney function, as measured by glomerular
filtration rate (GFR)
• According to Kidney Disease – Improving Global Outcomes (KDIGO), AKI is the presence
of any of the following:
Increase in serum creatinine by 0.3 mg/dL or more (26.5 micromoles/L or more) within 48
hours.
Increase in serum creatinine to 1.5 times or more baseline, within the prior 7 days
Urine volume less than 0.5 mL/kg/h for at least 6 hours
6. History of the patient
Patient Profile
Personal habits Use of herbs,
vitamins, and
dietary supplements
Illicit drug use
Financial problems
resulting from illness
Sexual function
7. History of the patient
Family History Current Medication Use
Hypertension
Diabetes mellitus
Polycystic kidney disease
Chronically swollen extremities
Nonsteroidal anti-inflammatory
medications
Antibiotics
Antihypertensive
Diuretics
Use of iodine-based
radiographic contrast media
12. Electrolyte and Waste Product Status
Chvostek & Trousseau signs sodium, potassium, calcium levels
13. Electrolyte and Waste Product Status
Therapies that can alter
electrolyte status
( diuretics,
antihypertensives, calcium
channel blockers)
Gastrointestinal changes
(nausea and
vomiting
Muscle strength
(potassium, BUN)
Behavioral and
mental changes
(sodium, BUN
levels)
17. Laboratory Studies
Assessment
Test
BUN is increased when kidney function deteriorates.
Blood urea nitrogen
(BUN)
is used to trend kidney function in critical illness as creatine is not re sorbed by the
kidney tubules and rises when kidney function deteriorates.
Serum creatinine
is a newer serum biomarker for early identification of acute kidney injury
Cystatin C
Electrolyte derangements are frequent in kidney failure including: sodium, potassium,
phosphate, calcium, chloride, and bicarbonate..
Electrolyte
increased in kidney failure in association with electrolyte and acid–base changes.
Anion gap
provide valuable information about kidney function, but results are not reliable if the
patient has recently been administered diuretics
Urinalysis
19. Step 1
Rule out the immediate life-threats
• Vital signs - Temp, Bp, saturation ….etc
• Hyperkalemia – ECG, electrolytes sample
• Severe acidosis – Blood Gas
20. Step 2
Assess for adequate perfusion – are they in shock?
• Use your history, physical examination and POCUS to assess
for perfusion and treat shock (hemorrhagic,
vasodilatory, cardiogenic shock etc.) accordingly.
21. Step 3
Assess for both pulmonary and peripheral edema
• Assess JVP and lungs with POCUS for pulmonary edema, look
and palpate for peripheral edema (including pre-tibial edema,
sacral edema)
• If there is no evidence of pulmonary or peripheral edema, give a
fluid challenge.
22. Step 3
A. AKI with adequate perfusion, with pulmonary edema (with or without peripheral
edema)
• furosemide 1 mg/kg IV (or 1.5 mg/kg IV if on furosemide already)
• Think about pulmonary renal syndromes other than CHF
B. AKI with adequate perfusion, with peripheral edema but not pulmonary edema
• furosemide 1 mg/kg IV (or 1.5 mg/kg IV if on furosemide already)
• If no improvement in renal function think about hypovolemia (“pre renal”) despite peripheral edema
Low serum albumin – treat underlying cause, and consider hepatorenal syndrome which may require IV
albumin
Venous insufficiency and/or lymphedema – give crystalloid
Drug induced edema – give crystalloid, reassess offending drug
Severe myxedema – give L-thyroxine and monitor
23. Step 4
The golden rules of AKI workup
Measure a post-void residual (PVR) with bladder scan or
urethral catheter
Get a urine dip to look for blood and protein suggestive of
nephritic syndrome
Monitor urine output ideally with a urethral catheter
Avoid nephrotoxins (NSAIDs, ACEi, ARBs, gentamicin etc)
24. Step 5
Consider imaging for a small subset of post-renal AKI
Radiology department imaging should be reserved for those patients who:
Do not improve with fluid challenge (making pre-renal less likely),
Have a normal urine dip (making intra-renal less likely),
Have a post-void residual <100mL (making BPH less likely)
Have obvious bilateral hydronephrosis on POCUS
These patients warrant further imaging as they might have a rare post-
renal bilateral ureteric obstruction cause of AKI such as obstructive
metastatic cancer, lymphoma or a kidney stone with a solitary kidney.
25. The indications for dialysis for any patient with AKI
>use the mnemonic AEIOU
Acidemia – pH<7.1 despite medical management
Electrolyte abnormalities – hyperkalemia refractory to medical
management
Ingestion – nephrotoxic drug ingestion
Overload – volume overload resulting in respiratory failure
Uremia with bleeding, pericarditis or encephalopathy
26. References:
AKI - Simple ED Approach | Emergency Medicine Cases
Overview of the management of acute kidney injury (AKI) in adults – UpToDate
https://www.stgeorges.nhs.uk/service/renal-medicine/acute-kidney-injury-aki-clinic/
https://www.theinternatwork.com/nephrology-week/2020/4/1/day-1-acute-kidney-injury
https://journals.lww.com/cjasn/fulltext/2008/07000/evaluation_and_initial_management_of_acute_kidn
ey.11.aspx
ds/Patricia_Gonce_Morton_Dorrie_K_Fontaine_Critical_Care_Nursing version 3
Normal creatinine level for men=0.74 to 1.35 mg/dl (65.4 to 119.3micromoles/L (
Normal creatinine level for women =0.59 to 1.04 mg/dl (52.2 to 91.9 micromoles/L (
Urine out put 0.5-1.5ml/kg/hr
Normal anion gap 4-12meq/l
NA+K-(CL+HCO3)
NA-(CL+HCO3)
