PrEvalence of Acute and Chronic Kidney Disease treated by Renal Replacement Therapy in the ICU Environment (PEACE) A prospective international, multi-centre, prevalence study on the epidemiology of the use of renal replacement therapy for ICU patients who have acute kidney injury and chronic end stage kidney disease. Notes: For the entry of creatinine: one of two entry fields will appear based upon entries in the ICU profile. A: Creatinine mg/dl: or B: Creatinine μmol/l The same will be done for all entries having multiple values. Each of the multiple values are stored separately in the database, So that the investigator will see the value they entered upon returning to the patient When the data is downloaded to an Excel spreadsheet only the study value is shown. Values entered with other units of measure will be converted to the unit of measure for the study. For diagnostic purposes the spreadsheet also can be downloaded showing all the values entered. Note: is a symbol for checkbox, all applicable can be checked is a symbol for radio box, only one of the group may be selected. E Hoste, PEACE CRF draft version 1.0, 24 apr 2013 Pagina 1 I have placed "/ " next to a heading which I do not know which to use. inasmuch that the same researchers will be participating in this study as did in AKIEPI.ORG, I had planned to use the same database for ICU units for this study, everyone registered for AKIEPI.org would be registered for AKIPeace.org. No need to re-enter the same data Their old login and password will still work ?? Agreed y/n ?? E Hoste, PEACE CRF draft version 1.0, 24 apr 2013 Pagina 2 This is the data entry specifications for the peace project Version 4.2 Patient data: Age: Number Min=18 Max Gender: Male Female Race: White Native Hawaiian / Pacific Islander Black / African American Asian Other Specify: _______________ Ethnicity: Hipanic or Latino Not Hispanic or Latino Height: ______ cm _______ in Cm Min Max in Min Max lbs Min Max mmol/L Min=18 Max mmol/L Min=18 Max mmol/L Min=18 Max Weight: ______ kg _______ lbs Kg Min Creatinine: mg/dl Max BASELINE: Min=2 Max At HOSPITAL admission: mg/dl Min=2 Max At ICU admission mg/dl Min=2 Max Admission data: Admission date Hospital: ______________ (dd/mmm/yyyy) Admission date ICU: ______________ (dd/mmm/yyyy) Referred from: Home Emergency Room Ward E Hoste, PEACE CRF draft version 1.0, 24 apr 2013 Pagina 3 Other Hospital Other ICU Reason for ICU admission: Medical Emergency Surgical Elective Surgical Other Specify: ________________ Main admission diagnosis: Data on Severity of illness and processes of care for RRT - First meeting AKI stage 3 criterion based upon serum creatinine or urine output criteria - Initiation of RRT For patients who progress from AKI stage 3 to initiation of RRT during the study period, data will be recorded at both time points. When RRT was already initiated at time of the index study date, the investigator needs to record data at time of initiation. RRT: Date of First meeting AKI 3 criterion: ______________ (dd/mmm/yyyy) Date of Initiation: ________________ (dd/mmm/yyyy) Who made the decision: / Nephrologist Intensivist Indications for RRT: (tick all that apply) Hyperkalaemia Anuria / Oliguria with/without volume overload Acidosis – low pH - BD Urea concentration Creatinine Phosphorus Lactate Low Creatinine Clearance (value _______ ) This should be range checked for values that would indicate low creatinine clearance mg/dl Min=2 Max mmol/L Min=18 Max . FE sodium E Hoste, PEACE CRF draft version 1.0, 24 apr 2013 Pagina 4 FE urea Chronic end stage kidney disease Other Specify: ________________ Modality at time of initiation: / Hr Min CVVH CVVHD CVVHDF CAVH CAVHD SLEDD (duration ____ H.) Max Intermittent duration (duration ____ H.) Hr Min Max Peritoneal dialysis Other Specify: _______________ Continuous Therapies: Replacement fluid buffer: / Replacement fluid: Bicarbonate Lactate Acetate Other Specify: _______________ Pre-dilution Post dilution Both, proportion ______ Peritoneal dialysis: / Manual Machine Type of peritoneal dialysis Acute intermittent PD High Volume PD Catheter placement by: Chronic equilibrated PD Continuous flow PD Tidal PD Intensivist Nephrologist Surgeon Other Specify: _______________ E Hoste, PEACE CRF draft version 1.0, 24 apr 2013 Pagina 5 Catheter placement on: OR ICU Other Specify: _______________ Dwell Time: ____ H. ____ min. Hr min max Mi 0 59 Dwell Volume: _______ ml Ml Min Max Number of exchanges per 24H.: ______ Number Min Max Type of PD fluid: ________________ From Excel Data Sheet drop down options Method of peritoneal dialysis manual machine Acute intermittent PD chronic equilibrated PD Type of peritoneal dialysis Tidal PD Continuous flow PD High flow PD Operator who placed PD catheter Intensivist Nephrologist Surgeon Other Location of catheter placement Operating room ICU Other Dwell time Hr Dwell volume Ml Min 24hr Mi numeric (hours and minutes) 0 59 numeric max 24hours max 3000ml Max=3000 E Hoste, PEACE CRF draft version 1.0, 24 apr 2013 Pagina 6 Number of exchanges per 24 hrs Number Min Max Type of PD fluid numeric text Who does the setup of the RRT machine: Renal nurse ICU nurse Nephrologist Other Intensivist Who monitors the RRT machine: Renal nurse ICU nurse Specify: _______________ Other Specify: _______________ Duration of RRT: Prescribed _____ H. Hr Max Administered _____ H. Hr Max Net Fluid removal: Prescribed _____ Unit Max Actual net fluid removal Unit Max Anticoagulation strategy: Unfractionated Heparin monitored with / ACT APTT antiXa None LMWH monitored with / antiXa None Citrate monitored with / Cai patient Cai circuit Total Calcium patient None E Hoste, PEACE CRF draft version 1.0, 24 apr 2013 Pagina 7 Saline flushes Prostaglandins None Other Specify: ______________ Vascular access: catheter: / Double lumen Single lumen French: _____ Unit Min Max Unit Min Max Unit Min Max In Min Max Gauge: _____ Unit Min Max Length: _____ cm _____ in Cm Min Insertion site: / Max Jugular Vein Left Subclavian Vein Femoral Vein Right Left Left Right Right SOFA-score: Respiratory Ventilation First meeting AKI 3 criterion Yes No At Initiation of RRT Yes No 5 Lowest P/F Renal Highest Creatinine 24H. Urine output Liver Highest Total Bilirubin mg/dl 0.2 0 mg/dL E Hoste, PEACE CRF draft version 1.0, 24 apr 2013 1000 15.0 mmol/L 18 1326 25.0 µmol/L 8.6 427.5 4000 0.5 Pagina 8 Hemato Lowest Platelets Cardio Lowest MAP x 1000/mm3 5 1000 mmHg mmHg Unit Min Max Unit Min Max µgr/kg/min µgr/kg/min Unit Min Max Unit Min Max µgr/kg/min µgr/kg/min Unit Min Max Unit Min Max DOPA µgr/kg/min µgr/kg/min Unit Min Max Unit Min Max ADR µgr/kg/min µgr/kg/min Unit Min Max Unit Min Max VASO µgr/kg/min µgr/kg/min Min Max Unit Min Max Min Max and DOBU Unit NOR Neuro GCS Sedation Unit Yes No Yes Min Max Unit No Outcomes: ICU discharge Date : Status: RRT: Creatinine: ______________ (dd/mmm/yyyy) Alive Death Yes No ______ ______ (unit) Hospital discharge Date: ______________ (dd/mmm/yyyy) Status: Alive Death RRT: Yes No Creatinine: ______ ______ (unit) Index study date +30 Date: ______________ (dd/mmm/yyyy) Status: Alive Death RRT: Yes No Creatinine: ______ ______ (unit) Index study date +60 Date: ______________ (dd/mmm/yyyy) Status: Alive Death RRT: Yes No Creatinine: ______ ______ (unit) E Hoste, PEACE CRF draft version 1.0, 24 apr 2013 Pagina 9 E Hoste, PEACE CRF draft version 1.0, 24 apr 2013 Pagina 10