PrEvalence of Acute and Chronic Kidney

advertisement
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
Download