Minimum Care Bundle for AKI comments
I have reviewed this document with particular regard to the perspective of
centres without renal doctors on site.
Patients at such centres are at increased risk of delayed recognition and gaps in
reliable timely and efficient care. These centres would benefit most from concise,
clear guidance on AKI identified in hospital.
General Considerations on review:

This document should be welcomed but could be more concise and offer
greater clarity than the current format.

In particular the Easy Reference Guide needs to be less detailed and with
a clearer stepwise structure.
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It should also be strongly recommended that non-renal centres are aware
of where to turn for advice 24hrs per day. The advice regarding need for
urgent dialysis could be from critical care or renal services depending
upon local arrangements. Separate arrangements should be clear
regarding the process for advice and referral to local renal centre.s

Greater reference should be made to NICE CG50 guidance ‘For the
Management of the Acutely Ill Patient’ – it is this aspect of care that when
not performed well often leads to AKI or worsening AKI. It should be
hyper-linked from the Easy Reference guide.
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No comment is made regarding renal transplant AKI. This document
should perhaps suggest that all AKIs in this population should be
discussed. Although a small fraction of AKI burden; it is a more common
clinical scenario than HUS for example, which is mentioned several times.
I have made the following general observations and then more detailed section
comments follow.
1. Is this a care bundle or checklist or guidance or protocol based care?
A definitionfrom the IHI group – “A bundle is a structured way of improving the
processes of care and patient outcomes: a small, straightforward set of evidencebased practices — generally three to five — that, when performed collectively
and reliably, have been proven to improve patient outcomes”
Protocol based care might be a more accurate description.
http://www.institute.nhs.uk/quality_and_service_improvement_tools/qual
ity_and_service_improvement_tools/protocol_based_care.html
The authors reference and demonstrate a much clearer care bundle in appendix
6 – sepsis care bundle (pg 13). A similar stepwise approach should be adopted
to help improve uptake and implementation.
2. Who is the target audience?
This should be specified in the introduction. Is it aimed at Nursing staff, trainee
doctors etc? Guidance could be broken down into tasks for different staff
members.
3. Is there a difference depending on settings?
Steps to be taken will be different when identified on non-medical wards.
I would suggest that the steps taken should be limited in non-medical areas with
earlier escalation to medical or renal review depending on location/severity;
particularly regarding some of the investigations.
Specific section comments
1. Easy reference guide – sections highlighted in bold
This could be much clearer. The boxes should follow in a logical sequence if the
document is intended as a Care Bundle. The flow of information should be stepwise from identification through to referral – as the authors have listed in Key
Themes on page 5.
Most items could be hyper-linked from the easy reference guide page –
shortening the length of the document perhaps.
Potential life-threatening complications is the first box but seems out of place
– it should also hyperlink to the relevant management section.
The referral box should list items in order of clinical priority. Indications for
dialysis should come first and be hyper-linked. I don’t think many non-medical
specialities will consider or need to consider an Esoteric cause and this phrase is
not as clear as ‘rare & important’ for example.
Esoteric causes, or whatever phrase is used, should be the last item in the renal
referral section. I note in Appendix 4 the term ‘rare diagnosis’ is used rather
than Esoteric. Language should be consistent.
It might be worth highlighting that Stage 1 AKI could represent early important
cases – if not explicit then non-renal centres may dismiss significant Stage 1 AKI
rare diagnoses.
Finally, the most important referral should come first - which would be critical
care referral in most centres (approx 390 centres in England without access to
on-site emergency renal services delivered dialysis).
In Assessment; pulmonary oedema and tachypnoea (acidosis) should be listed
as signs of severe AKI complications before rarer uraemic complications. I
appreciate the Authors will be aware of these features but for junior doctors and
nursing staff these problems can be mis-interpreted (described as bilateral
pneumonia or anxiety respectively in recent real-life referrals).
Monitoring – this should list daily bloods first and include bicarbonate amongst
the recommended tests on the easy reference guide. It is a common failing on
non-medical and medical wards not to repeat assessments of U&Es plus other
cations/anions. Many laboratories do not routinely report bicarbonate to save
costs. Rather than ‘U&Es etc’ it would help many centres if tests were specified.
It is in this section specifically that distinct target audiences could be envisaged
and given clearer tasks.
Initial treatment – medication review could state stop nephrotoxic medications.
Investigation – the blood cultures/MSU line should follow from lactate and
earlier sepsis recommendation; or a link could be made to sepsis guidance
locally or nationally. All labs report a differential blood count – this may confuse
some centres who might think a different test is required – simply stating Raised
Eosinophils with accompanying possible differentials might be clearer.
To save space; additional renal tests based on clinical suspicion could be
hyperlinked to the appropriate appendix.
More detailed sections from page 5 onwards:
Key themes might be better numbered.
Assessment describes ‘..less common cause..’ – again inconsistent and should be
rarer or esoteric etc.
In relevant examination; the document formatting suggests reagent strip
urinalysis or palpation for enlarged bladder – I imagine the others intended both
to occur. This should be made clearer.
Severe AKI complications signs as per earlier comments.
Initial treatment
This lacks details for the medications. It should specify which common
medications should be stopped. It should also include a comment on
trimethoprim - a common confounder for referring teams and poorly recognised
source of hyperkalaemia outside of renal teams.
Relieve obstruction – this section covers catheterisation but catheterisation is
such an important topic it is worthy of separate point in the intitial treatment.
Section.
This section on obstruction does not describe or suggest close liaison with
Urology and Interventional Radiology for upper tract obstruction. There is
overlap with investigations but the importance of IR should be emphasised here
– again there might not be local IR capable of nephrostomies but the route to this
procedure should be clear.
The risks of catheterisation are not described and the inference from the text
used is that the benefit of fluid balance management outweighs risk of
catheterisation. ‘. . but also remembering the importance of estimating accurate
urine output measurement…’
It is still practised as a reflex to catheterise patients with AKI. – Often on the
advice of renal SpRs.
I think this document is an opportunity to spell out risks:
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Urethral/prostatic trauma
Transient bacteraemia and increased risk of sepsis
Catheter associated UTI
Iatrogenic pulmonary oedema from ‘chasing poor urine output’
This section should also specify the removal of urinary catheters if patient is
anuric.
The hypovolaemic section is displaced by a formatting error but it should refer to
sepsis and NICE IV fluids guidance in this section.
Investigations
The recommendation for phase contrast microscopy needs to be clarified. Most
non-renal centres will likely repeatedly ask Microbiology to perform this task. It
should be placed much lower down the list of suggested investigations with
clarity about who is likely to have this skill (Would Royal Pathology Society be
able to offer guidance on likelihood of this being available?).
The guidance regarding renal USS if high index of upper tract obstruction is
appropriate but it will not be necessary to place a urinary catheter first to have
this suspicion. A bladder scan and non-palpable bladder should be sufficient.
ABG is not mentioned in this list but is in the Easy Reference Guide – consistency
between the easy reference guide and this section would be better. The same
applies to all sections.
Monitoring – no comments
Referral sections – as previously described.
Further information sections:
Could these be grouped together rather than on separate pages?
Appendix 1 has brackets closing without opening in the parameters section. Can
the reader be directed to the exact RA page rather than the Guidelines
homepage?
Appendix 3 – Pulm Oedema - is there a role for venesection here if IV nitrates is
being suggested also?
No other comments.