P3
CLINICAL ASSESSMENT OF HYPOVOLEMIA IN ACUTE KIDNEY INJURY: DO
WE PRACTICE A COMMON STANDARD?
Bond, J1, Thomas, M2
1
University Hospitals Coventry and Warwickshire, UK, 2Heartlands Hospital,
Birmingham
BACKGROUND: Acute kidney injury (AKI) is a common and serious condition
affecting 10-20% of all hospital admissions, commonly caused by hypovolemia and
sepsis. Poor clinical assessment of hypovolemia and consequent inadequate fluid
resuscitation results in significant morbidity. The NCEPOD report “Adding Insult to
Injury” 2009 found that undergraduate and postgraduate education in this area was
poor.
PURPOSE: This mixed methods study primarily aims to describe how specialists,
generalists, trainees and students practice fluid assessment. Secondary objectives of
this study were to define what aspects of AKI non-specialists would prefer further
education, and to describe if doctors can define AKI referring to AKIN criteria.
DESIGN: We piloted a questionnaire, and validated it by renal consultants and
registrars responses (n=14). We distributed it to 4th year students and junior doctors
(n=61) initially. The questionnaire asked for open text responses which we used
thematic analysis to identify recurring topics until saturation occurred.
RESULTS: When asked to describe how to undertake a clinical assessment of fluid
status, junior doctors tended to describe use of blood pressure, heart rate and urine
output. Jugular venous pulse was suggested by 42% of junior doctors and students vs
100% of renal trainees and consultants. Postural blood pressure was assessed in 0%
of junior doctors vs 42% of renal specialists. There was no consensus between
specialist’s opinions on what constituted an full assessment. Renal specialists named
this assessment “fluid assessment” (50%) and “volume assessment” by (21%) and
other labels for the remainder, with junior doctors similarly variable. Most junior
doctors were unable to define AKI either by change in creatinine or urine output
(5%). Key teaching areas identified were “definition”, “management”, “when to call
nephrology” and “when to use diuretics”.
CONCLUSION: We highlight significant variability in the clinical practice of
volume assessment. There is no clear consensus on a standard assessment between
renal specialists. In addition variability in the nomenclature of such assessment
exists. Knowledge of AKI definitions remains poor. Without an agreed definition of
clinical assessment or standard of examination it is difficult to improve the quality of
the assessment undertaken. We suggest that a standardised clinical examination of
fluid status be developed, which should be taught alongside basic “cardiovascular” or
“abdominal” examinations at undergraduate level. Recurring themes for education on
AKI highlight areas for local educators.
RELEVANCE: Defining a standard clinical examination for volume assessment
reduces confusion and allows objective assessment of clinical skills. This would
improve doctors’ clinical ability to recognise and manage hypovolemia, reducing the
burden of AKI.