JOURNAL ARTICLE

Prevention and treatment of sepsis-induced acute kidney injury: an update

Patrick M Honore, Rita Jacobs, Inne Hendrickx, Sean M Bagshaw, Olivier Joannes-Boyau, Willem Boer, Elisabeth De Waele, Viola Van Gorp, Herbert D Spapen
Annals of Intensive Care 2015, 5 (1): 51
26690796
Sepsis-induced acute kidney injury (SAKI) remains an important challenge in critical care medicine. We reviewed current available evidence on prevention and treatment of SAKI with focus on some recent advances and developments. Prevention of SAKI starts with early and ample fluid resuscitation preferentially with crystalloid solutions. Balanced crystalloids have no proven superior benefit. Renal function can be evaluated by measuring lactate clearance rate, renal Doppler, or central venous oxygenation monitoring. Assuring sufficiently high central venous oxygenation most optimally prevents SAKI, especially in the post-operative setting, whereas lactate clearance better assesses mortality risk when SAKI is present. Although the adverse effects of an excessive "kidney afterload" are increasingly recognized, there is actually no consensus regarding an optimal central venous pressure. Noradrenaline is the vasopressor of choice for preventing SAKI. Intra-abdominal hypertension, a potent trigger of AKI in post-operative and trauma patients, should not be neglected in sepsis. Early renal replacement therapy (RRT) is recommended in fluid-overloaded patients' refractory to diuretics but compelling evidence about its usefulness is still lacking. Continuous RRT (CRRT) is advocated, though not sustained by convincing data, as the preferred modality in hemodynamically unstable SAKI. Diuretics should be avoided in the absence of hypervolemia. Antimicrobial dosing during CRRT needs to be thoroughly reconsidered to assure adequate infection control.

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Isabel Acosta-Ochoa

Independent from time frames, you should choose braod spectrum antibiotics and avoid nephrotoxic medications in general and antibiotics in particular.

8

Jonathan Hammond-Williams

What is the general consensus on IM vs IV abx in this circumstance?
In the pre-hospital setting IM may be quicker and more time-appropriate, so as to make extrication to hospital quicker and easier. However with septicaemia being 'of the blood', IV would seem to make more sense.

5

Eva Marie Gonzales

Administration of effective intravenous antimicrobials within the first hour of recognition of septic shock (grade 1B) and severe sepsis without septic shock (grade 1C) as the goal of therapy.

5

Karthik Raghunathan

It's a question of balancing timely delivery with what is convenient. IM is easier in the pre-hospital setting... If getting to the hospital is going to "take time", giving Antibiotics IM makes sense.

2

harshavardhan gantyala

When does antibiotics be started and what antibiotics can be used in treating aski?

1

Neal Hughes

I work for Greenville County EMS in Greenville, SC we recently received an award for “Best EMS Professional Research Presentation” at the National Association of EMS Physicians (NAEMSP) annual meeting.

Can Paramedics Draw uncontaminated blood cultures prior to prehospital antibiotic administration?

Background: Early antibiotic administration in the presence of sepsis can significantly decrease morbidity and mortality. CMS core measures require blood culture collections prior to administration of antibiotics. If uncontaminated blood cultures could be obtained by EMS prior to ED arrival, this would considerably reduce time to antibiotic administration for patients with the potential diagnosis of sepsis. In order to facilitate meeting core measures, we determined the rate of contaminated prehospital Paramedic blood cultures. This analysis is part of a larger “Sepsis Alert” prehospital protocol that calls for Paramedic administered antibiotics.

Methods: Retrospective, case series from a 3rd service EMS system model in the Greenville, South Carolina metropolitan area between November 14, 2014 and April 30, 2015 of blood cultures drawn from all 9-1-1 call adult patients. “Sepsis Alert” criteria were created using current Surviving Sepsis guidelines: 2 of 3 signs of systemic inflammatory response [HR, RR, oral temperature] and a known or suspected source of infection. Paramedics received 12 h of didactic and practical training that included aseptic technique and proper extremity blood culture collection. Contamination was defined by the receiving hospital laboratory analysis. Patient demographic data was gathered for descriptive statistical analysis.

Results: During the 6-month pilot, 120 trained paramedics acquired 356 blood cultures from 379 patients (55.3% male and mean age 65) with a 94.10% (335/356) no contamination rate. Contamination was found in 5.89% (21/356) with 14/21 (66.7%) of these identified as skin flora (coagulase negative Staphylococci). Most common ED admitting diagnoses were Sepsis 202/356 (56.7%), Severe Sepsis 47/356 (13.2%), and Septic Shock 30/356 (8.4%). Primary infection source included 46% pulmonary, 24% GU, 16% unknown, 6% skin, 4% GI, 3% other, and 1% implanted device.

Conclusion: This study demonstrates the potential for Paramedics to facilitate completing 1 component of the Core Measure Bundle for sepsis treatment in the field by acquiring prehospital blood cultures with a low contamination rate prior to antibiotic administration. It is yet to be determined if 6% contamination rate is clinically acceptable and if these findings are stable.

Walchok JG, Lutz ME, Shope CF, Gue G, Furmanek D, Pirrallo RG, Dix AC: Can paramedics draw uncontaminated blood cultures prior to prehospital antibiotic administration?
Prehospital Emergency Care 2016; 20:154 (A76)

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