Baby NINJA (Nephrotoxic Injury Negated by Just-in-Time Action): Reduction of Nephrotoxic Medication-Associated Acute Kidney Injury in the Neonatal Intensive Care Unit.

OBJECTIVE(S): To test if acute kidney injury (AKI) is preventable in patients in the neonatal intensive care unit and if infants at high-risk of nephrotoxic medication-induced AKI can be identified using a systematic surveillance program previously used in the pediatric non-intensive care unit setting. STUDY DESIGN: Quality improvement project that occurred between March 2015 and September 2017 in a single center, level IV neonatal intensive care unit. Infants were screened for high-risk nephrotoxic medication exposure (≥3 nephrotoxic medication within 24 hours or ≥4 calendar days of an intravenous [IV] aminoglycoside). If infants met criteria, a daily serum creatinine (SCr) was obtained until 2 days after end of exposure or end of AKI, whichever occurred last. The study was divided into 3 eras: pre-Nephrotoxic Injury Negated by Just-in-time Action (NINJA), initiation, and sustainability. Differences for 5 metrics across 3 eras were compared: SCr surveillance, high nephrotoxic medication exposure rate (per 1000 patient-days), AKI rate (per 1000 patient-days), nephrotoxin-AKI percentage, and AKI intensity (number of AKI days per 100 susceptible patient-days). RESULTS: Comparing the initiation with sustainability era, there was a reduction in high nephrotoxic medication exposures from 16.4 to 9.6 per 1000 patient-days (P = .03), reduction in percentage of nephrotoxic medication-AKI from 30.9% to 11.0% (P < .001), and reduction in AKI intensity from 9.1 to 2.9 per 100 susceptible patient-days (P < .001) while maintaining a high SCr surveillance rate. This prevented 100 AKI episodes during the 18-month sustainability era. CONCLUSION(S): A systematic surveillance program to identify high-risk infants can prevent nephrotoxic-induced AKI and has the potential to prevent short and long-term consequences of AKI in critically ill infants.

Advocating for the inclusion of kidney health outcomes in neonatal research: best practice recommendations by the Neonatal Kidney Collaborative.

Acute kidney injury (AKI) occurs in nearly 30% of sick neonates. Chronic kidney disease (CKD) can be detected in certain populations of sick neonates as early as 2 years. AKI is often part of a multisystem syndrome that negatively impacts developing organs resulting in short- and long-term pulmonary, neurodevelopmental, and cardiovascular morbidities. It is critical to incorporate kidney-related data into neonatal clinical trials in a uniform manner to better understand how neonatal AKI or CKD could affect an outcome of interest. Here, we provide expert opinion recommendations and rationales to support the inclusion of short- and long-term neonatal kidney outcomes using a tiered approach based on study design: (1) observational studies (prospective or retrospective) limited to data available within a center's standard practice, (2) observational studies involving prospective data collection where prespecified kidney outcomes are included in the design, (3) interventional studies with non-nephrotoxic agents, and (4) interventional studies with known nephrotoxic agents. We also provide recommendations for biospecimen collection to facilitate ancillary kidney specific research initiatives. This approach balances the costs of AKI and CKD ascertainment with knowledge gained. We advocate that kidney outcomes be included routinely in neonatal clinical study design. Consistent incorporation of kidney outcomes across studies will increase our knowledge of neonatal morbidity.

Implementation Strategies for Baby NINJA (Nephrotoxic Injury Negated by Just-in-Time Action) to Prevent Neonatal Medication-Induced Kidney Injury.

Acute kidney injury (AKI) is a common complication among patients admitted to the neonatal intensive care unit. Nephrotoxic medications (NTMs) are known to increase the incidence of AKI, but the use of these -medications is often unavoidable. Baby NINJA (Nephrotoxic Injury Negated by Just-in-Time Action) is a -quality improvement (QI) project that may be implemented at individual institutions and aims to systematically identify AKI in neonates and infants receiving NTMs. The purpose of this review is to describe nephrotoxic AKI in the neonatal population, introduce the Baby NINJA QI project and its potential to reduce neonatal AKI, and outline strategies for effective implementation of Baby NINJA.

Ketorolac in Postoperative Neonates and Infants: A Systematic Review.

OBJECTIVE: To evaluate the pharmacokinetics and pharmacodynamics, dosing, efficacy, and safety of ketorolac in postoperative patients younger than 6 months of age. METHODS: PubMed (1988-July 2020), Medline (1946-July 2020), and EBSCO Discovery Service (1988-July 2020) were searched to identify relevant published articles using the following search terms: ketorolac, neonate, infant. English-language articles evaluating the use of ketorolac in infants younger than 6 months of age were included. RESULTS: Eight reports that included 239 infants receiving ketorolac were included. Of the included patients, 237 were younger than 6 months of age. Ketorolac exhibits rapid elimination of the analgesia-producing S (-) isomer, elimination half-life of 0.83 hours. Most patients received 0.5 mg/kg/dose every 6 hours for 48 to 72 hours. Analgesia was demonstrated by reduced use of open-label morphine and significant lowering of Neonatal/Infant Pain Scale scores. Adverse effects were minimal when ketorolac was used in term neonates and infants without baseline renal dysfunction. CONCLUSIONS: Randomized placebo-controlled trials of ketorolac use in this population are lacking; however, most published reports noted efficacy and safety with ketorolac in properly selected infants.

Achieving Vancomycin Troughs Within Goal Range in Low Birth Weight Neonates.

OBJECTIVE: Vancomycin is commonly used in the neonatal population to treat Gram-positive bacterial infections. Despite frequent use, consensus on the ideal dosing regimen in low birth weight (LBW) neonates is lacking. The objective of this research is to determine how frequently vancomycin troughs within goal range (10-20 mg/L) are achieved with empiric dosing in critically ill neonates and infants weighing less than 2500 g. METHODS: This retrospective review evaluated LBW infants who were admitted to a level IV NICU from January 2015 to December 2016. Patients were included if they had a vancomycin trough sample collected at steady state (after at least 3 doses). Three trough cohorts (subtherapeutic: <10 mg/L, therapeutic: 10-20 mg/L, and supratherapeutic: >20 mg/L) were compared with 1-way ANOVA for continuous data and a chi-square analysis for categorical data. RESULTS: A total of 74 patients were included, with a mean birth weight (BW) of 819.7 ± 355.4 g and a mean gestational age (GA) of 26.4 ± 3.7 weeks. Only 27 patients (36.5%) had therapeutic vancomycin trough concentrations. Subtherapeutic troughs were recorded in 40 patients (54.1%), while supratherapeutic troughs were recorded in 7 patients (9.5%). Although there was no difference between the initial dose, initial frequency was significantly different between cohorts (p = 0.04). CONCLUSION: Empiric dosing regimens do not produce vancomycin troughs within the goal range in most LBW patients.