Development and performance of electronic acute kidney injury triggers to identify pediatric patients at risk for nephrotoxic medication-associated harm.

BACKGROUND: Nephrotoxic medication-associated acute kidney injury (NTMx-AKI) is a costly clinical phenomenon and more common than previously recognized. Prior efforts to use technology to identify AKI have focused on detection after renal injury has occurred. OBJECTIVES: Describe an approach and provide a technical framework for the creation of risk-stratifying AKI triggers and the development of an application to manage the AKI trigger data. Report the performance characteristics of those triggers and the refinement process and on the challenges of implementation. METHODS: Initial manual trigger screening guided design of an automated electronic trigger report. A web-based application was designed to alleviate inefficiency and serve as a user interface and central workspace for the project. Performance of the NTMx exposure trigger reports from September 2011 to September 2013 were evaluated using sensitivity (SN), specificity (SP), positive and negative predictive values (PPV, NPV). RESULTS: Automated reports were created to replace manual screening for NTMx-AKI. The initial performance of the NTMx exposure triggers for SN, SP, PPV, and NPV all were ≥0.78, and increased over the study, with all four measures reaching ≥0.95 consistently. A web-based application was implemented that simplifies data entry and couriering from the reports, expedites results viewing, and interfaces with an automated data visualization tool. Sociotechnical challenges were logged and reported. CONCLUSION: We have built a risk-stratifying system based on electronic triggers that detects patients at-risk for NTMx-AKI before injury occurs. The performance of the NTMx-exposed reports has neared 100% through iterative optimization. The complexity of the trigger logic and clinical workflows surrounding NTMx-AKI led to a challenging implementation, but one that has been successful from technical, clinical, and quality improvement standpoints. This report summarizes the construction of a trigger-based application, the performance of the triggers, and the challenges uncovered during the design, build, and implementation of the system.

Delayed compared with immediate use of peritoneal catheter in pediatric peritoneal dialysis.

Delayed use of the peritoneal catheter may be one method of reducing catheter-related complications in chronic peritoneal dialysis (PD); however, the risks and benefits of immediate as compared with delayed use have not been examined in children. We retrospectively analyzed 33 peritoneal catheter placements in 27 children between 1997 and 2000. Eleven catheters were used for PD immediately following insertion (group I); 22 catheters were used only after a delay averaging 20 days (group D). Characteristics of the children in the two groups were similar. Catheter-related complications within the first 3 months after placement--including dialysate leak, fibrin plug, outflow obstruction, cuff extrusion, herniation, exit-site and tunnel infection, peritonitis, and catheter revision and replacement--were evaluated. Rates of individual complications in the two groups were similar, but several trends were noted. Dialysate leaks were more common in group I (rate of 0.36 in group I vs 0.09 in group D), and infectious complications were more common in group D (rate of exit-site or tunnel infection of 0.14 in group D vs 0.09 in group I; rate of peritonitis of 0.36 in group D vs 0.18 in group I). We conclude from this small study that delayed use of the peritoneal catheter does not appear to convey significant advantages over immediate use; however, immediate use may be associated with more frequent dialysate leaks. On the other hand, delayed use may be associated with a greater risk of infection. Further studies involving larger numbers of children will be necessary to confirm these findings.

Intravenous nicardipine for treatment of severe hypertension in children.

OBJECTIVE: To examine the effect of intravenous nicardipine in the treatment of children with severe hypertension. METHODS: The medical records of 29 children (mean age 94 months) treated with intravenous nicardipine were retrospectively reviewed. The mean duration of severe hypertension before nicardipine use was 12.5 hours. Most (74%) patients were receiving other antihypertensive agents before nicardipine. RESULTS: The initial nicardipine dose was 0.8 +/- 0.3 microg/kg/min (mean +/- SD). The mean effective dose was 1.8 +/- 1.0 microg/kg/min (range, 0.3 to 4.0). Blood pressure control was achieved within 2.7 +/- 2.1 hours after nicardipine was started. Nicardipine treatment produced a 16% reduction in systolic blood pressure, a 23% reduction in diastolic blood pressure, and a 7% increase in heart rate. Nicardipine was effective as a single agent on 26 (84%) of 31 occasions. Adverse effects included tachycardia, flushing, palpitations, and hypotension. CONCLUSIONS: When administered in the intensive care unit setting with close patient monitoring, intravenous nicardipine effectively lowered blood pressure in children with severe hypertension. Larger prospective studies should be conducted to confirm these findings.

AN-69 membrane reactions are pH-dependent and preventable.

We report two pediatric patients who required blood priming for continuous venovenous hemodiafiltration. Both of these patients developed a significant hypotensive episode with initiation of continuous venovenous hemodiafiltration with immediate resolution on discontinuation. The most notable common characteristics of these patients were the use of the Multi-flo 60 (AN-69) dialyzer membrane and blood priming. No similar episodes were encountered when patients were primed with saline or albumin. The AN-69 membrane is exquisitely pH sensitive. The lower the pH concentration of the blood passing by the membrane, the greater the activation of bradykinin, a known hypotensive-inducing agent, by the dialyzer. On review of blood available from our blood bank, the following parameters became apparent. The pH of standard blood available from our blood bank ranged from 6.1 to 6.4. The blood obtained from our blood bank had significant hyperkalemia, hyponatremia, and hypocalcemia. No reactions were noted when patients were primed with normal saline, which has a pH of around 5.9. We speculate that the presence of endogenous blood substances, such as bradykinin, may have induced the hypotensive episodes. We describe two techniques we developed that should allow for the increased safe and effective use of the AN-69 membranes in continuous venovenous hemodiafiltration circuits. These observations indicate the requirement for careful and close attention to detail when delivering renal replacement therapy to anyone, but especially patients weighing less than 10 kg.