Four hour creatinine clearance is better than plasma creatinine for monitoring renal function in critically ill patients.

Crit Care. 2012 Jun 19;16(3):R107

Authors: Pickering JW, Frampton CM, Walker RJ, Shaw GM, Endre ZH

Abstract

ABSTRACT: INTRODUCTION: Acute kidney injury (AKI) diagnosis is based on an increase in plasma creatinine, which is a slowly changing surrogate of decreased glomerular filtration rate. We investigated whether serial creatinine clearance, a direct measure of the glomerular filtration rate, provided more timely and accurate information on renal function than serial plasma creatinine in critically ill patients. METHODS: Serial plasma creatinine and 4-hour creatinine clearance were measured 12-hourly for 24 hours and then daily in 484 patients. AKI was defined either as >50% increase in plasma creatinine from baseline, or >33.3% decrease in creatinine clearance. The diagnostic and predictive performance of the two AKI definitions were compared. RESULTS: Creatinine clearance decrease diagnosed AKI in 24% of those not diagnosed by plasma creatinine increase on entry. These patients entered the ICU sooner after insult than those diagnosed with AKI by plasma creatinine elevation (P=0.0041). Mortality and dialysis requirement increased with the change in creatinine clearance-acute kidney injury severity class (P=0.0021). Amongst patients with plasma creatinine<1.24mg/dl on entry, creatinine clearance improved the prediction of AKI considerably (Net Reclassification Improvement 83%, Integrated Discrimination Improvement 0.29). On-entry, creatinine clearance associated with AKI severity and duration (P<0.0001) predicted dialysis need (area under the curve: 0.75) and death (0.61). A >33.3% decrease in creatinine clearance over the first 12 hours was associated with a 2.0-fold increased relative risk of dialysis or death. CONCLUSIONS: Repeated 4-hour creatinine clearance measurements in critically ill patients allow earlier detection of AKI, as well as progression and recovery compared to plasma creatinine. Trial Registration Australian New Zealand Clinical Trials Registry ACTRN012606000032550.

PMID: 22713519 [PubMed - as supplied by publisher]

Beyond winning: mediation, conflict resolution, and non-rational sources of conflict in the ICU.

Crit Care. 2012 Jun 19;16(3):308

Authors: Knickle K, McNaughton N, Downar J

Abstract

ABSTRACT: A 55-year-old woman with widely metastatic breast cancer was admitted to your intensive care unit (ICU) because of a decreased level of consciousness and respiratory failure. She had documented cerebral and meningeal metastases that were progressing despite chemotherapy and radiotherapy. The admitting physician met with her family and suggested a palliative approach, making them very upset. The family insisted that the team 'do everything' and now they refuse to discuss any change in the plan of treatment. They maintain a constant presence at the bedside, taking notes and questioning everyone who enters the room. They have threatened legal action toward several of the nursing staff, and hospital security has been called twice because of shouting matches between family and staff members. As the physician taking over care for the ICU, you would like to resolve this conflict.

PMID: 22713247 [PubMed - as supplied by publisher]