Knowledge and practice patterns of pediatric critical care attending physicians in the diagnosis and management of acute kidney injury
Hassinger, Amanda Brooks
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Problem under investigation: Acute kidney injury (AKI) is a frequent problem in children with critical illness which carries significant morbidity and mortality and is increasing in incidence. Significant discrepancies exist between recent advances in AKI research and outcomes for children with AKI. It is unknown if the bedside clinician is aware of these advances and is using or operating with the latest knowledge. The current status of AKI care is not well understood in pediatric critical care. Objective: This study was performed to examine the variation in the knowledge and practice patterns of pediatric critical care attending physicians in the diagnosis, management, and follow-up of pediatric patients with AKI. Practice patterns were hypothesized to deviate significantly from current national guidelines for AKI management as outlined in the Kidney Disease: Improving Global Outcomes (KDIGO) expert consensus statement in 2012. Associations between degree of adherence to national guidelines and provider or facility characteristics were also investigated to identify target populations for future educational interventions. Research Design and Methods: An anonymous electronic questionnaire containing 27 items was distributed to attending physicians in pediatric critical care via two international research networks: the Society of Critical Care Medicine and the Pediatric Acute Lung Injury and Sepsis Investigators. Results: Of the 201 surveys which were started, 170 respondents (85% completion rate) completed more than 50% of the survey and were included in the final analysis. Median total adherence score was 11 (IQR 9-13) out of 25, equivalent to 44% adherence to guidelines. The median knowledge adherence score was 3 out of 10 (IQR2-4) and practice patterns adherence score was 8 out of 15 (IQR 6-9). There were no significant associations between physician experience, pediatric intensive care unit size, nephrology presence or geographic region and AKI knowledge or management performance scores (p-values for comparisons of scores between all demographic variables >0.05). Largest areas of discrepancy between respondents' answers and the guidelines were in questions related to AKI diagnosis, guideline knowledge and use, fluid overload management, and awareness of the long-term implications of AKI. Guideline awareness and use was associated with lower odds of poor AKI performance, OR 0.70 (95%CI 0.51-0.96, p=0.03) and had a significant correlation with practice patterns, r s =0.354, p<0.0001. Conclusion: Pediatric critical care physicians with all levels of experience, volume of renal replacement therapy, and institution size would benefit from increased education regarding AKI detection and impact. Increasing physician awareness of the limitations of serum creatinine, of the AKI guidelines, of the need for nephrology referral, and of the impact of fluid overload could lessen the burden of pediatric AKI in critically ill children.