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Care bundles

When implemented effectively, care bundles utilised in response to an AKI episode can improve outcomes in moderate to severe AKI (1). However, for a variety of reasons there is widespread variation in their implementation. There is currently no single care bundle recommended for universal use and many hospitals have adopted bundles in general circulation or have adapted and formulated their own.

Care bundles should be concise, accessible and understandable to healthcare professionals without specialist kidney knowledge given that the overwhelming majority of AKI episodes are managed by non-specialist clinicians.

The proposed essential components of any bundle should cover at least the elements of an initial assessment and management with attention to the core aspects of risk identification and prompt treatment of life threatening causes and complications. A suggested list of these components is detailed here:

Initial Assessment

  1. ABCDE Assessment
  2. Identify and start management for life threatening features if present:
    • Hyperkalaemia
    • Pulmonary oedema
  3. Assess fluid status: is the patient intravascularly dry, euvolaemic, or wet?
  4. Is the patient passing urine?
  5. Rule out obstruction – consider a bedside bladder scan

Initial Treatment

  1. Treat sepsis promptly if identified or suspected
  2. Fluid resuscitation if intravascularly dry
  3. Review medications:
    • What needs to stop
    • What needs to be dose adjusted
  4. Consider a urinary catheter
    • To monitor urine output
    • To relieve obstruction
  5. Who else do I need to involve?
    • Critical Care
    • Urology/Interventional Radiology
    • Renal Team

Further Investigation:

  • Urinalysis
  • Blood gas (to check acid/base status and lactate)
  • USS KUB within 24 hours if cause unclear/not recovering
  • CXR to assess for pulmonary oedema
  • Other tests based on clinical suspicion (see section ‘when to suspect a rare diagnosis’)

Ongoing Monitoring:

  • Input/output fluid balance chart
  • Daily weights
  • Appropriate NEWS2 monitoring frequency
  • Daily clinical assessment including volume status
  • Daily drug dosing review, including when to increase/restart when function improves
  • Consider dietician involvement

Care Bundle Examples:

ROUNDUP-26, created by the Society of Acute Medicine

STOP AKI, developed by the International Society of Nephrology

  1. Schaubroeck HAI, Vargas D, Vandenberghe W, et al. Impact of AKI care bundles on kidney and patient outcomes in hospitalized patients: a systematic review and meta-analysis. BMC Nephrol. 2021;22:335. doi:10.1186/s12882-021-02534-4.
Timing of review
Fluid Therapy