(336) Targeting Nephrotoxic Medication Exposures to Reduce Acute Kidney Injury in Critically Ill Children

Introduction: Acute kidney injury (AKI) occurs in approximately 25% of critically ill children and is independently associated with worse clinical outcomes including chronic renal sequelae and up to an eightfold increase in mortality in PICU patients with severe AKI. Acute kidney injury risk is multi-factorial and often includes exposure to certain medications. Our PICU utilized a Nephrotoxic AKI (NAKI) quality improvement project modeled after multi-center quality improvement project, Nephrotoxic Injury Negated by Just-in-time Action (NINJA), to develop interventions to increase awareness of nephrotoxic medication exposures and reduce nephrotoxic drug associated AKIs.

Methods: A comprehensive, multi-disciplinary approach was used to increase recognition of nephrotoxic medication exposure in critically ill children and its association with AKI development. Nephrotoxic exposure criteria was defined as either having three medications in a 24-hour period or three consecutive days of vancomycin or an aminoglycoside. Our first phase introduced a monthly resident lecture provided by our unit-based pharmacists focusing on the exposure definition. The second phase provided a NAKI project informational handout reviewed during monthly resident orientation and available on the unit as a reference. During a third phase, pharmacists provided attending physicians daily notifications of patients with a nephrotoxic exposure and offered alternatives to commonly used nephrotoxic drugs.

Results: Our cohort included 208 unique patients (591 ICU patient days) between October 1st, 2022, and May 30th, 2023, who met nephrotoxic exposure criteria. Thirty-two patients developed AKI associated with their exposure episode. During this time, rates of nephrotoxic medication exposure dropped by 22.66% from 35.09 to 27.14 per 1000 patient days and NAKIs dropped by 43.59% from 5.30 to 2.99 per 1000 patient days.

Conclusions: Efforts to decrease AKI in critically ill children should target multiple provider levels. Providing repeated education for residents, an accessible reference guide for trainees, and daily alerts to attendings can collectively help decrease nephrotoxic medication exposures and NAKI rates in PICU patients.