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Gebhardt B, Jain A. Beyond the Beat: A Cardiac Anesthesiologist's Perspective on Cardiovascular-Kidney-Metabolic Health in Perioperative Care. J Cardiothorac Vasc Anesth 2024; 38:1078-1080. [PMID: 38467526 DOI: 10.1053/j.jvca.2024.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Accepted: 02/19/2024] [Indexed: 03/13/2024]
Affiliation(s)
- Brian Gebhardt
- Department of Anesthesiology and Perioperative Medicine University of Massachusetts Medical Center, Worcester, MA
| | - Ankit Jain
- Department of Anesthesiology and Perioperative Medicine, Medical College of Georgia, Augusta University, Augusta, GA
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2
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D'Amico F, Pruna A, Putowski Z, Dormio S, Ajello S, Scandroglio AM, Lee TC, Zangrillo A, Landoni G. Low Versus High Blood Pressure Targets in Critically Ill and Surgical Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Crit Care Med 2024:00003246-990000000-00330. [PMID: 38656245 DOI: 10.1097/ccm.0000000000006314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
OBJECTIVES Hypotension is associated with adverse outcomes in critically ill and perioperative patients. However, these assumptions are supported by observational studies. This meta-analysis of randomized controlled trials aims to compare the impact of lower versus higher blood pressure targets on mortality. DATA SOURCES We searched PubMed, Cochrane, and Scholar from inception to February 10, 2024. STUDY SELECTION Randomized trials comparing lower versus higher blood pressure targets in the management of critically ill and perioperative settings. DATA EXTRACTION The primary outcome was all-cause mortality at the longest follow-up available. This review was registered in the Prospective International Register of Systematic Reviews, CRD42023452928. DATA SYNTHESIS Of 2940 studies identified by the search string, 28 (12 in critically ill and 16 in perioperative settings) were included totaling 15,672 patients. Patients in the low blood pressure target group had lower mortality (23 studies included: 1019/7679 [13.3%] vs. 1103/7649 [14.4%]; relative risk 0.93; 95% CI, 0.87-0.99; p = 0.03; I2 = 0%). This corresponded to a 97.4% probability of any increase in mortality with a Bayesian approach. These findings were mainly driven by studies performed in the ICU setting and with treatment lasting more than 24 hours; however, the magnitude and direction of the results were similar in the majority of sensitivity analyses including the analysis restricted to low risk of bias studies. We also observed a lower rate of atrial fibrillation and fewer patients requiring transfusion in low-pressure target groups. No differences were found in the other secondary outcomes. CONCLUSIONS Based on pooled randomized trial evidence, a lower compared with a higher blood pressure target results in a reduction of mortality, atrial fibrillation, and transfusion requirements. Lower blood pressure targets may be beneficial but there is ongoing uncertainty. However, the present meta-analysis does not confirm previous findings and recommendations. These results might inform future guidelines and promote the study of the concept of protective hemodynamics.
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Affiliation(s)
- Filippo D'Amico
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Pruna
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Zbigniew Putowski
- Department of Intensive Care and Perioperative Medicine, Center for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Sara Dormio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Silvia Ajello
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Todd C Lee
- Division of Infectious Diseases, Department of Medicine, McGill University, Montreal, QC, Canada
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
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3
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Wang F, Zhu Y. Intraoperative hypotension and postoperative outcomes. Comment on Br J Anaesth 2023; 131: 823-831. Br J Anaesth 2024; 132:178-180. [PMID: 37923583 DOI: 10.1016/j.bja.2023.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 10/05/2023] [Indexed: 11/07/2023] Open
Affiliation(s)
- Fei Wang
- Department of Anesthesiology, Sichuan Academy of Medical Science and Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Yihao Zhu
- Department of Anesthesiology, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China.
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Cheruku SR, Raphael J, Neyra JA, Fox AA. Acute Kidney Injury after Cardiac Surgery: Prediction, Prevention, and Management. Anesthesiology 2023; 139:880-898. [PMID: 37812758 PMCID: PMC10841304 DOI: 10.1097/aln.0000000000004734] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
Acute kidney injury (AKI) is a common complication in cardiac surgery patients, with a reported incidence of 20 to 30%. The development of AKI is associated with worse short- and long-term mortality, and longer hospital length of stay. The pathogenesis of cardiac surgery-associated AKI is poorly understood but likely involves an interplay between preoperative comorbidities and perioperative stressors. AKI is commonly diagnosed by using increases in serum creatinine or decreased urine output and staged using a standardized definition such as the Kidney Disease Improving Global Outcomes classification. Novel biomarkers under investigation may provide earlier detection and better prediction of AKI, enabling mitigating therapies early in the perioperative period. Recent clinical trials of cardiac surgery patients have demonstrated the benefit of goal-directed oxygen delivery, avoidance of hyperthermic perfusion and specific fluid and medication strategies. This review article highlights both advances and limitations regarding the prevention, prediction, and treatment of cardiac surgery-associated AKI.
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Affiliation(s)
- Sreekanth R Cheruku
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jacob Raphael
- Department of Anesthesiology and Perioperative Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Javier A Neyra
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Amanda A Fox
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas; McDermott Center for Human Growth and Development, University of Texas Southwestern Medical Center, Dallas, Texas
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5
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D'Amico F, Fominskiy EV, Turi S, Pruna A, Fresilli S, Triulzi M, Zangrillo A, Landoni G. Intraoperative hypotension and postoperative outcomes: a meta-analysis of randomised trials. Br J Anaesth 2023; 131:823-831. [PMID: 37739903 DOI: 10.1016/j.bja.2023.08.026] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 08/11/2023] [Accepted: 08/16/2023] [Indexed: 09/24/2023] Open
Abstract
INTRODUCTION Intraoperative hypotension is associated with adverse postoperative outcomes; however these findings are supported only by observational studies. The aim of this meta-analysis of randomised trials was to compare the postoperative effects permissive management with targeted management of intraoperative blood pressure. METHODS We searched PubMed, Cochrane, and Embase up to June 2023 for studies comparing permissive (mean arterial pressure ≤60 mm Hg) with targeted (mean arterial pressure >60 mm Hg) intraoperative blood pressure management. Primary outcome was all-cause mortality at the longest follow-up available. Secondary outcomes were atrial fibrillation, myocardial infarction, acute kidney injury, delirium, stroke, number of patients requiring transfusion, time on mechanical ventilation, and length of hospital stay. RESULTS We included 10 randomised trials including a total of 9359 patients. Mortality was similar between permissive and targeted blood pressure management groups (89/4644 [1.9%] vs 99/4643 [2.1%], odds ratio 0.88, 95% confidence interval [CI], 0.65-1.18, P=0.38, I2=0% with nine studies included). Atrial fibrillation (102/3896 [2.6%] vs 130/3887 [3.3%] odds ratio 0.71, 95% CI 0.53-0.96, P=0.03, I2=0%), and length of hospital stay (mean difference -0.20 days, 95% CI -0.26 to -0.13, P<0.001, I2=0%) were reduced in the permissive management group. No significant differences were found in subgroup analysis for cardiac and noncardiac surgery. CONCLUSION Pooled randomised evidence shows that a target intraoperative mean arterial pressure ≤60 mm Hg is not associated with increased mortality; nevertheless it is surprisingly associated with a reduced rate of atrial fibrillation and of length of hospital stay. SYSTEMATIC REVIEW PROTOCOL PROSPERO CRD42023393725.
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Affiliation(s)
- Filippo D'Amico
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Evgeny V Fominskiy
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Turi
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Pruna
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Fresilli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Margherita Triulzi
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy.
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Rasmussen SB, Boyko Y, Ranucci M, de Somer F, Ravn HB. Cardiac surgery-Associated acute kidney injury - A narrative review. Perfusion 2023:2676591231211503. [PMID: 37905794 DOI: 10.1177/02676591231211503] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
Cardiac Surgery-Associated Acute Kidney Injury (CSA-AKI) is a serious complication seen in approximately 20-30% of cardiac surgery patients. The underlying pathophysiology is complex, often involving both patient- and procedure related risk factors. In contrast to AKI occurring after other types of major surgery, the use of cardiopulmonary bypass comprises both additional advantages and challenges, including non-pulsatile flow, targeted blood flow and pressure as well as the ability to manipulate central venous pressure (congestion). With an increasing focus on the impact of CSA-AKI on both short and long-term mortality, early identification and management of high-risk patients for CSA-AKI has evolved. The present narrative review gives an up-to-date summary on definition, diagnosis, underlying pathophysiology, monitoring and implications of CSA-AKI, including potential preventive interventions. The review will provide the reader with an in-depth understanding of how to identify, support and provide a more personalized and tailored perioperative management to avoid development of CSA-AKI.
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Affiliation(s)
- Sebastian Buhl Rasmussen
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Yuliya Boyko
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | - Marco Ranucci
- Department of Cardiovascular Anaesthesiology and Intensive Care, IRCCS Policlinico San Donato, Milan, Italy
| | | | - Hanne Berg Ravn
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Hui V, Ho KM, Hahn R, Wright B, Larbalestier R, Pavey W. The association between intraoperative cardiopulmonary bypass power and complications after cardiac surgery. Perfusion 2023:2676591231187958. [PMID: 37442644 DOI: 10.1177/02676591231187958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/15/2023]
Abstract
BACKGROUND Low cardiac power (product of flow and pressure) has been shown to be associated with mortality in patients with cardiogenic shock after acute myocardial infarction, but has not been studied in cardiac surgical patients. This study's hypothesis was that cardiac power during cardiopulmonary bypass for cardiac surgery would have a greater association with adverse events than either flow or MAP (mean arterial pressure) alone. METHODS We undertook a retrospective observational study using patient data from February 2015 to March 2022 undergoing cardiac surgery at Fiona Stanley Hospital in Perth Australia. Excluded were patient age less than 18 years old, patients undergoing thoracic transplantation, ventricular assist devices, off pump cardiac surgery and aortic surgery. The primary outcome was a composite outcome of 30-days mortality, stroke or new-onset renal insufficiency. RESULTS Overall, 1984 cardiac surgeries were included in the analysis. Neither duration nor area below thresholds tested for power, MAP or flow was associated with the primary composite outcome. However, we found that an area below MAP thresholds 35-50 mmHg was associated with new renal insufficiency (adjusted odds ratio 1.17 [95% CI 1.02 to 1.35] for patients spending 10 min at 10 mmHg below 50 mmHg MAP compared to those who did not). CONCLUSIONS This study suggests that MAP during cardiopulmonary bypass, but not power or flow, was an independent risk factor for adverse renal outcomes for cardiac surgical patients.
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Affiliation(s)
- Victor Hui
- Department of Anaesthesia and Pain Medicine, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Heart Lung Research Institute of Western Australia, WA, Australia
| | - Kwok M Ho
- Medical School, University of Western Australia, Perth, WA, Australia
- School of Veterinary and Life Sciences, Murdoch University, Perth, WA, Australia
| | - Rebecca Hahn
- Heart Lung Research Institute of Western Australia, WA, Australia
| | - Brian Wright
- Department of Anaesthesia, Pain and Perioperative Medicine, Fiona Stanley Hospital, Perth, WA, Australia
| | - Robert Larbalestier
- Department of Cardiothoracic Surgery, Fiona Stanley Hospital, Perth, WA, Australia
| | - Warren Pavey
- Heart Lung Research Institute of Western Australia, WA, Australia
- Department of Anaesthesia, Pain and Perioperative Medicine, Fiona Stanley Hospital, Perth, WA, Australia
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8
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Kant S, Banerjee D, Sabe SA, Sellke F, Feng J. Microvascular dysfunction following cardiopulmonary bypass plays a central role in postoperative organ dysfunction. Front Med (Lausanne) 2023; 10:1110532. [PMID: 36865056 PMCID: PMC9971232 DOI: 10.3389/fmed.2023.1110532] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 01/30/2023] [Indexed: 02/17/2023] Open
Abstract
Despite significant advances in surgical technique and strategies for tissue/organ protection, cardiac surgery involving cardiopulmonary bypass is a profound stressor on the human body and is associated with numerous intraoperative and postoperative collateral effects across different tissues and organ systems. Of note, cardiopulmonary bypass has been shown to induce significant alterations in microvascular reactivity. This involves altered myogenic tone, altered microvascular responsiveness to many endogenous vasoactive agonists, and generalized endothelial dysfunction across multiple vascular beds. This review begins with a survey of in vitro studies that examine the cellular mechanisms of microvascular dysfunction following cardiac surgery involving cardiopulmonary bypass, with a focus on endothelial activation, weakened barrier integrity, altered cell surface receptor expression, and changes in the balance between vasoconstrictive and vasodilatory mediators. Microvascular dysfunction in turn influences postoperative organ dysfunction in complex, poorly understood ways. Hence the second part of this review will highlight in vivo studies examining the effects of cardiac surgery on critical organ systems, notably the heart, brain, renal system, and skin/peripheral tissue vasculature. Clinical implications and possible areas for intervention will be discussed throughout the review.
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Affiliation(s)
| | | | | | | | - Jun Feng
- Cardiothoracic Surgery Research Laboratory, Department of Cardiothoracic Surgery, Rhode Island Hospital, Lifespan, Providence, RI, United States
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9
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Mukaida H, Matsushita S, Yamamoto T, Minami Y, Sato G, Asai T, Amano A. Oxygen delivery-guided perfusion for the prevention of acute kidney injury: A randomized controlled trial. J Thorac Cardiovasc Surg 2023; 165:750-760.e5. [PMID: 33840474 DOI: 10.1016/j.jtcvs.2021.03.032] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 03/02/2021] [Accepted: 03/05/2021] [Indexed: 01/18/2023]
Abstract
OBJECTIVES The reduction of postoperative acute kidney injury in patients undergoing cardiopulmonary bypass surgery using an oxygen delivery-guided perfusion strategy (oxygen delivery strategy) for cardiopulmonary bypass management compared with a fixed flow perfusion (conventional strategy) remains controversial. The purpose of this study was to determine whether a oxygen delivery strategy would reduce the incidence of postoperative acute kidney injury in patients undergoing cardiopulmonary bypass surgery. METHODS We randomly enrolled 300 patients undergoing cardiopulmonary bypass surgery. Patients were randomly assigned to a oxygen delivery strategy (maintaining a oxygen delivery index value >300 mL/min/m2 through pump flow adjustments during cardiopulmonary bypass) or a conventional strategy (a target pump flow was determined on the basis of the body surface area). The primary end point was the development of acute kidney injury. Secondary end points were the red blood cell transfusion rate and number of red blood cell units, intubation time, postoperative length of stay in the intensive care unit and the hospital, predischarge estimated glomerular filtration rate, and hospital mortality. RESULTS Acute kidney injury occurred in 20 patients (14.6%) receiving the oxygen delivery strategy and in 42 patients (30.4%) receiving the conventional strategy (relative risk, 0.48; 95% confidence interval, 0.30-0.77; P = .002). The secondary end points were not significantly different between strategies. In a prespecified subgroup analysis of patients who had nadir hematocrit less than 23% or body surface area less than 1.40 m2, the oxygen delivery strategy seemed to be superior to the conventional strategy and the existence of quantitative interactions was suggested. CONCLUSIONS An oxygen delivery strategy for cardiopulmonary bypass management was superior to a conventional strategy with respect to preventing the development of acute kidney injury.
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Affiliation(s)
- Hiroshi Mukaida
- Department of Clinical Engineering, Juntendo University Hospital, Tokyo, Japan; Department of Cardiovascular Surgery, Juntendo University, Faculty of Medicine, Tokyo, Japan
| | - Satoshi Matsushita
- Department of Cardiovascular Surgery, Juntendo University, Faculty of Medicine, Tokyo, Japan.
| | - Taira Yamamoto
- Department of Cardiovascular Surgery, Juntendo University, Faculty of Medicine, Tokyo, Japan
| | - Yuki Minami
- Department of Clinical Engineering, Juntendo University Hospital, Tokyo, Japan
| | - Go Sato
- Department of Clinical Engineering, Juntendo University Hospital, Tokyo, Japan
| | - Tohru Asai
- Department of Cardiovascular Surgery, Juntendo University, Faculty of Medicine, Tokyo, Japan
| | - Atsushi Amano
- Department of Cardiovascular Surgery, Juntendo University, Faculty of Medicine, Tokyo, Japan
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10
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Ranucci M, Cotza M, Di Dedda U. The Conundrum of Systemic Arterial Pressure Management on Cardiopulmonary Bypass. J Clin Med 2023; 12:jcm12030806. [PMID: 36769463 PMCID: PMC9918189 DOI: 10.3390/jcm12030806] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 01/05/2023] [Accepted: 01/16/2023] [Indexed: 01/20/2023] Open
Abstract
The recently released EACTS/EACTA/EBCP guidelines on cardiopulmonary bypass (CPB) in adult cardiac surgery [...].
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11
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Tran PNT, Kusirisin P, Kaewdoungtien P, Phannajit J, Srisawat N. Higher blood pressure versus normotension targets to prevent acute kidney injury: a systematic review and meta-regression of randomized controlled trials. Crit Care 2022; 26:364. [PMID: 36434726 PMCID: PMC9700976 DOI: 10.1186/s13054-022-04236-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 11/10/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Renal hypoperfusion is one of the most common causes of acute kidney injury (AKI), especially in shock and perioperative patients. An optimal blood pressure (BP) target to prevent AKI remains undetermined. We conducted a systematic review and meta-analysis of available randomized clinical trial (RCT) results to address this knowledge gap. METHODS From inception to May 13, 2022, we searched Ovid Medline, EMBASE, Cochrane Library, SCOPUS, clinicaltrials.gov, and WHO ICTRP for RCTs comparing higher BP target versus normotension in hemodynamically unstable patients (shock, post-cardiac arrest, or surgery patients). The outcomes of interest were post-intervention AKI rate and renal replacement therapy (RRT) rate. Two investigators independently screened the citations and reviewed the full texts for eligible studies according to a predefined form. RESULTS Twelve trials were included, enrolling a total of 5759 participants, with shock, non-cardiac, and cardiac surgery patients accounting for 3282 (57.0%), 1687 (29.3%) and 790 (13.7%) patients, respectively. Compared to lower mean arterial blood pressure (MAP) targets that served as normotension, targeting higher MAP had no significant effect on AKI rates in shock (RR [95% CI] = 1.10 [0.93, 1.29]), in cardiac-surgery (RR [95% CI] = 0.87 [0.73, 1.03]) and non-cardiac surgery patients (RR [95% CI] = 1.25 [0.98, 1.60]) using random-effects meta-analyses. In shock patients with premorbid hypertension, however, targeting MAP above 70 mmHg resulted in significantly lower RRT risks, RR [95%CI] = 1.20 [1.03, 1.41], p < 0.05. CONCLUSIONS Targeting a higher MAP in shock or perioperative patients may not be superior to normotension, except in shock patients with premorbid hypertension. Further studies are needed to assess the effects of a high MAP target to preventing AKI in hypertensive patients across common settings of hemodynamic instability. Trial registration This systematic review has been registered on PROSPERO ( CRD42021286203 ) on November 19, 2021, prior to data extraction and analysis.
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Affiliation(s)
- Phu Nguyen Trong Tran
- grid.7922.e0000 0001 0244 7875Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand ,grid.411628.80000 0000 9758 8584Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand ,grid.413054.70000 0004 0468 9247Department of Internal Medicine, Faculty of Medicine, Can Tho University of Medicine and Pharmacy, Cantho, Vietnam
| | - Prit Kusirisin
- grid.7922.e0000 0001 0244 7875Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand ,grid.411628.80000 0000 9758 8584Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand ,grid.7922.e0000 0001 0244 7875Center of Excellence in Critical Care Nephrology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand ,grid.7132.70000 0000 9039 7662Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Piyanut Kaewdoungtien
- grid.7922.e0000 0001 0244 7875Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand ,grid.411628.80000 0000 9758 8584Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand ,grid.7922.e0000 0001 0244 7875Center of Excellence in Critical Care Nephrology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand ,grid.415092.b0000 0004 0576 2645Division of Nephrology, Police General Hospital, Royal Thai Police Headquarters, Bangkok, Thailand
| | - Jeerath Phannajit
- grid.7922.e0000 0001 0244 7875Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand ,grid.7922.e0000 0001 0244 7875Division of Clinical Epidemiology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Nattachai Srisawat
- grid.7922.e0000 0001 0244 7875Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand ,grid.411628.80000 0000 9758 8584Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand ,grid.7922.e0000 0001 0244 7875Center of Excellence in Critical Care Nephrology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand ,grid.512985.2Academy of Science, Royal Society of Thailand, Bangkok, Thailand
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12
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Ju JW, Yoo SJ, Park D, Bae J, Lee S, Nam K, Cho YJ, Lee HC, Jeon Y. Association between intraoperative plantar regional oxygen saturation and acute kidney injury after cardiac surgery. J Clin Monit Comput 2022; 37:525-540. [PMID: 36319881 DOI: 10.1007/s10877-022-00917-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 09/09/2022] [Indexed: 11/05/2022]
Abstract
Acute kidney injury (AKI) is one of the most common complications after cardiac surgery, associated with increased mortality and morbidity. Near-infrared spectroscopy (NIRS) continuously measures regional oxygen saturation(rSO2) in real-time. This exploratory retrospective study aimed to investigate the association between intraoperative plantar rSO2 and postoperative AKI in cardiac surgery patients. Between August 2019 and March 2021, 394 patients were included. Plantar and cerebral rSO2 were monitored using NIRS intraoperatively. The primary outcome was AKI within 7 postoperative days. The nonlinear association between plantar rSO2, cerebral rSO2, and mean arterial blood pressure (MBP) and AKI was assessed, and plantar rSO2<45% was related to an increased risk of AKI. Multivariable logistic regression analyses revealed that longer duration and higher area under the curve below plantar rSO2<45% and MBP<65 mmHg were more likely to be associated with increased odds of AKI. In additional multivariable regression analyses, association between plantar rSO2<45% and AKI was still maintained after adjusting the duration or AUC of MBP<65 mmHg as a covariate. Cerebral rSO2 levels were not associated with AKI. Independent of MAP, intraoperative plantar rSO2 was associated with AKI after cardiac surgery. However, intraoperative cerebral rSO2 was not associated with AKI. Intraoperative plantar rSO2 monitoring may be helpful in preventing AKI.
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13
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Hughes C, Djaiani G, Pungsornruk K, Agarwal S. Renal failure in cardiac surgery: in search of the magic bullet. Anaesthesia 2022; 77:1197-1201. [PMID: 36059270 DOI: 10.1111/anae.15857] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2022] [Indexed: 01/11/2023]
Affiliation(s)
- C Hughes
- Unit of Academic Anaesthesia, Critical Care and Peri-operative Medicine, University of Glasgow, Glasgow, UK
| | - G Djaiani
- Department of Anaesthesia and Pain Management, University Health Network, Toronto, ON, Canada.,University of Toronto, ON, Canada
| | - K Pungsornruk
- Department of Anaesthesia and Pain Management, University Health Network, Toronto, ON, Canada
| | - S Agarwal
- Department of Cardiothoracic Anaesthesia, Manchester University Hospitals, Manchester, UK.,Manchester University, Manchester, UK
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Society of Cardiovascular Anesthesiologists Clinical Practice Update for Management of Acute Kidney Injury Associated With Cardiac Surgery. Anesth Analg 2022; 135:744-756. [PMID: 35544772 DOI: 10.1213/ane.0000000000006068] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Cardiac surgery-associated acute kidney injury (CS-AKI) is common and is associated with increased risk for postoperative morbidity and mortality. Our recent survey of the Society of Cardiovascular Anesthesiologists (SCA) membership showed 6 potentially renoprotective strategies for which clinicians would most value an evidence-based review (ie, intraoperative target blood pressure, choice of specific vasopressor agent, erythrocyte transfusion threshold, use of alpha-2 agonists, goal-directed oxygen delivery on cardiopulmonary bypass [CPB], and the "Kidney Disease Improving Global Outcomes [KDIGO] bundle of care"). Thus, the SCA's Continuing Practice Improvement Acute Kidney Injury Working Group aimed to provide a practice update for each of these strategies in cardiac surgical patients based on the evidence from randomized controlled trials (RCTs). PubMed, EMBASE, and Cochrane library databases were comprehensively searched for eligible studies from inception through February 2021, with search results updated in August 2021. A total of 15 RCTs investigating the effects of the above-mentioned strategies on CS-AKI were included for meta-analysis. For each strategy, the level of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. Across the 6 potentially renoprotective strategies evaluated, current evidence for their use was rated as "moderate," "low," or "very low." Based on eligible RCTs, our analysis suggested using goal-directed oxygen delivery on CPB and the "KDIGO bundle of care" in high-risk patients to prevent CS-AKI (moderate level of GRADE evidence). Our results suggested considering the use of vasopressin in vasoplegic shock patients to reduce CS-AKI (low level of GRADE evidence). The decision to use a restrictive versus liberal strategy for perioperative red cell transfusion should not be based on concerns for renal protection (a moderate level of GRADE evidence). In addition, targeting a higher mean arterial pressure during CPB, perioperative use of dopamine, and use of dexmedetomidine did not reduce CS-AKI (a low or very low level of GRADE evidence). This review will help clinicians provide evidence-based care, targeting improved renal outcomes in adult patients undergoing cardiac surgery.
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Van Praet KM, Kofler M, Sündermann SH, Kempfert J. Endoaortic Balloon Occlusion During Minimally Invasive Mitral Valve Surgery. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2022; 17:83-87. [PMID: 35275021 DOI: 10.1177/15569845221083047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Karel M Van Praet
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Germany
| | - Markus Kofler
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Germany
| | - Simon H Sündermann
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Germany.,Department of Cardiothoracic Surgery, Charité-Universitätsmedizin Berlin, Germany
| | - Jörg Kempfert
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Germany
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McEwen CC, Amir T, Qiu Y, Young J, Kennedy K, Grocott HP, Kessani H, Mazer D, Brudney S, Kavosh M, Jacobsohn E, Vedel A, Wang E, Whitlock RP, Belley-Coté EP, Spence J. Morbidity and mortality in patients managed with high compared with low blood pressure targets during on-pump cardiac surgery: a systematic review and meta-analysis of randomized controlled trials. Can J Anaesth 2022; 69:374-386. [PMID: 35014001 DOI: 10.1007/s12630-021-02171-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 11/02/2021] [Accepted: 11/02/2021] [Indexed: 12/29/2022] Open
Abstract
PURPOSE Many believe that blood pressure management during cardiac surgery is associated with postoperative outcomes. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to determine the impact of high compared with low intraoperative blood pressure targets on postoperative morbidity and mortality in adults undergoing cardiac surgery on cardiopulmonary bypass (CPB). Our primary objective was to inform the design of a future large RCT. SOURCE We searched MEDLINE, EMBASE, Web of Science, CINAHL, and CENTRAL for RCTs comparing high with low intraoperative blood pressure targets in adult patients undergoing any cardiac surgical procedure on CPB. We screened reference lists, grey literature, and conference proceedings. PRINCIPAL FINDINGS We included eight RCTs (N =1,116 participants); all examined the effect of blood pressure management only during the CPB. Trial definitions of high compared with low blood pressure varied and, in some, there was a discrepancy between the target and achieved mean arterial pressure. We observed no difference in delirium, cognitive decline, stroke, acute kidney injury, or mortality between high and low blood pressure targets (very-low to low quality evidence). Higher blood pressure targets may have increased the risk of requiring a blood transfusion (three trials; n = 456 participants; relative risk, 1.4; 95% confidence interval, 1.1 to 1.9; P = 0.01; moderate quality evidence) but this finding was based on a small number of trials. CONCLUSION Individual trial definitions of high and low blood pressure targets varied, limiting inferences. The effect of high (compared with low) blood pressure targets on other morbidity and mortality after cardiac surgery remains unclear because of limitations with the body of existing evidence. Research to determine the optimal management of blood pressure during cardiac surgery is required. STUDY REGISTRATION PROSPERO (CRD42020177376); registered: 5 July 2020.
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Affiliation(s)
- Charlotte C McEwen
- Department of Surgery (Cardiac Surgery), McMaster University, Hamilton, ON, Canada
| | - Takhliq Amir
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Yuan Qiu
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Jack Young
- Health Sciences Library, McMaster University, Hamilton, ON, Canada
| | - Kevin Kennedy
- Department of Health Research Methods, Evaluation, and Impact, McMaster University, Hamilton, ON, Canada
| | - Hilary P Grocott
- Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Hesham Kessani
- Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - David Mazer
- Department of Anesthesia, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Scott Brudney
- Departments of Medicine (Critical Care) and Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Morvarid Kavosh
- Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Eric Jacobsohn
- Departments of Medicine (Critical Care) and Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Anne Vedel
- Department of Cardiothoracic Anesthesiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Eugene Wang
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Richard P Whitlock
- Departments of Surgery (Cardiac Surgery) and Health Research Methods, Evaluation, and Impact, McMaster University, Hamilton, ON, Canada.,Perioperative Research Division, Population Health Research Institute, Hamilton, ON, Canada
| | - Emilie P Belley-Coté
- Perioperative Research Division, Population Health Research Institute, Hamilton, ON, Canada.,Departments of Medicine (Cardiology and Critical Care) and Health Research Methods, Evaluation, and Impact, McMaster University, Hamilton, ON, Canada
| | - Jessica Spence
- Perioperative Research Division, Population Health Research Institute, Hamilton, ON, Canada. .,Departments of Anesthesia and Critical Care and Health Research Methods, Evaluation, and Impact, McMaster University, Hamilton, ON, Canada.
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Velho TR, Pereira RM, Guerra NC, Ferreira H, Sena A, Ferreira R, Nobre Â. Low Mean Arterial Pressure During Cardiopulmonary Bypass and the Risk of Acute Kidney Injury: A Propensity Score Matched Observational Study. Semin Cardiothorac Vasc Anesth 2021; 26:179-186. [PMID: 34720005 DOI: 10.1177/10892532211045765] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Low mean arterial pressure (MAP) periods occur frequently during cardiopulmonary bypass (CPB), and their management remains controversial. Our aim was to correlate MAP during CPB with the occurrence of post-operative acute kidney injury (AKI), considering two different parameters: consecutive and cumulative low MAP periods. METHODS Single-centre observational retrospective study including 250 patients submitted to non-emergent aortic valve replacement, with tepid to mild hypothermia (not below 32°C). The primary outcome was the occurrence of AKI. A propensity scored matching of 43 patients was used to adjust both populations (AKI and No AKI). MAP measures were automatically and continuously recorded during CPB. Low MAP periods were analysed employing two parameters: consecutive and the cumulative sum of time. RESULTS Patients who experienced at least 5 min with MAP <50 mmHg had an increased risk of post-operative AKI (OR infinity; 95% CI, 1.47 to infinity; P = .026). The risk is also significant with MAP <40 mmHg (OR 2.78; 95% CI 1.1-6.9; = .044) and <30 mmHg (OR 3.36; 95% CI 1.2-9.2; P = .029). Post-operative AKI was associated with cumulative and consecutive periods of low MAP. Patients with periods of low MAP had higher levels of post-operative creatinine and reduced glomerular filtration rate (GFR). Patients with AKI had prolonged endotracheal ventilation time, and ICU and ward lengths of stay. CONCLUSION Low MAP periods during CPB are associated with an increased occurrence of post-operative AKI, leading to 1) higher creatinine levels; 2) decreased GFR and 3) longer ICU and ward lengths of stay. Both consecutive and cumulative periods of low MAP are associated with an increased risk of AKI. MAP appears to be an important contributor to post-operative AKI and should be carefully managed during CPB. Further studies must address if MAP variations lead to definitive and long-term consequences.
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Affiliation(s)
- Tiago R Velho
- Cardiothoracic Surgery Department, 70899Hospital de Santa Maria, CHLN, Lisboa, Portugal, Lisboa, Portugal.,Innate Immunity and Inflammation Laboratory, 70899Instituto Gulbenkian de Ciência, Oeiras, Portugal
| | - Rafael M Pereira
- Cardiothoracic Surgery Department, 70899Hospital de Santa Maria, CHLN, Lisboa, Portugal, Lisboa, Portugal
| | - Nuno C Guerra
- Cardiothoracic Surgery Department, 70899Hospital de Santa Maria, CHLN, Lisboa, Portugal, Lisboa, Portugal
| | - Hugo Ferreira
- Cardiothoracic Surgery Department, 70899Hospital de Santa Maria, CHLN, Lisboa, Portugal, Lisboa, Portugal
| | - André Sena
- Cardiothoracic Surgery Department, 70899Hospital de Santa Maria, CHLN, Lisboa, Portugal, Lisboa, Portugal
| | - Ricardo Ferreira
- Cardiothoracic Surgery Department, 70899Hospital de Santa Maria, CHLN, Lisboa, Portugal, Lisboa, Portugal
| | - Ângelo Nobre
- Cardiothoracic Surgery Department, 70899Hospital de Santa Maria, CHLN, Lisboa, Portugal, Lisboa, Portugal
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Li CN, Ge YP, Liu H, Zhang CH, Zhong YL, Chen SW, Liu YM, Zheng J, Zhu JM, Sun LZ. Blood Transfusion and Acute Kidney Injury After Total Aortic Arch Replacement for Acute Stanford Type A Aortic Dissection. Heart Lung Circ 2021; 31:136-143. [PMID: 34120843 DOI: 10.1016/j.hlc.2021.05.087] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 03/28/2021] [Accepted: 05/06/2021] [Indexed: 12/26/2022]
Abstract
AIM To evaluate the effect of packed red blood cells (pRBCs), fresh frozen plasma (FFP), and platelet concentrate (PC) transfusions on acute kidney injury (AKI) in patients with acute Stanford type A aortic dissection (ATAAD) with total arch replacement (TAR). METHOD From December 2015 to October 2017, 421 consecutive patients with ATAAD undergoing TAR were included in the study. The clinical data of the patients and the amount of pRBCs, FFP, and PC were collected. Acute kidney injury was defined using the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Logistic regression was used to identify whether pRBCs, FFP, and platelet transfusions were risk factors for KDIGO AKI, stage 3 AKI, and AKI requiring renal replacement therapy (RRT). RESULTS The mean ± standard deviation age of the patients was 47.67±10.82 years; 77.7% were men; and the median time from aortic dissection onset to operation was 1 day (range, 0-2 days). The median transfusion amount was 8 units (range, 4-14 units) for pRBCs, 400 mL (range, 0-800 mL) for FFP, and no units (range, 0-2 units) for PC. Forty-one (41; 9.7%) patients did not receive any blood products. The rates of pRBC, PC, and FFP transfusions were 86.9%, 49.2%, and 72.9%, respectively. The incidence of AKI was 54.2%. Considering AKI as the endpoint, multivariate logistic regression showed that pRBCs (odds ratio [OR], 1.11; p<0.001) and PC transfusions (OR, 1.28; p=0.007) were independent risk factors. Considering KDIGO stage 3 AKI as the endpoint, multivariate logistic regression showed that pRBC transfusion (OR, 1.15; p<0.001), PC transfusion (OR, 1.28; p<0.001), a duration of cardiopulmonary bypass (CPB) ≥293 minutes (OR, 2.95; p=0.04), and a creatinine clearance rate of ≤85 mL/minute (OR, 2.12; p=0.01) were independent risk factors. Considering RRT as the endpoint, multivariate logistic regression showed that pRBC transfusion (OR, 1.12; p<0.001), PC transfusion (OR, 1.33; p=0.001), a duration of CPB ≥293 minutes (OR, 3.79; p=0.02), and a creatinine clearance rate of ≤85 mL/minute (OR, 3.34; p<0.001) were independent risk factors. CONCLUSIONS Kidney Disease: Improving Global Outcomes-defined stage AKI was common after TAR for ATAAD. Transfusions of pRBCs and PC increased the incidence of AKI, stage 3 AKI, and RRT. Fresh frozen plasma transfusion was not a risk factor for AKI.
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Affiliation(s)
- Cheng-Nan Li
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Aortic Disease Center, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Yi-Peng Ge
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Aortic Disease Center, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Hao Liu
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Aortic Disease Center, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Chen-Han Zhang
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Aortic Disease Center, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Yong-Liang Zhong
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Aortic Disease Center, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Su-Wei Chen
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Aortic Disease Center, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Yong-Min Liu
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Aortic Disease Center, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Jun Zheng
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Aortic Disease Center, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Jun-Ming Zhu
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Aortic Disease Center, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Li-Zhong Sun
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Aortic Disease Center, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China.
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Abstract
Acute kidney injury (AKI) occurs frequently after cardiac surgery and is associated with high morbidity and mortality. Although the number of cardiac surgical procedures is constantly growing worldwide, incidence of cardiac surgery-associated AKI is still around 40% and has a significant impact on global health care costs. Numerous trials attempted to identify strategies to prevent AKI and attenuate its detrimental consequences. Effective options remained elusive. Current evidence supports a multimodal risk-stratification approach with biomarker-guided management of high-risk patients, perioperative administration of dexmedetomidine, and implementation of a care bundle as recommended by the Kidney Disease: Improving Global Outcomes group.
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20
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Willcox TW, Newland RF, Baker RA. Cardiopulmonary bypass management and acute kidney injury in 118 Jehovah's Witness patients: a retrospective propensity-matched multicentre cohort from 30,942 patients. Perfusion 2020; 35:833-841. [PMID: 32106764 DOI: 10.1177/0267659120908119] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
INTRODUCTION Patients refusing blood products in cardiac surgery present challenges for cardiopulmonary bypass. Accurate detail of the modifiable factors of cardiopulmonary bypass relating to acute kidney injury is previously unreported in this patient population. METHODS A total of 118 adult Jehovah's Witness patients refusing transfusion were propensity matched to 118 adult patients accepting transfusion from the 30,942 patients in the Australian and New Zealand Collaborative Perfusion Registry. The primary endpoint was acute kidney injury. Intraoperative and bypass management characteristics were also compared between early (2007-2012) and late (2013-2018) cohorts along with the acceptance or refusal of transfusion. RESULTS In patients accepting transfusion, 49% received a blood product. In patients refusing transfusion, acute kidney injury was lower (8% vs. 22%; p = 0.003) cell salvage use was higher (70% vs. 22%; p < 0.001), as was use of haemofiltration (8% vs. 4%; p = 0.03) and tranexamic acid in the early period (87% vs. 62%, p = 0.004) but not late (100% vs. 97%; p = 0.15). There was no difference in modifiable cardiopulmonary bypass factors (mean arterial pressure, minimum oxygen delivery (DO2i), retrograde autologous prime, circuit prime volume) between the two groups; however, prime volume decreased and DO2i increased over time for both. Patients refusing transfusion had lower postoperative blood loss (p = 0.02) and shorter postoperative length of stay (p < 0.001) with no difference in morbidity (p = 0.46) or mortality (p = 0.68). CONCLUSION Refusal of transfusion in patients undergoing cardiopulmonary bypass was associated with reduced acute kidney injury, hospital stay and postoperative blood loss, while not impacting mortality.
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Affiliation(s)
- Timothy W Willcox
- Green Lane Cardiothoracic Surgery Unit, Auckland City Hospital, Auckland, New Zealand
- Department of Anaesthesiology, The University of Auckland, Auckland, New Zealand
| | - Richard F Newland
- Perfusion Service, Flinders Medical Centre, Adelaide, SA, Australia
- CTSU Quality and Outcomes Unit, Flinders Medical Centre, Adelaide, SA, Australia
- Cardiothoracic Surgery Unit, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Robert A Baker
- Perfusion Service, Flinders Medical Centre, Adelaide, SA, Australia
- CTSU Quality and Outcomes Unit, Flinders Medical Centre, Adelaide, SA, Australia
- Cardiothoracic Surgery Unit, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
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