Efficacy of cold renal perfusion protection for open complex aortic aneurysm repair: a meta-analysis

BACKGROUND

Cold renal perfusion (CRP) with 4°C crystalloid fluids has been described as a method to reduce renal injury during open surgical repair of complex aortic aneurysms (cAAs) (those requiring at least a suprarenal clamp site). We performed a meta-analysis to ascertain whether CRP improves kidney-related outcomes after open surgical cAA repair.

METHODS

Patients of any age or gender who had undergone open surgical repair of cAAs were included. Primary outcomes were the presence of postoperative kidney injury, the need for dialysis and mortality related to kidney injury. We compared patients who were treated with any intraoperative CRP strategy to a control population without CRP. We used a fixed-effects model to analyze derived odds ratios (ORs) and assess heterogeneity. We performed risk of bias analysis to identify potential confounding elements.

RESULTS

Among the 935 studies screened, 5 primary articles met the inclusion criteria. Cold renal perfusion significantly reduced postoperative acute kidney injury (OR 0.46 [95% confidence interval 0.32-0.68], Z = 3.98, p = 0.001). Only 1 study included data for the other primary outcomes. The data were considered homogeneous, with Cochrane Q = 0.23 and I 2 of 0%.

CONCLUSION

This meta-analysis showed reduced postoperative acute kidney injury with the use of CRP during open cAA repair. A prospective randomized controlled trial to perform further subgroup analysis and research the various types of CRP solutions may be warranted to identify further possible benefits.

Angiotensin-Converting Enzyme Inhibitor/Receptor Blocker, Diuretic, or Nonsteroidal Anti-inflammatory Drug Use After Major Surgery and Acute Kidney Injury: A Case-Control Study

BACKGROUND

Acute kidney injury (AKI) is common after surgery and associated with increased mortality, costs, and lengths of hospitalization. We examined associations between angiotensin-converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB), diuretic, or nonsteroidal anti-inflammatory drug (NSAID) use after major surgery and AKI.

MATERIALS AND METHODS

We conducted a nested case-control study of patients who underwent major cardiac, thoracic, general, or vascular surgery in Calgary, Alberta, Canada. Cases with AKI were matched on age, gender, and surgery type with up to five controls without AKI within 30-d after surgery. Adjusted odds ratios (ORs) for AKI were determined based on postoperative administration of ACEIs/ARBs, diuretics, or NSAIDs.

RESULTS

Among 33,648 patients in the cohort, 2911 cases with AKI were matched to 9309 controls without AKI. Postoperative diuretic [OR = 1.96; 95% confidence interval (CI) = 1.68-2.29], but not ACEI/ARB (OR = 0.83; 95% CI = 0.72-0.95) or NSAID (OR = 1.12; 95% CI = 0.96-1.31), use was independently associated with higher odds of AKI (including stages 1 and 2/3 AKI) after all types of major surgery. There were increased adjusted odds of AKI 1 to 5 d after first exposure to diuretics and 1 d after first exposure to NSAIDs (but not after later exposures). Relationships between ACEI/ARB use and AKI varied by surgery type (p-interaction = 0.004), with lower odds of AKI observed among ACEI/ARB use after cardiac surgery (OR = 0.70; 95% CI = 0.57-0.81), but no difference after other major surgeries.

CONCLUSIONS

Postoperative administration of diuretics and NSAIDs was associated with increased odds of AKI after major surgery. These findings characterize potentially modifiable medication exposures associated with AKI after surgery.

Development and initial implementation of electronic clinical decision supports for recognition and management of hospital-acquired acute kidney injury

Background

Acute kidney injury (AKI) is common in hospitalized patients and is associated with poor patient outcomes and high costs of care. The implementation of clinical decision support tools within electronic medical record (EMR) could improve AKI care and outcomes. While clinical decision support tools have the potential to enhance recognition and management of AKI, there is limited description in the literature of how these tools were developed and whether they meet end-user expectations.

Methods

We developed and evaluated the content, acceptability, and usability of electronic clinical decision support tools for AKI care. Multi-component tools were developed within a hospital EMR (Sunrise Clinical Manager™, Allscripts Healthcare Solutions Inc.) currently deployed in Calgary, Alberta, and included: AKI stage alerts, AKI adverse medication warnings, AKI clinical summary dashboard, and an AKI order set. The clinical decision support was developed for use by multiple healthcare providers at the time and point of care on general medical and surgical units. Functional and usability testing for the alerts and clinical summary dashboard was conducted via in-person evaluation sessions, interviews, and surveys of care providers. Formal user acceptance testing with clinical end-users, including physicians and nursing staff, was conducted to evaluate the AKI order set.

Results

Considerations for appropriate deployment of both non-disruptive and interruptive functions was important to gain acceptability by clinicians. Functional testing and usability surveys for the alerts and clinical summary dashboard indicated that the tools were operating as desired and 74% (17/23) of surveyed healthcare providers reported that these tools were easy to use and could be learned quickly. Over three-quarters of providers (18/23) reported that they would utilize the tools in their practice. Three-quarters of the participants (13/17) in user acceptance testing agreed that recommendations within the order set were useful. Overall, 88% (15/17) believed that the order set would improve the care and management of AKI patients.

Conclusions

Development and testing of EMR-based decision support tools for AKI with clinicians led to high acceptance by clinical end-users. Subsequent implementation within clinical environments will require end-user education and engagement in system-level initiatives to use the tools to improve care.