Case Scenario: Hemodynamic Management of Postoperative Acute Kidney Injury

Abstract

A cute kidney injury (AKI) is associated with poor outcome both in critically ill patients and after major surgery. 1 The occurrence of AKI has been associated with poor short-term and long-term outcome, increased risk of chronic renal failure, and increased risk of death.2 Several risk factors of postoperative AKI have been identified, and may help identifying patients with the highest risk of AKI. However, recognizing contributors to AKI (e.g., systemic inflammation, systemic hemodynamics alterations, nephrotoxic agents, and others) remains a challenge for anesthesiologists and intensivists because these factors are often associated and AKI multifactorial.The early diagnosis of AKI remains another issue. Interest in the development and validation of AKI biomarkers has increased among the medical community. In this article, we analyze the risk factors of and contributors to AKI after major surgery, and specifically discuss the strategy of fluid management and potential negative outcome associated with inappropriate fluid administration, with a case scenario intended to illustrate the current knowledge of perioperative AKI. We emphasize hemodynamic management for the prevention and correction of acute renal failure. Case ReportA 59-yr-old woman with a history of diabetes and hypertension underwent abdominal surgery for recurrent ovarian cancer. She had received systemic chemotherapy during the 18 months preceding the surgery, including paclitaxel, carboplatin, bevacizumab, doxorubicin, and cyclophosphamide, and had remained asymptomatic since then. The surgery included an ovarian resection and peritoneal carcinosis cytoreduction. The only preoperative medication was an angiotensin-converting enzyme inhibitor to treat arterial hypertension. The preoperative creatinine clearance was estimated at 80 ml/min (Modification of Diet in Renal Disease formula). Because she was asymptomatic (no dyspnea or recent change in her clinical status), left ventricular function was not preoperatively assessed.The known large fluid losses associated with peritoneal carcinosis cytoreduction, intraoperative oliguria, and hypotension led to the infusion of a total of 24 ml·kg −1 ·h −1 of crystalloids during the 9-h surgery (half saline and half Ringer's lactate solutions). Perioperative maintenance of mean arterial pressure at 70 mmHg was achieved by intravenous infusion of neosynephrine (0.35 μg·kg −1 ·min −1 ). In the recovery room, cold extremities and discrete knee mottles were noted, which motivated a switch to norepinephrine infusion (0.2-0.3 μg·kg −1 ·min −1 ). Because of oliguria during the surgical procedure and anuria in the immediate postoperative period, with urine output less than 0.5 ml·kg −1 ·h −1 , the patient was transferred to the postoperative intensive care unit (Icu). Blood analysis showed a metabolic acidosis, with a chloride concentration of 114 mM and bicarbonates of 12 mM, with a normal anion gap (14 mM). Serum alanine aminotransferase and alanine transaminase were increased (245 and 257 u, respectively), and s...

Serum Creatinine in the Critically Ill Patient With Sepsis

“…Early identification of AKI, however, allows for rapid identification of sepsis severity, 4 which may facilitate earlier initiation of optimal care and avoidance of nephrotoxins (ie, vancomycin). 5 It is important to recognize that AKI can develop in patients with sepsis, despite absence of arterial hypotension or shock. 6 What Are Alternative Diagnostic Testing Approaches?…”

Effects of perioperative goal-directed fluid therapy combined with the application of alpha-1 adrenergic agonists on postoperative outcomes: a systematic review and meta-analysis

“…Schimid et al [ 44 ] found that the short-term postoperative renal outcome was influenced by body mass index, preoperative creatinine clearance, perioperative hypovolemia, and the use of hydroxyethyl starch; the last two were controllable factors. Legrand et al [ 12 ] showed that vasoconstriction induced by the recommended dosages of alpha-1 adrenergic receptor agonists did not significantly threaten renal perfusion and microcirculatory blood flow at proper volume status and cardiac function. However, anesthesiologists should still pay attention to elderly patients, especially patients with previous renal insufficiency, and limit the use of colloids during the perioperative period.…”

Evidence of Uncoupling between Renal Dysfunction and Injury in Cardiorenal Syndrome: Insights from the BIONICS Study

“…On our cohort, only 3 out of 8 who died had change <+20% in Screat. With the development of biomarkers potentially indicative of renal injury comes the opportunity to potentially better characterize episodes of WRF, thus providing better phenotyping of [12], [13]. In this line it is expected that early recognition of on-going renal injury (i.e.…”