Goal-directed therapy after cardiac surgery and the incidence of acute kidney injury

Thomson, Rebekah; Meeran, Hanif; Valencia, Oswaldo

doi:10.1016/j.jcrc.2014.06.011

Cited by 45 publications

(24 citation statements)

References 31 publications

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“…At UM, MUF is commonly used following cardiopulmonary bypass, which predictably resulted in rising serum creatinine within the first 24 postoperative hours. Potential additional factors contributing to the difference in CS-AKI incidence include intraoperative and postoperative intravascular volume status, CPB strategy, postoperative fluid administration, residual heart disease, blood loss and total blood product administration (21–23). For example, excessive fluid overload (which was unmeasured in our study) may result in prolonged mechanical ventilation and LOS, but which may be modified by MUF, reducing the impact of CS-AKI on those outcomes.…”

Section: Discussionmentioning

confidence: 99%

Acute Kidney Injury After Pediatric Cardiac Surgery: A Secondary Analysis of the Safe Pediatric Euglycemia After Cardiac Surgery Trial*

Blinder

Asaro

Wypij

et al. 2017

Pediatric Critical Care Medicine

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Objectives To understand the effect of tight glycemic control (TGC) on cardiac surgery-associated acute kidney injury (CS-AKI). Design Secondary analysis of data from the Safe Pediatric Euglycemia after Cardiac Surgery (SPECS) trial of TGC vs. standard care Setting Pediatric cardiac intensive care units (ICU) at University of Michigan (UM) C.S. Mott Children’s Hospital and Boston Children’s Hospital (BCH). Patients Children 0–36 months of age undergoing congenital cardiac surgery. Interventions None. Measurements and Main Results CS-AKI was assigned using the Acute Kidney Injury Network criteria with the modification that a >0.1 mg/dL increase in serum creatinine was required to assign CS-AKI. We explored associations between CS-AKI and TGC and clinical outcomes. Of 799 patients studied, CS-AKI occurred in 289 (36%) patients, most of whom had Stage II or III disease (72%). CS-AKI rates were similar between treatment groups (36% vs. 36%, p=0.99). Multivariable modeling showed that patients with CS-AKI were younger (p=0.002), underwent more complex surgery (p=0.005) and had longer cardiopulmonary bypass times (p=0.002). CS-AKI was associated with longer mechanical ventilation and ICU and hospital stays and increased mortality. Patients at UM had higher rates of CS-AKI compared to BCH patients (66% vs. 15%, p<0.001) but UM patients with CS-AKI had shorter time to extubation and ICU and hospital stays compared to BCH. Conclusions TGC did not reduce the CS-AKI rate in this trial cohort. We observed significant differences in CS-AKI rates between the two study sites, and there was a differential effect of CS-AKI on clinical outcomes by site. These findings warrant further investigation to identify causal variation in perioperative practices that affect CS-AKI epidemiology.

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Section: Discussionmentioning

confidence: 99%

Acute Kidney Injury After Pediatric Cardiac Surgery: A Secondary Analysis of the Safe Pediatric Euglycemia After Cardiac Surgery Trial*

Blinder

Asaro

Wypij

et al. 2017

Pediatric Critical Care Medicine

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“…A Finnish study showed that patients with sepsis who developed AKI within 5 days of ICU admission had a significantly lower MAP (74 mmHg) compared with patients with sepsis without AKI (MAP 79 mmHg) (31). Finally, a recent prospective observational study in 264 patients after cardiac surgery concluded that GDT for 8 hours from admission to the ICU was associated with a significantly lower incidence of AKI (32). However, other studies in humans failed to show a benefit with strategies to increase MAP.…”

Section: Discussionmentioning

confidence: 99%

Low Systemic Oxygen Delivery and BP and Risk of Progression of Early AKI

Raimundo

Crichton

Syed

et al. 2015

Clinical Journal of the American Society of Nephrology

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Background and objectives The optimal hemodynamic management of patients with early AKI is unknown. This study aimed to investigate the association between hemodynamic parameters in early AKI and progression to severe AKI and hospital mortality.Design, setting, participants, & measurements This study retrospectively analyzed the data of all patients admitted to the adult intensive care unit in a tertiary care center between July 2007 and June 2009 and identified those with stage 1 AKI (AKI I) per the AKI Network classification. In patients in whom hemodynamic monitoring was performed within 12 hours of AKI I, hemodynamic parameters in the first 12 hours of AKI I and on the day of AKI III (if AKI III developed) or 72 hours after AKI I (if AKI III did not develop) were recorded. Risk factors for AKI III and mortality were identified using univariate and multivariate logistic regression analyses.Results Among 790 patients with AKI I, 210 (median age 70 years; 138 men) had hemodynamic monitoring within 12 hours of AKI I; 85 patients (41.5%) progressed to AKI III and 91 (43%) died in the hospital. AKI progressors had a significantly higher Sequential Organ Failure Assessment score (8.0 versus 9.6; P,0.001), lower indexed systemic oxygen delivery (DO 2 I) (median 325 versus 405 ml/min per m 2 ; P,0.001), higher central venous pressure (16 versus 13; P=0.02), and lower mean arterial blood pressure (MAP) (median 71 versus 74 mmHg; P=0.01) in the first 12 hours of AKI I compared with nonprogressors. Multivariate analysis confirmed that raised lactate, central venous pressure, and Sequential Organ Failure Assessment score as well as mechanical ventilation were independently associated with progression to AKI III; higher DO 2 I and MAP were independently associated with a lower risk of AKI III but not survival. The associations were independent of sepsis, heart disease, recent cardiac surgery, or chronic hypertension. ConclusionsHigher DO 2 I and MAP in early AKI were independently associated with a lower risk of progression.

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“…Clinical indication for a FC was according to the standard clinical post-operative protocol 10 (Supplemental Digital Content (SDC) Figure 1). …”

Section: Methodsmentioning

confidence: 99%

Hemodynamic Effect of Different Doses of Fluids for a Fluid Challenge: A Quasi-Randomized Controlled Study

Aya

Rhodes

Ster

et al. 2017

Critical Care Medicine

100

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Objective: The objectives of this study are to determine what is the minimal volume required to perform an effective fluid challenge (FC) and to investigate how different doses of intravenous fluids in a FC affect the changes in cardiac output and the proportion of responders and non-responders.Design: quasi-randomised controlled trial. Setting: Cardiothoracic intensive care unit, tertiary university hospitalPatients: 80 Post-cardiac surgery patients.Intervention: intravenous infusion of 1, 2, 3 or 4 mL/Kg (body weight) of crystalloid over 5 minutes.Measurements: Mean systemic filling pressure measured using the transient stop-flow arm arterial-venous equilibrium pressure (Pmsf-arm), arterial and central venous pressure (CVP), cardiac output (CO; LiDCOplus, LiDCO, Cambridge, UK) and heart rate. Results:The groups were well matched with respect to demographic and baseline physiological variables.The proportion of responders increased from 20% in the group of 1mL/kg to 65% in the group of 4 mL/kg (p = 0.04). The predicted minimal volume required for a FC was between 321 to 509 mL. Only 4 mL/Kg increase Pmsf-arm beyond the limits of precision and was significantly associated with a positive response (OR 7.73, 95% CI 1.78 to 31.04). Conclusion:The doses of fluids used for a FC modify the proportions of responders in postoperative patients. A dose of 4 ml/Kg increases Pmsf-arm and reliably detects responders and non-responders.

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Goal-directed therapy after cardiac surgery and the incidence of acute kidney injury

Cited by 45 publications

References 31 publications

Acute Kidney Injury After Pediatric Cardiac Surgery: A Secondary Analysis of the Safe Pediatric Euglycemia After Cardiac Surgery Trial*

Acute Kidney Injury After Pediatric Cardiac Surgery: A Secondary Analysis of the Safe Pediatric Euglycemia After Cardiac Surgery Trial*

Low Systemic Oxygen Delivery and BP and Risk of Progression of Early AKI

Hemodynamic Effect of Different Doses of Fluids for a Fluid Challenge: A Quasi-Randomized Controlled Study

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