Goal-directed resuscitation following cardiac surgery reduces acute kidney injury: A quality initiative pre-post analysis
Goal-directed resuscitation following cardiac surgery reduces acute kidney injury: A quality initiative pre-post analysis
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DOI：
10.1016/j.jtcvs.2019.03.135
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发表时间：
2020-05-01
影响因子：
6
通讯作者：
Isbell, James M.
中科院分区：
文献类型：
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作者：
Johnston, Lily E.;Thiele, Robert H.;Isbell, James M.
目的：心脏手术后20%的患者发生急性肾损伤（阿基）。为了减少我们机构的阿基，我们采用目标导向的容量复苏方案制定了质量改进（QI）计划。我们的方案旨在使用液体和血管活性药物达到可量化的生理目标（例如，心脏指数> 2.5 L/min/m2，平均动脉压>65 mm Hg）。本研究的目的是评估阿基在前和后QI时代，假设阿基的发病率将降低后QI时代的erase.Methods：在这项观察性回顾性队列研究中，我们确定了从2011年7月到2015年7月接受心脏手术的患者，并提供了风险评分。使用手术7天内的最低术后GFR和标准风险、损伤、衰竭、肾功能丧失和终末期肾病（步枪）分类标准确定肾损伤。主要结局是阿基的发生率，定义为肾小球滤过率为基础的步枪分类标准损伤，在后与前QI eras.Results：共1979例患者，其中725人在前QI队列，和1254后QI队列。总体而言，步枪分类标准风险、损伤和失败的发生率分别为27.5%、5.9%和3.6%。步枪分类标准损伤在QI后队列中下降幅度最大（8.1% vs 4.6%; P = 0.001）。多变量分析表明，QI后队列中阿基的几率降低了37%（调整后的比值比为0.63; 95%置信区间为0.43-0.90）。结论：以患者液体反应性为中心的目标导向容量复苏方案与心脏手术后阿基风险显著降低相关。重症监护病房应采用方案驱动的方法来改善结局。
Objective: Acute kidney injury (AKI) occurs in 20% of patients following cardiac surgery. To reduce AKI in our institution, we instituted a quality improvement (QI) initiative using a goal-directed volume resuscitation protocol. Our protocol was designed to achieve quantifiable physiologic goals (eg, cardiac index> 2.5 L/min/m(2), mean arterial pressure>65 mm Hg) using fluid and vasoactive agents. The objective of this study was to evaluate AKI in the pre- and post-QI eras, hypothesizing that AKI incidence would decrease in the post-QI era.Methods: In this observational retrospective cohort study, we identified patients who underwent cardiac operations from July 2011 to July 2015 with a risk score available. Kidney injury was determined using the lowest postoperative GFR within 7 days of surgery and standard Risk, Injury, Failure, Loss of Kidney Function, and End-Stage Kidney Disease (RIFLE) classification criteria. The primary outcome was the rate of AKI, as defined by glomerular filtration rate-based RIFLE classification criteria injury, in the post-versus pre-QI eras.Results: A total of 1979 patients were included, of whom 725 were in the pre-QI cohort, and 1254 in the post-QI cohort. Overall, rates of RIFLE classification criteria risk, injury and failure were 27.5%, 5.9%, and 3.6%, respectively. RIFLE classification criteria injury saw the largest decrease in the post-QI cohort (8.1% vs 4.6%; P = .001). Multivariable analysis demonstrated a 37% reduction in the odds of AKI in the post-QI cohort (adjusted odds ratio, 0.63; 95% confidence interval, 0.43-0.90).Conclusions: A goal-directed volume resuscitation protocol centered on patient fluid responsiveness is associated with significantly reduced risk for AKI after cardiac surgery. Protocol-driven approaches should be employed in intensive care units to improve outcomes.