8. Evidences
• Retrospective studies: 26.4% versus 2.5%
– Abelha FJ, Botelho M, Fernandes V, Barros H. Outcome and quality 5 of
life of patients with acute kidney injury after major surgery. Nefrologia
2009;29:404-14.
• Observational study: 25 times more likely to die
– Englberger L, Suri RM, Greason KL, Burkhart HM, Sundt TM 3rd, Daly 7
RC, et al. Deep hypothermic circulatory arrest is not a risk factor for
acute kidney injury in thoracic aortic surgery. J Thorac Cardiovasc Surg
2010; epub: 13 Apr
9. Evidences
• Patients who completely recover after postoperative AKI still
have an increased adjusted hazard ratio for death of 1.20
(95% confidence interval 1.10 to 1.31, P<0.001) over the
longer term compared with patients without AKI according to
a recent cohort study.
– Ann Surg 2009;249:851-8.
10. Careful preoperative assessment can identify
patients at particular risk of AKI and could
allow for additional monitoring and planning
11. Screen patients before OP
• Impaired clinical status
≧ 6 risk factors, 10% of AKI, hazzard ratio: 42.6
– age ≥56 years
– male sex
– active congestive cardiac failure
– presence of ascites
– Hypertension
– emergency surgery
– intraperitoneal surgery
– preoperative creatinine >106 μmol/l (1.19mg/dl)
– diabetes mellitus
– Anesthesiology 2009;110:505-15.
12. Screen patient before OP
• ASA physical status score of IV or V odds ratio for AKI: 3.94
(95% confidence interval 2.07 to 7.51; P<0.001)
• High risk surgery (intraperitoneal, intrathoracic, or
suprainguinal vascular) odds ratio for AKI: 3.34 (95%
confidence interval 2.02 to 5.53; P<0.001)
• Congestive heart disease odds ratio for AKI: 2.34 (95%
confidence interval 1.42 to 3.88; P=0.001)
13. Revised cardiac risk index
• Revised cardiac risk index score
• ≧ 3 For AKI: odds ratio 2.45
• ≧ 3 For major cardiac complication: 9%
– high risk surgery
– congestive heart disease
– ischaemic heart disease
– cerebrovascular disease
– insulin dependent diabetes mellitus
– Creratinie > 2.0mg/dl
14. Risk factors for AKI (NICE guideline)
for individuals undergoing Surgery
• Emergency surgery
– when the patient has sepsis or hypovolaemia
• Intraperitoneal surgery
• Patients with known risk factors for AKI
– Chronic kidney disease stage ≧ 3
– DM
– Heart failure
– Age ≧ 65
– Liver disease
– Nephrotoxic drug
15.
16. Daily practice
• Use the risk assessment to inform a surgical
management plan
– include the risks of developing AKI in the routine
discussion of risks and benefits of surgery
17. Perioperative AKI rarely indicates an isolated
renal problem but rather a physiologically
unstable patient who may deteriorate further
and must not be ignored
18. The successful prevention and management
of AKI involves timely recognition of perhaps
subtle abnormalities, basic clinical
assessments and observations, and quick and
appropriate reaction to information, including
getting senior and specialist help
Right thing, right time
20. Ensure that the patient with a diagnosis of
AKI is normovolaemic, has an adequate mean
arterial pressure, and preferably is not
exposed to nephrotoxins
21. How to do
• Minimise exposure to perioperative nephrotoxins
– ACEI
– NSAID
• NSAIDs are best avoided in hypovolaemia or in patients who have sepsis, even if
their serum creatinine concentration is normal. (drug safety advice from MHRA UK)
– Perioperative contrast
– Antibiotics
• Aminoglycosides, penicillins, cephalosporins, and fluoroquinolones
22. How to do
• Intraoperative management and haemodynamic optimisation
– The aim is to maintain a systemic arterial perfusion pressure that is
appropriate for the patient (taking into account preoperative blood
pressure and surgical requirements for relative hypotension)
– Inotrope only after adequate hydration
• Hydration: 500 ml crystalloid or 250 ml colloid, repeated as necessary with careful
monitoring for fluid overload.
• Monitoring: capillary refill time <3 seconds, restoration of blood pressure, and fall
in arterial lactate concentration.
23. Many surgical patients have a history of
ventricular dysfunction, and optimisation of
cardiac function may require inotropic
support
24. Evidence
• Optimising intravascular volume and cardiac output may have
a positive effect on perioperative renal function.
– Optimisation of cardiac output or oxygen delivery resulted in a
decreased risk of perioperative AKI
• both in the subgroup in which this was started preoperatively and in the combined
subgroup in which it was started either intraoperatively or in the early
postoperative phase.
– Both normal and supranormal target achievement were effective in
reducing AKI.
• Oxygen delivery index: 500 ml/min/m2,
– Crit Care Med 2009;37:2079-90.
25. Renal tract obstruction must be excluded
radiologically within 24 hours of a diagnosis
of AKI
Bladder extension ??
