Intraoperative Hypotension and Acute Kidney Injury after Noncardiac Surgery in Infants and Children: A Retrospective Cohort Analysis

Intraoperative hypotension is associated with decreased long-term survival in older patients after major noncardiac surgery: Secondary analysis of three randomized trials

STUDY OBJECTIVE

To assess the association of intraoperative hypotension with long-term survivals in older patients after major noncardiac surgery mainly for cancer.

DESIGN

A secondary analysis of databases from three randomized trials with long-term follow-up.

SETTING

The underlying trials were conducted in 17 tertiary hospitals in China.

PATIENTS

Patients aged 60 to 90 years who underwent major noncardiac thoracic or abdominal surgeries (≥ 2 h) in a single center were included in this analysis.

EXPOSURES

Restricted cubic spline models were employed to determine the lowest mean arterial pressure (MAP) threshold that was potentially harmful for long-term survivals. Patients were arbitrarily divided into three groups according to the cumulative duration or area under the MAP threshold. The association between intraoperative hypotension exposure and long-term survivals were analyzed with the Cox proportional hazard regression models.

MEASUREMENTS

Our primary endpoint was overall survival. Secondary endpoints included recurrence-free and event-free survivals.

MAIN RESULTS

A total of 2664 patients (mean age 69.0 years, 34.9% female sex, 92.5% cancer surgery) were included in the final analysis. MAP < 60 mmHg was adopted as the threshold of intraoperative hypotension. Patients were divided into three groups according to duration under MAP < 60 mmHg (<1 min, 1-10 min, and > 10 min) or area under MAP <60 mmHg (< 1 mmHg⋅min, 1-30 mmHg⋅min, and > 30 mmHg⋅min). After adjusting confounders, duration under MAP < 60 mmHg for > 10 min was associated with a shortened overall survival when compared with the < 1 min patients (adjusted hazard ratio [HR] 1.31, 95% confidence interval [CI] 1.09 to 1.57, P = 0.004); area under MAP < 60 mmHg for > 30 mmHg⋅min was associated with a shortened overall survival when compared with the < 1 mmHg⋅min patients (adjusted HR 1.40, 95% CI 1.16 to 1.68, P < 0.001). Similar associations exist between duration under MAP < 60 mmHg for > 10 min or area under MAP < 60 mmHg for > 30 mmHg⋅min and recurrence-free or event-free survivals.

CONCLUSIONS

In older patients who underwent major noncardiac surgery mainly for cancer, intraoperative hypotension was associated with worse overall, recurrence-free, and event-free survivals.

Urinary oxygen tension and its role in predicting acute kidney injury: A narrative review

Acute kidney injury occurs frequently in the perioperative setting. The renal medulla often endures hypoxia or hypoperfusion and is susceptible to the imbalance between oxygen supply and demand due to the nature of renal blood flow distribution and metabolic rate in the kidney. The current available evidence demonstrated that the urine oxygen pressure is proportional to the variations of renal medullary tissue oxygen pressure. Thus, urine oxygenation can be a candidate for reflecting the change of oxygen in the renal medulla. In this review, we discuss the basic physiology of acute kidney injury, as well as techniques for monitoring urine oxygen tension, confounding factors affecting the reliable measurement of urine oxygen tension, and its clinical use, highlighting its potential role in early detection and prevention of acute kidney injury.

Ephedrine to treat intraoperative hypotension in infants: what is the target?

Off-label use of medications in paediatric anaesthesia is common practice, owing to the relative paucity of evidence-based dosing regimens in children. Well-performed dose-finding studies, especially in infants, are rare and urgently needed. Unanticipated effects can result when paediatric dosing is based on adult parameters or local traditions. A recent dose-finding study on ephedrine highlights the uniqueness of paediatric dosing in comparison with adult dosing. We discuss the problems of off-label medication use and the lack of evidence for various definitions of hypotension and associated treatment strategies in paediatric anaesthesia. What is the aim of treating hypotension associated with anaesthesia induction: restoring the MAP to awake baseline values or elevating it above a provisional hypotension threshold?

Intraoperative arterial pressure and delayed cerebral ischemia in patients with aneurysmal subarachnoid hemorrhage after surgical clipping: A retrospective cohort study

Background

Delayed cerebral ischemia (DCI) is the major predictor of poor outcomes in patients with aSAH. Previous studies have attempted to assess the relationship between controlling blood pressure and DCI. However, the management of intraoperative blood pressure in reducing the occurrence of DCI still remains inconclusive.

Methods

All patients with aSAH who received general anesthesia for surgical clipping between January 2015 and December 2020 were prospectively reviewed. Patients were divided in the DCI group or the non-DCI group depending on whether DCI occurred or not. Intraoperative arterial pressure was measured every minute and recorded in an electronic anesthesia recording system along with intraoperative medication and other vital signs. The initial neurological function score, aneurysm characteristics, surgical and anesthetic information, and outcomes were compared between the DCI and the non-DCI groups.

Results

Among 534 patients who were enrolled, a total of 164 (30.71%) patients experienced DCI. The baseline characteristics of patients were similar between the groups. The World Federation of Neurosurgical Societies (WFNS) Scale > 3, age ≥ 70 years, and the modified Fisher Scale > 2 were significantly higher in patients with DCI than those without. Though it was the second derivative of the regression analysis, 105 mmHg was adopted as the threshold for intraoperative hypotension and was not associated with DCI.

Conclusions

The threshold of 105 mmHg was adopted as intraoperative hypotension even though it was the second derivative of the regression analysis and could not be proved to be associated with delayed cerebral ischemia adjusted by the baseline severity of aSAH and age.

Mild acute kidney injury after pediatric surgery is not-associated with long-term renal dysfunction: A retrospective cohort study

BACKGROUND AND STUDY OBJECTIVE

Acute kidney injury (AKI) is a sudden deterioration in renal function and is common in pediatric patients undergoing cardiac and non-cardiac surgery. Few studies have investigated the association of postoperative AKI with kidney dysfunction seen long-term and other adverse outcomes in pediatric patients. The study aimed to determine the association between postoperative AKI (mild AKI vs. no AKI and mild AKI vs. moderate-severe AKI) and chronic kidney dysfunction (CKD) seen long-term in pediatric patients undergoing cardiac and non-cardiac major surgery.

DESIGN

Restrospective, cohort study.

SETTING

Tertiary care hospital.

PATIENTS

This retrospective cohort study included patients aged 2-18 years who underwent cardiac and non-cardiac major surgery lasting >2 h at the Cleveland Clinic Main Campus between June 2005 and December 2020.

MEASUREMENTS

Postoperative AKI and CKD seen in long-term were defined and staged according to the Kidney Disease: Improving Global Outcomes criteria.

MAIN RESULTS

Among 10,597 children who had cardiac and non-cardiac major surgery, 1,302 were eligible. A total of 682 patients were excluded for missing variables and baseline kidney dysfunction and 620 patients were included. The mean age was 11 years, and 307 (49.5%) were female. Postoperative mild AKI was detected in 5.8% of the patients, while moderate-severe AKI was detected in 2.4%. There was no significant difference in CKD seen in long-term between patients with and without postoperative AKI, p = 0.83. The CKD seen in long-term developed in 27.7% of patients with postoperative mild AKI and 33.3% of patients with postoperative moderate and severe AKI. Patients without postoperative AKI had an estimated 1.09 times higher odds of having CKD seen in long-term compared with patients who have postoperative mild AKI (odds ratio [95% CI] 1.09 [0.48,2.52]).

CONCLUSION

In contrast to adult patients, the authors did not find any association between postoperative AKI and CKD seen in long-term in pediatric patients.