Intraoperative Hypothermia Is Associated with Reduced Acute Kidney Injury After Spine Surgery Under General Anesthesia: A Retrospective Observational Study

Threshold heterogeneity of perioperative hemoglobin drop for acute kidney injury after noncardiac surgery: a propensity score weighting analysis

Background

Perioperative hemoglobin drop after noncardiac surgery is associated with acute kidney injury (AKI). However, opinion on the tolerable difference in postoperative hemoglobin drop in patients with different preoperative hemoglobin levels does not reach a consensus. This study aimed to identify hemoglobin drop thresholds for AKI after noncardiac surgery stratified by preoperative hemoglobin levels.

Method

This was a single-center retrospective cohort study for elective noncardiac surgery from January 1, 2012, to December 31, 2018. The endpoint was the occurrence of AKI 7 days postoperatively in the hospital. The generalized additive model described the non-linear relationship between hemoglobin drop and AKI occurrence. The minimum P-value approach identified cut-off points of hemoglobin drop within postoperative 7 days for patients with or without preoperative anemia. Stratified by preoperative anemia, hemoglobin drop’s odds ratio as continuous, quintile and dichotomous variables by various cut-off points for postoperative AKI were calculated in multivariate logistic regression models before and after propensity score weighting (PSW).

Results

Of the 35,631 surgery, 5.9% (2105 cases) suffered postoperative AKI. Non-linearity was found between hemoglobin drop and postoperative AKI occurrence. The thresholds and corresponding odds ratio of perioperative hemoglobin drop for patients with and without preoperative anemia were 18 g/L (1.38 (95%CI 1.14 -1.62), P < .001; after PSW: 1.42 (95%CI 1.17 -1.74), P < .001) and 43 g/L (1.81 (95%CI 1.35—2.27), P < .001; after PSW: 2.88 (95%CI 1.85—4.50), P < .001) respectively. Overall thresholds and corresponding odds ratio were 43 g/L (1.82 (95%CI 1.42—2.21)), P < .001; after PSW: 3.29 (95%CI 2.00—5.40), P < .001). Sensitivity analysis showed similar results. Heterogeneity subgroup analysis showed that intraoperatively female patients undergoing intraperitoneal surgery without colloid infusion seemed to be more vulnerable to higher hemoglobin drop. Further analysis showed a possible linear relationship between preoperative hemoglobin and perioperative hemoglobin drop thresholds. Additionally, this study found that the creatinine level changed simultaneously with hemoglobin level within five postoperative days.

Conclusions

Heterogeneity of hemoglobin drop endurability exists after noncardiac non-kidney surgery. More care and earlier intervention should be put on patients with preoperative anemia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-022-02834-3.

The association between modifiable perioperative parameters and renal function after nephrectomy

OBJECTIVE

To evaluate the association between intraoperative anaesthetic parameters, primarily intraoperative hypotension, and postoperative renal function in patients undergoing nephrectomy.

PATIENTS AND METHODS

We reviewed data from 3240 consecutive patients who underwent nephrectomy between 2010 and 2018. Anaesthetic parameters evaluated included duration of hypotension, tachycardia, hypothermia, volatile anaesthetic use and mean arterial pressure in the post-anaesthesia care unit. Outcomes included acute kidney injury (AKI) and estimated glomerular filtration rate (eGFR) within the first year after nephrectomy. Associations between anaesthetic parameters and outcomes were evaluated with multivariable logistic regression and generalised estimating equation, respectively, adjusted for predictors of renal function after nephrectomy.

RESULTS

Before nephrectomy, 677 (21%) patients had moderate-severe chronic kidney disease. A quarter of patients (n = 809) had postoperative AKI and 35% (n = 746) had Stage ≥3 chronic kidney disease 12-months after surgery. Only 12% of patients (n = 386) had >5 min of intraoperative hypotension. While not statistically significant, longer duration of intraoperative hypotension was associated with slightly higher rates of AKI (odds ratio [OR] per 10-min 1.14, 95% confidence interval [CI] 0.98, 1.32). Prolonged hypothermia was associated with increased rate of AKI (OR per 10-min 1.02, 95% CI 1.00, 1.04), and decreased eGFR (change in eGFR per 10-min -0.19, 95% CI -0.27, -0.12); however, these results have limited clinical significance.

CONCLUSIONS

Under current practice, intraoperative anaesthetic parameters are tightly maintained, restricting the significance of their effect on postoperative renal function. Future studies should evaluate whether haemodynamic parameters during the early postoperative period, when they are monitored less frequently, are associated with renal functional outcome.

Inadvertent hypothermia and acute kidney injury (AKI) in neonates undergoing gastrointestinal surgeries: a retrospective study

OBJECTIVE

The purpose of our study was to evaluate the association between intraoperative hypothermia and AKI in neonates undergoing gastrointestinal surgeries.

STUDY DESIGN

This retrospective study was conducted for neonates who underwent gastrointestinal surgeries from June 2018 to August 2020. Neonates with a minimum of two documented creatinine values before and after surgical procedures within 48 h were included. According to the mean intraoperative temperature, the eligible neonates were divided into three groups. The primary outcome was the incidence of AKI (as defined by the modified KDIGO criteria). The association between variables and AKI or hospital mortality was also examined.

RESULTS

A total of 295 neonates fulfilled the eligibility criteria. AKI was more common in patients with lower intraoperative temperature compared to the normothermia group. Intraoperative mean temperature was independently associated with AKI. Patients developing AKI had a higher hospital mortality. AKI and gestational age were independently associated with hospital mortality.

CONCLUSIONS

Inadvertent intraoperative hypothermia was associated with developing postoperative AKI.

Perioperative Care of Patients Undergoing Major Complex Spinal Instrumentation Surgery: Clinical Practice Guidelines From the Society for Neuroscience in Anesthesiology and Critical Care

Evidence-based standardization of the perioperative management of patients undergoing complex spine surgery can improve outcomes such as enhanced patient satisfaction, reduced intensive care and hospital length of stay, and reduced costs. The Society for Neuroscience in Anesthesiology and Critical Care (SNACC) tasked an expert group to review existing evidence and generate recommendations for the perioperative management of patients undergoing complex spine surgery, defined as surgery on 2 or more thoracic and/or lumbar spine levels. Institutional clinical management protocols can be constructed based on the elements included in these clinical practice guidelines, and the evidence presented.

Detrimental effect of intraoperative hypothermia on pancreatic fistula after pancreaticoduodenectomy: A single-centre retrospective study

BACKGROUND

Although perioperative hypothermia was found to be associated with gastrointestinal anastomotic leakage in preclinical studies, its association with postoperative pancreatic fistula (POPF) following pancreaticoduodenectomy was never evaluated. We investigated the association between intraoperative hypothermia and clinically relevant (CR)-POPF following pancreaticoduodenectomy.

METHODS

We retrospectively reviewed 2163 consecutive patients who underwent pancreaticoduodenectomy during 2007-2019. Based on intraoperative time-weighted average core temperature, patients were grouped into normothermia (36.0-37.5°C), mild hypothermia (35.0-<36.0°C), and severe hypothermia (<35°C). We conducted multivariable logistic regression analysis for CR-POPF, a propensity score analysis using inverse probability of treatment weighting (IPTW) to adjust the baseline differences between the three groups, followed by multivariable logistic regression with IPTW for CR-POPF.

RESULTS

Among the 2008 patients analysed, 1118 (55.7%) and 120 (6.0%) had mild and severe hypothermia, respectively, and 14.2% overall incidence of CR-POPF. Severe intraoperative hypothermia was significantly associated with CR-POPF before and after IPTW (before: odds ratio [OR] 1.79, 95% confidence interval [CI]: 1.03-3.09, P = .038; after: OR 2.48, 95% CI: 1.28-4.81, P = .007); however, mild hypothermia had no significant associations.

CONCLUSION

Severe intraoperative hypothermia is significantly associated with the occurrence of CR-POPF following pancreaticoduodenectomy, suggesting that hypothermia is deleterious on pancreaticojejunal anastomotic healing.

Pathway for enhanced recovery after spinal surgery-a systematic review of evidence for use of individual components

BACKGROUND

Enhanced recovery in spinal surgery (ERSS) has shown promising improvements in clinical and economical outcomes. We have proposed an ERSS pathway based on available evidence. We aimed to delineate the clinical efficacy of individual pathway components in ERSS through a systematic narrative review.

METHODS

We included systematic reviews and meta-analysis, randomized controlled trials, non-randomized controlled studies, and observational studies in adults and pediatric patients evaluating any one of the 22 pre-defined components. Our primary outcomes included all-cause mortality, morbidity outcomes (e.g., pulmonary, cardiac, renal, surgical complications), patient-reported outcomes and experiences (e.g., pain, quality of care experience), and health services outcomes (e.g., length of stay and costs). Following databases (1990 onwards) were searched: MEDLINE, EMBASE, and Cochrane Library (Cochrane Database of Systematic Reviews and CENTRAL). Two authors screened the citations, full-text articles, and extracted data. A narrative synthesis was provided. We constructed Evidence Profile (EP) tables for each component of the pathway, where appropriate information was available. Due to clinical and methodological heterogeneity, we did not conduct a meta-analyses. GRADE system was used to classify confidence in cumulative evidence for each component of the pathway.

RESULTS

We identified 5423 relevant studies excluding duplicates as relating to the 22 pre-defined components of enhanced recovery in spinal surgery. We included 664 studies in the systematic review. We identified specific evidence within the context of spinal surgery for 14/22 proposed components. Evidence was summarized in EP tables where suitable. We performed thematic synthesis without EP for 6/22 elements. We identified appropriate societal guidelines for the remainder of the components.

CONCLUSIONS

We identified the following components with high quality of evidence as per GRADE system: pre-emptive analgesia, peri-operative blood conservation (antifibrinolytic use), surgical site preparation and antibiotic prophylaxis. There was moderate level of evidence for implementation of prehabilitation, minimally invasive surgery, multimodal perioperative analgesia, intravenous lignocaine and ketamine use as well as early mobilization. This review allows for the first formalized evidence-based unified protocol in the field of ERSS. Further studies validating the multimodal ERSS framework are essential to guide the future evolution of care in patients undergoing spinal surgery.

Intraoperative Data Enhance the Detection of High-Risk Acute Kidney Injury Patients When Added to a Baseline Prediction Model

BACKGROUND

Aspects of intraoperative management (eg, hypotension) are associated with acute kidney injury (AKI) in noncardiac surgery patients. However, it is unclear if and how the addition of intraoperative data affects a baseline risk prediction model for postoperative AKI.

METHODS

With institutional review board (IRB) approval, an institutional cohort (2005-2015) of inpatient intra-abdominal surgery patients without preoperative AKI was identified. Data from the American College of Surgeons National Surgical Quality Improvement Program (preoperative and procedure data), Anesthesia Information Management System (intraoperative data), and electronic health record (postoperative laboratory data) were linked. The sample was split into derivation/validation (70%/30%) cohorts. AKI was defined as an increase in serum creatinine ≥0.3 mg/dL within 48 hours or >50% within 7 days of surgery. Forward logistic regression fit a baseline model incorporating preoperative variables and surgical procedure. Forward logistic regression fit a second model incorporating the previously selected baseline variables, as well as additional intraoperative variables. Intraoperative variables reflected the following aspects of intraoperative management: anesthetics, beta-blockers, blood pressure, diuretics, fluids, operative time, opioids, and vasopressors. The baseline and intraoperative models were evaluated based on statistical significance and discriminative ability (c-statistic). The risk threshold equalizing sensitivity and specificity in the intraoperative model was identified.

RESULTS

Of 2691 patients in the derivation cohort, 234 (8.7%) developed AKI. The baseline model had c-statistic 0.77 (95% confidence interval [CI], 0.74-0.80). The additional variables added to the intraoperative model were significantly associated with AKI (P < .0001) and the intraoperative model had c-statistic 0.81 (95% CI, 0.78-0.83). Sensitivity and specificity were equalized at a risk threshold of 9.0% in the intraoperative model. At this threshold, the baseline model had sensitivity and specificity of 71% (95% CI, 65-76) and 69% (95% CI, 67-70), respectively, and the intraoperative model had sensitivity and specificity of 74% (95% CI, 69-80) and 74% (95% CI, 73-76), respectively. The high-risk group had an AKI risk of 18% (95% CI, 15-20) in the baseline model and 22% (95% CI, 19-25) in the intraoperative model.

CONCLUSIONS

Intraoperative data, when added to a baseline risk prediction model for postoperative AKI in intra-abdominal surgery patients, improves the performance of the model.

Neuroanesthesiology Update

This review summarizes the literature published in 2020 that is relevant to the perioperative care of neurosurgical patients and patients with neurological diseases as well as critically ill patients with neurological diseases. Broad topics include general perioperative neuroscientific considerations, stroke, traumatic brain injury, monitoring, anesthetic neurotoxicity, and perioperative disorders of cognitive function.