Prevention of acute kidney injury and protection of renal function in the intensive care unit : update 2017

Background: Acute kidney injury (AKI) in the intensive care unit is associated with significant mortality and morbidity. Objectives: To determine and update previous recommendations for the prevention of AKI, specifically the role of fluids, diuretics, inotropes, vasopressors/vasodilators, hormonal and nutritional interventions, sedatives, statins, remote ischaemic preconditioning and care bundles. Method: A systematic search of the literature was performed for studies published between 1966 and March 2017 using these potential protective strategies in adult patients at risk of AKI. The following clinical conditions were considered: major surgery, critical illness, sepsis, shock, exposure to potentially nephrotoxic drugs and radiocontrast. Clinical endpoints included incidence or grade of AKI, the need for renal replacement therapy and mortality. Studies were graded according to the international GRADE system. Results: We formulated 12 recommendations, 13 suggestions and seven best practice statements. The few strong recommendations with high-level evidence are mostly against the intervention in question (starches, low-dose dopamine, statins in cardiac surgery). Strong recommendations with lower-level evidence include controlled fluid resuscitation with crystalloids, avoiding fluid overload, titration of norepinephrine to a target MAP of 65-70 mmHg (unless chronic hypertension) and not using diuretics or levosimendan for kidney protection solely. Conclusion: The results of recent randomised controlled trials have allowed the formulation of new recommendations and/or increase the strength of previous recommendations. On the other hand, in many domains the available evidence remains insufficient, resulting from the limited quality of the clinical trials and the poor reporting of kidney outcomes

Postoperative atrial fibrillation in patients on statins undergoing isolated cardiac valve surgery: a meta-analysis

Introduction: The efficacy of perioperative statin therapy in decreasing postoperative morbidity in patients undergoing valve replacements and repairs is unknown. The aim of our study was to determine whether or not the literature supports the hypothesis that statins decrease postoperative atrial fibrillation (AF), and hence improve short-term postoperative outcomes in patients undergoing isolated cardiac valve surgery.Method: We conducted a meta-analysis of studies on postoperative outcomes associated with statin therapy following isolated valve replacement or repair. The data was taken from published studies on valvular heart surgery patients. Participants were patients who underwent either isolated cardiac valve replacement or repair. Patients in the intervention group received statins prior to their surgery. Three databases were searched: Ovid Healthstar, 1966 to April 2012; Ovid Medline, 1946 to 31 May 2012; and Embase, 1974 to 30 May 2012. The meta-analysis was conducted using Review Manager® version 5.1.Results: Statins did not decrease the incidence of postoperative AF in patients undergoing isolated cardiac valve surgery [odds ratio (OR) 1.19, 95% confidence interval (CI): 0.80– 1.77)], although there was significant heterogeneity for the outcome of postoperative AF (I2 55%, 95% CI: 27–72). Statins were associated with a decrease in 30-day mortality (OR 0.43, 95% CI: 0.24–0.75).Conclusion: Although this meta-analysis suggests that chronic statin therapy did not prevent postoperative AF in unselected valvular heart surgical patients, the heterogeneity indicates that this outcome should be viewed with caution and further research is recommended.Keywords: atrial fibrillation, cardiac surgery, statin

Statin pretreatment and risk of in-hospital atrial fibrillation among patients undergoing cardiac surgery: a collaborative meta-analysis of 11 randomized controlled trials

Aims Statin pretreatment in patients undergoing cardiac surgery is understood to prevent postoperative atrial fibrillation (AF). However, this is based on observational and limited randomized trial evidence, resulting in uncertainty about any genuine anti-arrhythmic benefits of these agents in this setting.We therefore aimed to quantify precisely the association between statin pretreatment and postoperative AF among patients undergoing cardiac surgery. Methods and results A detailed search of MEDLINE and PubMed databases (1st January 1996 to 31st July 2012)was conducted, followed by a review of the reference lists of published studies and correspondence with trial investigators to obtain individual– participant data for meta-analysis. Evidence was combined across prospective, randomized clinical trials that compared the risk of postoperative AF among individuals randomized to statin pretreatment or placebo/control medication before elective cardiac surgery. Postoperative AF was defined as episodes of AF lasting ≥5 min. Overall, 1105 participants from 11 trials were included; of them, 552 received statin therapy preoperatively. Postoperative AF occurred in 19% of these participants when compared with 36% of those not treated with statins (odds ratio 0.41, 95% confidence interval 0.31–0.54, P , 0.00001, using a random-effects model). Atrial fibrillation prevention by statin pretreatmentwas consistent across different subgroups. Conclusion Short-term statin pretreatment may reduce the risk of postoperative AF among patients undergoing cardiac surgery

Effect of preoperative statins in patients without coronary artery disease who undergo cardiac surgery

Objective3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) have been shown to have pleiotropic effects in addition to their lipid-lowering properties. Some studies have shown the beneficial effect of preoperative statins on operative outcomes in coronary artery bypass grafting. However, the effect of preoperative statins in patients without coronary artery disease who undergo cardiac surgery remains poorly defined.MethodsWe performed a retrospective review of 1389 consecutive patients undergoing cardiac valve surgery between January of 2002 and December of 2005. Patients undergoing concomitant coronary artery bypass surgery and those with a history of myocardial infarction and coronary interventions were excluded. Of this cohort, 363 patients were receiving a statin preoperatively and 1026 patients were not. Propensity scores were constructed with patients' demographics, clinical data, and the year of procedure. Generalized estimating equations, including the propensity score as a covariate, were used to investigate whether preoperative statin use is associated with improved operative outcomes.ResultsThe crude operative mortality rate was 0.8% and 2.3%, the incidence of stroke was 1.7% and 2.9%, and the incidence of perioperative myocardial infarction was 2.2% and 2.4% in the statin and non-statin groups, respectively. Generalized estimating equations showed that preoperative statin use is associated with lower mortality (odds ratio: 0.25, 95% confidential interval: 0.12–0.54). Preoperative statin use was not significantly associated with an incidence of stroke (odds ratio: 0.48, 95% confidential interval: 0.19–1.22) or perioperative myocardial infarction (odds ratio: 0.91, 95% confidential interval: 0.43–1.91) in this cohort.ConclusionPreoperative use of statins may improve operative outcomes in patients without coronary artery disease who undergo cardiac surgery

How to prevent perioperative myocardial injury: The conundrum continues

BACKGROUND: Perioperative myocardial injury (PMI) remains a major cause of perioperative morbidity and mortality but clinical strategies to prevent PMI are still uncertain. METHODS AND RESULTS: We comprehensively searched PubMed for major research articles concerning clinical strategies to prevent PMI. The key findings are as follows: (1) the American College of Cardiology/American Heart Association guideline update for perioperative cardiovascular evaluation for noncardiac surgery is very useful to stratify cardiac risk preoperatively; (2) cardiac troponin has emerged as a biomarker to diagnose postoperative PMI and to predict clinical outcomes; (3) coronary revascularization before noncardiac surgery probably would provide cardiac protection in select patients, especially in patients with high-risk coronary artery disease; (4) elective noncardiac surgery should be postponed in patients who received coronary stenting recently because of high incidence of serious cardiac complications (minimum 6-8 weeks for bare metal stents and 6-12 months for drug-eluting stents); and (5) beta-blockers and statins are very promising drugs and probably would prevent PMI in a select patient population, especially in patients with intermediate risk and stable coronary artery disease. CONCLUSIONS: Further studies, especially randomized clinical trials and mechanistic investigation are needed to find the best and effective clinical strategies to prevent/reduce PMI

Perioperative use of statins in noncardiac surgery

Background: Statins (3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors) can significantly decrease cardiovascular mortality and morbidity, irrespective of the patients' cholesterol status. This paper reviews the effects of perioperative statin therapy in patients undergoing noncardiac surgery. Method: A systematic literature review was undertaken of all published literature on this subject using Medline and cross-referenced. All published relevant papers on the perioperative use of statins were used. Results: Perioperative statin therapy is associated with a lower perioperative morbidity and mortality in patients undergoing elective or emergency surgery. The effects are due to a combination of lipid-lowering and pleiotropic properties of statins. Conclusion: Ideally a large scale multi-centre randomized controlled trial of perioperative statin therapy should be performed but this may be difficult to conduct since there is already overwhelming evidence in the literature to suggest perioperative cardiovascular protective properties. Statins may still be under-prescribed in surgical patients. © 2008 Chan et al, publisher and licensee Dove Medical Press Ltd.published_or_final_versio

Relationship Between Preoperative Statin Use and Postoperative Infectious Complications in General and Non-Cardiac Surgery

Relationship Between Preoperative Statin Use And Postoperative Infectious Complications in General and Non-Cardiac Surgery Johnathan A. Bernard1,2, Ronnie A. Rosenthal1, Selwyn O. Rogers2 1: Department of Surgery, West Haven VA Medical Center, Yale University School of Medicine, New Haven, CT 2: Center for Surgery and Public Health, Harvard School of Public Health, Boston, MA Objective: Characterize the impact of preoperative statin use on postoperative infectious complications and 30-day postoperative mortality in general and non-cardiac surgery patients. Background: The lipid lowering effects of statins have been well documented for the treatment of coronary artery disease. There has been mounting evidence to support use of statins for their pleiotropic effect. Among these, immune system modulation, improved endothelial function, attenuation of sepsis, and organ protection are particularly relevant to the surgical patient. However, the pleiotropic effects of statins are poorly understood postoperatively in general and non-cardiac surgery patients. Design: Retrospective observational study conducted to test the hypothesis that preoperative statin use leads to a risk reduction of postoperative infectious complications (POIC) (any occurrence of surgical site infection, deep surgical site infection, wound dehiscence,pneumonia, urinary tract infection, sepsis, or septic shock) and would reduce the risk of 30 day postoperative mortality, while identifying independent risk factors for POIC. To do so, the ACS NSQIP database at a 777-bed academic medical center was merged with pharmacy data and electronic medical records at the same institution from January 1, 2006 to January 1, 2008. Results: Two thousand, five hundred and eighty four patients underwent major general and non-cardiac surgery during the study time period. Five hundred and seventy eight of these patients were on statin therapy before admission and continued statin therapy after surgery. A total of two hundred and twenty four POIC occurred. Best-fit logistic regression models demonstrated that ASA classification, length of operation, and emergent status of case were associated with an increase in POIC. Patients receiving statins, when adjusted for ASA classification, length of operation, and case emergency, did not have a reduced risk of POIC, with an AOR 0.978 (95% CI 0.58 1.63, p = 0.93). Statin use was, however, associated with a reduction in 30 day postoperative mortality (OR 0.45; 95% CI 0.23 0.87, p = 0.019). Conclusion: Preoperative statin therapy reduces the risk of 30 day mortality, but its effect on reducing POIC after general surgery remains to be proven. Further research is needed to evaluate the role of preoperative statin therapy and its pleiotropic effects in surgical patients

Effect of Perioperative Lipid Status on Clinical Outcomes after Cardiac Surgery

Abstract Patients undergoing cardiac surgery are at increased cardiovascular risk, which includes altered lipid status. However, data on the effect of cardiac surgery and cardiopulmonary bypass (CPB) on plasma levels of key lipids are scarce. We investigated potential effects of CPB on plasma lipid levels and associations with early postoperative clinical outcomes. This is a prospective bio-bank study of patients undergoing elective cardiac surgery at our center January to December 2019. The follow-up period was 1 year after surgery. Blood sampling was performed before induction of general anesthesia, upon weaning from cardiopulmonary bypass (CPB), and on the first day after surgery. Clinical end points included the incidence of postoperative stroke, myocardial infarction, and death of any cause at 30 days after surgery as well as 1-year all-cause mortality. A total of 192 cardiac surgery patients (75% male, median age 67.0 years (interquartile range 60.0–73.0), median BMI 26.1 kg/m2 (23.7–30.4)) were included. A significant intraoperative decrease in plasma levels compared with preoperative levels (all p < 0.0001) was observed for total cholesterol (TC) (Cliff’s delta d: 0.75 (0.68–0.82; 95% CI)), LDL-Cholesterol (LDL-C) (d: 0.66 (0.57–0.73)) and HDL-Cholesterol (HDL-C) (d: 0.72 (0.64–0.79)). At 24h after surgery, the plasma levels of LDL-C (d: 0.73 (0.650.79)) and TC (d: 0.77 (0.69–0.82)) continued to decrease compared to preoperative levels, while the plasma levels of HDL-C (d: 0.46 (0.36–0.55)) and TG (d: 0.40 (0.29–0.50)) rebounded, but all remained below the preoperative levels (p < 0.001). Mortality at 30 days was 1.0% (N = 2/192), and 1-year mortality was 3.8% (N = 7/186). Postoperative myocardial infarction occurred in 3.1% of patients (N = 6/192) and postoperative stroke in 5.8% (N = 11/190). Adjusting for age, sex, BMI, and statin therapy, we noted a protective effect of postoperative occurrence of stroke for pre-to-post-operative changes in TC (adjusted odds ratio (OR) 0.29 (0.07–0.90), p = 0.047), in LDL-C (aOR 0.19 (0.03–0.88), p = 0.045), and in HDL-C (aOR 0.01 (0.00–0.78), p = 0.039). No associations were observed between lipid levels and 1-year mortality. In conclusion, cardiac surgery induces a significant sudden drop in levels of key plasma lipids. This effect was pronounced during the operation, and levels remained significantly lowered at 24 h after surgery. The intraoperative drops in LDL-C, TC, and HDL-C were associated with a protective effect against occurrence of postoperative stroke in adjusted models. We demonstrate that the changes in key plasma lipid levels during surgery are strongly correlated, which makes attributing the impact of each lipid to the clinical end points, such as postoperative stroke, a challenging task. Large-scale analyses should investigate additional clinical outcome measures