Postoperative AKI Avoided by Intraoperative Haemodynamic Monitoring: Joint Consensus
“Goal-directed therapy can reduce the risk of Postoperative AKI”…
says a newly published article in Nature (Nature Reviews Nephrology). The Acute Disease Quality Initiative (ADQI-24) and the PeriOperative Quality Initiative (POQI-7) provides a comprehensive scientific review of the association between major surgery and postoperative AKI (Acute Kidney Injury).
Find the article here: Postoperative acute kidney injury (PO-AKI) in adult non-cardiac surgery: joint consensus report of the Acute Disease Quality Initiative and PeriOperative Quality Initiative, Prowle et al.
Search for AKI (or renal failure) and one is rewarded with a rich seam of results. It’s a few pages down, however, before one finds the condition as attributed to having major surgery. It’s perhaps surprising that postoperative AKI slips this far under the radar. After all, it occurs all too frequently and is a debilitating condition with a host of very poor long term health outcomes, including death. Indeed multiple clinical trials point to incidence rates of well over 10% in major surgery. While only a small proportion of these cases could be classed as serious, any ongoing iatrogenic kidney problem has the potential to result in short term complications, longer hospital stays long term adverse outcomes and early death. In fact the article points to a “considerable health-care and societal burden.”
AKI “Canary in the Coalmine” for damage to perfusion-dependent organs
In a recent Deltex-sponsored TopMedTalk podcast, experts discussed the adoption of Enhanced Recovery After Surgery (ERAS) principles to improve efficiency in dealing with the post-COVID surgical backlog. The panel saw AKI as a “Canary in the Coalmine” for cellular injury of other perfusion-dependent organs. That theme returns in the Nature piece, which talks of AKI as being the “sentinel” post-operative complication. In other words, by doing the things that protect the kidneys, clinicians can simultaneously maintain perfusion of vital tissues and avoiding a host of adverse outcomes.
The article goes on to state that; “Despite the importance of AKI as a complication after all forms of major surgery, lack of consensus exists with regard to the definition, prevention and treatment of postoperative AKI and the pathophysiology (of PO-AKI) in the non-cardiac setting has not been well described.”
The source of this new paper is a joint meeting of the Acute Disease Quality Initiative (ADQI-24) and the PeriOperative Quality Initiative (POQI-7) held in late 2019 at Emmanuel College Cambridge. The group came together to address PO-AKI after major non-cardiac surgery. Based on a review of evidence by and professional judgment of the faculty, what resulted were clinical recommendations. The output therefore provides positive steps which are proven to reduce the risk of patients acquiring the condition.
Postoperative AKI Prevention: It’s all about accurate haemodynamic management
Intraoperative strategies focus entirely on fluid, both volume and composition of fluids given. Evidence supports haemodynamic management in the intraoperative and early postoperative periods as having a major impact on the development of PO-AKI. In fact the article singles out algorithms that use cardiac output monitoring to optimise cardiac stroke volume and/or increase global oxygen delivery. Deltex Medical’s oesophageal Doppler monitoring (TrueVue ODM+) is unique in this regard, providing accurate, real-time flow data directly from the patient’s aorta.
In 2018 the FEDORA RCT (Calvo-Vecchio et al) investigated the very population being discussed in the new Nature article. Patients subjected to Goal-Directed Haemodynamic Therapy (GDHT) saw a reduction in AKI of 92% as well as a reduction in overall complications from 16.6% to 8.6%. Of these, fewer suffer moderate or severe AKI, acute respiratory distress syndrome, acute pulmonary oedema, pneumonia and superficial or deep surgical site infection
Goal-directed therapy has been the subject of multiple RCTs. A resulting Cochrane review and meta-analysis suggested that GDHT can reduce the risk of PO-AKI. Intraoperative hypotension is reportedly common and is known to be associated with kidney related complications. This means the anaesthetist needs to have the best possible insight into the patient’s haemodynamic status throughout the procedure. The article says this extends into the postoperative period, stating that “therapeutic strategies used in the hours after surgery could likely modify the risk of AKI.”
Deltex Medical CEO comments
Deltex Medical CEO Andy Mears states; “This is an excellent article and once more draws attention to a condition that is both dangerous and importantly avoidable. From Deltex’s unique perspective, multiple high quality trials point to TrueVue ODM+ monitoring as being the best way of maintaining haemodynamic balance in patients where this is all-important.
“This review of the current state of play confirms and builds on previous findings. We look forward to further adoption of TrueVue ODM+ based on the strength of the arguments provided here and elsewhere.”