Preventing AKI in Cardiac Surgery

Daniel Engelman MD, FACS Associate Professor of Surgery, UMASS-Baystate

President, ERAS® Cardiac Society Medical Director, Heart, Vascular, and Critical Care Surgical Services

Baystate Medical Center Springfield, MA

Preventing AKI in Cardiac Surgery

Daniel Engelman MD, FACSAssociate Professor of Surgery, UMASS-Baystate

President, ERAS® Cardiac SocietyMedical Director, Heart, Vascular, and Critical Care Surgical Services

Baystate Medical CenterSpringfield, MA

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DISCLOSURES

ConsultantforAstuteMedical,Zimmer-Biomet,andEdwardsLifesciences

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OuroldstandardprotocolforpatientswithnocreatinineriseonPOD#1

•  PatientsmaintainedonvasopressorsandinotropesprntokeepMAP>65andCI>2.0

•  Fulldosepotentiallynephrotoxicmedications(antibiotics,ACE-I’s,ARB’s)

•  Highthresholdforbloodtransfusion(notransfusionsforHCT>21)

•  Maintain>30cc/hrofurineoutputwithacombinationofLasixandfluids(oftenatthesametime)

•  Swanorminimallyinvasive(FloTrac)monitor,centrallineandarteriallines,andFoleyallremovedandpatientstransferredtotelemetrythemorningaftersurgery.

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LIMITATIONS:

•  SerumcreatininehasbeenshowntobealaggingindicatorofAKIdevelopmentanditiseasilyinfluencedbymanyfactors,includingsex,musclemassandothermedications.

•  Urineoutputismonitoredinmostcriticalcaresettings,however,theabilityofurineoutputtopredictsubsequentAKIcomplicationsaftercardiacsurgeryislimited.

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KDIGOVERSUSSTSDEFINITIONOFAKI

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AKIPREVALENCEAFTERCARDIACSURGERY

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READMISSIONRATES

9.3%

16.1%

21.8%

28.6%

0%

10%

20%

30%

No AKI Mild (Stage 1)

Moderate (Stage 2)

Severe (Stage 3)

30-D

ay R

eadm

issi

ons

(%)

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REDUCEDSHORT-TERMSURVIVAL

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30-DAYMORTALITYINCREASES

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LONG-TERMSURVIVAL

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THEAKIEFFECT

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THEACUTEKIDNEYRESPONSETEAM(AKRT)•  Sowhatdowedoandhowdowedoit?•  DevelopedaprotocoltointegratetheuseofNephroCheckintoamultidisciplinaryAcuteKidneyResponseTeam(AKRT)topotentiallyreduceAKIdevelopment,severityandthenumberofpatientswhoneeddialysis.

•  Designedasteppedalarmsystemforsurgeons,advancedpractitioners,nephrologists,criticalcarephysiciansandnursesthatstartswiththedrawingoftheurinarybiomarkerat5:30amthemorning.KDIG

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Our Multidisciplinary Approach to Reduce AKI

•  Cardiac Surgeons •  Nephrologist •  Cardiologist •  Advanced Practitioners •  Pharmacist •  Critical Care Nurses

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POCKETCARDS

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ISOLATEDCABGPATIENTS(PRESENTEDATASN)

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MOSTCOMMONINTERVENTIONS

•  Avoiding over-diuresis on POD #1

•  Discontinuing nephrotoxins.

•  Raising the PAD pressure to 14-16 mm/Hg with balanced crystalloid.

•  Instituting inotropes for depressed cardiac function to keep CI>2.5 & SBP>130.

•  Prolonging hemodynamic monitoring.

•  Increasing the frequency of urine output monitoring.

•  Obtaining an early nephrology consultation.

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FURTHERTHOUGHTS….•  Asthenegativepredictivevalue(NPV)withaNCthresholdof0.3was100%:

•  Thesepatientsmaybecandidatesforliberalearlyuseofpotentiallynephrotoxicagentssuchas:aggressivediuresis,ACE-I’s,ARB’s,Antibiotics,Toradol,etc

•  Isthe“positiveNC”valueof.3toolow?(Toomanyfalsenegatives)•  Ahigherpositivevalue(i.e.0.7)mayreduce“falsepositives”withoutsignificantlycompromisingpatientsafety. KDIG

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CONCLUSIONS•  An Acute Kidney Response Team (AKRT) triggered by NephroCheck and

implementation of AKI stress modulators reduced the progression to AKI.

•  The success of the AKRT is related to the successful formation and coordination of a multidisciplinary team.

•  Future research is needed to determine the optimal NephroCheck threshold to trigger the AKRT team. KDIG

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ERASCARDIACSOCIETY-MISSIONTooptimizeperioperativecareofcardiacsurgicalpatientsthroughcollaborativediscovery,analysis,expertconsensus,anddisseminationofbestpractices.•  Aresearch-basedapproachusingselectedpre-,intra-,andpost-operativeinterventionsinconcerttooptimizeoutcomesandthepatientexperience.

•  ERASprogramshavebeenastandardpracticeinEuropeformanyyearsandconsistofupto21differentcomponents.

•  TheseenhancedrecoveryprogramshavedemonstratedsignificantreductionsinLOS,bloodloss,timetoambulation,andcomplications;andincreasesinpatientsatisfactionaroundpain.

•  Theyandarebeingusedin95%ofsurgerypatientsintheUK.

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We are a “Disruptive” Society•  Suggestingthatstandardacceptedperioperativepracticesmaybewrong:

•  Elective patients should be optimized with 4 weeks of prehab prior to surgery.

(Especially those with malnutrition, anemia, frailty, ETOH/smoking) •  Ending preop dietary restrictions •  Wire cerclage versus rigid sternal fixation •  Ambulation restrictions •  Chest tube management strategies •  Increased ambulation and less dietary restrictions

•  “PerioperativeMedicine”•  Includes preoperative period •  May be more important to outcomes than the intraoperative component

of CT Surgery • WhatisPatient-Centered“Value”?

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