A pilot goal-directed perfusion initiative is associated with less acute kidney injury after cardiac surgery

Abstract

Background: We sought to determine whether a pilot goal-directed perfusion initiative could reduce the incidence of acute kidney injury after cardiac surgery.

Methods: On the basis of the available literature, we identified goals to achieve during cardiopulmonary bypass (including maintenance of oxygen delivery >300 mL O2/min/m² and reduction in vasopressor use) that were combined into a goal-directed perfusion initiative and implemented as a quality improvement measure in patients undergoing cardiac surgery at Johns Hopkins during 2015. Goal-directed perfusion initiative patients were matched to controls who underwent cardiac surgery between 2010 and 2015 using propensity scoring across 15 variables. The primary and secondary outcomes were the incidence of acute kidney injury and the mean increase in serum creatinine within the first 72 hours after cardiac surgery.

Results: We used the goal-directed perfusion initiative in 88 patients and matched these to 88 control patients who were similar across all variables, including mean age (61 years in controls vs 64 years in goal-directed perfusion initiative patients, P = .12) and preoperative glomerular filtration rate (90 vs 83 mL/min, P = .34). Controls received more phenylephrine on cardiopulmonary bypass (mean 2.1 vs 1.4 mg, P < .001) and had lower nadir oxygen delivery (mean 241 vs 301 mL O2/min/m², P < .001). Acute kidney injury incidence was 23.9% in controls and 9.1% in goal-directed perfusion initiative patients (P = .008); incidences of acute kidney injury stage 1, 2, and 3 were 19.3%, 3.4%, and 1.1% in controls, and 5.7%, 3.4%, and 0% in goal-directed perfusion initiative patients, respectively. Control patients exhibited a larger median percent increase in creatinine from baseline (27% vs 10%, P < .001).

Conclusions: The goal-directed perfusion initiative was associated with reduced acute kidney injury incidence after cardiac surgery in this pilot study.

Keywords: CPB inflammatory response; acute kidney injury; cardiopulmonary bypass; goal-directed perfusion; kidney; postoperative care; renal failure.

FIGURE 1

Flow chart of patients included and excluded. GDP, Goal-directed perfusion; AKI, acute kidney injury; ESRD, end-stage renal disease; PS, propensity score.

FIGURE 2

Graph showing median percent creatinine changes from baseline, by postoperative day. Error bars denote IQR. Note that because these values are measured daily, they differ from our defined outcomes in the text. Serum creatinine in milligrams/deciliters. Cr, Creatinine; GDP, goal-directed perfusion.