心血管麻醉师学会心脏手术相关急性肾损伤管理的临床实践更新

Ke Peng, D. McIlroy, B. Bollen, F. Billings, A. Zarbock, W. Popescu, A. Fox, L. Shore-lesserson, Shaofeng Zhou, M. Geube, Fuhai Ji, Meena Bhatia, N. Schwann, A. Shaw, Hong Liu
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引用次数: 19

摘要

心脏手术相关的急性肾损伤(CS-AKI)是常见的,并且与术后发病率和死亡率增加的风险相关。我们最近对心血管麻醉师学会(SCA)会员进行的调查显示,临床医生最重视的是6种潜在的肾保护策略(即术中目标血压、特定血管加压剂的选择、红细胞输血阈值、α -2激动剂的使用、体外循环(CPB)中目标定向供氧,以及“肾脏疾病改善全球结局(KDIGO)一揽子护理”)。因此,SCA的持续实践改进急性肾损伤工作组旨在根据随机对照试验(rct)的证据,为心脏手术患者提供每种策略的实践更新。在PubMed、EMBASE和Cochrane图书馆数据库中全面检索了从成立到2021年2月的符合条件的研究,检索结果于2021年8月更新。共纳入15项调查上述策略对CS-AKI影响的随机对照试验进行meta分析。对于每种策略,使用推荐、评估、发展和评价分级(GRADE)方法评估证据水平。在评估的6种潜在的肾保护策略中,目前的使用证据被评为“中等”、“低”或“非常低”。基于符合条件的随机对照试验,我们的分析建议在高危患者中使用CPB的目标定向氧输送和“KDIGO一揽子护理”来预防CS-AKI(中度GRADE证据)。我们的结果建议考虑在血管瘫痪休克患者中使用血管加压素来减少CS-AKI(低等级GRADE证据)。围手术期使用限制性或自由输血策略的决定不应基于对肾脏保护的担忧(GRADE证据的中等水平)。此外,CPB期间以较高的平均动脉压为目标,围手术期使用多巴胺和使用右美托咪定并没有降低CS-AKI(低或极低水平的GRADE证据)。本综述将帮助临床医生提供循证护理,以改善接受心脏手术的成人患者的肾脏预后为目标。
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Society of Cardiovascular Anesthesiologists Clinical Practice Update for Management of Acute Kidney Injury Associated With Cardiac Surgery
Cardiac surgery-associated acute kidney injury (CS-AKI) is common and is associated with increased risk for postoperative morbidity and mortality. Our recent survey of the Society of Cardiovascular Anesthesiologists (SCA) membership showed 6 potentially renoprotective strategies for which clinicians would most value an evidence-based review (ie, intraoperative target blood pressure, choice of specific vasopressor agent, erythrocyte transfusion threshold, use of alpha-2 agonists, goal-directed oxygen delivery on cardiopulmonary bypass [CPB], and the “Kidney Disease Improving Global Outcomes [KDIGO] bundle of care”). Thus, the SCA’s Continuing Practice Improvement Acute Kidney Injury Working Group aimed to provide a practice update for each of these strategies in cardiac surgical patients based on the evidence from randomized controlled trials (RCTs). PubMed, EMBASE, and Cochrane library databases were comprehensively searched for eligible studies from inception through February 2021, with search results updated in August 2021. A total of 15 RCTs investigating the effects of the above-mentioned strategies on CS-AKI were included for meta-analysis. For each strategy, the level of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. Across the 6 potentially renoprotective strategies evaluated, current evidence for their use was rated as “moderate,” “low,” or “very low.” Based on eligible RCTs, our analysis suggested using goal-directed oxygen delivery on CPB and the “KDIGO bundle of care” in high-risk patients to prevent CS-AKI (moderate level of GRADE evidence). Our results suggested considering the use of vasopressin in vasoplegic shock patients to reduce CS-AKI (low level of GRADE evidence). The decision to use a restrictive versus liberal strategy for perioperative red cell transfusion should not be based on concerns for renal protection (a moderate level of GRADE evidence). In addition, targeting a higher mean arterial pressure during CPB, perioperative use of dopamine, and use of dexmedetomidine did not reduce CS-AKI (a low or very low level of GRADE evidence). This review will help clinicians provide evidence-based care, targeting improved renal outcomes in adult patients undergoing cardiac surgery.
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