Objective To describe rates and risk factors for prolonged postoperative use of opioids in patients who had not previously used opioids and undergoing major elective surgery.

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Background-Acute kidney injury (AKI) after cardiac surgery is a major health issue. Lacking effective therapies, risk factor modification may offer a means of preventing this complication. The objective of the present study was to identify and determine the prognostic importance of such risk factors. Methods and Results-Data from a multicenter cohort of 3500 adult patients who underwent cardiac surgery at 7 hospitals during 2004 were analyzed (using multivariable logistic regression modeling) to determine the independent relationships between 3 thresholds of AKI (Ͼ25%, Ͼ50%, and Ͼ75% decrease in estimated glomerular filtration rate within 1 week of surgery or need for postoperative dialysis) with death rates, as well as to identify modifiable risk factors for AKI. The 3 thresholds of AKI occurred in 24% (nϭ829), 7% (nϭ228), and 3% (nϭ119) of the cohort, respectively. All 3 thresholds were independently associated with a Ͼ4-fold increase in the odds of death and could be predicted with several perioperative variables, including preoperative intra-aortic balloon pump use, urgent surgery, and prolonged cardiopulmonary bypass. In particular, 3 potentially modifiable variables were also independently and strongly associated with AKI. These were preoperative anemia, perioperative red blood cell transfusions, and surgical reexploration. Conclusions-AKI after cardiac surgery is highly prevalent and prognostically important. Therapies aimed at mitigating preoperative anemia, perioperative red blood cell transfusions, and surgical reexploration may offer protection against this complication. (Circulation. 2009;119:495-502.)

*Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. †ACC/AHA Representative.

In this analysis, postoperative AKI is associated with sustained intraoperative periods of MAP less than 55 and less than 60 mmHg. This study provides an impetus for clinical trials to determine whether interventions that promptly treat IOH and are tailored to individual patient physiology could help reduce the risk of AKI.

*Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. †ACC/AHA Representative.

QuestionCan Bayesian analysis clarify the interpretation of clinical trial results? FindingsIn a post hoc Bayesian analysis of the recent EOLIA (ECMO to Rescue Acute Lung Injury) trial, the posterior probability of mortality benefit (relative risk<1) ranged between 88% and 99% given a range of prior assumptions reflecting varying degrees of skepticism and enthusiasm regarding previous evidence for the benefit of ECMO. Probabilities varied according to the definition of minimum clinically important mortality benefit; for example, the posterior probability of relative risk <0.67 ranged between 0% to 48%given the same range of prior assumptions. MeaningInformation about the posterior probability of treatment effect provided by Bayesian analysis may help to clarify the interpretation of clinical trial findings. ConclusionPost hoc Bayesian analysis of data from a randomized trial of early ECMO compared with conventional lung-protective ventilation with the option for rescue ECMO among patients with very severe ARDS provides information about the posterior probability of mortality benefit under a broad set of assumptions that may help inform interpretation of the study findings.

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