Does the Implementation of a Quality Improvement Care Bundle Reduce the Incidence of Acute Kidney Injury in Patients Undergoing Emergency Laparotomy?

Abstract

Purpose: Previous work has demonstrated a survival improvement following the introduction of an enhanced recovery protocol in patients undergoing emergency laparotomy (the emergency laparotomy pathway quality improvement care (ELPQuiC) bundle). Implementation of this bundle increased the use of intra-operative goal directed fluid therapy and ICU admission, both evidence-based strategies recommended to improve kidney outcomes. The aim of this study was to determine if the observed mortality benefit could be explained by a difference in the incidence of AKI pre- and post-implementation of the protocol. Method: The primary outcome was the incidence of AKI in the pre- and post-ELPQuiC bundle patient population in four acute trusts in the United Kingdom. Secondary outcomes included the KDIGO stage specific incidence of AKI. Serum creatinine values were obtained retrospectively at baseline, in the post-operative period and the maximum recorded creatinine between day 1 and day 30 were obtained. Results: A total of 303 patients pre-ELPQuiC bundle and 426 patients post-ELPQuiC bundle implementation were identified across the four centres. The overall AKI incidence was 18.4% in the pre-bundle group versus 19.8% in the post bundle group p = 0.653. No significant differences were observed between the groups. Conclusions: Despite this multi-centre cohort study demonstrating an overall survival benefit, implementation of the quality improvement care bundle did not affect the incidence of AKI.

Impact of Enhanced Recovery After Surgery (ERAS) protocol versus standard of care on postoperative Acute Kidney Injury (AKI): A meta-analysis

“…Of the included 19 studies, all of studies showed the rate of AKI after surgery, six of these studies [ 11 – 13 , 27 , 30 , 32 ] also reported postoperative complications other than AKI, only 3 studies [ 16 , 33 , 34 ] were not reported a difference in length of stay (LOS) in the ERAS vs. standard group. Rate of 30-day readmission or reoperation reported in 13 studies [ 9 – 12 , 15 , 17 , 25 – 30 , 32 ] and mortality in 8 studies [ 11 , 12 , 14 , 15 , 25 , 26 , 30 , 32 ]. 11 studies adopted the fluid management mode of goal-directed fluid therapy (GDFT) [ 10 – 17 , 27 , 29 , 30 ], 6 studies used restrictive fluid management intraoperatively [ 9 , 25 , 26 , 28 , 33 , 34 ], and the remaining 2 studies [ 31 , 32 ] did not elaborate the fluid management mode.…”

“…Our initial search yielded 7,441 potentially relevant cohort studies on postoperative complications including AKI occurring with ERAS versus conventional therapy in patients who underwent surgery. After screening and reviewing, 19 studies [9][10][11][12][13][14][15][16][17][25][26][27][28][29][30][31][32][33][34] met our inclusion criteria. Of the nineteen, seventeen were retrospective and two were prospective cohort studies.…”

“…Proven by studies that ERAS protocol exacerbates the risk of AKI development after colorectal surgery [9][10][11][12][13]. However, some scholars have objected that ERAS will not aggravate the occurrence of postoperative AKI [14][15][16][17]. In order to investigate and address this concern, we used this systematic review of the literature with meta-analysis was to assess the impact of ERAS protocols vs. standard of care on kidney function and the incidence of postoperative AKI.…”

Enhanced Recovery After Surgery (ERAS®) Society Consensus Guidelines for Emergency Laparotomy Part 3: Organizational Aspects and General Considerations for Management of the Emergency Laparotomy Patient

“…Although less common, cardiovascular and renal complications on any postoperative day were highly predictive of mortality, other major studies of non-cardiac surgery have found that cardiovascular complications are highly predictive of mortality [ 48 , 49 ]. Acute kidney injury is also common in patients undergoing EL and predicts mortality [ 50 , 51 ].…”

"Acute Kidney Injury predictive models: advanced yet far from application in resource-constrained settings."

“… 3 Electronic health records are prohibitively expensive in resource-constrained settings. The application of AKI bundle interventions has yielded mixed results in terms of benefit in reducing AKI rates, 8 , 9 with even less evidence of benefit from individual interventions such as avoidance of nephrotoxins and overzealous fluid resuscitation, raising the possibility of heightened awareness and improved care quality as the reason for improvement rather than the interdependence of the interventions.…”