Intraoperative venous congestion rather than hypotension is associated with acute adverse kidney events after cardiac surgery: a retrospective cohort study

Chen, Lihai; Hong, Liang; Ma, Aixia; Chen, Yanfei; Xiao, Yue; Jiang, Feng; Huang, Rong; Zhang, Cui; Bu, Xinyi; Ge, Yali; Zhou, Jifang

doi:10.1016/j.bja.2022.01.032

Cited by 22 publications

(18 citation statements)

References 38 publications

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“…Secondly, we incorporated various hemodynamic time-series features that were considered difficult to incorporate in prediction models ( 32 – 34 ). In our previous study, we demonstrated an association between hemodynamic time-series data and postoperative organ dysfunction ( 35 ). It is well known that intraoperative hypotension and venous congestion may be a reflection of LCOS.…”

Section: Discussionmentioning

confidence: 94%

Prediction of low cardiac output syndrome in patients following cardiac surgery using machine learning

Hong

et al. 2022

Front. Med.

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BackgroundThis study aimed to develop machine learning models to predict Low Cardiac Output Syndrome (LCOS) in patients following cardiac surgery using machine learning algorithms.MethodsThe clinical data of cardiac surgery patients in Nanjing First Hospital between June 2019 and November 2020 were retrospectively extracted from the electronic medical records. Six conventional machine learning algorithms, including logistic regression, support vector machine, decision tree, random forest, extreme gradient boosting and light gradient boosting machine, were employed to construct the LCOS predictive models with all predictive features (full models) and selected predictive features (reduced models). The discrimination of these models was evaluated by the area under the receiver operating characteristic curve (AUC) and the calibration of the models was assessed by the calibration curve. Shapley Additive explanation (SHAP) and Local Interpretable Model-Agnostic Explanations (LIME) were used to interpret the predictive models.ResultsData from 1,585 patients [982 (62.0%) were male, aged 18 to 88, 212 (13.4%) with LCOS] were employed to train and validate the LCOS models. Among the full models, the RF model (AUC: 0.909, 95% CI: 0.875–0.943; Sensitivity: 0.849, 95% CI: 0.724–0.933; Specificity: 0.835, 95% CI: 0.796–0.869) and the XGB model (AUC: 0.897, 95% CI: 0.859–0.935; Sensitivity: 0.830, 95% CI: 0.702–0.919; Specificity: 0.809, 95% CI: 0.768–0.845) exhibited well predictive power for LCOS. Eleven predictive features including left ventricular ejection fraction (LVEF), first post-operative blood lactate (Lac), left ventricular diastolic diameter (LVDd), cumulative time of mean artery blood pressure (MABP) lower than 65 mmHg (MABP < 65 time), hypertension history, platelets level (PLT), age, blood creatinine (Cr), total area under curve above threshold central venous pressure (CVP) 12 mmHg and 16 mmHg, and blood loss during operation were used to build the reduced models. Among the reduced models, RF model (AUC: 0.895, 95% CI: 0.857–0.933; Sensitivity: 0.830, 95% CI: 0.702–0.919; Specificity: 0.806, 95% CI: 0.765–0.843) revealed the best performance. SHAP and LIME plot showed that LVEF, Lac, LVDd and MABP < 65 time significantly contributed to the prediction model.ConclusionIn this study, we successfully developed several machine learning models to predict LCOS after surgery, which may avail to risk stratification, early detection and management of LCOS after cardiac surgery.

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Section: Discussionmentioning

confidence: 94%

Prediction of low cardiac output syndrome in patients following cardiac surgery using machine learning

Hong

et al. 2022

Front. Med.

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“…In our study, concomitant multiple valves replacement and higher incidence of comorbidity associated with advanced age prolonged the length of ICU stay. Venous congestion due to high CVP during perioperative cardiac surgery is associated with poor patient outcomes and prolonged ICU/hospital stays [ 30 , 31 ]. High CVP impedes venous return and causes multiple organ dysfunction.…”

Section: Discussionmentioning

confidence: 99%

Incidence of and Risk Factors for Prolonged Intensive Care Unit Stay After Open Heart Surgery Among Elderly Patients

Yeşiler¹,

Akmatov²,

Nurumbetova³

et al. 2022

Cureus

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Objective: Open heart surgery (OHS) is frequently performed on elderly patients. We aimed to investigate the risk factors associated with prolonged intensive care unit (ICU) stay in elderly patients undergoing open heart surgery.Materials and Methods: Medical records of all patients ≥ 75 years who underwent OHS (coronary artery bypass grafting (CABG) and/or heart valve surgery) between June 1, 2013, and December 31, 2020, were retrospectively analyzed. Those staying in the ICU longer than five days were determined as prolonged ICU stay. Patients were divided into two groups, according to ICU stay <5 days and ≥5 days.Results: Out of the 198 patients included in the study, 130 (65.7%) were male. Seventy patients (35.4%) had prolonged ICU stay. The mean age was higher in patients within the prolonged ICU stay group when compared to the other group (79.9±3.5 years vs.78.1±2.7 years, p<0.001). The patients who used statins and angiotensin-converting enzyme inhibitors (ACEi)/angiotensin receptor blockers (ARBs) in the preoperative period had a shorter ICU stay compared to those who did not (45% vs 31.4%, p=0.04; 57% vs 42.9%, p=0.03). The history of previous thoracic surgery (2.3% vs 10% p=0.03), emergency surgery (12.5% vs 24.5% p=0.04), and preoperative pacemaker usage (0.8% vs 7%, 1 p=0.01) were higher in the group of patients with prolonged ICU stay compared to the other group. Preoperative ejection fraction (EF)% (47.7±11.3 vs 51.1±8.8, p<0.001) and hemoglobin level (11.8±1.9 mg/dL vs 12.9±1.6, p<0.001) were lower in the group with prolonged ICU stay compared to the other group. Incidence of cardiac arrest (3.9% vs 15.7% p=0.006), presence of arrhythmia (16.4% vs 41.6%,p<0.001), frequency of pacemaker and intra-aortic balloon pump (IABP) usage (0 vs 10% p=0.002; 1.6% vs 8.6% p=0.02), and need for renal replacement therapy (3.1% vs 12.9%,p=0.02) were higher in the group with prolonged ICU stay compared to the other group. According to the logistic regression analysis; higher age (OR: 1.225, 95%CI 1.104-1.360, p<0.001), preoperative pacemaker usage (OR: 0.100, 95%CI 0.01-0.969, p<0.04), preoperative statin non-use (OR: 2.056, 95%CI 1.040-4.066, p<0.03) and preoperative low EF (OR: 0.947, 95%CI 0.915-0.981, p=0.002) were determined as independent risk factors for prolonged ICU stay. Conclusion:The incidence of prolonged ICU stay after OHS among patients ≥75 years was 35.4% in our cohort. Higher age, preoperative pacemaker usage, preoperative statin non-use, and low preoperative EF were associated with prolonged ICU stay.

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“…On the other hand, there were also studies that have demonstrated the excellent performance of CVP in predicting the risks of extrathoracic organ congestion, such as liver congestion (31) and renal congestion (14,(21)(22)(23)32,33). Patients with elevated CVP values were also noticed to exhibit higher incidence of AKI, which aligns to this present study (14,(21)(22)(23)32). Specifically, Lopez et al (21) found that intraoperative CVP >12 mm Hg was independently associated with increased AKI after cardiac surgery (OR was 1.06 at 95% CI of 1.02-1.10; P = 0.008).…”

Section: Discussionmentioning

confidence: 99%

The Effects of Early-Phase Furosemide Use on the Progression of Oliguric Acute Kidney Injury Across Different Central Venous Pressure: A Retrospective Analysis

Huang

et al. 2022

Shock

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Background: Furosemide is a commonly used loop diuretic in critical care. However, its effect on the progression of oliguric acute kidney injury across different central venous pressure (CVP) remains unknown. This study therefore aims to investigate the association between furosemide6–12h (defined as the use of furosemide within 6 h after the diagnosis of AKI according to the urine output [UO] criteria set by the Kidney Disease: Improving Global Outcomes [KDIGO] guidelines) and the progression of AKI across different CVP6–12h (defined as CVP within 6 h after the diagnosis of AKI by the KDIGO UO criteria) levels. Methods: Patients involved in this study were identified from the Medical Information Mart for Intensive Care IV database with the following criteria: (i) adults with UO <0.5 mL/kg per hour for the first 6 h upon admission to the intensive care unit (ICU) (meeting stage 1 AKI by UO) and (ii) CVP6–12h ranging from 0 to 30 mm Hg. From there on, the target primary outcome would be progression to stage 3 AKI by UO among these chosen patients. The secondary outcome was 28-d mortality since ICU admission. The risks of severe-stage AKI progression and 28-d mortality were respectively examined against furosemide6–12h (vs. without furosemide6–12h) within the full cohort and across different subgroups of CVP6–12h, using multivariate adjusted logistic regression and inverse probability treatment weighting (IPTW). Sensitivity analyses were performed to assess the robustness of our findings. Results: One thousand one hundred eighty patients were ultimately selected for this study, of whom 643 (54.5%) progressed to stage 3 AKI from stage 1 based on the UO criteria by KDIGO. Multivariate analysis showed that furosemide6–12h is significantly associated with this severe-stage progression within the full cohort (odds ratio [OR] was 0.62 at 95% confidence interval [CI] of 0.43–0.90, P = 0.011). After dividing the patients into CVP6–12h subgroups according to their CVP during the early phases, lower risk of AKI progression was observed only in furosemide6–12h application at CVP6–12h of ≥12 mm Hg (adjusted OR was 0.40 at 95% CI of 0.25–0.65, P < 0.001), as confirmed by the IPTW analysis (OR was 0.47 at 95% CI of 0.29–0.76, P = 0.002). The robustness of these findings was confirmed by sensitivity analyses. In addition, for patients with CVP6–12h ≥12 mm Hg, furosemide6–12h is also significantly associated with lower risk of 28-d mortality (adjusted OR was 0.47 at 95% CI of 0.25–0.92, P = 0.026) in the multivariate logistic regression analysis, and there was a similar trend in the IPTW analysis (adjusted OR was 0.55 at 95% CI of 0.28–1.10, P = 0.092). Conclusions: Among the identified early-stage AKI patients in critical care, the use of furosemide was associated only with lower risk of oliguric AKI progression and 28-d mortality within the high CVP group. These findings suggest the potential of CVP as a guidance or reference point in the usage of furosemide among early-stage oliguric AKI patients in the ICU.

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Intraoperative venous congestion rather than hypotension is associated with acute adverse kidney events after cardiac surgery: a retrospective cohort study

Cited by 22 publications

References 38 publications

Prediction of low cardiac output syndrome in patients following cardiac surgery using machine learning

Prediction of low cardiac output syndrome in patients following cardiac surgery using machine learning

Incidence of and Risk Factors for Prolonged Intensive Care Unit Stay After Open Heart Surgery Among Elderly Patients

The Effects of Early-Phase Furosemide Use on the Progression of Oliguric Acute Kidney Injury Across Different Central Venous Pressure: A Retrospective Analysis

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