Reducing Hypotension and Acute Kidney Injury in the Elective Total Joint Arthroplasty Population: A Multi-Disciplinary Approach

Lands, Vince W; Malige, Ajith; Carmona, Aldo; Roscher, Christopher; Gayner, Robert; Rowbotham, Jaclyn; DeLong, William G.

doi:10.1016/j.arth.2018.01.061

Cited by 13 publications

(11 citation statements)

References 40 publications

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“…Clinically important postoperative hypotension (defined as systolic blood pressure <90 mmHg and requiring medical intervention) affects over 30% of patients, often goes uncorrected for longer than intraoperative hypotension and is associated with an increased risk of all-cause mortality and myocardial injury 84 . These findings suggest that maintenance of fluid and haemodynamic status in the early postoperative phase is important to avoid organ injuries including AKI 28 . A trial that used stroke volume optimization and vasopressors to target a MAP within 10% of the preoperative baseline value during and for 4 h after surgery showed that this strategy was associated with a reduction in postoperative organ injury, but was not powered to assess kidney-specific outcomes 85 .…”

Section: Prevention Of Postoperative Akimentioning

confidence: 85%

Postoperative acute kidney injury in adult non-cardiac surgery: joint consensus report of the Acute Disease Quality Initiative and PeriOperative Quality Initiative

et al. 2021

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Postoperative acute kidney injury (PO-AKI) is a common complication of major surgery that is strongly associated with short-term surgical complications and long-term adverse outcomes, including increased risk of chronic kidney disease, cardiovascular events and death. Risk factors for PO-AKI include older age and comorbid diseases such as chronic kidney disease and diabetes mellitus. PO-AKI is best defined as AKI occurring within 7 days of an operative intervention using the Kidney Disease Improving Global Outcomes (KDIGO) definition of AKI; however, additional prognostic information may be gained from detailed clinical assessment and other diagnostic investigations in the form of a focused kidney health assessment (KHA). Prevention of PO-AKI is largely based on identification of high baseline risk, monitoring and reduction of nephrotoxic insults, whereas treatment involves the application of a bundle of interventions to avoid secondary kidney injury and mitigate the severity of AKI. As PO-AKI is strongly associated with long-term adverse outcomes, some form of follow-up KHA is essential; however, the form and location of this will be dictated by the nature and severity of the AKI. In this Consensus Statement, we provide graded recommendations for AKI after non-cardiac surgery and highlight priorities for future research.

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Section: Prevention Of Postoperative Akimentioning

confidence: 85%

Postoperative acute kidney injury in adult non-cardiac surgery: joint consensus report of the Acute Disease Quality Initiative and PeriOperative Quality Initiative

et al. 2021

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“…In a prospective study, Lands et al . [ 32 ] achieved a significant reduction in AKI rates, after the implementation of a targeted protocol, from 6.3 to 1.2%. Some of the risk factors found in the current study to be associated with the development of AKI can be carefully optimized prior to surgery, namely, avoidance of bilateral procedures and optimization of hematocrit levels especially in patients with diabetes, obesity or lower kidney function.…”

Section: Discussionmentioning

confidence: 99%

Incidence and risk factors for acute kidney injury after total joint arthroplasty

et al. 2022

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Background Acute kidney injury (AKI) is one of the most common medical causes for readmission following total joint arthroplasty (TJA). This study aimed to (1) examine whether the incidence of AKI has changed over the past decade with the adoption of modern perioperative care pathways and (2) identify the risk factors and concomitant adverse events (AEs) associated with AKI. Methods 535,291 primary TJA procedures from the American College of Surgeons National Surgical Quality Improvement Program from 2011 to 2018 were retrospectively reviewed. The annual incidence of AKI was analyzed for significant changes over time. Matched cohort analyses were performed to identify the risk factors and AEs associated with AKI using multivariate logistic regression. Results The mean incidence of AKI was 0.051%, which remained unchanged during the study period (P = 0.121). Factors associated with AKI were diabetes (OR 1.96, P = 0.009), bilateral procedure (OR 6.93, P = 0.030), lower preoperative hematocrit level (OR 1.09, P = 0.015), body mass index (OR 1.04, P = 0.025), and higher preoperative BUN (OR 1.03, P = 0.043). AKI was associated with length of stay (LOS) > 2 days (OR 4.73, P < 0.001), non-home discharge (OR 0.25, P < 0.001), 30-day readmission (OR 12.29, P < 0.001), and mortality (OR 130.7, P < 0.001). Conclusions The incidence of AKI has not changed over the past decade, and it remains a major bundle buster resulting in greater LOS, non-home discharge, readmissions, and mortality. Avoidance of bilateral TJA in patients with DM and high BMI as well as preoperative optimization of anemia and BUN levels are advised.

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“…Regardless of the fact that hypotensive anesthesia has so many advantages, we still cannot ignore the adverse events caused by the relatively low blood pressure intraoperatively. Lands et al reported that lower blood pressure could increase the risk of perioperative acute Table 3 Complications Data are presented as Mean ± standard deviation *P values were calculated using 1-way ANOVA and the Tukey post hoc multiple comparison test for independent means for continuous variables and the Pearson chi-square test or the Fisher exact test for independent proportions among the 3 groups kidney injury [43]. Walsh et al found that intraoperative blood pressure levels and duration were associated with postoperative complications; the lower the intraoperative blood pressure level and the longer the duration of hypotension caused a higher risk of acute kidney injury and myocardial injury in patients after non-cardiac surgery, especially when the MAP lower than 55 mmHg [44].…”

Section: Discussionmentioning

confidence: 99%

Finding the optimal control level of intraoperative blood pressure in no tourniquet primary total knee arthroplasty combine with tranexamic acid: a retrospective cohort study which supports the enhanced recovery strategy

et al. 2020

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Background: With the use of tranexamic acid and control of the blood pressure during the operation, total knee arthroplasty (TKA) without tourniquet can be achieved. There is no exact standard for the control level of blood pressure during no tourniquet TKA. We explored the optimal level of blood pressure control during no tourniquet TKA surgery with the use of tranexamic acid in this study. Methods: Patients underwent TKA were divided into three groups: the mean intraoperative systolic blood pressure in group A was < 90 mmHg, 90-100 mmHg in group B, > 100 mmHg in group C. Total blood loss (TBL), intraoperative blood loss, hidden blood loss, transfusion rate, maximum hemoglobin drop, operation time, and postoperative hospitalization days were recorded. Results: Two hundred seventy-eight patients were enrolled, 82 in group A, 105 in group B, and 91 in group C. Group A (663.3 ± 46.0 ml) and group B (679.9 ± 57.1 ml) had significantly lower TBL than group C (751.7 ± 56.2 ml). Group A (120.2 ± 18.7 ml) had the lowest intraoperative blood loss than groups B and C. Group C (26.0 ± 4.1 g/l) had the largest Hb change than groups A and B. Group A (62.3 ± 4.7 min) had the shortest operation time. The incidence rate of postoperative hypotension in group A (8, 9.8%) was significantly greater than groups B and C. No significant differences were found in other outcomes. Conclusion: The systolic blood pressure from 90 to 100 mmHg was the optimal strategy for no tourniquet primary TKA with tranexamic acid.

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Reducing Hypotension and Acute Kidney Injury in the Elective Total Joint Arthroplasty Population: A Multi-Disciplinary Approach

Cited by 13 publications

References 40 publications

Postoperative acute kidney injury in adult non-cardiac surgery: joint consensus report of the Acute Disease Quality Initiative and PeriOperative Quality Initiative

Postoperative acute kidney injury in adult non-cardiac surgery: joint consensus report of the Acute Disease Quality Initiative and PeriOperative Quality Initiative

Incidence and risk factors for acute kidney injury after total joint arthroplasty

Finding the optimal control level of intraoperative blood pressure in no tourniquet primary total knee arthroplasty combine with tranexamic acid: a retrospective cohort study which supports the enhanced recovery strategy

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