Surgery News - December 2008 - (Page 16) 16 POSTOP MANAGEMENT SURGERY NEWS • D E C E M B E R 2 0 0 8 Predictors Found for Likely Acute Renal Failure BY DAMIAN MCNAMARA Else vier Global Medical Ne ws O R L A N D O — About a 1% incidence of acute renal failure can be expected following general surgery, and researchers have identified independent risk predictors that may help clinicians determine which patients are most likely to experience this outcome. Citing a paucity of studies looking at acute renal failure after general surgery, Dr. Sachin Kheterpal and his colleagues at the University of Michigan, Ann Arbor, reviewed 150,490 operations in the American College of Surgeons’ National Surgical Quality Improvement Program data set performed over a 1-year period (20052006). They assessed information prospectively gathered by trained nurse–data collectors from 121 centers, including community and academic centers, Dr. Kheterpal said during a poster discussion session at the annual meeting of the American Society of Anesthesiologists. “The data collection system is very de- tailed. It includes 30-day outcomes, even if the patient leaves and dies at another hospital,” said Dr. Kheterpal of the department anesthesiology at the university. Excluded from the study were patients with preexisting acute renal failure or those requiring dialysis; patients undergoing any nongeneral surgery procedures, including cases performed by vascular, cardiac, urology, ophthalmology, podiatry, or obstetric services; outpatients; and general surgery patients on whom concurrent urology procedures were performed. NOW AVAILABLE Data for 68,147 operations were assessed further. Of these, 712 patients (1%) experienced acute renal failure (ARF) postoperatively. ARF was defined as progressive renal insufficiency—an increase in serum creatinine of 2 mg/dL or more above baseline—or a requirement for postoperative dialysis. This 1% incidence of acute kidney injury is very close to a previous incidence of 0.8% (Anesthesiology 2007;107:892902). The use of vasopressors and diuretics was among the factors associated with ARF in this single-center study of more than 65,000 noncardiac procedures. In addition, patients who experienced ARF had increased 30-day, 60-day, and 1-year allcause mortality. In the current study, 11 independent risk factors predicted ARF in a logistic regression model. The researchers calculated hazard ratios to compare the likelihood of ARF between patients with and without each risk factor. Preoperative renal insufficiency was associated with the greatest hazard ratio, 8.5. Other risk factors were heart failure (HR, 7.6), ascites (HR, 6.4), ‘WE ARE VERY AGGRESSIVE NOW ABOUT HYDRATION, AND WE’RE VERY AGGRESSIVE NOW ABOUT NOT USING DIURETICS INTRAOPERATIVELY.’ myocardial infarction within 6 months (HR, 5.7), high-risk surgery (HR, 3.8), aged 58 years or older (HR, 3.2), hypertension requiring chronic medication (HR, 3.1), male sex (HR, 1.9), diabetes mellitus (HR, 2.6), previous cardiac procedure (HR, 2.2), and emergency surgery (HR, 2.7). Dr. Kheterpal and his associates developed a “robust” risk-prediction model—an index based on the number of preoperative risk factors. The association between these risk factors and ARF incidence was as follows: one to two risk factors, 0.2% ARF incidence; three risk factors, 1% incidence; four factors, 2% incidence; five factors, 3.3% incidence; and six factors, 9% incidence. “This is really surprising when you look at how many older patients we have, who are also men, and have hypertension and diabetes—[they] have a fairly good chance of acute renal failure,” he said. The prediction index could be the foundation for informed consent in these patients, he added. When asked whether he and other physicians at the University of Michigan are doing anything different based on the study findings, he said, “Yes, we are very aggressive now about hydration. And we’re very aggressive now about not using diuretics intraoperatively.” Having a study with nearly 70,000 general surgery cases allowed Dr. Kheterpal and his associates to do an internal validation study. He acknowledged limitations such as the fact that intraoperative data beyond length of each procedure were “very limited,” and information on the use of preoperative medications was lacking. ■ The American College of Surgeons ATLS Program was developed to teach doctors one safe, reliable method for assessing and initially managing the trauma patient. The course teaches an organized approach for evaluation and management of seriously injured patients and offers a foundation of common knowledge for all members of the trauma team. The emphasis is on the critical “first hour” of care, focusing on initial assessment, lifesaving intervention, reevaluation, stabilization, and, when needed, transfer to a trauma center. The 8th edition has been redesigned for readability and to improve comprehension and retention of knowledge. It features new, up-to-date technical content and references and includes a DVD with skills from the course demonstrated in video segments. Price: $100 each. To obtain an ATLS for Doctors Student Course Manual, visit the American College of Surgeons online publication catalog at https://web2.facs.org/timssnet464/acspub/frontpage.cfm?product_class=trauma https://web2.facs.org/timssnet464/acspub/frontpage.cfm?product_class=trauma https://web2.facs.org/timssnet464/acspub/frontpage.cfm?product_class=trauma
Table of Contents Feed for the Digital Edition of Surgery News - December 2008 Surgery News - December 2008 Contents The 20/20 Vision: Health Reform News From the College: Nominations Thoracic: Breathing Easier Postop Management: Renal Failure Surgery News - December 2008 Surgery News - December 2008 - Contents (Page 1) Surgery News - December 2008 - Contents (Page 2) Surgery News - December 2008 - Contents (Page 3) Surgery News - December 2008 - Contents (Page 4) Surgery News - December 2008 - Contents (Page 5) Surgery News - December 2008 - The 20/20 Vision: Health Reform (Page 6) Surgery News - December 2008 - The 20/20 Vision: Health Reform (Page 7) Surgery News - December 2008 - The 20/20 Vision: Health Reform (Page 8) Surgery News - December 2008 - The 20/20 Vision: Health Reform (Page 9) Surgery News - December 2008 - News From the College: Nominations (Page 10) Surgery News - December 2008 - News From the College: Nominations (Page 11) Surgery News - December 2008 - Thoracic: Breathing Easier (Page 12) Surgery News - December 2008 - Thoracic: Breathing Easier (Page 13) Surgery News - December 2008 - Thoracic: Breathing Easier (Page 14) Surgery News - December 2008 - Thoracic: Breathing Easier (Page 15) Surgery News - December 2008 - Postop Management: Renal Failure (Page 16) Surgery News - December 2008 - Postop Management: Renal Failure (Page 17) Surgery News - December 2008 - Postop Management: Renal Failure (Page 18) Surgery News - December 2008 - Postop Management: Renal Failure (Page 19) Surgery News - December 2008 - Postop Management: Renal Failure (Page 20)
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