David McIlroy1,2, Deirdre Murphy3, Jessica Kasza4, Dhiraj Bhatia5, Lisa Wutzlhofer5, Silvana Marasco6,7. 1. Department of Anaesthesia and Perioperative Medicine, Alfred Hospital, 55 Commercial Road, Melbourne, VIC, 3004, Australia. D.mcilroy@alfred.org.au. 2. Monash University, Commercial Road, Melbourne, VIC, 3004, Australia. D.mcilroy@alfred.org.au. 3. Intensive Care Unit, Alfred Hospital, Melbourne, VIC, Australia. 4. Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia. 5. Department of Anaesthesia and Perioperative Medicine, Alfred Hospital, 55 Commercial Road, Melbourne, VIC, 3004, Australia. 6. Monash University, Commercial Road, Melbourne, VIC, 3004, Australia. 7. Department of Surgery, Alfred Hospital, Melbourne, VIC, Australia.
Abstract
PURPOSE: The administration of chloride-rich intravenous (IV) fluid and hyperchloraemia have been associated with perioperative renal injury. The aim of this study was to determine whether a comprehensive perioperative protocol for the administration of chloride-limited IV fluid would reduce perioperative renal injury in adults undergoing cardiac surgery. METHODS: From February 2014 through to December 2015, all adult patients undergoing cardiac surgery within a single academic medical center received IV fluid according to the study protocol. The perioperative protocol governed all fluid administration from commencement of anesthesia through to discharge from the intensive care unit and varied over four sequential periods, each lasting 5 months. In periods 1 and 4 a chloride-rich strategy, consisting of 0.9% saline and 4% albumin, was adopted; in periods 2 and 3, a chloride-limited strategy, consisting of a buffered salt solution and 20% albumin, was used. Co-primary outcomes were peak delta serum creatinine (∆SCr) within 5 days after the operation and KDIGO-defined stage 2 or stage 3 acute kidney injury (AKI) within 5 days after the operation. RESULTS: We enrolled and analysed data from 1136 patients, with 569 patients assigned to a chloride-rich fluid strategy and 567 to a chloride-limited one. Compared with a chloride-limited strategy and adjusted for prespecified covariates, there was no association between a chloride-rich perioperative fluid strategy and either peak ∆S Cr, transformed to satisfy the assumptions of multivariable linear regression [regression coefficient 0.03, 95% confidence interval (CI) -0.03 to 0.08); p = 0.39], or stage 2 or 3 AKI (adjusted odds ratio 0.97, 95% CI 0.65-1.47; p = 0.90]. CONCLUSIONS: A perioperative fluid strategy to restrict IV chloride administration was not associated with an altered incidence of AKI or other metrics of renal injury in adult patients undergoing cardiac surgery. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT02020538.
PURPOSE: The administration of chloride-rich intravenous (IV) fluid and hyperchloraemia have been associated with perioperative renal injury. The aim of this study was to determine whether a comprehensive perioperative protocol for the administration of chloride-limited IV fluid would reduce perioperative renal injury in adults undergoing cardiac surgery. METHODS: From February 2014 through to December 2015, all adult patients undergoing cardiac surgery within a single academic medical center received IV fluid according to the study protocol. The perioperative protocol governed all fluid administration from commencement of anesthesia through to discharge from the intensive care unit and varied over four sequential periods, each lasting 5 months. In periods 1 and 4 a chloride-rich strategy, consisting of 0.9% saline and 4% albumin, was adopted; in periods 2 and 3, a chloride-limited strategy, consisting of a buffered salt solution and 20% albumin, was used. Co-primary outcomes were peak delta serum creatinine (∆SCr) within 5 days after the operation and KDIGO-defined stage 2 or stage 3 acute kidney injury (AKI) within 5 days after the operation. RESULTS: We enrolled and analysed data from 1136 patients, with 569 patients assigned to a chloride-rich fluid strategy and 567 to a chloride-limited one. Compared with a chloride-limited strategy and adjusted for prespecified covariates, there was no association between a chloride-rich perioperative fluid strategy and either peak ∆S Cr, transformed to satisfy the assumptions of multivariable linear regression [regression coefficient 0.03, 95% confidence interval (CI) -0.03 to 0.08); p = 0.39], or stage 2 or 3 AKI (adjusted odds ratio 0.97, 95% CI 0.65-1.47; p = 0.90]. CONCLUSIONS: A perioperative fluid strategy to restrict IV chloride administration was not associated with an altered incidence of AKI or other metrics of renal injury in adult patients undergoing cardiac surgery. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT02020538.
Authors: F Roques; S A Nashef; P Michel; E Gauducheau; C de Vincentiis; E Baudet; J Cortina; M David; A Faichney; F Gabrielle; E Gams; A Harjula; M T Jones; P P Pintor; R Salamon; L Thulin Journal: Eur J Cardiothorac Surg Date: 1999-06 Impact factor: 4.191
Authors: Nor'azim Mohd Yunos; Rinaldo Bellomo; Colin Hegarty; David Story; Lisa Ho; Michael Bailey Journal: JAMA Date: 2012-10-17 Impact factor: 56.272
Authors: David R McIlroy; Michael Argenziano; David Farkas; Tianna Umann; Robert N Sladen Journal: J Cardiothorac Vasc Anesth Date: 2013-06-02 Impact factor: 2.628
Authors: Paul Young; Michael Bailey; Richard Beasley; Seton Henderson; Diane Mackle; Colin McArthur; Shay McGuinness; Jan Mehrtens; John Myburgh; Alex Psirides; Sumeet Reddy; Rinaldo Bellomo Journal: JAMA Date: 2015-10-27 Impact factor: 56.272
Authors: Jia-Rui Xu; Jia-Ming Zhu; Jun Jiang; Xiao-Qiang Ding; Yi Fang; Bo Shen; Zhong-Hua Liu; Jian-Zhou Zou; Lan Liu; Chun-Sheng Wang; Claudio Ronco; Hong Liu; Jie Teng Journal: Medicine (Baltimore) Date: 2015-11 Impact factor: 1.817
Authors: Nathan M Lee; Lev Deriy; Timothy R Petersen; Vallabh O Shah; Michael P Hutchens; Neal S Gerstein Journal: J Cardiothorac Vasc Anesth Date: 2018-08-01 Impact factor: 2.894
Authors: Lenar Yessayan; Javier A Neyra; Fabrizio Canepa-Escaro; George Vasquez-Rios; Michael Heung; Jerry Yee Journal: BMC Nephrol Date: 2017-12-02 Impact factor: 2.388