Blood pressure excursions below the cerebral autoregulation threshold during cardiac surgery are associated with acute kidney injury

Masahiro Ono, George J. Arnaoutakis, Derek M Fine, Kenneth Brady, R. Blaine Easley, Yueying Zheng, Charles Brown, Nevin M. Katz, Morgan Grams, Charles W. Hogue

Research output: Contribution to journalArticle

Abstract

OBJECTIVES: To determine whether mean arterial blood pressure excursions below the lower limit of cerebral blood flow autoregulation during cardiopulmonary bypass are associated with acute kidney injury after surgery. SETTING: Tertiary care medical center. PATIENTS: Four hundred ten patients undergoing cardiac surgery with cardiopulmonary bypass. DESIGN: Prospective observational study. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Autoregulation was monitored during cardiopulmonary bypass by calculating a continuous, moving Pearson's correlation coefficient between mean arterial blood pressure and processed near-infrared spectroscopy signals to generate the variable cerebral oximetry index. When mean arterial blood pressure is below the lower limit of autoregulation, cerebral oximetry index approaches 1, because cerebral blood flow is pressure passive. An identifiable lower limit of autoregulation was ascertained in 348 patients. Based on the RIFLE criteria (Risk, Injury, Failure, Loss of kidney function, End-stage renal disease), acute kidney injury developed within 7 days of surgery in 121 (34.8%) of these patients. Although the average mean arterial blood pressure during cardiopulmonary bypass did not differ, the mean arterial blood pressure at the limit of autoregulation and the duration and degree to which mean arterial blood pressure was below the autoregulation threshold (mm Hg × min/hr of cardiopulmonary bypass) were both higher in patients with acute kidney injury than in those without acute kidney injury. Excursions of mean arterial blood pressure below the lower limit of autoregulation (relative risk 1.02; 95% confidence interval 1.01 to 1.03; p <0.0001) and diabetes (relative risk 1.78; 95% confidence interval 1.27 to 2.50; p = 0.001) were independently associated with for acute kidney injury. CONCLUSIONS: Excursions of mean arterial blood pressure below the limit of autoregulation and not absolute mean arterial blood pressure are independently associated with for acute kidney injury. Monitoring cerebral oximetry index may provide a novel method for precisely guiding mean arterial blood pressure targets during cardiopulmonary bypass.

Original languageEnglish (US)
Pages (from-to)464-471
Number of pages8
JournalCritical Care Medicine
Volume41
Issue number2
DOIs
StatePublished - Feb 2013

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Acute Kidney Injury
Thoracic Surgery
Arterial Pressure
Homeostasis
Blood Pressure
Cardiopulmonary Bypass
Oximetry
Cerebrovascular Circulation
Confidence Intervals
Near-Infrared Spectroscopy
Ambulatory Surgical Procedures

Keywords

  • acute kidney injury
  • blood pressure
  • cardiac surgery
  • cerebral autoregulation

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine

Cite this

Blood pressure excursions below the cerebral autoregulation threshold during cardiac surgery are associated with acute kidney injury. / Ono, Masahiro; Arnaoutakis, George J.; Fine, Derek M; Brady, Kenneth; Easley, R. Blaine; Zheng, Yueying; Brown, Charles; Katz, Nevin M.; Grams, Morgan; Hogue, Charles W.

In: Critical Care Medicine, Vol. 41, No. 2, 02.2013, p. 464-471.

Research output: Contribution to journalArticle

Ono, Masahiro ; Arnaoutakis, George J. ; Fine, Derek M ; Brady, Kenneth ; Easley, R. Blaine ; Zheng, Yueying ; Brown, Charles ; Katz, Nevin M. ; Grams, Morgan ; Hogue, Charles W. / Blood pressure excursions below the cerebral autoregulation threshold during cardiac surgery are associated with acute kidney injury. In: Critical Care Medicine. 2013 ; Vol. 41, No. 2. pp. 464-471.
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AU - Arnaoutakis, George J.

AU - Fine, Derek M

AU - Brady, Kenneth

AU - Easley, R. Blaine

AU - Zheng, Yueying

AU - Brown, Charles

AU - Katz, Nevin M.

AU - Grams, Morgan

AU - Hogue, Charles W.

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N2 - OBJECTIVES: To determine whether mean arterial blood pressure excursions below the lower limit of cerebral blood flow autoregulation during cardiopulmonary bypass are associated with acute kidney injury after surgery. SETTING: Tertiary care medical center. PATIENTS: Four hundred ten patients undergoing cardiac surgery with cardiopulmonary bypass. DESIGN: Prospective observational study. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Autoregulation was monitored during cardiopulmonary bypass by calculating a continuous, moving Pearson's correlation coefficient between mean arterial blood pressure and processed near-infrared spectroscopy signals to generate the variable cerebral oximetry index. When mean arterial blood pressure is below the lower limit of autoregulation, cerebral oximetry index approaches 1, because cerebral blood flow is pressure passive. An identifiable lower limit of autoregulation was ascertained in 348 patients. Based on the RIFLE criteria (Risk, Injury, Failure, Loss of kidney function, End-stage renal disease), acute kidney injury developed within 7 days of surgery in 121 (34.8%) of these patients. Although the average mean arterial blood pressure during cardiopulmonary bypass did not differ, the mean arterial blood pressure at the limit of autoregulation and the duration and degree to which mean arterial blood pressure was below the autoregulation threshold (mm Hg × min/hr of cardiopulmonary bypass) were both higher in patients with acute kidney injury than in those without acute kidney injury. Excursions of mean arterial blood pressure below the lower limit of autoregulation (relative risk 1.02; 95% confidence interval 1.01 to 1.03; p <0.0001) and diabetes (relative risk 1.78; 95% confidence interval 1.27 to 2.50; p = 0.001) were independently associated with for acute kidney injury. CONCLUSIONS: Excursions of mean arterial blood pressure below the limit of autoregulation and not absolute mean arterial blood pressure are independently associated with for acute kidney injury. Monitoring cerebral oximetry index may provide a novel method for precisely guiding mean arterial blood pressure targets during cardiopulmonary bypass.

AB - OBJECTIVES: To determine whether mean arterial blood pressure excursions below the lower limit of cerebral blood flow autoregulation during cardiopulmonary bypass are associated with acute kidney injury after surgery. SETTING: Tertiary care medical center. PATIENTS: Four hundred ten patients undergoing cardiac surgery with cardiopulmonary bypass. DESIGN: Prospective observational study. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Autoregulation was monitored during cardiopulmonary bypass by calculating a continuous, moving Pearson's correlation coefficient between mean arterial blood pressure and processed near-infrared spectroscopy signals to generate the variable cerebral oximetry index. When mean arterial blood pressure is below the lower limit of autoregulation, cerebral oximetry index approaches 1, because cerebral blood flow is pressure passive. An identifiable lower limit of autoregulation was ascertained in 348 patients. Based on the RIFLE criteria (Risk, Injury, Failure, Loss of kidney function, End-stage renal disease), acute kidney injury developed within 7 days of surgery in 121 (34.8%) of these patients. Although the average mean arterial blood pressure during cardiopulmonary bypass did not differ, the mean arterial blood pressure at the limit of autoregulation and the duration and degree to which mean arterial blood pressure was below the autoregulation threshold (mm Hg × min/hr of cardiopulmonary bypass) were both higher in patients with acute kidney injury than in those without acute kidney injury. Excursions of mean arterial blood pressure below the lower limit of autoregulation (relative risk 1.02; 95% confidence interval 1.01 to 1.03; p <0.0001) and diabetes (relative risk 1.78; 95% confidence interval 1.27 to 2.50; p = 0.001) were independently associated with for acute kidney injury. CONCLUSIONS: Excursions of mean arterial blood pressure below the limit of autoregulation and not absolute mean arterial blood pressure are independently associated with for acute kidney injury. Monitoring cerebral oximetry index may provide a novel method for precisely guiding mean arterial blood pressure targets during cardiopulmonary bypass.

KW - acute kidney injury

KW - blood pressure

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KW - cerebral autoregulation

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