Multimodal Analgesia and Decreased Opioid Use in Adult Trauma Patients

2020 ◽  
Vol 86 (8) ◽  
pp. 950-954
Author(s):  
Andrew L. Drahos ◽  
Anthony M. Scott ◽  
Tracy J. Johns ◽  
Dennis W. Ashley
Keyword(s):  
Acute Kidney Injury ◽  
Management Strategies ◽  
Kidney Injury ◽  
Multimodal Analgesia ◽  
The United States ◽  
Control Group ◽  
Trauma Patients ◽  
Opioid Use ◽  
Trauma Service ◽  
The Impact

Background There is an opioid epidemic in the United States. With the increased concern of over-prescribing opioids, physicians are seeking alternative pain management strategies. The purpose of this study is to review the impact of instituting a multimodal analgesia (MMA) guideline on decreasing opioid use in trauma patients at a Level 1 trauma center. Methods In 2017, an MMA guideline was developed and included anti-inflammatories, muscle relaxants, neuropathic agents, and local analgesics in addition to opioids. Staff were educated and the guideline was implemented. A retrospective review of medications prescribed to patients admitted from 2016 through 2018 was performed. Patients admitted in 2016 served as the control group (before MMA). In 2018, all patients received multimodal pain therapy as standard practice, and served as the comparison group. Results A total of 10 340 patients were admitted to the trauma service from 2016 through 2018. There were 3013 and 3249 patients for review in 2016 and 2018, respectively. Total morphine milligram equivalents were 2 402 329 and 1 975 935 in 2016 and 2018, respectively, a 17.7% decrease ( P < .001). Concurrently, there was a statistically significant increase in the use of multimodal pain medications. A secondary endpoint was studied to evaluate for changes in acute kidney injury; there was not a statistically significant increase (0.56% versus 0.68%, P = .55). Discussion Implementation of an MMA guideline significantly reduced opioid use in trauma patients. The use of nonopioid MMA medications increased without an increased incidence of acute kidney injury.

The Impact of Hemodynamic Transesophageal Echocardiography on the Use of Continuous Renal Replacement Therapy in Trauma

2017 ◽  
Vol 83 (8) ◽  
pp. 855-859 ◽  
Author(s):  
Madison Griffin ◽  
Brett Howard ◽  
Sam Devictor ◽  
Josh Ferenczy ◽  
Frances Cobb ◽  
...  
Keyword(s):  
Acute Kidney Injury ◽  
Renal Replacement Therapy ◽  
Continuous Renal Replacement Therapy ◽  
Transesophageal Echocardiography ◽  
Replacement Therapy ◽  
Kidney Injury ◽  
Volume Overload ◽  
P Value ◽  
Trauma Patients ◽  
The Impact

Post-traumatic fluid management is a widely debated topic. No best-practice consensus exists. Adverse outcomes such as acute kidney injury or volume overload are common. Continuous renal replacement therapy (CRRT) is an adjunct therapy for severe acute renal failure and volume overload, but is costly and not without risk. Hemodynamic transesophageal echocardiography (hTEE) is widely accepted as a reliable way to monitor volume status of intensive care unit (ICU) patients. Although data exist evaluating hTEE and CRRT independently, there is a lack of research mutually inclusive of the two. We hypothesized that the use of hTEE is associated with less need for CRRT. Retrospective review of a level I trauma center from 2009 to 2015 identified patients that required CRRT. In 2013, we implemented a protocol using hTEE in trauma patients with significant resuscitation needs. We compared CRRTuse before and after implementation of the protocol (pre- and post-hTEE). Multivariate analysis using two sample t tests and χ2 test of the odds ratio (O.R.) was completed on variables such as injury severity score (ISS), acute kidney injury network (AKIN), days of CRRT, ICU length of stay (LOS), and hospital LOS. A total of 5037 and 6699 trauma patients were evaluated in the pre- and post-hTEE groups, respectively. Mean ISS was 22 and 28 for pre- and post-hTEE, respectively (P value 0.19). Mean AKIN was 2.7 for both groups. Mean days on CRRT was eight before hTEE and seven after hTEE (P value 0.7); 23 patients required CRRT pre-hTEE, and 15 required CRRT post-hTEE (P value 0.01 O.R. 2.4). Given, the odds of CRRT pre-hTEE are more than twice that of CRRT post-hTEE; we conclude that the use of hTEE is associated with a reduction of CRRT.

The Impact of Hemodynamic Transesophageal Echocardiography on Acute Kidney Injury Management and Use of Continuous Renal Replacement Therapy in Trauma

2020 ◽  
Vol 86 (3) ◽  
pp. 190-194
Author(s):  
Alex Sapp ◽  
Andrew Drahos ◽  
Madison Lashley ◽  
Amy Christie ◽  
D. Benjamin Christie
Keyword(s):  
Acute Kidney Injury ◽  
Renal Replacement Therapy ◽  
Continuous Renal Replacement Therapy ◽  
Transesophageal Echocardiography ◽  
Replacement Therapy ◽  
Hospital Costs ◽  
Kidney Injury ◽  
Acute Kidney Injury Network ◽  
Trauma Patients ◽  
The Impact

Resuscitation of critically ill trauma patients can be precarious, and errors can cause acute kidney injuries. If renal failure develops, continuous renal replacement therapy (CRRT) may be necessary, but adds expense. Hemodynamic transesophageal echocardiography (hTEE) provides objective data to guide resuscitation. We hypothesized that hTEE use improved acute kidney injury (AKI) management, reserved CRRT use for more severe AKIs, and decreased cost and resource utilization. We retrospectively reviewed 2413 trauma patients admitted to a Level I trauma center's ICU between 2009 and 2015. Twenty-three patients required CRRT before standard hTEE use and 11 required CRRTafter; these are the “CRRT” and “CRRT/hTEE” groups, respectively. The hTEE group comprised 83 patients evaluated with hTEE, with AKI managed without CRRT. We compared the average creatinine, change in creatinine, and Acute Kidney Injury Network (AKIN) of “CRRT” with “CRRT/hTEE” and “hTEE.” We also analyzed several quality measures including ICU length of stay and cost. “CRRT” had a lower AKIN score (1.6) than “CRRT/hTEE” (2.9) ( P = 0.0003). “hTEE” had an AKIN score of 2.1 ( P = 0.0387). “CRRT” also had increased ICU days (25.1) compared with “CRRT/hTEE” (20.2) ( P = 0.014) and “hTEE” (16.8) ( P = 0.003). “CRRT” accrued on average $198,695.81 per patient compared with “CRRT/ hTEE” ($167,534.19) and “hTEE” ($53,929.01). hTEE provides valuable information to tailor resuscitation. At our institution, hTEE utilization reserved CRRT for worse AKIs and decreased hospital costs.

Acute Kidney Injury before Dialysis Initiation Predicts Adverse Outcomes in Hemodialysis Patients

2018 ◽  
Vol 47 (6) ◽  
pp. 427-434 ◽  
Author(s):  
Timmy Lee ◽  
Silvi Shah ◽  
Anthony C. Leonard ◽  
Pratik Parikh ◽  
Charuhas V. Thakar
Keyword(s):  
Acute Kidney Injury ◽  
Kidney Injury ◽  
The United States ◽  
Hemodialysis Patients ◽  
Adverse Outcomes ◽  
Study Cohort ◽  
All Cause Mortality ◽  
Arteriovenous Access ◽  
The Impact ◽  
Esrd Patients

Background: Acute kidney injury (AKI) is associated with increased morbidity and mortality. Mortality in end-stage renal disease (ESRD) patients is highest during the first year of dialysis. The impact of pre-ESRD AKI events on long-term outcomes in incident ESRD patients remains unknown. Methods: We evaluated a retrospective cohort of 47,341 incident hemodialysis patients from the United States Renal Data System with linked Medicare data for at least 2 years prior to hemodialysis initiation. We examined the impact of pre-ESRD AKI events in the 2-year pre-ESRD period on the type of vascular access used at hemodialysis initiation (central venous catheter (CVC) versus arteriovenous access), and 1-year all-cause mortality after initiating hemodialysis. Results: The mean age was 72 ± 11 years. Of the study cohort, 18% initiated hemodialysis with arteriovenous access, and 54% of patients had at least one pre-ESRD AKI event. One-year, all-cause mortality was 32%. Compared to 75% for patients without a pre-ESRD AKI event, 89% of patients with a pre-ESRD AKI event initiated hemodialysis with CVC than arteriovenous access (p < 0.001). A pre-ESRD AKI event was associated with lower adjusted odds of starting hemodialysis with an arteriovenous access (OR 0.47; 95% CI 0.44–0.50, p < 0.001), and higher adjusted odds of 1-year mortality (OR 1.36; 95% CI 1.30–1.42, p < 0.001). Conclusion: An AKI event prior to initiating hemodialysis independently increases the risk of CVC use and predicts 1-year mortality. Improving processes of care after AKI events may improve dialysis outcomes in patients who progress to ESRD.

scholarly journals Balanced forced-diuresis compared to control as a reno-protective approach in cardiac surgery: secondary outcome of a randomized controlled trial, assessment of neutrophil gelatinase-associated lipocalin levels

2021 ◽  
Vol 16 (1) ◽  
Author(s):  
Heyman Luckraz ◽  
Ramesh Giri ◽  
Benjamin Wrigley ◽  
Kumaresan Nagarajan ◽  
Eshan Senanayake ◽  
...  
Keyword(s):  
Acute Kidney Injury ◽  
Cardiac Surgery ◽  
Kidney Injury ◽  
Secondary Outcome ◽  
Control Group ◽  
Neutrophil Gelatinase Associated Lipocalin ◽  
Forced Diuresis ◽  
Increased Risk ◽  
Neutrophil Gelatinase ◽  
The Impact

Abstract Background Neutrophil gelatinase-associated lipocalin (NGAL) is a recognised biomarker for acute kidney injury (AKI).This study investigated the impact of balanced forced-diuresis using RenalGuard® system (RG), in reducing acute kidney injury (AKI) rates and the associated NGAL levels (6-h post-CPB plasma level) post adult cardiac surgery with cardiopulmonary bypass (CPB). Methods Patients included in the study were at high-risk for AKI post cardiac surgery, namely history of diabetes and/or anaemia, e-GFR 20–60 ml/min/1.73 m2, Logistic EuroScore > 5, anticipated CPB time > 120 min. Patients were randomized to either RG (n = 110) or managed as per current practice (control = 110). RIFLE-defined AKI rate (based on serum creatinine level increase) within first 3 days of surgery and 6-h post CPB NGAL levels were the primary and secondary end-points. Results Pre and intra-operative characteristics between the two groups were similar (p > 0.05) including the pre-op NGAL levels, the oxygen delivery (ecDO2i) and the carbon dioxide production (ecVCO2i) during CPB. Patients in the RG group had a significantly lower post-operative RIFLE-defined AKI rate compared to control (10% (11/110) v/s 20.9% (23/110), p = 0.03). Overall, median 6-h post CPB NGAL levels in patients with AKI were significantly higher than those who did not develop AKI (211 vs 150 ng/ml, p < 0.001). Patients managed by balanced forced-diuresis had lower post-operative NGAL levels (146 vs 178 ng/ml, p = 0.09). Using previously reported NGAL cut-off level for AKI (142 ng/ml), binary logistic regression analysis confirmed a beneficial effect of the RG system, with an increased risk of AKI of 2.2 times in the control group (OR 2.2, 95% CI 1.14–4.27, p = 0.02). Conclusions Overall, the 6-h post-CPB plasma NGAL levels were significantly higher in patients who developed AKI. Patients managed with the novel approach of balanced forced-diuresis, provided by the RenalGuard® system, had a lower AKI rate and lower NGAL levels indicating a lesser degree of renal tissue injury. Trial registration ClinicalTrials.gov website, NCT02974946, https://clinicaltrials.gov/ct2/show/NCT02974946.

scholarly journals Increased Risk of Complications After Pancreatoduodenectomy in Uninephrectomized Patients

2018 ◽  
Vol 103 (7-8) ◽  
pp. 386-395
Author(s):  
Tadataka Takagi ◽  
Masayuki Sho ◽  
Satoshi Nishiwada ◽  
Takahiro Akahori ◽  
Minako Nagai ◽  
...  
Keyword(s):  
Acute Kidney Injury ◽  
Postoperative Complications ◽  
Kidney Injury ◽  
Surgical Site Infections ◽  
Morbidity Rate ◽  
Control Group ◽  
Study Objective ◽  
Soft Pancreas ◽  
Increased Risk ◽  
The Impact

Objective: The study objective is to investigate the impact of unilateral nephrectomy on the complications after pancreatoduodenectomy (PD). Summary of background data: Preoperative renal insufficiency is a risk factor for postoperative complications and mortality after various types of surgery. However, the specific postoperative risks in uninephrectomized (UN) patients are largely unknown. Methods: Between January 2010 and June 2014, a total of 177 patients underwent PD at the Department of Surgery, Nara Medical University. Among them, 7 patients (4.0%) were UN. We retrospectively evaluated the influence of the UN status on the postoperative complications. Results: The rate of acute kidney injury in the UN group was significantly higher than that in the control group (28.6% versus 1.2%; P = 0.017). In addition, the rates of surgical site infection of the organ/space (57.1% versus 9.0%; P = 0.006) and sepsis (42.9% versus 3.5%; P = 0.003) in UN group were significantly higher. Even on a reanalysis of only patients with soft pancreas, the significance remained. Conclusions: The UN status has a significant impact on the rate of morbidities, such as acute kidney injury and various infectious complications, including surgical site infections of organ/space, sepsis, and cholangitis after PD. Appropriate intervention should be implemented to decrease the morbidity rate for UN patients.

scholarly journals Enhancing Military Burn- and Trauma-Related Acute Kidney Injury Prediction Through an Automated Machine Learning Platform and Point-of-Care Testing

2021 ◽  
Vol 145 (3) ◽  
pp. 320-326
Author(s):  
Hooman H. Rashidi ◽  
Amy Makley ◽  
Tina L. Palmieri ◽  
Samer Albahra ◽  
Julia Loegering ◽  
...  
Keyword(s):  
Machine Learning ◽  
Acute Kidney Injury ◽  
Point Of Care ◽  
Total Body Surface Area ◽  
Kidney Injury ◽  
Reference Method ◽  
Trauma Patients ◽  
Learning Platform ◽  
Delayed Recognition ◽  
The Impact

Context.— Delayed recognition of acute kidney injury (AKI) results in poor outcomes in military and civilian burn-trauma care. Poor predictive ability of urine output (UOP) and creatinine contribute to the delayed recognition of AKI. Objective.— To determine the impact of point-of-care (POC) AKI biomarker enhanced by machine learning (ML) algorithms in burn-injured and trauma patients. Design.— We conducted a 2-phased study to develop and validate a novel POC device for measuring neutrophil gelatinase-associated lipocalin (NGAL) and creatinine from blood samples. In phase I, 40 remnant plasma samples were used to evaluate the analytic performance of the POC device. Next, phase II enrolled 125 adults with either burns that were 20% or greater of total body surface area or nonburn trauma with suspicion of AKI for clinical validation. We applied an automated ML approach to develop models predicting AKI, using a combination of NGAL, creatinine, and/or UOP as features. Results.— Point-of-care NGAL (mean [SD] bias: 9.8 [38.5] ng/mL, P = .10) and creatinine results (mean [SD] bias: 0.28 [0.30] mg/dL, P = .18) were comparable to the reference method. NGAL was an independent predictor of AKI (odds ratio, 1.6; 95% CI, 0.08–5.20; P = .01). The optimal ML model achieved an accuracy, sensitivity, and specificity of 96%, 92.3%, and 97.7%, respectively, with NGAL, creatinine, and UOP as features. Area under the receiver operator curve was 0.96. Conclusions.— Point-of-care NGAL testing is feasible and produces results comparable to reference methods. Machine learning enhanced the predictive performance of AKI biomarkers including NGAL and was superior to the current techniques.

scholarly journals Therapy with lopinavir/ritonavir and hydroxychloroquine is associated with acute kidney injury in COVID-19 patients

PLoS ONE ◽  
2021 ◽  
Vol 16 (5) ◽  
pp. e0249760
Author(s):  
Johanna Schneider ◽  
Bernd Jaenigen ◽  
Dirk Wagner ◽  
Siegbert Rieg ◽  
Daniel Hornuss ◽  
...  
Keyword(s):  
Acute Kidney Injury ◽  
Triple Therapy ◽  
Kidney Injury ◽  
University Hospital ◽  
Early Warning Score ◽  
Matched Pair ◽  
Control Group ◽  
Maximum Serum ◽  
Icu Patients ◽  
The Impact

Background Acute kidney injury (AKI) is an independent risk factor for mortality, which affects about 5% of hospitalized coronavirus disease-2019 (COVID-19) patients and up to 25–29% of severely ill COVID-19 patients. Lopinavir/ritonavir and hydroxychloroquine show in vitro activity against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and have been used for the treatment of COVID-19. Both, lopinavir and hydroxychloroquine are metabolized by cytochrome P450 (CYP) 3A4. The impact of a triple therapy with lopinavir/ritonavir and hydroxychloroquine (triple therapy) on kidney function in COVID-19 is currently not known. Methods We retrospectively analyzed both non-ICU and ICU patients with COVID-19 receiving triple therapy for the incidence of AKI. Patients receiving standard therapy served as a control group. All patients were hospitalized at the University Hospital of Freiburg, Germany, between March and April 2020. A matched-pair analysis for the National Early Warning Score (NEWS) 2 was performed to control for the severity of illness among non-intensive care unit (ICU) patients. Results In non-ICU patients, the incidence of AKI was markedly increased following triple therapy (78.6% vs. 21.4% in controls, p = 0.002), while a high incidence of AKI was observed in both groups of ICU patients (triple therapy: 80.0%, control group: 90.5%). ICU patients treated with triple therapy showed a trend towards more oliguric or anuric kidney injury. We also observed a linear correlation between the duration of the triple therapy and the maximum serum creatinine level (p = 0.004, R2 = 0.276, R = 0.597). Conclusion Triple therapy is associated with an increase in the incidence of AKI in non-ICU COVID-19 patients. The underlying mechanisms may comprise a CYP3A4 enzyme interaction, and may be relevant for any future therapy combining hydroxychloroquine with antiviral agents.

Challenges Associated with Managing a Multicenter Clinical Trial in Severe Burns

2020 ◽  
Vol 41 (3) ◽  
pp. 681-689
Author(s):  
Elsa C Coates ◽  
Elizabeth A Mann-Salinas ◽  
Nicole W Caldwell ◽  
Kevin K Chung
Keyword(s):  
Septic Shock ◽  
Acute Kidney Injury ◽  
Kidney Injury ◽  
High Volume ◽  
The United States ◽  
Data Safety Monitoring Board ◽  
Institutional Review Boards ◽  
Severe Burns ◽  
High Volume Hemofiltration ◽  
The Impact

Abstract Managing multicenter clinical trials (MCTs) is demanding and complex. The Randomized controlled Evaluation of high-volume hemofiltration in adult burn patients with Septic shoCk and acUte kidnEy injury (RESCUE) trial was a prospective, MCT involving the impact of high-volume hemofiltration continuous renal replacement therapy on patients experiencing acute kidney injury and septic shock. Ten clinical burn centers from across the United States were recruited to enroll a target sample size of 120 subjects. This manuscripts reviews some of the obstacles and knowledge gained while coordinating the RESCUE trial. The first subject was enrolled in February 2012, 22 months after initial IRB approval and 29 months from the time the grant was awarded. The RESCUE team consisted of personnel at each site, including the lead site, a data coordination center, data safety monitoring board, steering committees, and the sponsor. Seven clinical sites had enrolled 37 subjects when enrollment stopped in February 2016. Obstacles included changes in institutional review boards, multiple layers of review, staffing changes, creation and amendment of study documents and procedures, and finalization of contracts. Successful completion of a MCT requires a highly functional research team with sufficient patient population, expertise, and research infrastructure. Additionally, realistic timelines must be established with strategies to overcome challenges. Inevitable obstacles should be discussed in the pretrial phase and continuous correspondence must be maintained with all relevant research parties throughout all phases of study.

scholarly journals Outcomes and factors leading to graft failure in kidney transplants from deceased donors with acute kidney injury—A retrospective cohort study

PLoS ONE ◽  
2021 ◽  
Vol 16 (8) ◽  
pp. e0254115
Author(s):  
Cheol Woong Jung ◽  
Dana Jorgensen ◽  
Puneet Sood ◽  
Rajil Mehta ◽  
Michele Molinari ◽  
...  
Keyword(s):  
Risk Factors ◽  
Acute Kidney Injury ◽  
Graft Failure ◽  
Graft Function ◽  
Kidney Injury ◽  
The United States ◽  
Kidney Transplants ◽  
Ischemic Time ◽  
Cold Ischemic Time ◽  
The Impact

Due to shortage of donor, kidney transplants (KTs) from donors with acute kidney injury (AKI) are expanding. Although previous studies comparing clinical outcomes between AKI and non-AKI donors in KTs have shown comparable results, data on high-volume analysis of KTs outcomes with AKI donors are limited. This study aimed to analyze the selection trends of AKI donors and investigate the impact of AKI on graft failure using the United states cohort data. We analyzed a total 52,757 KTs collected in the Scientific Registry of Transplant Recipient (SRTR) from 2010 to 2015. The sample included 4,962 (9.4%) cases of KTs with AKI donors (creatinine ≥ 2 mg/dL). Clinical characteristics of AKI and non-AKI donors were analyzed and outcomes of both groups were compared. We also analyzed risk factors for graft failure in AKI donor KTs. Although the incidence of delayed graft function was higher in recipients of AKI donors compared to non-AKI donors, graft and patient survival were not significantly different between the two groups. We found donor hypertension, cold ischemic time, the proportion of African American donors, and high KDPI were risk factors for graft failure in AKI donor KTs. KTs from deceased donor with AKI showed comparable outcomes. Thus, donors with AKI need to be considered more actively to expand donor pool. Caution is still needed when donors have additional risk factors of graft failure.

scholarly journals 363. Acute Kidney Injury and Renal Replacement Therapy in Hospitalized COVID-19 Patients in the United States and Other Geographic Regions

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S251-S251
Author(s):  
Shannon NovosadShannon NovosadLeah Gilbert ◽  
Ibironke W Apata ◽  
Rahsaan Overton ◽  
Shikha Garg ◽  
Lindsey Kim ◽  
...  
Keyword(s):  
Acute Kidney Injury ◽  
Renal Replacement Therapy ◽  
Kidney Disease ◽  
Replacement Therapy ◽  
Kidney Injury ◽  
Resource Planning ◽  
The United States ◽  
Icu Patients ◽  
The Us ◽  
The Impact

Abstract Background Acute kidney injury (AKI) is a complication that has been described among severely ill patients with COVID-19 and may be more common in those with underlying chronic kidney disease (CKD). Some patients with AKI require renal replacement therapy (RRT), including continuous RRT (CRRT). During the COVID-19 pandemic, some US areas experienced CRRT supply shortages. We sought to describe the percent of hospitalized COVID-19 patients who developed AKI or needed RRT to inform patient care and resource planning. Methods We searched for studies in the literature and public health investigations that described CKD, AKI, and/or RRT in COVID-19 patients from January 2020 onward. Studies were excluded if no CKD, AKI, or RRT information was provided. We abstracted counts of hospitalized COVID-19 patients, including those admitted to intensive care units (ICU) who developed AKI, underwent RRT, and/or had CKD. Data were pooled across cohorts by geographic region with available data (US, China, or United Kingdom [UK]). We compared proportions using Chi-square tests. Results A total of 311 studies were identified; 23 studies (US n=11; China n=11; UK n=1) that described kidney disease and/or kidney-related outcomes in hospitalized COVID-19 patients were included. Underlying CKD prevalence was higher in US cohorts (10.3%) compared with China (2.5%) or UK (1.5%) (p&lt; 0.0001). AKI was markedly higher among hospitalized (31.3% vs. 6.4%; p &lt; 0 .001) and ICU patients (55.4% vs. 18.2%; p&lt; 0.0001) in the US compared to China. The percent of ICU patients requiring RRT in the US (16.8%) was significantly different from that reported in China (12.5%) and the UK (23.9%) (p&lt; 0.0001). Limitations include differences in CKD and RRT definitions across studies. Conclusion AKI is a frequent outcome among US COVID-19 patients, affecting almost one third of hospitalized and more than half of ICU patients. AKI was reported more frequently in the US than China. The percent of ICU patients who received RRT was higher in the US and UK than in China. Understanding the occurrence of kidney-related outcomes among patients with COVID-19 including the impact of underlying CKD and regional practice variations is essential for healthcare systems to successfully plan for RRT needs during the pandemic. Disclosures All Authors: No reported disclosures

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