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Blood Pressure Excursions Below the Cerebral Autoregulation Threshold During Cardiac Surgery are Associated With Acute Kidney Injury*

Ono, Masahiro MD, PhD1; Arnaoutakis, George J. MD1; Fine, Derek M. MD2; Brady, Kenneth MD3; Easley, R. Blaine MD3; Zheng, Yueying MD4; Brown, Charles MD5; Katz, Nevin M. MD1; Grams, Morgan E. MD, MHS2; Hogue, Charles W. MD5

doi: 10.1097/CCM.0b013e31826ab3a1
Clinical Investigations

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.

1 Department of Surgery, Division of Cardiac Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD.

2 Department of Medicine, Division of Nephrology, The Johns Hopkins University School of Medicine, Baltimore, MD.

3 Department of Anesthesiology, The Texas Children’s Hospital, Houston, TX.

4 The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.

5 Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD.

*See also p. 671.

Supported, in part, by Grant-In-Aid Number 103363 from the Mid-Atlantic Affiliate of the American Heart Association; Grant R01HL092259 from the National Institutes of Health (to Dr. Hogue).

Dr. Hogue has received research support from Somanetics and its parent company Covidien (Boulder, CO). Dr. Brady has consulted for Somanetics in a relationship that was managed by the committee for outside interests at the Johns Hopkins University School of Medicine.

The authors have not disclosed any potential conflicts of interest.

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© 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins