Minimal fresh gas flow sevoflurane anesthesia and postoperative acute kidney injury in on-pump cardiac surgery: a randomized comparative trial
Anestesia com fluxo mínimo de gás fresco com sevoflurano e lesão renal aguda pós-operatória em cirurgia cardíaca com CEC: um estudo comparativo randomizado
Eric Benedet Lineburger, Norma Sueli Pinheiro Módolo, Leandro Gobbo Braz, Paulo do Nascimento Junior
Abstract
Background
: Compound A is generated by sevoflurane when it reacts with carbon dioxide absorbers with strong bases at minimal fresh gas flow (FGF) and is nephrotoxic in animals. No conclusive data has shown increased risk in humans. The aim of this study was to investigate if minimal FGF promotes an increase in the incidence of acute kidney injury (AKI) when compared to high FGF in patients undergoing on-pump cardiac surgery under sevoflurane anesthesia.
Methods
: Two hundred and four adult patients scheduled for on-pump cardiac surgery under sevoflurane anesthesia were randomly allocated to two groups differentiated by FGF: minimal FGF (0.5 L.min−1) or high FGF (2.0 L.min−1). Baseline creatinine measured before surgery was compared daily to values assayed on the first five postoperative days, and 24-hour urinary output was monitored, according to the KDIGO (Kidney Disease Improving Global Outcomes) guideline to define postoperative cardiac surgery-associated acute kidney injury (CSA-AKI). Creatinine measurements were also obtained 20 and 120 days after hospital discharge.
Results
: Postoperative AKI occurred in 55 patients, 26 patients (29.5%) in the minimal FGF group and 29 patients (31.5%) in the high FGF group (p = 0.774). Twenty days after discharge, 11 patients (6.1%) still had CSA-AKI and 120 days after discharge only 2 patients (1.6%) still had CSA-AKI.
Conclusions
: When compared to high FGF, minimal FGF sevoflurane anesthesia during on-pump cardiac surgery is not associated with increased risk of postoperative AKI in this population at high risk for renal injury.
Keywords
Resumo
Introdução
O composto A é gerado pelo sevoflurano quando reage com absorvedores de dióxido de carbono com bases fortes em fluxo mínimo de gás fresco (FGF) e é nefrotóxico em animais. Nenhum dado conclusivo mostrou risco aumentado em humanos. O objetivo deste estudo foi investigar se o FGF mínimo promove um aumento na incidência de lesão renal aguda (LRA) quando comparado ao FGF alto em pacientes submetidos à cirurgia cardíaca com CEC sob anestesia com sevoflurano.
Métodos
Duzentos e quatro pacientes adultos agendados para cirurgia cardíaca com CEC sob anestesia com sevoflurano foram alocados aleatoriamente em dois grupos diferenciados por FGF: FGF mínimo (0,5 L.min−1) ou FGF alto (2,0 L.min−1). A creatinina basal medida antes da cirurgia foi comparada diariamente com os valores dosados nos primeiros cinco dias de pós-operatório, e o débito urinário de 24 horas foi monitorado, de acordo com a diretriz KDIGO (Kidney Disease Improving Global Outcomes) para definir lesão renal aguda associada à cirurgia cardíaca pós-operatória (LRA-PCC). As dosagens de creatinina também foram obtidas 20 e 120 dias após a alta hospitalar.
Resultados
LRA pós-operatória ocorreu em 55 pacientes, 26 pacientes (29,5%) no grupo FGF mínimo e 29 pacientes (31,5%) no grupo FGF alto (p = 0,774). Vinte dias após a alta, 11 pacientes (6,1%) ainda apresentavam LRA-PCC e 120 dias após a alta apenas 2 pacientes (1,6%) ainda apresentavam LRA-PCC.
Conclusão
Quando comparada ao FGF alto, a anestesia mínima de FGF com sevoflurano durante cirurgia cardíaca com CEC não está associada a risco aumentado de LRA pós-operatória nessa população com alto risco de lesão renal.
Palavras-chave
References
1 S Ryan, J Sherman Sustainable anesthesia Anesth Analg, 114 (2012), pp. 921-923
2 H Higuchi, Y Adachi, S Arimura, et al. Compound A concentrations during low-flow sevoflurane anesthesia correlate directly with the concentration of monovalent bases in carbon dioxide absorbents Anesth Analg, 91 (2000), pp. 434-439
3 M Morio, K Fujii, N Satoh, et al. Reaction of sevoflurane and its degradation products with soda lime. Toxicity of the byproducts Anesthesiology, 77 (1992), pp. 1155-1164
4 LCL Ong Sio, RGC Dela Cruz, AF Bautista Sevoflurane and renal function: a meta-analysis of randomized trials Med Gas Res, 7 (2017), pp. 186-193
5 JM. Feldman Managing fresh gas flow to reduce environmental contamination Anesth Analg, 114 (2012), pp. 1093-1101
6 DY Fuhrman, JA. Kellum Epidemiology and pathophysiology of cardiac surgery-associated acute kidney injury Curr Opin Anaesthesiol, 30 (2017), pp. 60-65
7 Q Yi, K Li, Z Jian, et al. Risk Factors for Acute Kidney Injury after Cardiovascular Surgery: Evidence from 2,157 Cases and 49,777 Controls - A Meta-Analysis Cardiorenal Med, 6 (2016), pp. 237-250
8 AB. Baker Low flow and closed circuits Anaesth Intensive Care, 22 (1994), pp. 341-342
9 Cavalcanti IL, Vane LA. Inhalation Anesthesia. Rio de Janeiro: Brazilian Society of Anesthesiology; 2007. 156 p.
10 S Morita, W Latta, K Hambro, et al. Accumulation of methane, acetone, and nitrogen in the inspired gas during closed-circuit anesthesia Anesth Analg, 64 (1985), pp. 343-347
11 A. Khwaja KDIGO clinical practice guidelines for acute kidney injury Nephron Clin Pract, 120 (2012), pp. c179-c184
12 AS Levey, LA Stevens, CH Schmid, et al. A new equation to estimate glomerular filtration rate Ann Intern Med, 150 (2009), pp. 604-612
13 Eger EI 2nd, Koblin DD, T Bowland, et al. Nephrotoxicity of sevoflurane versus desflurane anesthesia in volunteers Anesth Analg, 84 (1997), pp. 160-168
14 C Goeters, C Reinhardt, E Gronau, et al. Minimal flow sevoflurane and isoflurane anaesthesia and impact on renal function Eur J Anaesthesiol, 18 (2001), pp. 43-50
15 ZX Fang, L Kandel, MJ Laster, et al. Factors affecting production of compound A from the interaction of sevoflurane with Baralyme and soda lime Anesth Analg, 82 (1996), pp. 775-781
16 ZX Fang, EI Eger 2nd Factors affecting the concentration of compound A resulting from the degradation of sevoflurane by soda lime and Baralyme in a standard anesthetic circuit Anesth Analg, 81 (1995), pp. 564-568
17 JM Murray, CW Renfrew, A Bedi, et al. Amsorb: a new carbon dioxide absorbent for use in anesthetic breathing systems Anesthesiology, 91 (1999), pp. 1342-1348
18 RH Epstein, F Dexter, DP Maguire, et al. Economic and Environmental Considerations During Low Fresh Gas Flow Volatile Agent Administration After Change to a Nonreactive Carbon Dioxide Absorbent Anesth Analg, 122 (2016), pp. 996-1006
19 H Higuchi, Y Adachi, S Arimura, et al. The carbon dioxide absorption capacity of Amsorb is half that of soda lime Anesth Analg, 93 (2001), pp. 221-225
20 KM Souza, LG Braz, FR Nogueira, et al. Occupational exposure to anesthetics leads to genomic instability, cytotoxicity and proliferative changes Mutat Res (2016), pp. 791-792 42-8
21 AA El-Ebiary, AA Abuelfadl, NI Sarhan, et al. Assessment of genotoxicity risk in operation room personnel by the alkaline comet assay Hum Exp Toxicol, 32 (2013), pp. 563-570
22 S Izdes, S Sardas, E Kadioglu, et al. DNA damage, glutathione, and total antioxidant capacity in anesthesia nurses Arch Environ Occup Health, 65 (2010), pp. 211-217
23 AG Aun, MA Golim, FR Nogueira, et al. Monitoring early cell damage in physicians who are occupationally exposed to inhalational anesthetics Mutat Res, 812 (2018), pp. 5-9
24 AM Gaffney, RN. Sladen Acute kidney injury in cardiac surgery Curr Opin Anaesthesiol, 28 (2015), pp. 50-59
25 PF Conzen, ED Kharasch, SF Czerner, et al. Low-flow sevoflurane compared with low-flow isoflurane anesthesia in patients with stable renal insufficiency Anesthesiology, 97 (2002), pp. 578-584
26 JA. Baum Low-flow anaesthesia Eur J Anaesthesiol, 13 (1996), pp. 432-435
27 Y. Ishizawa Special article: general anesthetic gases and the global environment Anesth Analg, 112 (2011), pp. 213-217
Facebook
Google+
Twitter
LinkedIn
Mendeley
StumbleUpon
CiteULike
Reddit
Email