RESUMO

Abstract Postoperative acute kidney injury is an underdiagnosed condition. Its incidence is variable and depends on demographic, clinical, and surgical stress-associated factors; hence the pathophysiology is multifactorial. It is extremely important to acknowledge those risk factors early and use tools to estimate the risk of developing the condition, in order to adopt perioperative measures to mitigate its occurrence and impact. Some of the complications resulting from this condition include prolonged ICU stay, higher susceptibility for infections, hospitalization-related complications, progression to acute and chronic kidney failure, and even the need for transient or permanent renal replacement therapies (RRT) in addition to diseases that increase the cardiovascular risk, such as systemic high blood pressure and/or coronary heart disease that result in increased comorbidities and mortality, with subsequent increases in healthcare costs, lower quality of life and increased burden of the disease in the short and long term. A systematic search of the literature was conducted in PubMed, Google Schoolar, and Lilacs, under the terms MeSh and DeCs using Boolean operators; a review was conducted of the summary of the articles identified and 57 of them were selected for their comprehensive reading. This narrative review summarizes the relevant information on this pathology for prevention and identification purposes, for the adequate management of patients undergoing major non-cardiac surgery.

Resumen La lesión renal aguda posoperatoria es una entidad subdiagnosticada. Su incidencia es variable y depende de factores demográficos, clínicos y los inherentes al estrés quirúrgico; por ende, la fisiopatología es multifactorial. Es de vital importancia reconocer precozmente dichos factores de riesgo durante la valoración preanestésica y hacer uso de herramientas para calcular el riesgo de desarrollarla para, de esta forma, adoptar medidas perioperatorias para mitigar su aparición e impacto. Entre las complicaciones derivadas de esta entidad se encuentran la estancia en unidades de cuidado intensivo prolongadas, mayor susceptibilidad de infecciones, complicaciones derivadas de la hospitalización, progresión a enfermedad renal aguda y crónica e incluso necesidad de terapias de reemplazo renal (TRR) transitorias o permanentes, además de enfermedades que aumentan el riesgo cardiovascular como hipertensión arterial sistémica y/o enfermedad coronaria, lo que genera aumento en morbimortalidad, con aumento en costos asociado a la atención en salud, menor calidad de vida y mayor carga de la enfermedad a corto y largo plazo. Se realizó una búsqueda sistemática de la literatura en bases de datos PubMed, Google Schoolar, Lilacs, bajo los términos MeSh y DeCs, usando los operadores booleanos, se revisó el resumen de los artículos encontrados y se seleccionaron 57 artículos para su lectura completa. Esta revisión narrativa sintetiza la información relevante sobre esta patología que permita prevenirla y reconocerla para el manejo adecuado de los pacientes que van a cirugía mayor no cardiaca.

RESUMO

Background: Patients who develop postoperative delirium (POD) have several clinical complications, such as increased morbidity, increased hospital stays, higher hospital costs, cognitive and functional impairment, and higher mortality. POD is a clinical condition preventable by standard non-pharmacological measures An intensive Occupational Therapy (OT) intervention has been shown to be highly effective in preventing delirium in critically ill medical patients, but it is unknown the effect in surgical patients. Thus, we designed a prospective clinical study with the aim to determine whether patients undergoing intervention by the OT team have a lower incidence of POD compared to the group treated only with standard measures. Methods: A multicenter, single-blind, randomized clinical trial was conducted between October 2018 and April 2021, in Santiago of Chile, at a university hospital and at a public hospital. Patients older than 75 years undergoing elective major surgery were eligible for the trial inclusion. Patients with cognitive impairment, severe communication disorder and cultural language limitation, delirium at admission or before surgery, and enrolled in another study were excluded. The intervention consisted of OT therapy twice a day plus standard internationally recommended non-pharmacological prevention intervention during 5 days after surgery. Our primary outcome was development of delirium and postoperative subsyndromal delirium. Results: In total 160 patients were studied. In the interventional group, treated with an intensive prevention by OT, nine patients (12.9%) developed delirium after surgery and in the control group four patients (5.5%) [p = 0.125, RR 2.34 CI 95 (0.75-7.27)]. Whereas subsyndromal POD was present in 38 patients in the control group (52.1%) and in 34 (48.6%) in the intervention group [p = 0.4, RR 0.93 CI95 (0.67-1.29)]. A post hoc analysis determined that the patient's comorbidity and cognitive status prior to hospitalization were the main risk factors to develop delirium after surgery. Discussion: Patients undergoing intervention by the OT team did not have a lower incidence of POD compared to the group treated only with standard non-pharmacological measures in adults older than 75 years who went for major surgery. Clinical trial registration: www.ClinicalTrials.gov, identifier NCT03704090.