Acute renal injury (AKI) is a common complication after cardiac surgery and is associated with worse outcomes. It is now realized that intraoperative hypotension is an important risk factor for the development of AKI. In a recent randomized controlled trial of patients undergoing major noncardiac surgery, intraoperative individualized blood-pressure management reduced the incidence of postoperative organ dysfunction. The investigators hypothesize that, for patients undergoing off-pump CABG, targeted blood-pressure management during surgery may also reduce the incidence of postoperative AKI.
Age ≥ 50 years;
Scheduled to undergo off-pump CABG surgery.
Refuse to participate;
Untreated or uncontrolled severe hypertension (systolic blood pressure ≥180 mmHg or diastolic blood pressure ≥110 mmHg);
Chronic kidney disease with a glomerular filtration rate < 30 ml/min/1.73 m2 or end-stage renal disease requiring renal-replacement therapy;
Inability to communicate during the preoperative period because of coma, profound dementia, language barrier, or end-stage disease;
Parallel
Targeted blood-pressure management
DrugProphylactic norepinephrine infusion is started before anesthetic induction and maintained throughout surgery. The target is to maintain systolic blood pressure at 110 mmHg or higher.
Routine blood-pressure management
DrugPhenylephrine (25-50 ug) is injected or vasopressors is infused only when necessary. The target is to maintain systolic blood pressure at 90 mmHg or higher during surgery.
Incidence of acute kidney injury (AKI) within 7 days after surgery
Development of AKI within 7 days after surgery is diagnosed according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria
Classification of AKI within 7 days after surgery
Development of AKI within 7 days after surgery is diagnosed according to the KDIGO criteria
Incidence of delirium within 7 days after surgery
Development of delirium within 7 days after surgery is assessed with the Confusion Assessment Method (3D-CAM for patients without mechanical ventilation and CAM-ICU for patients with mechanical ventilation).
Duration of mechanical ventilation after surgery
Duration of mechanical ventilation after surgery
Length of stay in intensive care unit (ICU) after surgery
Length of stay in intensive care unit (ICU) after surgery
Pain severity within 3 days after surgery: NRS
Pain severity is assessed with the Numeric Rating Scale (NRS, an 11-point scale where 0=no pain and 10=the worst pain) twice daily (8:00-10:00 am, 18:00-20:00 pm) after surgery.
Daily prevalence of delirium during postoperative days 1-7
Daily prevalence of delirium during postoperative days 1-7
Duration of intraoperative cerebral desaturation (sub-study)
Duration of cerebral desaturation is monitored by near-infrared spectroscopy. Cerebral desaturation is defined as a decrease of more than 10% from baseline. Performed in part of enrolled patients.
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