Association between peripheral perfusion index and postoperative acute kidney injury in major noncardiac surgery patients receiving continuous vasopressors: a post hoc exploratory analysis of the VEGA-1 trial.

BACKGROUND: The peripheral perfusion index is the ratio of pulsatile to nonpulsatile static blood flow obtained by photoplethysmography and reflects peripheral tissue perfusion. We investigated the association between intraoperative perfusion index and postoperative acute kidney injury in patients undergoing major noncardiac surgery and receiving continuous vasopressor infusions. METHODS: In this exploratory post hoc analysis of a pragmatic, cluster-randomised, multicentre trial, we obtained areas and cumulative times under various thresholds of perfusion index and investigated their association with acute kidney injury in multivariable logistic regression analyses. In secondary analyses, we investigated the association of time-weighted average perfusion index with acute kidney injury. The 30-day mortality was a secondary outcome. RESULTS: Of 2534 cases included, 8.9% developed postoperative acute kidney injury. Areas and cumulative times under a perfusion index of 3% and 2% were associated with an increased risk of acute kidney injury; the strongest association was observed for area under a perfusion index of 1% (adjusted odds ratio [aOR] 1.32, 95% confidence interval [CI] 1.00-1.74, P=0.050, per 100%∗min increase). Additionally, time-weighted average perfusion index was associated with acute kidney injury (aOR 0.82, 95% CI 0.74-0.91, P<0.001) and 30-day mortality (aOR 0.68, 95% CI 0.49-0.95, P=0.024). CONCLUSIONS: Larger areas and longer cumulative times under thresholds of perfusion index and lower time-weighted average perfusion index were associated with postoperative acute kidney injury in patients undergoing major noncardiac surgery and receiving continuous vasopressor infusions. CLINICAL TRIAL REGISTRATION: NCT04789330.

Pragmatic platform trials to improve the outcome of patients with acute kidney injury.

PURPOSE OF REVIEW: There is an important need for improved diagnostic strategies and treatment among patients with acute kidney injury (AKI). Classical randomized clinical trials have generated relevant results in AKI but are associated with shortcomings, such as high costs and sometimes lack of generalizability. In this minireview, we discuss the value and limits of pragmatic trials and platform trials for AKI research. RECENT FINDINGS: The implementation of pragmatic and platform trials in critical care settings has generated relevant clinical evidence impacting clinical practice. Pragmatic and platform designs have recently been applied to patients at risk of AKI and represent a crucial opportunity to advance our understanding of optimized treatment and strategies in patients at risk of AKI or presenting with AKI. Trials embedded in electronic health records can facilitate patient enrollment and data collection. Platform trials have allowed for a more efficient study design. Although both pragmatic and platform trials have several advantages, they also come with the challenges and shortcomings discussed in this review. SUMMARY: Pragmatic and platform trials can provide clinical answers in 'real-life' settings, facilitate a significant sample size enrollment at a limited cost, and provide results that can have a faster implementation in clinical practice.

Investigational drugs for vasospasm after subarachnoid hemorrhage.

INTRODUCTION: Aneurysmal subarachnoid hemorrhage (aSAH) represents 3% of all strokes in the US. When the patient survives it can lead to permanent incapacity especially if the patient develops vasospasm. The vasospasm is a multifactorial disorder and can lead to delayed cerebral ischemia (DCI). Most of the drugs tested to treat vasospasm failed to improve outcome and the only exception is nimodipine. AREAS COVERED: In this review, the authors describe the multifactorial process of vasospasm leading DCI after aSAH, discussing the treatments available based on the past and latest researches. EXPERT OPINION: Nimodipine is the only FDA-approved medication with neuroprotective effect and able to improve outcomes after aSAH. Understanding nimodipine trials is mandatory to understand and criticize all the drug trials published until now. The mechanism to vasospasm is multifactorial and not completely understood and all the other attempts to find a better medication could not prove superior results. Newton and PEGylated Carboxyhemoglobin Bovine can be potentially effective to prevent vasospasm but we still need more data and large studies. Future research should investigate newer drugs, as well as the combination of multiple drugs therapy and the association with blood evacuation techniques.