Q. L. Hu1,2, J. Y. Liu1,3, C. Y. Ko1,2, M. E. Cohen1, K. Y. Bilimoria4, D. B. Hoyt1, R. P. Merkow1,4 1American College Of Surgeons,Chicago, IL, USA 2University Of California – Los Angeles,Department Of Surgery,Los Angeles, CA, USA 3Emory University School Of Medicine,Department Of Surgery,Atlanta, GA, USA 4Feinberg School Of Medicine – Northwestern University,Department Of Surgery,Chicago, IL, USA
Introduction:
Enhanced Recovery Pathways (ERPs) have been shown to dramatically improve perioperative outcomes in colorectal surgery. However, one important factor limiting its widespread adoption is concern regarding postoperative renal complications. Our objective was to evaluate the association of the overall use of an ERP protocol and adherence to its potentially renal-compromising components (e.g., epidural use [hypotension], multimodal pain management [NSAID use], fluid restriction [hypovolemia]) with postoperative renal complications.
Methods:
American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Enhanced Recovery data between 2014 and 2017 were used to identify patients who were managed under an ERP (ERP group). A 1:1 propensity-score match was used to identify control patients during the same time period who were managed without an ERP (non-ERP group). Hierarchical multivariable logistic regression models were used to evaluate the overall association of an ERP (vs. non-ERP) as well as adherence to individual ERP components with postoperative renal complications (either renal insufficiency or dialysis requirement).
Results:
We identified 36,452 patients who received at least one ERP component, including 16.1% who received epidural analgesia, 87.6% who received multi-modal pain management, and 53.0% who received fluid restrictive care. Compared to non-ERP, ERP management was not associated with postoperative renal complications (1.0% vs. 1.0%; OR 0.96, 95% CI 0.83-1.11). Independent predictors of renal complications included male sex, African American race, higher ASA class, severe obesity, and preoperative co-morbidities, including hypertension, heart failure, diabetes, ascites, and disseminated cancer. Among patients managed under ERPs, adherence with individual potentially renal-compromising components was not associated with renal complications: epidural use (1.0% vs. 1.0%; OR 0.77, 95% CI 0.54-1.11), multi-modal pain management (0.9% vs. 1.3%; OR 0.78, 95% CI 0.59-1.05), and fluid restriction (0.9% vs. 1.0%; OR 1.05, 95% CI 0.79-1.39). Finally, adherence with all three components versus none was also not associated with renal complications (1.2% vs. 1.0%; OR 0.92, 95% CI 0.52-1.65).
Conclusion:
Management under ERPs and adherence with individual potentially renal-compromising components were not associated with postoperative renal complications. Postoperative renal complication is a serious adverse event, however, clinicians should focus on other modifiable factors precipitating its occurrence other than the use of an ERP.
