Effects of remimazolam on hemodynamic changes during cardiac ablation for atrial fibrillation under general anesthesia: a propensity-score-matched retrospective cohort study.

PURPOSE: Abrupt hemodynamic changes or life-threatening arrhythmias are frequently observed in individuals receiving anesthesia for cardiac arrhythmia ablation. Remimazolam is a novel ultra-short-acting benzodiazepine that has been associated with better hemodynamic stability than conventional anesthetic agents do. This study aimed to investigate whether remimazolam reduces vasoactive agent use compared with desflurane in individuals undergoing ablation for atrial fibrillation under general anesthesia. METHODS: In a retrospective cohort study, we reviewed electronic medical records of adult patients who underwent ablation for atrial fibrillation under general anesthesia between July 2021 and July 2022. We divided patients into remimazolam and desflurane groups according to the principal agent used for anesthesia. The primary endpoint was the overall incidence of vasoactive agent use. We compared the groups using propensity-score matching (PSM) analysis. RESULTS: A total of 177 patients were included-78 in the remimazolam group and 99 in the desflurane group. After PSM, 78 final patients were included in each group. The overall incidence of vasoactive agent use was significantly lower in the remimazolam group than in the desflurane group (41% vs 74% before PSM; 41% vs 73% after PSM; both, P < 0.001). The incidence rate, duration, and maximum dose of continuous vasopressor infusion were also significantly lower in the remimazolam group (P < 0.001). Use of remimazolam was not associated with increased complications after the ablation procedures. CONCLUSIONS: General anesthesia using remimazolam vs desflurane was associated with significantly reduced vasoactive agent requirement and better hemodynamic stability without increased postoperative complications in patients undergoing ablation for atrial fibrillation.

RéSUMé: OBJECTIF: Des changements hémodynamiques brusques ou des arythmies potentiellement mortelles sont fréquemment observés chez les personnes recevant une anesthésie pour une ablation d'arythmie cardiaque. Le remimazolam est une nouvelle benzodiazépine à action ultra-courte qui a été associé à une meilleure stabilité hémodynamique que les agents anesthésiques conventionnels. Cette étude visait à déterminer si le remimazolam réduit l'utilisation d'agents vasoactifs par rapport au desflurane chez les personnes bénéficiant d'une ablation pour fibrillation auriculaire sous anesthésie générale. MéTHODE: Dans une étude de cohorte rétrospective, nous avons examiné les dossiers médicaux électroniques de patient·es adultes ayant bénéficié d'une ablation pour fibrillation auriculaire sous anesthésie générale entre juillet 2021 et juillet 2022. Nous avons divisé les patient·es en groupes de remimazolam et de desflurane en fonction de l'agent principal utilisé pour l'anesthésie. Le critère d'évaluation principal était l'incidence globale de l'utilisation d'agents vasoactifs. Nous avons comparé les groupes à l'aide d'une analyse d'appariement par score de propension (ASP). RéSULTATS: Au total, 177 patient·es ont été inclus·es, dont 78 dans le groupe remimazolam et 99 dans le groupe desflurane. Après l'ASP, 78 patient·es ont été inclus·es au final dans chaque groupe. L'incidence globale d'utilisation d'agents vasoactifs était significativement plus faible dans le groupe remimazolam que dans le groupe desflurane (41 % vs 74 % avant l'ASP; 41 % vs 73 % après l'ASP; les deux P < 0,001). Le taux d'incidence, la durée et la dose maximale de perfusion continue de vasopresseurs étaient également significativement plus faibles dans le groupe remimazolam (P < 0,001). L'utilisation de remimazolam n'a pas été associée à une augmentation des complications après les interventions d'ablation. CONCLUSION: L'anesthésie générale à base de remimazolam vs desflurane a été associée à une réduction significative des besoins en agents vasoactifs et à une meilleure stabilité hémodynamique sans augmentation des complications postopératoires chez les patient·es bénéficiant d'une ablation pour fibrillation auriculaire.

Prognostic value of left ventricular apical four-chamber longitudinal strain after heart valve surgery in real-world practice.

BACKGROUND: Left ventricular longitudinal strain is an emerging marker of ventricular systolic function. However, the prognostic value of apical four-chamber longitudinal strain after heart valve surgery in real-world clinical practice is uncertain. The authors investigated whether left ventricular apical four-chamber longitudinal strain measured in real-world practice is helpful for predicting postoperative outcomes in patients undergoing heart valve surgery. METHODS: This observational cohort study was conducted in patients who underwent heart valve surgery between January 2014 and December 2018 at a tertiary hospital in South Korea. The exposure of interest was preoperative left ventricular apical four-chamber longitudinal strain. The primary outcome was postoperative all-cause mortality. RESULTS: Among 1,773 study patients (median age, 63 years; female, 45.9%), 132 (7.4%) died during a median follow-up of 27.2 months. Preoperative left ventricular apical four-chamber longitudinal strain was significantly associated with all-cause mortality (adjusted hazard ratio, 0.94 per 1% increment in absolute value; 95% CI [0.90, 0.99], P = 0.022), whereas left ventricular ejection fraction (LVEF) was not significantly associated with all-cause mortality (adjusted hazard ratio: 1.01, 95% CI [0.99, 1.03], P = 0.222). Moreover, combining left ventricular apical four-chamber longitudinal strain to the LVEF and conventional prognostic factors enhance the prognostic model for all-cause mortality (P = 0.022). CONCLUSIONS: In patients undergoing heart valve surgery without coronary artery disease, left ventricular apical four-chamber longitudinal strain measured in real-world clinical practice was independently associated with postoperative survival. Left ventricular longitudinal strain measurement may be helpful for outcome prediction after valve surgery.

Application of the New Preoperative Frailty Risk Score in Elderly Patients Undergoing Emergency Surgery.

BACKGROUND: Predicting preoperative frailty risk in emergency surgery is difficult with limited information because preoperative evaluation is not commonly performed properly. A recent study attempted to predict preoperative frailty risk using only diagnostic and surgical codes that can be extracted from the electronic medical records system. OBJECTIVE: This study aimed to validate whether the prediction model of preoperative frailty risk presented in the previous study is well applied to other medical hospitals' data. METHODS: This is a retrospective cohort study including 1,557 patients (≥75 years old) who were admitted to a single institution for emergency operations between January 1, 2010, and December 31, 2019, for study analysis. The Charlson comorbidity index, Hospital Frailty Risk Score, and the recently developed Operation Frailty Risk Score (OFRS) were calculated using the patient's diagnostic and operation codes. The predictive performances of these calculated risk scores and the American Society of Anesthesiologists-Physical Status classification for postoperative 90-day mortality were compared by using the receiver operating characteristic curve analysis. FINDINGS: The predictive performance of the OFRS, Charlson comorbidity index, American Society of Anesthesiologists-Physical Status, and Hospital Frailty Risk Score for postoperative 90-day mortality was 0.81, 0.630, 0.699, and 0.549 on a c-statistics basis, respectively. CONCLUSIONS: The OFRS using diagnostic and operation codes may show the best predictive performance for 90-day mortality compared to other risk scores, and it can be the clinically applicable model to evaluate the preoperative frailty risk in elderly patients undergoing emergency surgery.

Anesthetic care for electroconvulsive therapy.

Counselling and medication are often thought of as the only interventions for psychiatric disorders, but electroconvulsive therapy (ECT) has also been applied in clinical practice for over 80 years. ECT refers to the application of an electric stimulus through the patient's scalp to treat psychiatric disorders such as treatment-resistant depression, catatonia, and schizophrenia. It is a safe, effective, and evidence-based therapy performed under general anesthesia with muscle relaxation. An appropriate level of anesthesia is essential for safe and successful ECT; however, little is known about this because of the limited interest from anesthesiologists. As the incidence of ECT increases, more anesthesiologists will be required to better understand the physiological changes, complications, and pharmacological actions of anesthetics and adjuvant drugs. Therefore, this review focuses on the fundamental physiological changes, management, and pharmacological actions associated with various drugs, such as anesthetics and neuromuscular blocking agents, as well as the comorbidities, indications, contraindications, and complications of using these agents as part of an ECT procedure through a literature review and our own experiences.

Predictive Model for the Assessment of Preoperative Frailty Risk in the Elderly.

Adequate preoperative evaluation of frailty can greatly assist in the efficient allocation of hospital resources and planning treatments. However, most of the previous frailty evaluation methods, which are complicated, time-consuming, and can have inter-evaluator error, are difficult to apply in urgent situations. Thus, the authors aimed to develop and validate a predictive model for pre-operative frailty risk of elderly patients by using diagnostic and operation codes, which can be obtained easily and quickly from electronic records. We extracted the development cohort of 1762 people who were hospitalized for emergency operations at a single institution between 1 January 2012 and 31 December 2016. The temporal validation cohort from 1 January 2017 to 31 December 2018 in the same center was set. External validation was conducted on 6432 patients aged 75 years or older from 2012 to 2015 who had emergency surgery in the Korean national health insurance database. We developed the Operation Frailty Risk Score (OFRS) by assessing the association of Operation Group and Hospital Frailty Risk Score with the 90-day mortality through logistic regression analysis. We validated the OFRS in both the temporal validation cohort and two external validation cohorts. In the temporal validation cohort and the external validation cohort I and II, the c-statistics for OFRS to predict 90-day mortality were 0.728, 0.626, and 0.619, respectively. OFRS from these diagnostic codes and operation codes may help evaluate the peri-operative frailty risk before emergency surgery for elderly patients where history-taking and pre-operative testing cannot be performed.

Changes in Left Ventricular Ejection Fraction after Mitral Valve Repair for Primary Mitral Regurgitation.

This study sought to identify the short- and long-term changes in left ventricular ejection fraction (LVEF) after mitral valve repair (MVr) in patients with chronic primary mitral regurgitation according to preoperative LVEF (pre-LVEF) and preoperative left ventricular end-systolic diameter (pre-LVESD). This study evaluated 461 patients. Restricted cubic spline regression models were constructed to demonstrate the long-term changes in postoperative LVEF (post-LVEF). The patients were divided into four groups according to pre-LVEF (<50%, 50-60%, 60-70%, and ≥70%). The higher the pre-LVEF was, the greater was the decrease in LVEF immediately after MVr. In the same pre-LVEF range, immediate post-LVEF was lower in patients with pre-LVESD ≥ 40 mm than in those with pre-LVESD < 40 mm. The patterns of long-term changes in post-LVEF differed according to pre-LVEF (p for interaction < 0.001). The long-term post-LVEF reached a plateau of approximately 60% when the pre-LVEF was ≥50%, but it seemed to show a downward trend after reaching a peak at approximately 3-4 years after MVr when the pre-LVEF was ≥70%. The patterns of short- and long-term changes in post-LVEF differed according to pre-LVEF and pre-LVESD values in patients with chronic primary mitral regurgitation after MVr.

Comparison between monitored anesthesia care and general anesthesia in patients undergoing device closure of atrial septal defect.

BACKGROUND: Percutaneous atrial septal defect (ASD) device closure is usually performed under general anesthesia (GA) because it can ensure protection of the airway from the effects of insertion of the transesophageal echocardiogram probe insertion. However, recent studies have suggested that this procedure can be performed safely under deep sedation also. Thus, we compared the efficacy of using monitored anesthesia care (MAC) with deep sedation versus GA to perform this procedure and the post-procedural outcomes and incidence of complications associated with these two methods of anesthesia. METHODS: We retrospectively analyzed cases involving 311 patients who underwent ASD device closures from January 2011 to December 2015. The demographics, laboratory values, echocardiographic findings, and intraoperative data of these patients were assessed. GA was induced with a continuous infusion of propofol and remifentanil using a target control infusion pump. MAC with deep sedation was performed by using a continuous infusion of dexmedetomidine and remifentanil. The primary outcome of the study was the overall complication rate that included the incidence of aspiration pneumonia, sore throat, dysphagia, vocal cord palsy, neurologic complication, device-related complications, and other minor complications during the procedure; and the secondary outcomes were the turnover time, procedure time, and duration of hospital stay. RESULTS: No significant differences were observed in the complication rate and length of the hospital stay between the MAC group and the GA group. However, the turnover time was significantly longer in the GA group than in the MAC group (56.2±13.3 vs. 51.0±15.4 min, P=0.004). CONCLUSIONS: MAC under deep sedation is an effective and safe anesthetic option comparable to GA for performing percutaneous ASD device closures.

Perioperative rupture risk of unruptured intracranial aneurysms in cardiovascular surgery.

Although unruptured intracranial aneurysms are increasingly being diagnosed incidentally, perioperative rupture risk of unruptured intracranial aneurysm in patients undergoing cardiovascular surgery remains unclear. Therefore, we conducted an observational study to assess the prevalence and perioperative rupture risk of unruptured intracranial aneurysm in patients undergoing cardiovascular surgery. Adult patients (n = 4864) who underwent cardiovascular surgery between January 2010 and December 2016 were included. We assessed the prevalence of unruptured intracranial aneurysms in these patients using preoperative neurovascular imaging. The incidence of postoperative 30-day subarachnoid haemorrhage from aneurysmal rupture was investigated in patients undergoing cardiovascular surgery with unruptured intracranial aneurysm. Postoperative outcomes were compared between patients with unruptured intracranial aneurysm and those without unruptured intracranial aneurysm. Of the 4864 patients (39.6% females; mean ± standard deviation age, 62.3 ± 11.3 years), 353 patients had unruptured intracranial aneurysms (prevalence rate, 7.26%; 95% confidence interval, 6.52-8.06%). Of these, eight patients received surgical or endovascular treatment before surgery and 345 patients underwent cardiovascular surgery with unruptured intracranial aneurysms. Within 30 days postoperatively, subarachnoid haemorrhage occurred only in one patient, and the cumulative postoperative 30-day subarachnoid haemorrhage incidence was 0.29% (95% confidence interval, 0.01% to 1.61%). The Kaplan-Meier estimated subarachnoid haemorrhage probabilities according to the unruptured intracranial aneurysm rupture risk scores were not higher than the previously reported risk in the general population. There were no significant differences in postoperative subarachnoid haemorrhage-free survival, haemorrhagic stroke-free survival, in-hospital mortality, and hospital length of stay between patients with unruptured intracranial aneurysm and those without unruptured intracranial aneurysm. In conclusion, the prevalence of unruptured intracranial aneurysm in patients undergoing cardiovascular surgery is higher than in the general population. However, incidentally detected unruptured intracranial aneurysms are not linked to an increased risk of subarachnoid haemorrhage or adverse postoperative outcomes. These findings may help determine the optimal management of unruptured intracranial aneurysms before cardiovascular surgery.

Preoperative dexamethasone for acute post-thoracotomy analgesia: a randomized, double-blind, placebo-controlled study.

BACKGROUND: The analgesic effects of dexamethasone have been reported previously, and the present study determined the effects of preoperative dexamethasone on postoperative pain in patients who received thoracotomy. METHODS: Forty patients participated in this randomized, double-blind study. All patients received either dexamethasone via a 0.1 mg/kg intravenous bolus before anesthetic induction or an equal volume of saline. Postoperative analgesia was provided to both groups via epidural patient-controlled analgesia (PCA), which consisted of 250 µg of sufentanil in 250 mL of ropivacaine (0.18%) for 72 h. The primary outcome was the cumulative consumption of epidural PCA at postoperative 24 and 72 h. The secondary outcomes were the pain intensity scores during resting and coughing at postoperative 24 and 72 h, quality of recovery, total amount of rescue analgesics required, and length of hospital stay. RESULTS: No significant differences was observed in the consumption of epidural PCA between the control and dexamethasone infusion groups at 24 h (63.6 [55.9-72.7] vs. 68.5 [60.2-89.0] ml, P = 0.281) and 72 h (199.4 [172.4-225.1] vs. 194.7 [169.1-252.2] ml, P = 0.890). Moreover, there was no significant difference in the pain intensity scores during resting and coughing at postoperative 24 and 72 h, quality of recovery, total amount of rescue analgesics required, and length of hospital stay. CONCLUSION: A single intravenous administration of dexamethasone during the preoperative period does not reduce opioid consumption and post-thoracotomy pain. TRIAL REGISTRATION: The study was registered at http://cris.nih.go.kr ( KCT0000359 ) and was conducted from December 2011 to October 2012.

Comparison of postoperative acute kidney injury between ileal conduit and neobladder urinary diversions after radical cystectomy: A propensity score matching analysis.

Ileal conduit and neobladder urinary diversions are frequently performed after radical cystectomy. However, complications after radical cystectomy may be different according to the type of urinary diversion. Acute kidney injury (AKI) is a common complication after surgery and increases costs, morbidity, and mortality of hospitalized patients. This study was performed to compare the incidence of postoperative AKI between ileal conduit and neobladder urinary diversions after radical cystectomy.All consecutive patients who underwent radical cystectomy in 2004 to 2014 in a single tertiary care center were identified. The patients were divided into the ileal conduit and ileal neobladder groups. Preoperative variables, including demographics, cancer-related data and laboratory values, as well as intraoperative data and postoperative outcomes, including AKI, intensive care unit admission rate, and the duration of hospital stay, were evaluated between the groups. Postoperative AKI was defined according to the Kidney Disease: Improving Global Outcome criteria. Propensity score matching analysis was performed to reduce the influence of possible confounding variables and adjust for intergroup differences.After performing 1:1 propensity score matching, the ileal conduit and ileal neobladder groups each included 101 patients. The overall incidence of AKI after radical cystectomy was 30.7% (62 out of 202) and the incidences did not significantly differ between the groups (27 [26.7%], ileal conduit group vs 35 [34.7%], ileal neobladder group, P = 0.268). Intraoperative data, intensive care unit admission rate, and the duration of hospital stay were not significantly different between the groups.Postoperative AKI did not significantly differ between ileal conduit and neobladder urinary diversions after radical cystectomy. This finding provides additional information useful for appropriate selection of the urinary diversion type in conjunction with radical cystectomy.

The effect of coronary angiography timing and use of cardiopulmonary bypass on acute kidney injury after coronary artery bypass graft surgery.

OBJECTIVE: Acute kidney injury is a common but serious complication of coronary artery bypass grafting. We investigated whether the effect of the timing of coronary angiography on acute kidney injury after coronary artery bypass grafting is influenced by the use of cardiopulmonary bypass. METHODS: We included, retrospectively, 2371 patients who underwent coronary artery bypass grafting whether cardiopulmonary bypass was used (on-pump coronary artery bypass) or not (off-pump coronary artery bypass). Postoperative acute kidney injury was defined by the consensus Kidney Disease: Improving Global Outcomes Definition and Staging criteria. Multivariate logistic regression and propensity score analysis were performed to evaluate the association of the time interval between coronary angiography and coronary artery bypass grafting with postoperative acute kidney injury. RESULTS: The incidence of acute kidney injury was higher in patients who underwent coronary angiography 7 days or less before coronary artery bypass grafting than in those who underwent it more than 7 days before coronary artery bypass grafting (42.7% vs 38.5%, P = .037). There was significant interaction between the timing of coronary angiography and the use of cardiopulmonary bypass for postoperative acute kidney injury (P = .019). The time interval between coronary angiography and surgery was independently associated with postoperative acute kidney injury in patients undergoing on-pump coronary artery bypass only. In an adjusted propensity score model, coronary angiography within 7 days of on-pump coronary artery bypass was a predictor of postoperative acute kidney injury (odds ratio, 1.742; 95% confidence interval, 1.144-2.653; P = .010). CONCLUSIONS: A shorter interval between coronary angiography and surgery influenced the occurrence of acute kidney injury in patients undergoing on-pump coronary artery bypass. However, the interval is not an independent risk factor for the development of postoperative acute kidney injury in patients who undergo off-pump coronary artery bypass.

Relationship between Serum Uric Acid Concentration and Acute Kidney Injury after Coronary Artery Bypass Surgery.

An elevated serum concentration of uric acid may be associated with an increased risk of acute kidney injury (AKI). The aim of this study was to investigate the impact of preoperative uric acid concentration on the risk of AKI after coronary artery bypass surgery (CABG). Perioperative data were evaluated from patients who underwent CABG. AKI was defined by the AKI Network criteria based on serum creatinine changes within the first 48 hr after CABG. Multivariate logistic regression was utilized to evaluate the association between preoperative uric acid and postoperative AKI. We evaluated changes in C statistic, the net reclassification improvement, and the integrated discrimination improvement to determine whether the addition of preoperative uric acid improved prediction of AKI. Of the 2,185 patients, 787 (36.0%) developed AKI. Preoperative uric acid was significantly associated with postoperative AKI (odds ratio, 1.18; 95% confidence interval, 1.10-1.26; P<0.001). Adding uric acid levels improved the C statistic and had significant impact on risk reclassification and integrated discrimination for AKI. Preoperative uric acid is related to postoperative AKI and improves the predictive ability of AKI. This finding suggests that preoperative measurement of uric acid may help stratify risks for AKI in in patients undergoing CABG.

Relationship between a perioperative intravenous fluid administration strategy and acute kidney injury following off-pump coronary artery bypass surgery: an observational study.

INTRODUCTION: Saline-based and hydroxyethyl starch solutions are associated with increased risk of renal dysfunction. In the present study, we tested the hypothesis that balanced solutions and a limited volume of hydroxyethyl starch solution (renal protective fluid management [RPF] strategy) would decrease the incidence of postoperative acute kidney injury (AKI) and improve clinical outcomes in patients undergoing off-pump coronary artery bypass graft surgery (OPCAB). METHODS: We investigated 783 patients who underwent elective OPCAB. All patients who underwent OPCAB between 1 January 2010 and 4 July 2012 formed the control group and were given intravenous fluids with saline-based solutions and unlimited volumes of colloid solutions. All patients who underwent OPCAB between 5 July 2012 and 31 December 2013 formed the RPF group and were given intravenous fluids with RPF. The primary outcome was the incidence of postoperative AKI. Secondary outcomes included the incidence of severe AKI, requirement for renal replacement therapy, renal outcome at the time of discharge, and other clinical outcomes. RESULTS: Postoperative AKI occurred in 33 patients (14.4 %) in the RPF group compared with 210 patients (37.9 %) in the control group (P < 0.001). The incidences of severe AKI and persistent AKI after OPCAB were significantly lower, and the postoperative extubation time and duration of hospital stay were significantly shorter, in patients in the RPF group than in those in the control group. After adjustment by multivariate regression analyses and inverse probability of treatment weighting adjustment, the RPF group was independently associated with a lower incidence of postoperative AKI, severe AKI, and persistent AKI and a shorter postoperative extubation time and duration of hospital stay. CONCLUSIONS: The RPF strategy is associated with a significantly decreased incidence of postoperative, severe, and persistent AKI in patients undergoing OPCAB, although residual confounding may be present.

Comparative Effects of Dexmedetomidine and Propofol on US-Guided Radiofrequency Ablation of Hepatic Neoplasm Under Monitored Anesthesia Care: A Randomized Controlled Study.

Percutaneous radiofrequency ablation (RFA) is a useful and safe procedure for treating hepatic neoplasm. However, liver RFA causes severe pain, which thereby increases the demand for monitored anesthesia care (MAC). Here, we compared the efficacy and safety of propofol and dexmedetomidine, which are commonly administered during MAC when performing RFA to assess hepatic neoplasm.In this randomized controlled trial, 40 patients were randomly allocated to 2 groups for elective RFA. Patients received either dexmedetomidine (group D) or propofol (group P). Both groups received the continuous infusion of remifentanil for pain control. The primary outcomes were opioid consumption and differences in partial pressure of arterial carbon dioxide (PaCO2) between pre- and postprocedure RFA. In addition, hemodynamic parameters, patient satisfaction, and interventional radiologist satisfaction were determined.There were significant differences in opioid consumption (50.1 ±â€Š16.8 ng/kg/min [group D] vs 71.2 ±â€Š18.7 ng/kg/min [group P]; P = 0.001) and delta PaCO2 (10.4 ±â€Š6.4 mm Hg vs 17.2 ±â€Š9.2 mm Hg, respectively; P = 0.016). Moreover, respiratory rates were significantly different between groups during RFA (P < 0.001). However, blood pressure and heart rate did not significantly change during RFA. Neither patient nor interventional radiologist satisfaction was significantly different between groups.Dexmedetomidine provides better respiratory stability and reduces opioid consumption in comparison with propofol when administered under MAC when performing RFA for hepatic neoplasm.

Incidence and Risk Factors of Acute Kidney Injury after Radical Cystectomy: Importance of Preoperative Serum Uric Acid Level.

BACKGROUND: Acute kidney injury (AKI) is a common complication after surgery and increases costs, morbidity, and mortality of hospitalized patients. While radical cystectomy associates significantly with an increased risk of serious complications, including AKI, risk factors of AKI after radical cystectomy has not been reported. This study was performed to determine the incidence and independent predictors of AKI after radical cystectomy. METHODS: All consecutive patients who underwent radical cystectomy in 2001-2013 in a single tertiary-care center were identified. Their demographics, laboratory values, and intraoperative data were recorded. Postoperative AKI was defined and staged according to the Acute Kidney Injury Network criteria on the basis of postoperative changes in creatinine levels. Independent predictors of AKI were identified by univariate and multivariate logistic regression analyses. RESULTS: Of the 238 patients who met the eligibility criteria, 91 (38.2%) developed AKI. Univariate logistic regression analyses showed that male gender, high serum uric acid level, and long operation time associated with the development of AKI. On multivariate logistic regression analysis, preoperative serum uric acid concentration (odds ratio [OR] = 1.251; 95% confidence interval [CI] = 1.048-1.493; P = 0.013) and operation time (OR = 1.005; 95% CI = 1.002-1.008; P = 0.003) remained as independent predictors of AKI after radical cystectomy. CONCLUSIONS: AKI after radical cystectomy was a relatively common complication. Its independent risk factors were high preoperative serum uric acid concentration and long operation time. These observations can help to prevent AKI after radical cystectomy.

Association of preoperative uric acid and acute kidney injury following cardiovascular surgery.

OBJECTIVE: Recent studies suggested that elevated serum uric acid levels may be associated with the risk of acute kidney injury (AKI) in several settings. However, the effect of uric acid on the risk of AKI after cardiovascular surgery remains uncertain. DESIGN: A retrospective analysis. SETTING: A tertiary care university hospital. PARTICIPANTS: All consecutive adult patients (n = 1,019) who underwent cardiovascular surgery between January 2011 and May 2012. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Preoperative and perioperative data were assessed in the study population. AKI was defined and staged as serum creatinine concentration-based Acute Kidney Injury Network criteria. Univariate and multivariate logistic regression analyses were conducted to evaluate the association between preoperative uric acid and postoperative AKI. Preoperative elevated uric acid (≥ 6.5 mg/dL) was associated independently with AKI after cardiovascular surgery (odds ratio 1.46; 95% confidence interval 1.04-2.06, p = 0.030). Results were the same in subgroup analyses. Preoperative elevated uric acid (≥ 6.5 mg/dL) also was associated with a higher incidence of prolonged ICU and hospital stay. CONCLUSIONS: Preoperative elevated serum uric acid is an independent risk factor for AKI in patients undergoing cardiovascular surgery. This finding suggests that preoperative measurements of serum uric acid concentration may help stratify risks for AKI in these patients.

Monitored anesthesia care with dexmedetomidine in transfemoral percutaneous trans-catheter aortic valve implantation: two cases report.

Percutaneous trans-catheter aortic valve implantation (TAVI) is recommended for inoperable patients with severe aortic stenosis at high risk for conventional aortic valve replacement. Originally, TAVI was mostly performed under general anesthesia. Here we describe two cases of transfemoral TAVI performed under monitored anesthesia care (MAC) with dexmedetomidine. Dexmedetomidine provides sedation, analgesia with minimal respiratory depression. Although MAC during transfemoral TAVI has limitations, such as unexpected patient movement and difficulty in intra-procedural use of transesophageal echocardiography, MAC with dexmedetomidine is feasible with close monitoring, fluoroscopic guidance and the participation of experienced anesthesiologists.

Effect of remote ischemic preconditioning on cognitive function after off-pump coronary artery bypass graft: a pilot study.

BACKGROUND: Several studies have shown in animal models that remote ischemic preconditioning (rIPC) has a neuroprotective effect. However, a randomized controlled trial in human subjects to investigate the neuroprotective effect of rIPC after cardiac surgery has not yet been reported. Therefore, we performed this pilot study to determine whether rIPC reduced the occurrence of postoperative cognitive dysfunction in patients who underwent off-pump coronary artery bypass graft (OPCAB) surgery. METHODS: Seventy patients who underwent OPCAB surgery were assigned to either the control or the rIPC group using a computer-generated randomization table. The application of rIPC consisted of four cycles of 5 min ischemia and 5 min reperfusion on an upper limb using a blood pressure cuff inflating 200 mmHg before coronary artery anastomosis. The cognitive function tests were performed one day before surgery and again on postoperative day 7. We defined postoperative cognitive dysfunction as decreased postoperative test values more than 20% of the baseline values in more than two of the six cognitive function tests that were performed. RESULTS: In the cognitive function tests, there were no significant differences in the results obtained during the preoperative and postoperative periods for all tests and there were no mean differences observed in the preoperative and postoperative scores. The incidences of postoperative cognitive dysfunction in the control and rIPC groups were 28.6% (10 patients) and 31.4% (11 patients), respectively. CONCLUSIONS: rIPC did not reduce the incidence of postoperative cognitive dysfunction after OPCAB surgery during the immediate postoperative period.

Impact of the time of coronary angiography on acute kidney injury after elective off-pump coronary artery bypass surgery.

BACKGROUND: Previous studies have suggested that early surgery after coronary angiography may be associated with the risk of acute kidney injury (AKI) in cardiac surgery with cardiopulmonary bypass. However, the effect of coronary angiography on the risk of AKI after off-pump coronary artery bypass graft surgery (OPCABG) remains uncertain. METHODS: We assessed preoperative and perioperative data in 1,364 consecutive adult patients who underwent elective OPCABG surgery after coronary angiography. Acute kidney injury was defined by Acute Kidney Injury Network criteria based on changes in serum creatinine within the first 48 hours after OPCABG. Multivariable logistic regression was performed to evaluate the association of the time interval between coronary angiography and OPCABG with postoperative AKI. RESULTS: Acute kidney injury occurred in 391 patients (28.7%). The unadjusted and adjusted rates of AKI according to the length of time between coronary angiogram and OPCABG did not show any increasing or decreasing trend (p = 0.86 and p = 0.33 for trends of unadjusted and adjusted AKI rates, respectively), and early OPCABG after coronary angiography was not related to postoperative AKI. Results were the same in high-risk patients with preoperative renal insufficiency, low ejection fraction, or who received an ionic contrast agent or a high dose of contrast agent. CONCLUSIONS: The risk of postoperative AKI was not related to the time between coronary angiography and OPCABG. These findings suggest that delaying elective OPCABG after coronary angiography owing to the sole concern for renal function may be unnecessary.