Enabling urban systems transformations: co-developing national and local strategies.

Transformative urban development is urgent to achieve future sustainable development and wellbeing. Transformation can benefit from shared and cumulative learning on strategies to guide urban development across local to national scales, while also reflecting the complex emergent nature of urban systems, and the need for context-specific and place-based solutions. The article addresses this challenge, drawing on extensive transdisciplinary engagement and National Strategy co-development processes for Australia. This includes generation of two frameworks as boundary objects to assist such transdisciplinary strategy development. An 'enabling urban systems transformation' framework comprises four generic overarching transformation enablers and a set of necessary underpinning urban capacities. This also built cumulatively on other sustainability and urban transformation studies. A complementary 'knowledge for urban systems transformation' framework comprises key knowledge themes that can support an integrated systems approach to mission-focused urban transformations, such as decarbonising cities. The article provides insights on the transdisciplinary processes, urban systems frameworks, and scoping of key strategies that may help those developing transformation strategies from local to national scales. Science highlights • Transdisciplinary national urban strategy development is used to distil generic frameworks and strategy scopes with potential international application. • The frameworks also build on other published framings to support convergent, cumulative and transdisciplinary urban science. • The 'enabling transformations' and 'urban knowledge' frameworks include the perspective of those developing sustainable urban systems strategies. • The enabling framework also informs 'National Urban Policy' and 'Knowledge and Innovation Hub' strategies, and prevailing power imbalances. • The knowledge framework can help frame urban challenges, missions and knowledge programs. Policy and practice recommendations • An urban 'transformation imperative' and 'strategic response' can be co-developed from local to national scales. • Local initiative is crucial to drive urban strategies, but sustained national leadership with coherent policy across sectors and scales is also key. • Diversity in engagement participation and processes generates whole-of-urban-systems and local-to-national perspectives. • Urban solutions are context-specific but generic frameworks can help collaborative issue framing and responses. • Collaborative issue framing informed by generic frameworks can bring broader perspectives to context-specific and contested policy and practice issues. Supplementary Information: The online version contains supplementary material available at 10.1186/s42854-023-00049-9.

Evolution of Accredited Pediatric Cardiac Anesthesiology Fellowship Training in the United States: A Step in the Right Direction.

Pediatric cardiac anesthesiology has developed as a subsubspecialty of anesthesiology over the past 70 years. The evolution of this specialty has led to the establishment in 2005 of a dedicated professional society, the Congenital Cardiac Anesthesia Society (CCAS). By 2010, multiple training pathways for pediatric cardiac anesthesia emerged. Eight programs in the United States offered advanced pediatric cardiac anesthesia with variable duration, ranging from 3 to 12 months. Other programs offered a combined fellow/staff position for 1 year. The need for a standardized training pathway was recognized by the Pediatric Anesthesia Leadership Council (PALC) and CCAS in 2014. Specifically, it was recommended that pediatric cardiac anesthesiology be a second, 12-month advanced fellowship following pediatric anesthesia to acquire skills unique from those acquired during a pediatric anesthesia fellowship. This was reiterated in 2018, when specific pediatric cardiac anesthesia training milestones were developed through consensus by the CCAS leadership. However, given the continuous increasing demand for well-trained pediatric cardiac anesthesiologists, it is essential that a supply of comprehensively trained physicians exists. High-quality training programs are therefore necessary to ensure excellent clinical care and enhanced patient safety. Currently, there are 23 programs offering one or more positions for 1-year pediatric cardiac anesthesia fellowship. Due to the diverse curriculum and evaluation process, formalization of the training with accreditation through the Accreditation Council for Graduate Medical Education (ACGME) was the obvious next step. Initial inquiry started in April 2020. The ACGME recognized pediatric cardiac anesthesia as a subsubspecialty in February 2021. The program requirements and milestones for the 1-year fellowship training were developed in 2021 and 2022. This special article reviews the history of pediatric cardiac anesthesia training, the ACGME application process, the development of program requirements and milestones, and implementation.

Effectiveness of Simulation- Versus Didactic Video-Based Learning to Teach Advanced Lung Isolation Techniques.

OBJECTIVES: Mastery of lung isolation is crucial for optimal cardiothoracic anesthesia education. The authors tested the hypothesis that simulation- is more effective than didactic video-based learning (cognitive, affective, and psychomotor) to teach anesthesiology fellows advanced lung isolation techniques. DESIGN: A prospective randomized study. SETTING: At a single academic heart center, simulation laboratory. PARTICIPANTS: Thirty anesthesiology fellows with equivalent prior experience in basic lung isolation techniques. INTERVENTIONS: Randomized participants received 1 of 2 structured educational interventions of equivalent duration designed to teach advanced lung isolation skills, a simulation workshop, or a video-based didactic session. MEASUREMENTS AND MAIN RESULTS: To assess Bloom's taxonomy domains, performance measurements included pre- and postintervention cognitive tests and affective surveys and a postintervention psychomotor task (time to complete lung isolation). Changes in test and survey scores and time to completion were compared using the Mann-Whitney U test; p values < 0.05 were considered significant. Improvements in lung isolation learning assessments were greater in the simulation group, but significant differences only existed in the affective domain. Specifically, affective survey score increases were greater in the simulation group (simulation- versus video-based didactic: +19.0 v +4.0; p ≤ 0.001), whereas there was no significant difference in cognitive pre- to posttest scores (simulation- versus video-based: +28.6 v +19.1, p = 0.23), and time to achieve lung isolation (simulation- versus video-based: 32 v 36 seconds, p = 0.46). CONCLUSIONS: Although greater affective learning of advanced lung isolation skills occurred with simulation-based compared to didactic video-based education, the authors found no differences between the teaching approaches in cognitive and psychomotor learning among anesthesiology fellows.

Identification of Trajectory-Based Acute Kidney Injury Phenotypes Among Cardiac Surgery Patients.

BACKGROUND: Acute kidney injury (AKI) is a common and serious complication of cardiac surgical procedures for which unrecognized heterogeneity may underpin poor success in identifying effective therapies. We aimed to identify phenotypically similar groups of patients as defined by their postoperative creatinine trajectories. METHODS: This was a retrospective, single-center cohort study in an academic tertiary care center including patients undergoing coronary artery bypass graft procedures. AKI phenotypes were evaluated through latent class mixed modeling of serum creatinine patterns (trajectories). To identify trajectory phenotypes, modeling was performed using postoperative creatinine values from 50% of patients (development cohort) and for comparison similarly conducted for the remaining sample (validation cohort). Subsequent assessments included comparisons of classes between development and validation cohorts for consistency and stability, and among classes for patient and procedural characteristics, complications, and long-term survival. RESULTS: We identified 12 AKI trajectories in both the development (n = 2647) and validation cohorts (n = 2647). Discrimination among classes was good (mean posterior class membership probability, 66%-88%), with differences in rate, timing, and degree of serum creatinine rise/fall, and recovery. In matched class comparisons between cohorts, many other phenotypic similarities were present. Notably, 4 high-risk phenotypes had greater long-term risk for death relative to lower risk classes. CONCLUSIONS: Latent class mixed modeling identified 12 reproducible AKI classes (serum creatinine trajectory phenotypes), including 4 with higher risk of poor outcome, in patients following coronary artery bypass graft procedures. Such hidden structure offers a novel approach to grouping patients for renoprotection investigations in addition to reanalysis of previously conducted trials.

Renal-Resistive Index for Prediction of Acute Kidney Injury in the Setting of Aortic Insufficiency.

Acute kidney injury (AKI) is a common postoperative complication after cardiac surgery with cardiopulmonary bypass (CPB), and leads to significant morbidity, mortality, and cost. Although early recognition and management of AKI may reduce the burden of renal disease, reliance on serum creatinine accumulation to confidently diagnose it leads to a significant and important delay (up to 48 hours). Hence, a search for earlier AKI biomarkers is warranted. The renal-resistive index (RRI) is a promising early AKI biomarker that reflects intrarenal arterial pulsatility as reflected by the peak systolic and end-diastolic blood velocities divided by the peak systolic velocity. During cardiac surgery, post-CPB elevation of RRI is correlated with renal injury. The RRI is influenced by intrarenal and extrarenal factors, as well as different hemodynamic states. Understanding its limitations may increase its usefulness as an early AKI biomarker. For example, tachycardia or aortic stenosis typically results in a lower RRI, whereas bradycardia or increased systemic pulse pressure (as seen with aortic insufficiency) are associated with a higher RRI, unrelated to any intrarenal effects. In this E-Challenge, the authors present two cases in which the RRI was used to evaluate a patient's risk of developing AKI.

Sex and race differences of cerebrospinal fluid metabolites in healthy individuals.

INTRODUCTION: Analyses of cerebrospinal fluid (CSF) metabolites in large, healthy samples have been limited and potential demographic moderators of brain metabolism are largely unknown. OBJECTIVE: Our objective in this study was to examine sex and race differences in 33 CSF metabolites within a sample of 129 healthy individuals (37 African American women, 29 white women, 38 African American men, and 25 white men). METHODS: CSF metabolites were measured with a targeted electrochemistry-based metabolomics platform. Sex and race differences were quantified with both univariate and multivariate analyses. Type I error was controlled for by using a Bonferroni adjustment (0.05/33 = .0015). RESULTS: Multivariate Canonical Variate Analysis (CVA) of the 33 metabolites showed correct classification of sex at an average rate of 80.6% and correct classification of race at an average rate of 88.4%. Univariate analyses revealed that men had significantly higher concentrations of cysteine (p < 0.0001), uric acid (p < 0.0001), and N-acetylserotonin (p = 0.049), while women had significantly higher concentrations of 5-hydroxyindoleacetic acid (5-HIAA) (p = 0.001). African American participants had significantly higher concentrations of 3-hydroxykynurenine (p = 0.018), while white participants had significantly higher concentrations of kynurenine (p < 0.0001), indoleacetic acid (p < 0.0001), xanthine (p = 0.001), alpha-tocopherol (p = 0.007), cysteine (p = 0.029), melatonin (p = 0.036), and 7-methylxanthine (p = 0.037). After the Bonferroni adjustment, the effects for cysteine, uric acid, and 5-HIAA were still significant from the analysis of sex differences and kynurenine and indoleacetic acid were still significant from the analysis of race differences. CONCLUSION: Several of the metabolites assayed in this study have been associated with mental health disorders and neurological diseases. Our data provide some novel information regarding normal variations by sex and race in CSF metabolite levels within the tryptophan, tyrosine and purine pathways, which may help to enhance our understanding of mechanisms underlying sex and race differences and potentially prove useful in the future treatment of disease.

Conventional Ultrafiltration During Elective Cardiac Surgery and Postoperative Acute Kidney Injury.

OBJECTIVE: Conventional ultrafiltration (CUF) during cardiopulmonary bypass (CPB) serves to hemoconcentrate blood volume to avoid allogeneic blood transfusions. Previous studies have determined CUF volumes as a continuous variable are associated with postoperative acute kidney injury (AKI) after cardiac surgery, but optimal weight-indexed volumes that predict AKI have not been described. DESIGN: Retrospective cohort. SETTING: Single-center university hospital. PARTICIPANTS: A total of 1,641 consecutive patients who underwent elective cardiac surgery between June 2013 and December 2015. INTERVENTIONS: The CUF volume was removed during CPB in all participants as part of routine practice. The authors investigated the association of dichotomized weight-indexed CUF volume removal with postoperative AKI development to provide pragmatic guidance for clinical practice at the authors' institution. MEASUREMENTS AND MAIN RESULTS: Primary outcomes of postoperative AKI were defined by the Kidney Disease: Improving Global Outcomes staging criteria and dichotomized, weight-indexed CUF volumes (mL/kg) were defined by (1) extreme quartiles (Q3) and (2) Youden's criterion that best predicted AKI development. Multivariate logistic regression models were developed to test the association of these dichotomized indices with AKI status. Postoperative AKI occurred in 827 patients (50.4%). Higher CUF volumes were associated with AKI development by quartiles (CUF >Q3 = 32.6 v CUF < Q1 = 10.4 mL/kg; odds ratio [OR] = 1.68, 95% CI: 1.19-2.3) and Youden's criterion (CUF ≥ 32.9 v CUF <32.9 mL/kg; OR = 1.60, 95% CI: 1.21-2.13). Despite similar intraoperative nadir hematocrits among groups (p = 0.8), higher CUF volumes were associated with more allogeneic blood transfusions (p = 0.002) and longer lengths of stay (p < 0.001). CONCLUSIONS: Removal of weight-indexed CUF volumes > 32 mL/kg increased the risk for postoperative AKI development. Importantly, CUF volume removal of any amount did not mitigate allogeneic blood transfusion during elective cardiac surgery. Prospective studies are needed to validate these findings.

Association between levosimendan, postoperative AKI, and mortality in cardiac surgery: Insights from the LEVO-CTS trial.

OBJECTIVES: We aimed to evaluate the association between levosimendan treatment and acute kidney injury (AKI) as well as assess the clinical sequelae of AKI in cardiac surgery patients with depressed left ventricular function (ejection fraction <35%). METHODS: Patients in the LEVO-CTS trial undergoing on-pump coronary artery bypass grafting (CABG), valve, or CABG/valve surgery were stratified by occurrence and severity of postoperative AKI using the AKIN classification. The association between levosimendan infusion and AKI was modeled using multivariable regression. RESULTS: Among 854 LEVO-CTS patients, 231 (27.0%) experienced postoperative AKI, including 182 (21.3%) with stage 1, 35 (4.1%) with stage 2, and 14 (1.6%) with stage 3 AKI. The rate of AKI was similar between patients receiving levosimendan or placebo. The odds of 30-day mortality significantly increased by AKI stage compared to those without AKI (stage 1: adjusted odds ratio [aOR] 2.0, 95% confidence interval [CI] 0.8-4.9; stage 2: aOR 9.1, 95% CI 3.2-25.7; stage 3: aOR 12.4, 95% CI 3.0-50.4). No association was observed between levosimendan, AKI stage, and odds of 30-day mortality (interaction P = .69). Factors independently associated with AKI included increasing age, body mass index, diabetes, and increasing baseline systolic blood pressure. Increasing baseline eGFR and aldosterone antagonist use were associated with a lower risk of AKI. CONCLUSIONS: Postoperative AKI is common among high-risk patients undergoing cardiac surgery and associated with significantly increased risk of 30-day death or dialysis. Levosimendan was not associated with the risk of AKI.

Use of weather and climate information essential for SDG implementation.

Owing to a lack of understanding, and data being unavailable, unusable or unsuitable, weather and climate information is currently underutilized in Sustainable Development Goal implementation. Improvements are essential in knowledge brokering, clarifying responsibilities, multi-institutional and multi-stakeholder governance arrangements and research on systemic risks and decisions.

Unplanned hospital admission after ambulatory surgery: a retrospective, single cohort study.

PURPOSE: We estimated the rate of unplanned hospital and intensive care unit (ICU) admissions following ambulatory surgery centre (ASC) procedures, and identified factors associated with their occurrence. METHODS: This retrospective cohort included adult patients who underwent ASC procedures within a large community practice from January 2010 to December 2014. Patients were categorized into two groups: unplanned postoperative hospital/ICU admission within 24 hr of procedure or uneventful discharge. Demographics, comorbidities, anesthesia type, procedure type, procedure group, and ASC facility were assessed. RESULTS: Of the 211,389 patients included, there were 211,147 uneventful discharges (99.89%) and 242 unplanned hospital admissions (0.11%), of which 75 were ICU admissions (0.04%). The multivariable logistic regression model for hospital admission showed an increased risk associated with age > 50 yr (odds ratio [OR], 1.53); American Society of Anesthesiologists (ASA) physical status (III vs II: OR, 1.45; IV vs II: OR, 1.88), comorbidity (chronic obstructive pulmonary disease: OR, 2.63; diabetes mellitus: OR, 1.62; transient ischemic attack: OR, 2.48) procedure (respiratory: OR, 2.92; digestive: OR, 2.66; musculoskeletal system: OR, 2.53), anesthetic management (general anesthesia [GA] and peripheral nerve block vs GA: OR, 1.79), and ASC facility (189BB: OR, 2.29; 30E9A: OR, 7.41; and BD21F: OR, 1.69). The multivariable logistic regression model for ICU admission showed increased risk of unplanned ICU admission associated with ASA physical status (ASA III vs II: OR, 3.0; ASA IV vs II: OR, 8.52), procedure (musculoskeletal system: OR, 2.45), and ASC facility (00E6C: OR, 3.14; 189BB: OR, 2.77; 30E9A: OR, 2.59; and BD21F: OR, 3.71). CONCLUSION: While a small percentage of adult patients who underwent ASC procedures required unplanned hospital admission (0.07%), approximately one-third of these admissions were to the ICU (0.04%). Facility was at least as strong a predictor of hospital admission as the patient- and/or procedure-specific variables.

RéSUMé: OBJECTIF: Nous avons estimé le taux d'admissions non planifiées à l'hôpital et à l'unité de soins intensifs (USI) après des interventions dans des centres de chirurgie ambulatoire (CCA), et identifié les facteurs associés à leur survenue. MéTHODE: Cette étude de cohorte rétrospective a porté sur des patients adultes ayant subi une intervention dans un CCA appartenant à une grande pratique communautaire entre janvier 2010 et décembre 2014. Les patients ont été catégorisés en deux groupes : admission postopératoire non planifiée à l'hôpital/USI dans les 24 h suivant l'intervention ou congé sans incident. Les données démographiques, les comorbidités, le type d'anesthésie, le type d'intervention, le groupe d'intervention et l'établissement de CCA ont été évalués. RéSULTATS: Parmi les 211 389 patients inclus, il y a eu 211 147 congés sans incident (99,89 %) et 242 admissions non planifiées à l'hôpital (0,11 %), 75 desquelles étaient des admissions à l'USI (0,04 %). Le modèle de régression logistique multivariée des admissions hospitalières a montré un risque accru associé à un âge > 50 ans (rapport de cotes [RC], 1,53); au statut physique ASA (American Society of Anesthesiologists) (III vs II : RC, 1,45; IV vs II : RC, 1,88), aux comorbidités (maladie pulmonaire obstructive chronique : RC, 2,63; diabète: RC, 1,62; accident ischémique transitoire : RC, 2,48); à l'intervention (respiratoire : RC, 2,92; digestive : RC, 2,66; appareil locomoteur : RC, 2,53); à la prise en charge anesthésique (anesthésie générale [AG] et bloc nerveux périphérique vs AG : RC, 1,79) et établissement de CCA (189BB : RC, 2,29; 30E9A : RC, 7,41; et BD21F : RC, 1,69). Le modèle de régression logistique multivariée des admissions à l'USI a montré un risque accru d'admission non planifiée à l'USI associé au statut physique ASA (ASA III vs II: RC, 3,0; ASA IV vs II: RC, 8,52), à l'intervention (appareil locomoteur : RC, 2,45), et à l'établissement de CCA (00E6C: RC, 3,14; 189BB: RC, 2,77; 30E9A: RC, 2,59; et BD21F: RC, 3,71). CONCLUSION: Alors qu'un faible pourcentage de patients adultes ayant subi des interventions en CCA ont nécessité une admission non planifiée à l'hôpital (0,11 %), environ un tiers de ces admissions étaient à l'USI (0,04 %). L'établissement était un prédicteur au moins aussi puissant d'admission à l'hôpital que les variables spécifiques au patient et/ou à l'intervention.

Apolipoprotein L1 (APOL1) Coding Variants Are Associated With Creatinine Rise After Cardiac Surgery.

OBJECTIVE: Acute kidney injury (AKI) is a complication of cardiac surgery that is considerably more common in African Americans (1.5-fold). Although homozygous status for apolipoprotein L1 (APOL1) risk alleles is associated with chronic kidney disease in individuals of African ancestry, whether these coding variants confer AKI risk is unknown. The present study examined whether APOL1 homozygous risk allele status was associated with AKI in African Americans after cardiac surgery. DESIGN: Retrospective analysis of a cohort. SETTING: Single-center university hospital. PARTICIPANTS: African American patients from the CATHeterization GENetics study cohort who underwent cardiac surgery with cardiopulmonary bypass. INTERVENTIONS: Genotyping of APOL1 alleles. MEASUREMENTS AND MAIN RESULTS: Data from 125 African American patients included 12 APOL1 risk (ie, homozygous for risk alleles) patients and 113 APOL1 control (ie, wildtype or heterozygous for risk alleles) patients. The primary outcome to reflect AKI was peak serum creatinine rise after surgery relative to the preoperative creatinine (%ΔCr). The secondary outcome was Kidney Disease: Improving Global Outcomes (KDIGO) AKI criteria. In the primary analysis, peak creatinine rise was higher in risk compared with control patients in both univariate (%ΔCr 69.1 v 29.6%; p = 0.005) and multivariate regression (%ΔCr 88.5 v 43.7%; p = 0.006) analyses. For the secondary outcome, a trend toward KDIGO AKI development was noted in APOL1 risk patients, but this was not statistically significant. CONCLUSIONS: African American cardiac surgery patients homozygous for APOL1 chronic kidney disease risk variants averaged a more than 2-fold higher postoperative creatinine rise even after adjustment for other risk factors, suggesting these alleles also are independent risk factors for AKI.

Association between primary graft dysfunction and acute kidney injury after orthotopic heart transplantation - a retrospective, observational cohort study.

Acute kidney injury (AKI) and primary graft dysfunction (PGD) are serious complications after heart transplantation (HT). The relationship between AKI and PGD is poorly understood. We sought to examine the incidence of AKI and identify risk factors associated with AKI. We hypothesized that PGD is one of the risk factors independently associated with post-HT AKI. We gathered data for all adult patients who underwent HT between 2009 and 2014. AKI was defined by the KDIGO criteria. PGD was categorized using ISHLT criteria. We assessed univariable and multivariable logistic regression to identify risk factors independently associated with post-HT AKI. Out of 316 patients, postoperative AKI occurred in 273 (86%) patients: 188 (68%) stage I, 44 (16%) stage II, and 41 (15%) stage III. Stage II/III AKI was associated with increased risk of mortality at 1 year. There was significant association between severe PGD and stage II/III AKI (P = 0.001, OR 3.63, 95% CI: 1.69-7.94). Other clinical factors significantly associated with stage II/III AKI included longer donor brain death duration and lower recipient baseline creatinine. We found that stage II/III AKI is common and independently associated with severe PGD. Another potentially modifiable risk factor is donor brain death duration.

Transforming Sustainability Science to Generate Positive Social and Environmental Change Globally.

Despite the decades-long efforts of sustainability science and related policy and action programs, humanity has not gotten closer to global sustainability. With its focus on the natural sciences, sustainability science is not able to contribute sufficiently to the global transition to sustainability. This Perspective argues for transforming sustainability science into a transdisciplinary enterprise that can generate positive social and environmental change globally. In such transformation, the social sciences, humanities, and the arts can play an important role to address the complex problems of culture, institutions, and human behavior. To realize a truly integrated sustainability science, we need renewed research and public policies that reshape the research ecosystem of universities, funding agencies, science communications, policymaking, and decision making. Sustainability science must also engage with society and creatively employ all available sources of knowledge in favor of creating a sustainable Earth.

Intraoperative renal resistive index threshold as an acute kidney injury biomarker.

STUDY OBJECTIVE: The lag in creatinine-mediated diagnosis of cardiac surgery-associated acute kidney injury (AKI) may be impeding the development of renoprotection therapies. Postoperative renal resistive index (RRI) measured by transabdominal Doppler ultrasound is a promising early AKI biomarker. RRI measured intraoperatively by transesophageal echocardiography (TEE) is available even earlier but is less evaluated. Therefore, we conducted an assessment of intraoperative RRI as an AKI biomarker using previously reported post-renal insult thresholds. DESIGN: Retrospective convenience sample. SETTING: Intraoperative. PATIENTS: 180 adult cardiac surgical patients between July 2013 and July 2014. INTERVENTION: None. MEASUREMENTS: Pre- and post-cardiopulmonary bypass (CPB) RRI thresholds, measured using intraoperative TEE, exceeding 0.74 or 0.79 were used to evaluate for an association with KDIGO AKI risk using the Chi-square test. Other consensus AKI criteria (AKIN, RIFLE) were similarly evaluated. Additional t-test analyses examined the relationship of pre- and pre-to-post (delta) CPB RRI with AKI. MAIN RESULTS: Post-CPB RRI for 99 patients included 36 and 23 with values exceeding 0.74 and 0.79, respectively. Analyses confirmed associations of both RRI thresholds with all consensus AKI definitions (0.74; KDIGO: p = 0.05, AKIN: p = 0.03, RIFLE: p = 0.03, 0.79; KDIGO: p = 0.002, AKIN: p = 0.001, RIFLE: p = 0.004). In contrast, pre-CPB and pre-to post-CPB RRI were not associated with AKI. CONCLUSIONS: RRI obtained intraoperatively in cardiac surgery patients, assessed using previously reported thresholds, is highly associated with AKI and warrants further evaluation as a promising "earliest" AKI biomarker. These significant findings suggest that RRI assessment should be included in the standard intraoperative TEE exam.

Intravenous Lidocaine Does Not Improve Neurologic Outcomes after Cardiac Surgery: A Randomized Controlled Trial.

BACKGROUND: Cognitive decline after cardiac surgery occurs frequently and persists in a significant proportion of patients. Preclinical studies and human trials suggest that intravenous lidocaine may confer protection in the setting of neurologic injury. It was hypothesized that lidocaine administration would reduce cognitive decline after cardiac surgery compared to placebo. METHODS: After institutional review board approval, 478 patients undergoing cardiac surgery were enrolled into this multicenter, prospective, randomized, double-blinded, placebo-controlled, parallel group trial. Subjects were randomized to lidocaine 1 mg/kg bolus after the induction of anesthesia followed by a continuous infusion (48 µg · kg · min for the first hour, 24 µg · kg · min for the second hour, and 10 µg · kg · min for the next 46 h) or saline with identical volume and rate changes to preserve blinding. Cognitive function was assessed preoperatively and at 6 weeks and 1 yr postoperatively using a standard neurocognitive test battery. The primary outcome was change in cognitive function between baseline and 6 weeks postoperatively, adjusting for age, years of education, baseline cognition, race, and procedure type. RESULTS: Among the 420 allocated subjects who returned for 6-week follow-up (lidocaine: N = 211; placebo: N = 209), there was no difference in the continuous cognitive score change (adjusted mean difference [95% CI], 0.02 (-0.05, 0.08); P = 0.626). Cognitive deficit (greater than 1 SD decline in at least one cognitive domain) at 6 weeks occurred in 41% (87 of 211) in the lidocaine group versus 40% (83 of 209) in the placebo group (adjusted odds ratio [95% CI], 0.94 [0.63, 1.41]; P = 0.766). There were no differences in any quality of life outcomes between treatment groups. At the 1-yr follow-up, there continued to be no difference in cognitive score change, cognitive deficit, or quality of life. CONCLUSIONS: Intravenous lidocaine administered during and after cardiac surgery did not reduce postoperative cognitive decline at 6 weeks.