Effects of dexmedetomidine on renal function after cardiac surgery for infective endocarditis: An interim analysis of a randomized controlled trial.

BACKGROUND: Patients undergoing cardiac surgery for infective endocarditis (IE) are at a high risk of postoperative acute kidney injury (AKI) owing to heightened systemic inflammation. Therefore, we aimed to investigate the effect of dexmedetomidine on postoperative AKI in patients who underwent cardiac surgery for IE. METHODS: A total of 63 patients who underwent cardiac surgery for IE were randomly assigned to receive either intravenous dexmedetomidine infusion of 0.4 µg kg-1 h-1 (DEX group) or normal saline infusion (control group) for 24 h after induction of anesthesia. The occurrence of AKI within seven days postoperation, epinephrine, norepinephrine, and interleukin-6 levels, as well as postoperative morbidities, were assessed. An intertrim analysis was conducted using Pocock's alpha spending function at α = 0.05 and ß = 0.2. RESULTS: This trial was early terminated according to the results of interim analysis performed when 60 % of the pre-set number of patients have been collected. The incidence of AKI was significantly lower in the DEX group than in the control group (32.3 % vs. 9.4 %, p = 0.025). Patients in the DEX group had significantly lower epinephrine levels than those in the control group, whereas norepinephrine and interleukin-6 levels were similar. Perioperative mean arterial pressure or heart rate did not differ between the groups. CONCLUSIONS: Dexmedetomidine administration for 24 h starting from induction of anesthesia significantly reduced the incidence of postoperative AKI after cardiac surgery for IE (by 29 % vs. control) without hemodynamic side effects. This was accompanied by a significant attenuation of postoperative increase in serum epinephrine levels.

Myocardial Injury after Non-Cardiac Surgery in Patients Who Underwent Open Repair for Abdominal Aortic Aneurysm: A Retrospective Study.

BACKGROUND: Myocardial injury after non-cardiac surgery (MINS) has been known to be associated with mortality in various surgical patients; however, its prognostic role in abdominal aortic aneurysm (AAA) open repair remains underexplored. This study aimed to investigate the role of MINS as a predictor of mortality in patients who underwent AAA open repair. METHODS: This retrospective study investigated 352 patients who underwent open repair for non-ruptured AAA. The predictors of 30-day and 1-year mortalities were investigated using logistic regression analysis. RESULTS: MINS was diagnosed in 41% of the patients after AAA open repair in this study. MINS was an independent risk factor of 30-day mortality (odds ratio [OR]: 10.440, 95% confidence interval [CI]: 1.278-85.274, p = 0.029) and 1-year mortality (OR: 5.189, 95% CI: 1.357-19.844, p = 0.016). Kaplan-Meier survival curves demonstrated significantly lower overall survival rates in patients with MINS compared to those without MINS (p = 0.003). CONCLUSION: This study revealed that MINS is a common complication after AAA open repair and is an independent risk factor of 30-day and 1-year mortalities. Patients with MINS have lower overall survival rates than those without MINS.

Prognostic role of body composition in peritoneal carcinomatosis patients undergoing cytoreduction and hyperthermic intraperitoneal chemotherapy.

BACKGROUND: Bioelectric impedance analysis (BIA)-measured body composition and nutritional status have been used as prognostic indicators in various cancer cohorts. This study investigated whether BIA could provide information on prognosis in peritoneal carcinomatosis patients undergoing cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). METHODS: We retrospectively analyzed the data of 99 patients with preoperative BIA data among those who underwent CRS and HIPEC. The association between BIA-derived parameters and intraoperative peritoneal cancer index (PCI) score was assessed. Predictive analysis for the occurrence of postoperative morbidities including major complications (Clavien-Dindo classification 3-4) and re-admission within 30 days after surgery as well as 1 year mortality was also performed. RESULTS: BIA-derived mineral (r = 0.224, p = 0.027), fat (r = - 0.202, p = 0.048), and total body water (TBW)/fat-free mass (FFM) (r = - 0.280, p = 0.005) showed significant associations with intraoperative PCI score. Lower TBW/FFM was an independent predictor of major postoperative complications (OR 0.047, 95% CI 0.003-0.749, p = 0.031) and re-admission (OR 0.094, 95% CI 0.014-0.657, p = 0.017) within 30 days after surgery. Higher fat mass was also independently associated with a higher risk of major postoperative complications (OR 1.120, 95% CI 1.006-1.248, p = 0.039) and re-admission (OR 1.123, 95% CI 1.024-1.230, p = 0.013). Intraoperative PCI score > 20 (OR 4.489, 95% CI 1.191-16.917, p = 0.027) and re-admission within 30 days after surgery (OR 5.269, 95% CI 1.288-21.547, p = 0.021) independently predicted postoperative 1-year mortality. CONCLUSIONS: We demonstrate that preoperative BIA-derived TBW/FFM and fat mass were significantly correlated with metastatic extent, assessed by PCI score, in patients with peritoneal carcinomatosis. In addition, BIA-derived TBW/FFM and fat mass showed independent predictability for postoperative 30-day major complications and re-admission in patients undergoing CRS and HIPEC. Our findings suggest that assessment of BIA may improve discrete risk stratification in patients who are planned to receive CRS and HIPEC.

Postoperative Hypoalbuminemia as a Predictor of Acute Kidney Injury After Open Repair of Ruptured Abdominal Aortic Aneurysm.

BACKGROUND: Perioperative hypoalbuminemia has a prognostic effect on mortality and morbidity in various cohorts. Patients undergoing open repair of ruptured abdominal aortic aneurysms (rAAA) are at a high risk of hypoalbuminemia due to bleeding and underlying diseases. Hence, this study aimed to investigate the predictive value of immediate postoperative hypoalbuminemia for the risk for acute kidney injury (AKI) in patients undergoing open rAAA repair. METHODS: We retrospectively reviewed 143 patients who underwent open rAAA repair between January 2008 and May 2022. The patients were divided into two groups according to the presence of postoperative AKI. The perioperative serum albumin levels of the two groups were compared. The patients were further divided into two groups based on the median immediate postoperative albumin level (2.4 g/dL). The incidence of AKI was compared between the two groups. Multivariate logistic regression analysis was performed to assess the predictors of postoperative AKI. Kaplan-Meier survival curves were used to evaluate potential of AKI and albumin level as prognostic factors for mortality. RESULTS: Immediate postoperative serum albumin was significantly lower in the AKI group than in the non-AKI group (2.11 ± 0.62 g/dL vs. 2.59 ± 0.62 g/dL, p < 0.001). The incidence of postoperative AKI was significantly higher in patients with albumin ≤ 2.4 g/dL than in patients with albumin > 2.4 g/dL (53.8% vs. 27.7%, p = 0.002). Immediate postoperative albumin level was an independent predictor of AKI (Odds ratio [OR], 0.310; 95% confidence interval [CI] 0.165-0.583, p < 0.001) and 1-year mortality (OR, 0.230; 95% CI 0.098-0.542, p = 0.001). CONCLUSIONS: Immediate postoperative hypoalbuminemia was associated with postoperative AKI and mortality in patients with rAAA.

Prognostic Value of Serum Albumin in Aortic Aneurysm Patients Undergoing Graft Replacement of Ascending Aorta and Aortic Arch.

Background: Hypoalbuminemia is a marker of poor overall health with influences from protein energy malnutrition, systemic inflammation and hepatic and renal disease. Albumin has been reported to have a prognostic impact in various cohorts. This study investigated whether preoperative serum albumin levels could be used to predict mortality in patients with aortic aneurysms undergoing graft replacement of ascending aorta and aortic arch. Methods: We retrospectively reviewed 183 patients who underwent graft replacement of ascending aorta and aortic arch between January 2010 and December 2020. The exclusion criteria included patients with traumatic aortic injuries (n=2), previous aortic repair within 6 months (n=2), ruptured aortic aneurysms (n=14), or a lack of preoperative laboratory data or medical records (n=10). The remaining 87% eligible patients were divided into two groups based on their preoperative serum albumin levels. The lower albumin group was defined as having serum albumin levels ≤3.5 g/dL, while the higher albumin group was defined as having albumin levels >3.5 g/dL. The incidence of mortality was compared between the two groups, and a logistic regression analysis was performed to evaluate the predictors of mortality. Results: The incidence of 1-year mortality was higher in the lower albumin group than in the higher albumin group (3.4% vs. 23.5%, p=0.006). The optimal cut-off value of albumin to predict 1-year mortality was 4.0 g/dL (area under the curve 0.885, 95% CI 0.821-0.949, p<0.001), with a sensitivity and specificity of 90.0% and 80.3%, respectively. Preoperative serum albumin levels (OR = 0.116, 95% CI 0.021-0.641, p=0.014) and diabetes mellitus (OR = 5.757, 95% CI 1.018-32.565, p=0.048) remained independent predictors of mortality. Conclusion: Preoperative serum albumin levels were an independent predictor of 1-year mortality after the graft replacement of ascending aorta and aortic arch. These findings underscore that the optimization of patients' nutritional status before surgery may be warranted and should be further explored in this high-risk population.

Association of Pre- and Post-Donation Renal Function with Midterm Estimated Glomerular Filtration Rate in Living Kidney Donors: A Retrospective Study.

PURPOSE: The estimated glomerular filtration rate (eGFR) at 6 months after donation (eGFR6m) is strongly associated with the risk of end-stage renal disease in living kidney donors. This study aimed to investigate the incidence of eGFR6m <60 mL/min/1.73 m² (eGFR6m <60) and identify the risk factors that can predict the occurrence of eGFR6m <60 in living kidney donors. MATERIALS AND METHODS: Living kidney donors who underwent nephrectomy at Severance Hospital between January 2009 and December 2019 were identified. We excluded 94 of 1233 donors whose creatinine values at 6 months after donation were missing. The risk factors for eGFR6m <60 were assessed using multivariate regression analysis. The optimal cutoff points for candidate risk factors for predicting eGFR6m <60 occurrence were determined using the Youden index. RESULTS: The eGFR6m <60 occurred in 17.3% of the participants. Older age (≥44 years), history of hypertension, lower preoperative eGFR (<101 mL/min/1.73 m²), and degree of increase in creatinine levels on postoperative day 2 compared to those before surgery (ΔCr2_pre) (≥0.39 mg/dL) increased the risk of eGFR6m <60. The addition of ΔCr2_pre to preoperative eGFR yielded a higher predictive accuracy for predicting eGFR6m <60 than that with preoperative eGFR alone {area under the receiver operating characteristic curve=0.886 [95% confidence interval (CI), 0.863-0.908] vs. 0.862 (95% CI, 0.838-0.887), p<0.001}. CONCLUSION: The incidence of eGFR6m <60 was 17.3%. Older age, lower preoperative eGFR, history of hypertension, and greater ΔCr2_pre were associated with the occurrence of eGFR6m <60 after living donor nephrectomy. The combination of preoperative eGFR and ΔCr2_pre showed the highest predictive power for eGFR6m <60.

Regulators impeding erythropoiesis following iron supplementation in a clinically relevant rat model of iron deficiency anemia with inflammation.

AIMS: While elevated hepcidin levels with inflammation have been postulated as a putative mechanism hindering effective erythropoiesis after intravenous (IV) iron therapy in anemic patients undergoing surgery, little is known about the concomitant changes in other major regulators affecting erythropoiesis. This study investigated the activities of relevant regulators after iron replenishment in a rat model of iron deficiency anemia with inflammation. MAIN METHODS: Inflammation was induced by administration of complete Freund's adjuvant (CFA) in male Sprague-Dawley rats. After 2 weeks of CFA treatment, the rats received IV iron (CFA­iron) or saline (CFA-saline). The control group received saline instead of CFA and iron (saline-saline). At 1, 3, and 10 days after iron or saline treatment, inflammatory cytokines, oxidative markers, iron profiles, hepcidin, erythropoietin (EPO), erythroferrone (ERFE), fibroblast growth factor 23 (FGF 23), and expression of mRNA and proteins in the liver involved in hepcidin signaling pathways were measured. KEY FINDINGS: CFA treatment and iron restriction decreased hemoglobin and serum iron levels, significantly increasing inflammatory and oxidative markers. Iron supplementation did not restore hemoglobin levels despite improved iron profiles. CFA injections increased hepcidin and FGF 23 levels and decreased EPO and ERFE levels, which further intensified after iron supplementation with concomitantly elevated levels of oxidative stress and inflammatory markers. SIGNIFICANCE: Under inflammatory conditions, IV iron administration exacerbated inflammatory and oxidative stress and did not resolve anemia, even under iron deficiency conditions. Iron therapy exerted adverse influences on the changes in key regulators toward impeding erythropoiesis that was already impeded by inflammation.

Prognostic value of preoperative serum alkaline phosphatase for predicting 3-year mortality in patients undergoing kidney transplantation: A retrospective study.

Serum alkaline phosphatase (ALP) levels are related to high-turnover bone disease and reflect vascular calcification and inflammation. ALP has been reported to have a prognostic impact in various cohorts including chronic kidney disease. This study investigated whether preoperative serum ALP level could be used for predicting mortality in patients undergoing kidney transplantation. We retrospectively reviewed 1,718 patients who underwent kidney transplantation between November 2005 and June 2017. Finally, 1,533 patients who met the inclusion criteria were classified into tertiles based on preoperative serum ALP level (< 51, 51-72, > 72 IU/L). The incidence of mortality was compared among the three tertiles, and a stepwise logistic regression analysis was performed to evaluate the predictors for mortality. The incidence of 3-year mortality was the highest in the third tertile (1.0% vs. 2.5% vs. 4.4% in the first, second, and third tertile, respectively, p = 0.003). The third tertile of ALP level (odds ratio [OR] 1.855, 95% CI 1.192-2.886, p = 0.006), age (OR 1.052, 95% CI 1.022-1.082, p = 0.011), and history of hypertension (OR 0.401, 95% CI 0.210-0.765, p = 0.006) remained as independent predictors of mortality. Preoperative serum ALP level was significantly higher in the non-survivor group than in the survivor group (58.00 [44.00-76.00] vs. 75.00 [56.25-113.00], p = 0.003). The optimal cut-off value of serum ALP to predict 3-year mortality was 71 IU/L (area under the curve 0.636, 95% CI 0.554-0.719, p = 0.003). Therefore, preoperative serum ALP level was an independent predictor of 3-year mortality in patients undergoing kidney transplantation.

Preoperative Neutrophil to Lymphocyte Ratio, Platelet to Lymphocyte Ratio, and Mean Platelet Volume as Predictors of 1-Year Mortality in Patients Undergoing an Open Repair of Abdominal Aortic Aneurysms: A Retrospective Study.

OBJECTIVES: To investigate if preoperative neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), or mean platelet volume (MPV) could be used to predict 1-year mortality in patients undergoing open abdominal aortic aneurysm (AAA) repair. METHODS: We retrospectively reviewed 382 patients who underwent open AAA repair between January 2008 and July 2019. We divided the patients into two groups based on 1-year mortality and compared the preoperative NLR, PLR, and MPV. The patients were then classified into tertiles based on their preoperative NLR (first tertile: <2.41 (n = 111); second tertile: 2.41 ≤ NLR ≤ 6.07 (n = 111); and third tertile: >6.07 (n = 112)). We compared the incidence of mortality and morbidity across the aforementioned tertiles. We performed a stepwise logistic regression analysis to evaluate the predictors for mortality. An additional subgroup analysis was performed by dividing the cases into non-ruptured and ruptured cases. RESULTS: The preoperative NLR was significantly higher in the non-survivor group than in the survivor group (10.53 ± 7.60 vs. 5.76 ± 6.44, respectively, p = 0.003). The PLR and MPV were similar between the groups (145.35 ± 91.11 vs. 154.20 ± 113.19, p = 0.626, 9.38 ± 1.20 vs. 9.11 ± 1.39, p = 0.267, respectively). The incidence of 1-year mortality was 2.7%, 9.0%, and 14.3% in the first, second, and third NLR tertiles, respectively (p = 0.009). Higher NLR (odds ratio 1.085, 95% confidence interval 1.016-1.159, p = 0.015) and ruptured AAA (odds ratio 2.706, 95% confidence interval 1.097-6.673, p = 0.031) were the independent predictors of 1-year mortality in all patients. Moreover, the preoperative NLR was significantly higher in the ruptured AAA than in the non-ruptured AAA group (11.17 ± 7.90 vs. 4.10 ± 4.75, p < 0.001). In subgroup analysis, preoperative NLR (odds ratio 1.144, 95% confidence interval 1.031-1.271, p = 0.012) and PLR (odds ratio 0.986, 95% confidence interval 16 0.975-0.998, p = 0.017) was an independent predictor for 1-year mortality in ruptured cases. CONCLUSIONS: We demonstrated an independent relationship between the preoperative NLR and 1-year mortality in patients undergoing open AAA repair, besides PLR and MPV. Furthermore, the NLR and PLR had predictive power for 1-year mortality in ruptured cases.

Effect of Equal Ratio Ventilation on Respiratory Mechanics and Oxygenation During Volume-Controlled Ventilation in Pediatric Patients.

PURPOSE: Children have few small alveoli, which reduce lung compliance; in contrast, their cartilaginous rib cage makes their chest wall highly compliant. This combination promotes lung collapse. Prolonged inspiratory to expiratory (I:E) ratio ventilation is used to optimize gas exchange and respiratory mechanics in surgery. However, the optimal ratio is unclear in children. We hypothesized that, compared to a 1:2 I:E ratio, a 1:1 I:E ratio would improve dynamic compliance and oxygenation, and affect the peak airway pressure in pediatric patients undergoing surgery. MATERIALS AND METHODS: Forty-eight patients aged ≤6 years who were scheduled to undergo surgery under general anesthesia with an arterial line were randomly allocated to receive 1:1 (group 1:1) or 1:2 (group 1:2) I:E ratio ventilation. Airway pressure, respiratory system compliance, and arterial blood gas analyses were compared between groups immediately after induction (T0), 30 min after induction (T1), 60 min after induction (T2), immediately after surgery (T3), and on arrival at the post-anesthesia care unit (T4). RESULTS: Peak and plateau airway pressures were significantly lower in group 1:1 than in group 1:2 at T1 (p=0.044 and 0.048, respectively). The dynamic and static compliances were significantly higher in group 1:1 than in group 1:2 at T1 (p=0.044 and 0.045, respectively). However, the partial pressure of oxygen did not significantly differ between groups. CONCLUSION: Compared to a 1:2 I:E ratio, a 1:1 I:E ratio improved dynamic compliance and lowered the peak airway pressure without complications in pediatric patients. Nevertheless, our results do not support its use solely for improving oxygenation.

Prognostic value of neutrophil/lymphocyte ratio and mean platelet volume/platelet ratio for 1-year mortality in critically ill patients.

Several studies have reported that the neutrophil to lymphocyte ratio (NLR) and mean platelet volume (MPV) are associated with poor prognosis. This study investigated whether NLR and/or the MPV/platelet ratio could function as predictive markers of mortality in critically ill patients. We retrospectively reviewed 1,154 patients admitted to the intensive care unit (ICU) between January 2017 and December 2017. Patients were divided into 2 groups according to 1-year mortality. We compared the NLR and MPV/platelet ratio on each day of ICU admission. Patients were classified into tertiles based on their NLR and MPV/platelet ratios, and the incidence of 1-year mortality was compared. Kaplan-Meier survival curves were plotted to evaluate their potential as prognostic factors for 1-year mortality. The NLR and MPV/platelet ratio were higher in the non-survivor group than in the survivor group. The incidence of 1-year mortality was the highest in the third tertile for both the NLR and MPV/platelet ratio. The MPV/platelet ratio was an independent predictor for 1-year mortality based on the Kaplan-Meier survival analysis. Our data showed that the MPV/platelet ratio is a predictive factor for 1-year mortality in critically ill patients.

Incidence and Risk Factors of Acute Kidney Injury after Kasai Operation for Biliary Atresia: A Retrospective Study.

Background: Biliary atresia is a progressive, inflammatory, and destructive pathology of the bile ducts. Patients who undergo surgery for correction of biliary atresia (Kasai operation) are at risk of acute kidney injury (AKI) because of their young age at the time of surgery, long operation time, and liver fibrosis or failure as complication of biliary atresia. Conversely, AKI is associated with poor outcomes after surgery. This study therefore aimed to evaluate the incidence, risk factors, and outcomes of AKI after Kasai operation. Methods: All consecutive patients who underwent Kasai operation between March 2006 and December 2015 in a single tertiary-care university hospital were enrolled. AKI was defined based on the Acute Kidney Injury Network criteria. Multivariate logistic regression models were used to assess risk factors for AKI. Results: One hundred sixty-six patients received Kasai operation during study period. Of these, AKI occurred in 37 of 166 patients (22.3%). In multivariate logistic regression analysis, age older than 30 days, higher preoperative estimated glomerular filtration rate, and preoperative contrast use within 7 days were associated with the development of AKI. Perioperative packed red blood cells transfusion was related to reduced occurrence of AKI. AKI was associated with longer ICU stay (OR = 1.015, p = 0.016). More patients with AKI were also found to receive additional surgery except liver transplantation within 1 year compared to those without AKI (10.8 % vs. 2.3 %, p = 0.045). Conclusions: Increased age is strongly associated with the development of AKI after Kasai operation. These findings indicate a rational basis for early corrective surgery for biliary atresia, early screening for AKI, and intervention to improve the results of Kasai operation.

Age-Related Difference in the Effect of Acute Hyperglycemia on Myocardial Ischemia-Reperfusion Injury.

Age and acute hyperglycemia are known risk factors of myocardial ischemia-reperfusion injury. We investigated age-related difference in the effect of acute hyperglycemia on myocardial ischemia-reperfusion injury in Sprague-Dawley rats (young, 3 months; middle-aged, 10-12 months; and old, 22-24 months). The rats received 1.2 g/kg dextrose or normal saline and were subjected to coronary artery occlusion for 45 minutes followed by reperfusion for 240 minutes. Infarct size and ejection fraction were measured. The levels of apoptosis-related proteins (C-PARP, Bcl-2, Bax, and cytochrome c) and autophagy-related proteins (Bnip3, Beclin-1, Atg5, and LC3B-II) were evaluated. Infarct size increased with acute hyperglycemia in young and middle-aged rats but not in old rats, whereas the reduction of ejection fraction after ischemia-reperfusion was aggravated by acute hyperglycemia in all age groups. Acute hyperglycemia increased Bnip3 and Beclin-1 expressions after ischemia-reperfusion in young and middle-aged rats but not in old rats, whereas it increased the expression of Bax, cytochrome c, Atg5, and LC3B-II only in young or middle-aged rats. Conclusively, acute hyperglycemia does not aggravate myocardial ischemia-reperfusion injury in old rats, unlike in young and middle-aged rats. This heterogeneity may be due to attenuated changes in protein signaling after ischemia-reperfusion injury under acute hyperglycemia in old rats.

Prognostic impact of preoperative serum alkaline phosphatase level on a composite of morbidity and mortality after thoracic endovascular aortic repair: A retrospective study.

BACKGROUND: Serum alkaline phosphatase (ALP) is related to vascular calcification and is known to have a prognostic impact in various cohorts. However, evidence in patients undergoing thoracic endovascular aortic repair (TEVAR) is lacking. Thus, we hypothesized that preoperative serum ALP level could be used for predicting adverse events after TEVAR. METHODS: We retrospectively reviewed 167 patients who underwent TEVAR between February 2013 and December 2016. Patients were classified into tertiles according to preoperative ALP level (<69, 69-92, and >92 IU/L). The composite of morbidity and mortality (composite MM) was defined as the presence of one or more of the following: myocardial infarction, cerebrovascular accident, dialysis requirement, pulmonary complication, infection, and mortality within 1 year after TEVAR. The incidence of composite MM was compared among the 3 tertiles, and stepwise logistic regression analysis was performed to evaluate the predictors for composite MM. RESULTS: The incidence of composite MM was 14.5% in the first tertile group, 17.9% in the second tertile group, and 35.7% in the third tertile group (P = .016). The third tertile of ALP level (odds ratio [OR] 1.766, 95% confidence interval [CI] 1.074-2.904, P = .025) and emergency TEVAR (OR 2.369, 95% CI 1.050-5.346, P = .038) remained as independent predictors of composite MM. CONCLUSIONS: Our data showed an independent relationship between high preoperative ALP levels and adverse outcomes in patients undergoing TEVAR. This finding might suggest a potential role of ALP level as a risk stratification marker.

Serum Alkaline Phosphatase as a Predictor of Cardiac and Cerebrovascular Complications after Lumbar Spinal Fusion Surgery in Elderly: A Retrospective Study.

We retrospectively enrolled 1395 patients aged > 65 years undergoing posterior lumbar spinal fusion surgery and classified them into tertiles based on serum Alkaline Phosphatase (ALP) levels (<63, 63-79, >79 IU/L). The primary outcome was the incidence of 30-day major adverse cardiac and cerebrovascular events (MACCE; composite endpoint defined as the occurrence of ≥1 of the following events: new-onset myocardial infarction, stroke, or cardiovascular mortality). The incidence of the composite endpoint was the highest in the third serum ALP tertile (0.4% vs. 0.2% vs. 2.2% in the first, second, and third tertile, respectively, p = 0.003). Multivariate analysis showed that the third serum ALP tertile was an independent predictor of the composite endpoint of MACCE (odds ratio 4.507, 95% confidence interval 1.378-14.739, p = 0.013). The optimal cut-off value of preoperative serum ALP showing the best discriminatory capacity to predict postoperative MACCE (measured by receiver-operating characteristic curve analysis) was 83 IU/L (area under curve 0.694, 95% confidence interval 0.574-0.813, p = 0.016). Preoperative serum ALP levels were independently associated with the composite endpoint of postoperative 30-days MACCE. We suggest that serum ALP can be used as a biomarker to predict cardiac and cerebrovascular complications following lumbar spinal fusion surgery in elderly patients.

Efficacy of Single-Dose Dexmedetomidine Combined with Low-Dose Remifentanil Infusion for Cough Suppression Compared to High-Dose Remifentanil Infusion: A Randomized, Controlled, Non-Inferiority Trial.

Background: Combination of dexmedetomidine and opioid may be an alternative to high-dose opioid in attenuating cough during emergence from anesthesia, while also reducing the adverse effects of high-dose opioid. We tested the hypothesis that a single-dose of dexmedetomidine combined with low-dose remifentanil infusion during emergence would not be inferior to high-dose remifentanil infusion alone in attenuating cough after thyroidectomy. Methods: One hundred sixty-nine patients undergoing thyroidectomy were enrolled and randomized in a 1:1 ratio into group DR or group R. Each patient received an infusion of dexmedetomidine (0.5 µg/kg) and low-dose remifentanil infusion of effect-site concentration (Ce) at 1 ng/mL or normal saline and high-dose remifentanil infusion of Ce at 2 ng/mL for 10 min at the end of surgery. Remifentanil was maintained until tracheal extubation. Primary endpoint was the severity of coughing, which was assessed for non-inferiority using a four-point scale at the time of extubation. For comparison of coughing incidence during emergence, coughing grade was also measured at three times: before extubation, at extubation, and after extubation. Time to awakening, hemodynamic and respiratory profile, pain, and postoperative nausea and vomiting were also evaluated for superiority. Results: The 95% confidence intervals for differences in cough grade during tracheal extubation were <0.9, indicating non-inferiority of the single dose of dexmedetomidine combined with low-dose remifentanil infusion. The incidence of coughing was similar in the two groups. Hemodynamic changes during tracheal extubation were attenuated, but emergence from anesthesia was delayed, in group DR. Use of rescue antiemetic was similar in both groups, but the incidence of vomiting was less in group DR. Conclusion: A single-dose of dexmedetomidine (0.5 µg/kg) combined with low-dose remifentanil infusion at 1 ng/mL of Ce during emergence from sevoflurane-remifentanil anesthesia was not inferior to high-dose remifentanil infusion alone at 2 ng/mL of Ce with regard to suppressing cough.

Prognostic role of carotid intima-media thickness in off-pump coronary artery bypass surgery.

Carotid intima-media thickness (IMT) is a well-known predictor of adverse outcomes in the ischemic heart disease patients; however, evidence is lacking in patients undergoing off-pump coronary artery bypass surgery (OPCAB). Data from 407 patients who underwent OPCAB between April 2013 and August 2016 were retrospectively reviewed. A composite of cardiovascular morbidity endpoints was defined as the presence of stroke, acute myocardial infarction, new cardiac arrhythmia (newly developed atrial fibrillation, atrial flutter, or atrioventricular block), cardiovascular death, or cerebrovascular death within 30 days after surgery. Increased carotid IMT was defined as ≥0.9 mm on one or both sides. The incidence of a composite of cardiovascular morbidity endpoints was 24.0% in the normal IMT group (n = 221) and 34.4% in the increased IMT group (n = 186) (p = 0.021). Multivariable analysis revealed increased IMT (odds ratio 1.719, 95% confidence interval 1.108 to 2.666, p = 0.016) and preoperative renal replacement therapy (odds ratio 4.264, 95% confidence interval 1.679 to 10.829, p = 0.002) as independent predictors of a composite of cardiovascular morbidity endpoints. In patients undergoing OPCAB, preoperative assessment of carotid IMT may help predicting the development of a postoperative composite of cardiovascular morbidity endpoints.

Periprocedural analgesic efficacy of a single, pre-emptive administration of propacetamol in catheter ablation for atrial fibrillation: a randomized controlled trial.

BACKGROUND: Anesthetic care for termination of atrial fibrillation with catheter ablation poses significant challenges due to significant pain and lengthy procedure. A delicate polypharmacy combining anesthetic agents to minimize respiratory depression and hemodynamic changes and to provide satisfactory sedation and analgesia is needed. METHODS: Ninety-eight patients were randomized into two groups receiving either two grams of propacetamol or normal saline intravenously for 20 minutes before anesthesia. Monitored anesthesia care was provided with midazolam and remifentanil. RESULTS: Total amounts of remifentanil infused were similar between the groups (626±251 vs. 597±315 µg, P=0.606). Accounting for the mean duration of the procedure and the elimination half-life of propacetamol, remifentanil requirements were significantly less among patients whose procedure ended within 180 minutes (N.=56) in the propacetamol group than those in the control group (540±194 vs. 421±164 µg, P=0.017). In the control group, the incidence of analgesics usage 24 hours after the procedure was significantly greater (43% vs. 23%, P=0.038), and patients exhibited a higher pain score (3.1±2.1 vs. 1.9±2.1, P=0.007), compared to the propacetamol group. CONCLUSIONS: The addition of a single dose of pre-emptive propacetamol showed promising results in terms of opioid consumption in patients whose procedure ended within 180 minutes. It provided better post-procedural pain control, compared with midazolam plus remifentanil alone.

Aprepitant for antiemesis after laparoscopic gynaecological surgery: A randomised controlled trial.

BACKGROUND: Ondansetron, a 5-HT3 receptor antagonist, and aprepitant, a neurokinin-1 receptor antagonist, block the emetic effect of serotonin and neurokinin, respectively. Aprepitant combined with ondansetron can be more effective for preventing emesis in patients at high risk of postoperative nausea and vomiting (PONV). OBJECTIVE: To investigate the prophylactic effect of combining aprepitant with ondansetron compared with ondansetron alone on PONV in patients with fentanyl-based patient-controlled analgesia (PCA) after laparoscopic gynaecological surgery. DESIGN: Single-centre, double-blinded randomised controlled trial. SETTING: A major university hospital in Seoul, Korea, between July 2012 and April 2013. PATIENTS: One hundred and twenty-five female patients (American Society of Anesthesiologists' physical status 1 or 2) with fentanyl-based intravenous PCA after gynaecological laparoscopy were recruited to the study, and 110 completed the protocol. INTERVENTIONS: Oral aprepitant 80 mg or placebo was given 1 h before anaesthesia. In all patients, ondansetron 4 mg was administered intravenously at the end of surgery and 12 mg was added to the PCA solution. MAIN OUTCOME MEASURES: The primary outcome measure was complete response (no PONV and no rescue antiemetics) up to 48 h postoperatively. RESULTS: There was no difference in the proportion of complete responses to 48 h between the groups (P = 0.05), but in the post-anaesthesia care unit and up to 24 h postoperatively, the proportion was significantly higher in the aprepitant and ondansetron group than in the ondansetron only group (76 vs. 50%, P = 0.004 and 38 vs. 16%, P = 0.011, respectively). In the aprepitant and ondansetron group, the time to first PONV was delayed (P = 0.014) and the incidence of nausea up to 24 h postoperatively was lower (P = 0.014). However, there were no differences in the incidences of retching or vomiting, the severity of nausea, use of rescue antiemetics or the incidence of side-effects. CONCLUSION: Aprepitant 80 mg orally with ondansetron is effective in suppressing early PONV up to 24 h postoperatively and delays the time to first PONV in patients with fentanyl-based intravenous PCA after gynaecological laparoscopy. However, the combination prophylaxis with aprepitant and ondansetron failed to reach the predefined primary study outcome when compared with ondansetron alone. TRIAL REGISTRATION: Clinicaltrial.gov identifier: NCT01897337.

Kidney function in living donors undergoing nephrectomy by sevoflurane or desflurane anesthesia.

PURPOSE: Although there is no clinical evidence of nephrotoxicity with the volatile anesthetics currently used in general anesthesia, a better agent should be needed in terms of preserving postoperative renal function in living kidney donors who have only single remaining kidney. The purpose of the current retrospective, single-center study was to evaluate and compare renal function of living kidney donors after nephrectomy under either sevoflurane or desflurane anesthesia. MATERIALS AND METHODS: From January 2006 through December 2011, a total of 228 donors undergoing video assisted minilaparotomy surgery nephrectomy for kidney donation were retrospectively enrolled in the current study. The donors were categorized into a sevoflurane group or desflurane group based on the type of volatile anesthetic used. We collected laboratory data from the patients preoperatively, immediately after the operation, on the first postoperative day and on the third postoperative day. We also compared renal function of the kidney donors after donor nephrectomy by comparing creatinine level and estimated glomerular filtration rate (eGFR). RESULTS: The decrease in renal function after surgery in both groups was the most prominent on the first postoperative day. There were no significant differences between the two groups in postoperative changes of creatinine or eGFR. CONCLUSION: Sevoflurane and desflurane can be used safely as volatile anesthetics in donors undergoing nephrectomy.