Risk Factors and Consequences of Acute Kidney Injury After Noncardiac Surgery in Children.

BACKGROUND: Postoperative acute kidney injury (AKI) is a serious complication that is associated with prolonged hospital stay, high risk of short-term postsurgical mortality, need for dialysis, and possible progression to chronic kidney disease. To date, very little data exist on the risk of postoperative AKI among children undergoing noncardiac surgical procedures. We used data from a large multicenter cohort to determine the factors associated with AKI among children who underwent inpatient noncardiac surgical procedures and its impact on the postoperative course. METHODS: We utilized the National Surgical Quality Improvement Program Pediatric participant user files to identify a cohort of children who underwent inpatient surgery between 2012 and 2018 (n = 257,439). We randomly divided the study population into a derivation cohort of 193,082 (75%) and a validation cohort of 64,357 (25%), and constructed a multivariable logistic regression model to identify independent risk factors for AKI. We defined AKI as the occurrence of either acute renal failure or progressive renal insufficiency within the 30 days after surgery. RESULTS: The overall rate of postoperative AKI was 0.10% (95% confidence interval [CI], 0.09-0.11). In a multivariable model, operating times longer than 140 minutes, preexisting hematologic disorder, and preoperative sepsis were the strongest independent predictors of AKI. Other independent risk factors for AKI were American Society of Anesthesiologists (ASA) physical status ≥III, preoperative inotropic support, gastrointestinal disease, ventilator dependency, and corticosteroid use. The 30-day mortality rate was 10.1% in children who developed AKI and 0.19% in their counterparts without AKI ( P < .001). Children who developed AKI were more likely to require an extended hospital stay (≥75th percentile of the study cohort) relative to their peers without AKI (77.4% vs 21.0%; P < .001). CONCLUSIONS: Independent preoperative risk factors for AKI in children undergoing inpatient noncardiac surgery were hematologic disorder, preoperative sepsis, ASA physical status ≥III, inotropic support, gastrointestinal disease, ventilator dependency, and steroid use. Children with AKI were 10 times more likely to die and nearly 3 times more likely to require an extended hospital stay, relative to their peers without AKI.

Managing fisheries in a world with more sea turtles.

For decades, fisheries have been managed to limit the accidental capture of vulnerable species and many of these populations are now rebounding. While encouraging from a conservation perspective, as populations of protected species increase so will bycatch, triggering management actions that limit fishing. Here, we show that despite extensive regulations to limit sea turtle bycatch in a coastal gillnet fishery on the eastern United States, the catch per trip of Kemp's ridley has increased by more than 300% and green turtles by more than 650% (2001-2016). These bycatch rates closely track regional indices of turtle abundance, which are a function of increased reproductive output at distant nesting sites and the oceanic dispersal of juveniles to near shore habitats. The regulations imposed to help protect turtles have decreased fishing effort and harvest by more than 50%. Given uncertainty in the population status of sea turtles, however, simply removing protections is unwarranted. Stock-assessment models for sea turtles must be developed to determine what level of mortality can be sustained while balancing continued turtle population growth and fishing opportunity. Implementation of management targets should involve federal and state managers partnering with specific fisheries to develop bycatch reduction plans that are proportional to their impact on turtles.

Sugammadex for Reversal of Neuromuscular Blockade: Uses and Limitations.

Sugammadex is a reversal agent that was engineered to reverse the effects of aminosteroid muscle relaxants. It is a modified gamma-cyclodextrin, i.e. a large glucose molecule bound in a ring-like structure. Sugammadex, when injected intravenously, creates a concentration gradient favoring the movement of aminosteroid muscle relaxants from the neuromuscular junction back into the plasma, and then encapsulates the aminosteroid muscle relaxants within its inner structure by forming tight water-soluble complexes. The dissociation of the aminosteroidal muscle relaxant from the post-synaptic acetylcholine receptors is responsible for the termination of neuromuscular blockade. This review article presents the current indication, mechanism of action, limitations, side effects and contraindications of sugammadex. An overview of monitoring of the adequacy of reversal of aminosteroid muscle relaxants with sugammadex is presented. Moreover, the use of sugammadex in special situations, including "cannot intubate cannot oxygenate" scenarios is also described.