Thoracic Anesthesia during the COVID-19 Pandemic: 2021 Updated Recommendations by the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC) Thoracic Subspecialty Committee.

The novel coronavirus pandemic has radically changed the landscape of normal surgical practice. Lifesaving cancer surgery, however, remains a clinical priority, and there is an increasing need to fully define the optimal oncologic management of patients with varying stages of lung cancer, allowing prioritization of which thoracic procedures should be performed in the current era. Healthcare providers and managers should not ignore the risk of a bimodal peak of mortality in patients with lung cancer; an imminent spike due to mortality from acute coronavirus disease 2019 (COVID-19) infection, and a secondary peak reflecting an excess of cancer-related mortality among patients whose treatments were deemed less urgent, delayed, or cancelled. The European Association of Cardiothoracic Anaesthesiology and Intensive Care Thoracic Anesthesia Subspecialty group has considered these challenges and developed an updated set of expert recommendations concerning the infectious period, timing of surgery, vaccination, preoperative screening and evaluation, airway management, and ventilation of thoracic surgical patients during the COVID-19 pandemic.

Oxidative Stress in Patients before and after On-Pump and Off-Pump Coronary Artery Bypass Grafting: Relationship with Syntax Score.

OBJECTIVE: Coronary artery bypass grafting (CABG) represents the significant source of increased oxidative stress (OS). We aimed to follow the OS status parameters (i.e., ischemia-modified albumin (IMA), malondialdehyde (MDA), superoxide anion, prooxidant-antioxidant balance (PAB), total oxidant status (TOS), total antioxidant status (TAS), and superoxide-dismutase (SOD)) change through the predefined study times in two different surgical procedures, i.e., cardiopulmonary bypass (CPB) and off-pump coronary artery bypass grafting (OPCAB). Additionally, we aimed to investigate those OS status parameters in specific study times according to SYNTAX score (SS), an established angiographic score for evaluating the extensity and severity of coronary artery disease. Patients and Methods. A total of 107 patients that were planned to undergo CABG were included (i.e., 47 patients in OPCAB and 60 patients in CPB group). Blood samples were taken at 6 time intervals: before surgery (t1), immediately after intervention (t2), 6 h (t3), 24 h (t4), 48 h (t5), and 96 h after termination of the operation (t6). RESULTS: IMA levels were higher in CPB than that in OPCAB baseline and rose in CPB group in t2 point. TOS decreased in both study groups, compared to baseline values, but without statistical significance. Superoxide anion and PAB significantly increased in t3-t6 study times, in both groups. MDA significantly increased only in CPB group in t5 and t6 interval. MDA was significantly higher in CPB group compared to OPCAB in t6 study point. CPB patients had significantly lower TAS compared to OPCAB patients at the beginning and in t2 and t3 study points. They also had significantly lower SOD activities compared to OPCAB, baseline, and in several study points. Moreover, TAS, SOD, and TAS/TOS ratio were significantly lower, whereas PAB and TOS/TAS were significantly higher in patients with high SS compared to corresponding groups. SOD activity, IMA, and TAS level were the best predictors of high SS. CONCLUSION: CPB patients were in more severe ischemia baseline than OPCAB group and IMA rose in CPB patients immediately after the surgery end, but not later. Also, the antioxidant status was significantly lower, whereas the prooxidant status was significantly higher in patients with high SS compared to corresponding groups. SOD activity, IMA, and TAS level were the best predictors of CAD (as determined with SS), showing that SOD and IMA had very good discriminatory capability towards higher SS status.

New Markers of Platelet Activation and Reactivity and Oxidative Stress Parameters in Patients Undergoing Coronary Artery Bypass Grafting.

OBJECTIVE: Recent studies have shown that the red cell distribution width- (RDW-) to-platelet (PLT) count ratio (i.e., RPR) and the mean platelet volume (MPV)/PLT ratio (i.e. MPR) are more sensitive markers of atherosclerosis-connected risk than RDW and PLT alone. The present study is aimed at investigating the oxidative stress status and these two new markers of platelet activation in two different heart surgery modalities: cardiopulmonary bypass (CPB) and off-pump coronary artery bypass (OPCAB). We also aimed to test the possible relationship between RPR and MPR, respectively, and the severity and complexity of atherosclerotic plaque, measured as Syntax Score. Patients and Methods. A total of 107 patients encompassed this prospective study (i.e., 60 patients in CPB group and 47 patients in OPCAB). Blood samples were drawn at several time intervals: before skin incision (t1), immediately after intervention (t2), 6 h (t3), 24 h (t4), 48 h (t5), and 96 h after cessation of the operation (t6). RESULTS: The values of RPR and MPR were similar in CPB and OPCAB before surgery and started to rise in t2 (i.e., immediately after the intervention). This increase lasted to t5 (i.e., 48 hours after the intervention), when it became the highest. After that, both markers started to regress about the 96th hour after the beginning of surgery. Nominal values of both indices were higher in CPB than in OPCAB in all study points after the surgery. Furthermore, a significantly higher level of antioxidative parameters (i.e., total sulfhydryl groups and paraoxonase 1) in the OPCAB group compared to the CPB group was noted at t5 study point (i.e., 48 hours after the surgery), whereas no significant difference was noted in prooxidant levels (i.e., lipid hydroperoxides and advanced oxidation protein products) between these groups at this study point. MPR and RPR correlated positively with Syntax Score at several study points after the surgery completion. Syntax Score, MPR, and RPR showed good clinical accuracy in surgery-related complication prediction ((AUC = 0.736), 95th CI (0.616-0.856), P = 0.003)). CONCLUSION: When combined, MPV, RDW, and platelet count, such as MPR and RPR, could be good predictors of coronary artery disease status, regarding the aspect of joint inflammation, oxidative stress, and thrombosis.

Thoracic Anesthesia of Patients With Suspected or Confirmed 2019 Novel Coronavirus Infection: Preliminary Recommendations for Airway Management by the European Association of Cardiothoracic Anaesthesiology Thoracic Subspecialty Committee.

The novel coronavirus has caused a pandemic around the world. Management of patients with suspected or confirmed coronavirus infection who have to undergo thoracic surgery will be a challenge for the anesthesiologists. The thoracic subspecialty committee of European Association of Cardiothoracic Anaesthesiology (EACTA) has conducted a survey of opinion in order to create recommendations for the anesthetic approach to these challenging patients. It should be emphasized that both the management of the infected patient with COVID-19 and the self-protection of the anesthesia team constitute a complicated challenge. The text focuses therefore on both important topics.

Effect of Transcranial Direct Current Stimulation Combined With Patient-Controlled Intravenous Morphine Analgesia on Analgesic Use and Post-Thoracotomy Pain. A Prospective, Randomized, Double-Blind, Sham-Controlled, Proof-of-Concept Clinical Trial.

BACKGROUND: Transcranial direct current stimulation (tDCS) is used for various chronic pain conditions, but experience with tDCS for acute postoperative pain is limited. This study investigated the effect of tDCS vs. sham stimulation on postoperative morphine consumption and pain intensity after thoracotomy. METHODS: This is a single-center, prospective, randomized, double-blind, sham-controlled trial in lung cancer patients undergoing thoracotomy under general anesthesia. All patients received patient-controlled (PCA) intravenous morphine and intercostal nerve blocks at the end of surgery. The intervention group (a-tDCS, n = 31) received anodal tDCS over the left primary motor cortex (C3-Fp2) for 20 min at 1.2 mA, on five consecutive days; the control group (n = 31) received sham stimulation. Morphine consumption, number of analgesia demands, and pain intensity at rest, with movement and with cough were recorded at the following intervals: immediately before (T1), immediately after intervention (T2), then every hour for 4 h (Т3-Т6), then every 6 h (Т7-Т31) for 5 days. We recorded outcomes on postoperative days 1 and 5 and conducted a phone interview inquiring about chronic pain 1 year later (NCT03005548). RESULTS: A total of 62 patients enrolled, but tDCS was prematurely stopped in six patients. Fifty-five patients (27 a-tDCS, 28 sham) had three or more tDCS applications and were included in the analysis. Cumulative morphine dose in the first 120 h after surgery was significantly lower in the tDCS [77.00 (54.00-123.00) mg] compared to sham group [112.00 (79.97-173.35) mg, p = 0.043, Cohen's d = 0.42]. On postoperative day 5, maximum visual analog scale (VAS) pain score with cough was significantly lower in the tDCS group [29.00 (20.00-39.00) vs. 44.50 (30.00-61.75) mm, p = 0.018], and pain interference with cough was 80% lower [10.00 (0.00-30.00) vs. 50.00 (0.00-70.00), p = 0.013]. One year after surgery, there was no significant difference between groups with regard to chronic pain and analgesic use. CONCLUSION: In lung cancer patients undergoing thoracotomy, three to five tDCS sessions significantly reduced cumulative postoperative morphine use, maximum VAS pain scores with cough, and pain interference with cough on postoperative day 5, but there was no obvious long-term benefit from tDCS.

Preoperative anxiety and implications on postoperative recovery: what can we do to change our history.

Preoperative anxiety can influence the intensity of postoperative pain and anesthesia and analgesia requirement. In certain types of surgery, anxiety may even increase postoperative morbidity and mortality. The goal of this narrative review is to remind anesthesiologists that anxiety measurement using specific tools can be done in clinical practice, to present the implications of preoperative anxiety on postoperative patient recovery, and to acknowledge the importance of a dedicated anesthesia plan in the management of anxious adult patients. Preoperative assessment performed several weeks before surgery in an outpatient clinic is a reasonable option to give information about surgery, anesthesia and postoperative pain. This is the time to assess patient preoperative anxiety by using VAS-A. If high anxiety level is detected early, the patient can be referred to a psychologist for preoperative preparation. This is consistent with the guidelines for enhanced recovery after surgeries, which underline the importance of patient-doctor discussion about hospitalization and perioperative care. Patients with preoperative anxiety could benefit from multimodal analgesia, including non-pharmacological methods, such as cognitive therapy and music therapy and relaxation. The authors' opinion is that greater education about preoperative anxiety consequences in the surgical community is needed. A systemized approach and guidelines about the management of preoperative anxiety should be followed.

Blood transfusion in cardiac surgery--does the choice of anesthesia or type of surgery matter?

BACKGROUND/AIM: In spite of the evidence suggesting a significant morbidity associated with blood transfusions, the use of blood and blood products remain high in cardiac surgery. To successfully minimize the need for blood transfusion, a systematic approach is needed. The aim of this study was to investigate the influence of different anesthetic techniques, general vs combine epidural and general anesthesia, as well as different surgery strategies, on-pump vs off-pump, on postoperative bleeding complications and the need for blood transfusions during perioperative period. METHODS: Eighty-two consecutive patients scheduled for coronary artery bypass surgery were randomized according to surgical and anesthetic techniques into 4 different groups: group 1 (patients operated on off-pump, under general anesthesia); group 2 (patients operated on off-pump, with combined general and high thoracic epidural anesthesia); group 3 (patients operated on using standard revascularization technique, with the use of extracorporeal circulation, under general anesthesia), and group 4 (patients operated on using standard revascularization technique, with the use of extracorporeal circulation, with combined general and high thoracic epidural anesthesia). Indications for transfusion were based on clinical judgment, but a restrictive policy was encouraged. Bleeding was considered significant if it required transfusion of blood or blood products, or reopening of the chest. The quantity of transfused blood or blood products was specifically noted. RESULTS: None of the patients was transfused blood or blood products during the surgery, and as many as 70/81 (86.4%) patients were not transfused at all during hospital stay. No difference in postoperative bleeding or blood transfusion was noted in relation to the type of surgery and anesthetic technique applied. If red blood cells were transfused, postoperative bleeding was the most influential parameter for making clinical decision. CONCLUSION: No influence of off-pump surgery or epidural anesthesia on blood transfusion requirements during a perioperative period was confirmed by this study. It seems, however, that encouraging lower hemoglobin triggers in clinical decision-making could result in less transfusions during surgery or hospital stay.

High thoracic epidural anesthesia in patients with synchronous carotid endarterectomy and off-pump coronary artery revascularization.

BACKGROUND/AIM: In order to reduce the risk of cerebrovascular insults (CVI), the latest recommendations suggest that carotid endarterectomy (CEA) is strongly indicated in patients scheduled for coronary surgery when significant carotid artery stenosis is symptomatic and/or bilateral. The best results are obtained in small studies with CEA performed immediately prior to off-pump coronary bypass (OPCAB). We present 16 consecutive patients who underwent synchronous CEA and OPCAB under general anesthesia combined with high thoracic epidural anesthesia (TEA) in order to evaluate the safety and potential benefits of such anesthetic management. METHODS: A total of 16 consecutive patients scheduled for simultaneous CEA and OPCAB with no contraindication for TEA were enrolled in the study. All the patients were anesthetized with TEA combined with general anesthesia. Early extubation was planed in all the patients for early assessment of neurological outcome. Demographics, comorbidity, quality of postoperative recovery, duration of mechanical ventilation, successful early extubation, outcome, length of Intensive Care Unit (ICU) and hospital stay were recorded. RESULTS: Only two patients did not fulfill the criteria for early extubation. The average duration of mechanical ventilation for patients who fulfilled criteria for early extubation was 87.9 +/- 85.0 (0-255) min. Five (31.25%) patients were extubated in the operating theater at the end of surgery. There were no deaths, nor neurological complications of TEA. Seven (43.7%) patients had at least one of the postoperative complications considered significant. None of them had CVI. None of the early extubated patients was reintubated or had postoperative respiratory failure. CONCLUSION: Our study revealed that a combination of general anesthesia with TEA appears to be good choice in synchronous CEA and OPCAB due to advantages of early extubation and early neurological assessment. Larger studies are necessary to determine real benefits on both short and long-term outcomes of such anesthetic management in synchronous CEA and OPCAB.

[Effects of epidural analgesia using different concentrations of bupivacaine during combined general and epidural anesthesia].

INTRODUCTION: Thoracic epidural analgesia, combined with general anesthesia, is an established anesthetic choice for abdominal aortic surgery. However, there are controversies about the level of anesthesia as well as the dose and concentration of the local anesthetic used. The aim of the study was to compare the effects of two different concentrations of epidural bupivacaine on sevoflurane requirements and hemodynamic parameters during aortic surgery under combined epidural/general anesthesia. METHODS AND MATERIAL: Sixty patients scheduled for abdominal aortic surgery were randomly divided into two groups according to the concentration of local anesthetic used for epidural anesthesia: group 1--low concentration--where 0.125% bupivacaine was used, and group 2--high concentration--where 0.5% bupivacaine was used at the beginning and then the concentration was reduced to 0.25%. Anesthesia was maintained with sevoflurane, the dose was adjusted to achieve the target entropy of 40-60. The measurements included the inspired sevoflurane concentrations, blood pressure, and heart rate at the beginning and every 5 min during the surgery. RESULTS: Both groups had similar heart rate and blood pressure, but the inspired sevoflurane concentration was significantly higher and more variable in patients where bupivacaine 0.125% was used. Vasopressors were used more often and in higher doses in the 0.5% bupivacaine group, and in the same group the blood loss and fluid requirements were reduced. CONCLUSION: When 0.5% bupivacaine is used in combined thoracic epidural/ general anesthesia for aortic surgery, the sevoflurane concentrations are lower and less variable. In addition, the blood loss and fluid requirements are reduced.

Preoperative assesment of the immunocompromised patient.

In some surgical patients immunosuppression is easily apparent and directly caused by known underlying disease or treatment. In others, although induced by the underlying disease, immunosuppression may be less obvious. Perioperative management of immunocompromised patient is mostly directed by the fact that immunosuppression itself does not cause pathology, but does leave the patient prone to infection. Immunodeficiency can be broadly characterized as congenital (primary) or acquired (secondary). The majority of immune deficiencies that are of interest to the anaesthetist are acquired. They can be present both in children and adults, in a huge variety of patients that are presented preoperatively. Most of them do not require different than usual perioperative anaesthetic management. However, in some of them specific aspects of treatment should be considered, such as HIV infected, cancer, transplant patients, and those scheduled for organ transplantation.

[Early extubation in cardiac surgery].

INTRODUCTION: An early extubation in cardiac surgery (fast track cardiac anaesthesia) refers to mechanical ventilation during 1-6 hours after the intervention, the extubation criteria being the same as for any other surgery. Different protocols have been established for managing patients undergoing fast track anaesthesia, with high-thoracic epidural anaesthesia being increasingly used in the last few years. MATERIAL AND METHODS: Thirty-five consecutive patients scheduled for OPCAB surgery, who were planned for very fast track cardiac anaesthesia (planned extubation within one hour after the end of the operation), were included in the study. Combined high-thoracic epidural and general anaesthesia was performed in all patients, with bupivacain as a local anaesthetic and inhalational or intravenous anesthetic used for general anaesthesia. RESULTS: Thirty three of 35 patients (94.3%) were extubated early, with the mean duration of the mechanical ventilation of 56 +/- 92 minutes. Very fast track cardiac anaesthesia was performed successfully in 24/35 (68.8%) patients; these patients had higher ejection fraction, lower Euroscore, shorter duration of the surgery, and fewer numbers of grafts, as compared to the patients extubated early. Euroscore was the only independent predictor of the early extubation (higher score--longer mechanical ventilation time). DISCUSSION AND CONCLUSION: Our results suggest that high-toracic epidural anaesthesia enables successful early tracheal extubation in the population of patients scheduled for OPCAB cardiac surgery. We had no complications related to this type of anaesthesia and very good perioperative results.

The incidence of difficult intubation in 2000 patients undergoing thyroid surgery--a single center expirience.

BACKGROUND/AIM: The incidence of difficult intubation (DI) is 1-10%, and DI leading to inability to intubate occurs in 0.04% of the population. The aim of this study was to evaluate the incidence of DI in thyroid surgery and to assess possible correlation of difficult tracheal intubation with sex and primary diagnosis. METHODS: We studied 2000 consecutive patients (1705 females) scheduled for thyroid surgery who were assessed for DI prior to general anesthesia, with respect to primary disease diagnosis and sex. Patients were divided into four groups: patients with nodal goiter (group A), polynodal goiter (group B), hyperthyroidism (group C) and thyroid carcinoma (group D). Difficult intubation was predicted using the scoring system which included 13 parameters ranged from 0 to 2. Additive score > 5 was accepted as a predictor of DI. True DI was defined as impossible visualization of glottis with direct laryngoscopy (grade III and IV). RESULTS: Difficult intubation was observed in 110/2000 patients (5.5%). The incidence of DI was higher in males (26/295, 8.8%) than females (84/1705, 4.9%) (p < 0.01). The incidence of DI was highest in the group B (6.2%). Extremely DI occurred in 15/2000 patients (0.75%), the most of them in the group C (1.1%). Sensitivity of used scoring system was 91.8% and specificity 86.5%. CONCLUSIONS: The incidence of DI was higest in patients with polynodal goiter but extremly DI was present mostly in patients with hyperthiroidism. Men seem to be at higher risk for DI than women. Scoring system used in this study for prediction of DI may be useful in this patient population.

Postendarterectomy common carotid artery pseudoaneurysm.

Pseudoaneurysm (PSA) formation is an uncommon complication in carotid surgery. PSA of the carotid artery requires surgical or endovascular treatment to prevent PSA thrombosis, embolization from the thrombotic material within the PSA, hemorrhage after rupture, or compression on the adjacent structures. We present a case of a symptomatic common carotid PSA that occurred 14 months after routinely performed eversion carotid endarterectomy.

[Reconstructive surgery of idiopathic hypertrophic subaortic stenosis with dynamic obstruction of the left ventricular outflow tract causing severe mitral insufficiency]. / Rekonstrukciona hirurgija idiopatske hipertroficne subaortne stenoze sa dinamskom opstrukcijom izlaznog trakta leve komore i posledicnom teskom mitralnom insuficijenciom.

Hypertrophic obstructive cardiomyopathy (HOCM) is an idiopathic disease frequently associated with systolic anterior motion (SAM). The anterior leaflet of mitral valve is sucked by Ventury effect into the left ventricle outflow tract making subaortic stenosis more severe and producing mitral insufficiency at the same time. Septal myectomy along with mitral valve replacement has been the treatment of choice for a long time. An understanding of pathoanatomy and hemodynamics of the disease has opened possibility for total reconstructive treatment of both subaortic stenosis and mitral insufficiency in such patients. This is a case report of 50-year-old male with severe subaortic stenosis (136/70 mmHg) due to HOCM and SAM along with grade IV mitral insufficiency. Septal myectomy was performed. Mitral insufficiency was managed by reducing the height of posterior cusp along with remodeling of mitral annulus by Carpentier-Classic ring. In that way, subaortic obstruction was reduced to 30.9/10 mmHg while mitral insufficiency was lowered to negligible level. The patient was discharged from hospital with sinus rhythm eight days after the surgery.

[High thoracic epidural anesthesia in coronary surgery]. / Visoka torakalna epiduralna anestezija u koronarnoj hirurgiji.

INTRODUCTION: High thoracic epidural anesthesia and analgesia are being increasingly used for coronary artery bypass graft surgery. The reasons for this include excellent perioperative pain control with advantage of early tracheal extubation, improved postoperative pulmonary function, and cardiac protection due to sympthatetic blockade. EFFECTS OF HIGH THORACIC EPIDURAL ANESTHESIA: Cardiac protection is the consequence of decreased heart rate, myocardial contractility and arterial blood pressure, without changes in coronary perfusion pressure. Therefore, high thoracic epidural analgesia beneficially alters major determinants of myocardial oxygen consumption, without jeopardizing coronary perfusion pressure. In addition, decrease of functional residual capacity, may reduce postoperative pulmonary morbidity. RESULTS OF CLINICAL STUDIES: Patients with high thoracic epidural anesthesia revealed a more favourable perioperative hemodynamic profile, lower incidence of ischemia and better response to perioperative stress. HIGH THORACIC EPIDURAL ANESTHESIA TECHNIQUE: The epidural catheter should be placed at the Th2/Th3 interspace at least one hour before administration of heparin. After local anesthetic bolus dose, a continuous epidural infusion is recommended. CONCLUSION: There is strong evidence for beneficial effects of high thoracic epidural anesthesia in patients undergoing surgical myocardial revascularization. However, it is still underutilized in current clinical practice.

Off-pump myocardial revascularization using the Octopus tissue stabilizer system.

Off-pump coronary artery bypass surgery (OPCAB) has changed the approach to contemporary coronary surgery. Development of new surgical devices and techniques has reduced morbidity and mortality during off-pump surgery. From March 2000-April 2002, a total of 136 patients underwent open heart surgery using off-pump technique and fast-track anesthesia at Dedinje Cardiovascular Institute. Octopus Medtronic coronary stabilizer was used for stabilization of targeted vessel. Arterial grafts were used 169 times and saphenous vein 69 times. Average number of anastomoses was 1,830,73 per patient. One patient (0.74%) died. Three patients (2.21%) underwent surgery revision due to postoperative bleeding and one (0.74%) because of graft dysfunction. Perioperative myocardial infarction was registered 2 times (1.47%), pneumothorax 3 times (2.21%), postoperative arrhythmias 11 times (8.09%), transitory ischemic attack once (0.74%) and deep wound infection once (0.74%). Twelve patients (8.82%) required prolonged inotropic support. Angiographies early revealed patent grafts in 8 patients (5.88%). OPCAB is a safe and effective alternative approach to coronary artery revascularization. Use of coronary stabilizer has improved the safety and quality of OPCAB surgery.

[Renal protection during surgical procedures on the infrarenal aorta]. / Zastita bubrega tokom hirurskih intervencija na infrarenalnoj aorti.

INTRODUCTION: Despite the progress in surgical and anaesthetic management, decreased renal function is still observed after abdominal infrarenal aortic surgery and remains an important problem in postoperative period. Although data regarding the efficacy of perioperative renal protection are conflicting, it is widely believed that renal protection before aortic cross-clamping is beneficial and therefore is commonly used. The aim of this study was to evaluate the impact of renal protection in patients undergoing elective infrarenal aortic surgery (1ARS). PATIENTS AND METHODS: We have prospectively studied 80 patients undergoing elective infrarenal aortic surgery from October 1996 to May 1998 in the Clinical Centre of Serbia, because of aorto-occlusive disease or aortic aneurysm. Patients were excluded from the study for three reasons: prior renal dysfunction, suprarenal aortic cross-clamping and ruptured aortic aneurysm. We have randomized the patients in two groups: without renal protection--group A (n = 40) and with renal protection--group B (n = 40). Preanaesthetic medication consisted of midazolam (5 mg i.m.). Anaesthesia was induced with etomidat 0.3 mg/kg, fentanyl 0.05-0.1 mg and succinil-holin Img/kg. Ventilation was controlled using 50% of nitrous oxyde and oxygen. Supplemental anaesthesia consisted of isoflurane and fentanyl, in order to maintain the mean arterial pressure and heart rate +/- 20% regarding preoperative values. In all patients two peripheral vein and radial artery catheters were cannulated before anaesthesia. Central venous catheter and Foley urinary bladder catheter were inserted after the induction of anaesthesia. Two-lead electrocardiograms were recorded. All patients in group B were given intravenously mannitol (0.3 g/kg) before aortic cross-clamping (ACC). After aortic cross-clamping, these patients received furosemide (20-40 mg) or dopamine (1-3 micrograms/kg/min) to the end of surgery (Table 1). In 8 time points (preoperatively, after induction, during ACC, 2 and 8 hours after ACC, on day 1, 2 and 3 postoperatively) haemodynamic parameters (mean arterial and central venous pressure), volume load, urinary output, creatinine and free-water clearance, serum electrolytes, BUN, creatinine, plasma and urine osmolality and ACC time were analyzed in each patient. Renal complications were classified as transient or persistent. Transient renal dysfunction was defined as a greater rise than 20% rise in peak serum creatinine level over baseline serum creatinine level, with a peak of at least 168 mumol/L. Persistent renal insufficiency was defined as a greater rise than 20% rise in discharge serum creatinine level over baseline serum creatinine level, with a peak of at least 168 mumol/L. Moreover, renal insufficiency was defined as a free-water clearance greater than -15 ml/h. Aortic cross-clamping time was defined as a period in which the proximal inflow was occluded. The results were expressed as means +/- SD. Statistical difference detected with Student's t-test, with p < 0.05 being considered significant. RESULTS: Patients in groups A and B were similar regarding the age (64.32 vs. 62.00), sex (males 35, females vs. males 34, females 6) and preoperative diseases. (Tab. 2) No difference was found between groups regarding any of the parameters (BUN, serum creatinine, electrolytes, volume load, creatinine and free-water clearance, haemodynamic parameters, plasma and urine osmolality). Urinary output was higher in group B during and 2 hours after ACC. (Graph 1.) ACC time was similar in two groups (24.1 min vs 24.5 min). (Graph. 2) Only one patient in group B revealed transitory renal insufficiency, not requiring special treatment. These data indicate that renal protection did not influence renal function. Short ACC time may have impact on the obtained results. Our results suggest that renal protection should not be considered as mandatory for elective infrarenal aortic surgery. Because of the short ACC time observed in this study (in comparison to other studies), further studies of renal protection in patients with longer ACC time are needed.