Perioperative serum syndecan-1 concentrations in patients who underwent cardiovascular surgery with cardiopulmonary bypass and its association with the occurrence of postoperative acute kidney injury: a retrospective observational study.

BACKGROUND: Various factors can cause vascular endothelial damage during cardiovascular surgery (CVS) with cardiopulmonary bypass (CPB), which has been suggested to be associated with postoperative complications. However, few studies have specifically investigated the relationship between the degree of vascular endothelial damage and postoperative acute kidney injury (pAKI). The objectives of this study were to measure perioperative serum syndecan-1 concentrations in patients who underwent CVS with CPB, evaluate their trends, and determine their association with pAKI. METHODS: This was a descriptive and case‒control study conducted at the National University Hospital. Adult patients who underwent CVS with CPB at a national university hospital between March 15, 2016, and August 31, 2020, were included. Patients who were undergoing preoperative dialysis, had preoperative serum creatinine concentrations greater than 2.0 mg dl-1, who were undergoing surgery involving the descending aorta were excluded. The perioperative serum syndecan-1 concentration was measured, and its association with pAKI was investigated. RESULTS: Fifty-two patients were included. pAKI occurred in 18 (34.6%) of those patients. The serum syndecan-1 concentration increased after CPB initiation and exhibited bimodal peak values. The serum syndecan-1 concentration at all time points was significantly elevated compared to that after the induction of anesthesia. The serum syndecan-1 concentration at 30 min after weaning from CPB and on postoperative day 1 was associated with the occurrence of pAKI (OR = 1.10 [1.01 to 1.21], P = 0.03]; OR = 1.16 [1.01 to 1.34], P = 0.04]; and the cutoff values of the serum syndecan-1 concentration that resulted in pAKI were 101.0 ng ml-1 (sensitivity = 0.71, specificity = 0.62, area under the curve (AUC) = 0.67 (0.51 to 0.83)) and 57.1 ng ml-1 (sensitivity = 0.82, specificity = 0.56, AUC = 0.71 (0.57 to 0.86)). Multivariate logistic regression analysis revealed that the serum syndecan-1 concentration on postoperative day 1 was associated with the occurrence of pAKI (OR = 1.02 [1.00 to 1.03]; P = 0.03). CONCLUSION: The serum syndecan-1 concentration at all time points was significantly greater than that after the induction of anesthesia. The serum syndecan-1 concentration on postoperative day 1 was significantly associated with the occurrence of pAKI. TRIAL REGISTRATION: This study is not a clinical trial and is not registered with the registry.

Effectiveness of remimazolam in preventing postoperative delirium in elderly patients with proximal femoral fractures.

PURPOSE: Elderly patients with proximal femoral fractures are known to be a high-risk group for postoperative delirium (POD). The aim of this study was to determine the association of the benzodiazepine drug remimazolam with POD in elderly patients with proximal femoral fractures. METHODS: In this single-center retrospective observational study, we included patients aged 65 years or older who underwent general anesthesia for proximal femoral fractures. We collected data for the incidence of POD within 3 days after surgery. We also obtained data for complications, preoperative blood examinations, maintenance anesthetic and intraoperative vital data. The occurrence of POD in patients who received remimazolam for general anesthesia (remimazolam group) was compared to that in patients who received general anesthesia with other anesthetic agents (other group). We finally conducted a multivariate analysis to assess the independent association of remimazolam with the risk of POD. RESULTS: A total of 230 patients, including 54 patients who received remimazolam for maintenance anesthesia, were included in this study. The incidence of POD in the patients was 26.1%. The incidence of delirium within 3 days after surgery was significantly lower in the remimazolam group than in the other group (14.8% vs. 29.5%, p = 0.03). The multivariate analysis showed that the use of remimazolam independently reduced the occurrence of POD (adjusted odds ratio = 0.42, p = 0.04). CONCLUSION: This retrospective observational study showed that the use of remimazolam is independently associated with a reduced incidence of POD. Remimazolam may be considered as an option to reduce POD in elderly patients with proximal femoral fractures.

Perioperative Management of a Needle-Phobic Parturient for a Cesarean Section: A Case Report.

We describe the perioperative management of a pregnant woman with severe needle phobia who underwent a cesarean section. General anesthesia with slow induction using an inhalant anesthetic for cesarean section is a rare and unique situation. Furthermore, the management of this case was more complicated because the patient not only refused the puncture procedure but also refused the presence of an indwelling object when she woke up from the anesthesia. After the operation, the patient was admitted to the intensive care unit (ICU) and received mechanical ventilation under deep sedation. The patient was managed under sedation until the day after surgery, and both mother and child progressed without perioperative complications.

Severe hypotension and postoperative cardiac arrest caused by 5-aminolevulinic acid: a case report.

BACKGROUND: Although 5-aminolevulinic acid is useful for the photodynamic diagnosis of bladder tumors, it often causes severe intraoperative hypotension. We report a case of postoperative cardiac arrest in addition to severe intraoperative hypotension, probably owing to the use of 5-aminolevulinic acid. CASE PRESENTATION: An 81-year-old Japanese man was scheduled to undergo transurethral resection of bladder tumor. The patient took 5-aminolevulinic acid orally 2 hours before entering the operating room. After the induction of anesthesia, his blood pressure decreased to 47/33 mmHg. The patient's hypotension did not improve even after noradrenaline was administered. After awakening from anesthesia, the patient's systolic blood pressure increased to approximately 100 mmHg, but approximately 5 hours after returning to the ward, cardiac arrest occurred for approximately 12 seconds. CONCLUSION: We experienced a case of postoperative cardiac arrest in a patient, probably owing to the use of 5-aminolevulinic acid. Although the cause of cardiac arrest is unknown, perioperative hemodynamic management must be carefully performed in patients taking 5-aminolevulinic acid.

Anesthetic management of extracorporeal membrane oxygenation-supported aortic bypass surgery for atypical coarctation with severe left ventricular dysfunction: A case report.

Atypical aortic coarctation is an exceedingly rare condition, and there are very few reported cases of anesthetic management for bypass surgery in patients with severe impaired cardiac function. We present the anesthetic management of a 68-year-old woman with atypical aortic coarctation due to Takayasu arteritis and severely impaired cardiac function, who underwent ascending-to-abdominal aorta bypass surgery under extracorporeal membrane oxygenation (ECMO). The patient's severe cardiac dysfunction was due to sustained afterload from the coarctation, leading to recurrent episodes of heart failure. Surgical intervention was deemed necessary, and a decision was made to perform a bypass operation. The patient experienced a transient state of shock following induction of anesthesia, but subsequent perioperative care was safely managed with the implementation of ECMO. For bypass surgery performed on patients with severe cardiac dysfunction due to atypical coarctation of the aorta, it is crucial to prepare for potential circulatory collapse during anesthesia induction and the surgical procedure. This preparation includes meticulous planning of the anesthesia induction method and ensuring that ECMO can be established promptly if needed.

Right-to-left shunt due to iatrogenic atrial septal defect manifested by aorto-caval fistula: a case report.

BACKGROUND: An aorto-caval fistula is a rare but critical complication of abdominal aortic aneurysm (AAA) rupture, leading to high-output heart failure and increased venous pressure. The anesthetic management of such cases, particularly when complicated by an intraoperative right-to-left shunt, is seldom reported. CASE PRESENTATION: A 71-year-old man with a history of atrial fibrillation and catheter ablation presented with heart failure and abdominal pain, leading to cardiac arrest. Imaging revealed an AAA rupture into the inferior vena cava. During emergency surgery, severe venous bleeding was managed using intra-aortic balloon occlusion (IABO). Transesophageal echocardiography (TEE) identified a right-to-left shunt due to an iatrogenic atrial septal defect. CONCLUSION: Early TEE recognition and timely IABO intervention were crucial in managing this complex case, underscoring the importance of these techniques in similar emergency scenarios.