The impact of relative hypotension on acute kidney injury progression after cardiac surgery: a multicenter retrospective cohort study.

BACKGROUND: Cardiac surgery is performed worldwide, and acute kidney injury (AKI) following cardiac surgery is a risk factor for mortality. However, the optimal blood pressure target to prevent AKI after cardiac surgery remains unclear. We aimed to investigate whether relative hypotension and other hemodynamic parameters after cardiac surgery are associated with subsequent AKI progression. METHODS: We retrospectively enrolled adult patients admitted to 14 intensive care units after elective cardiac surgery between January and December 2018. We defined mean perfusion pressure (MPP) as the difference between mean arterial pressure (MAP) and central venous pressure (CVP). The main exposure variables were time-weighted-average MPP-deficit (i.e., the percentage difference between preoperative and postoperative MPP) and time spent with MPP-deficit > 20% within the first 24 h. We defined other pressure-related hemodynamic parameters during the initial 24 h as exploratory exposure variables. The primary outcome was AKI progression, defined as one or more AKI stages using Kidney Disease: Improving Global Outcomes' creatinine and urine output criteria between 24 and 72 h. We used multivariable logistic regression analyses to assess the association between the exposure variables and AKI progression. RESULTS: Among the 746 patients enrolled, the median time-weighted-average MPP-deficit was 20% [interquartile range (IQR): 10-27%], and the median duration with MPP-deficit > 20% was 12 h (IQR: 3-20 h). One-hundred-and-twenty patients (16.1%) experienced AKI progression. In the multivariable analyses, time-weighted-average MPP-deficit or time spent with MPP-deficit > 20% was not associated with AKI progression [odds ratio (OR): 1.01, 95% confidence interval (95% CI): 0.99-1.03]. Likewise, time spent with MPP-deficit > 20% was not associated with AKI progression (OR: 1.01, 95% CI 0.99-1.04). Among exploratory exposure variables, time-weighted-average CVP, time-weighted-average MPP, and time spent with MPP < 60 mmHg were associated with AKI progression (OR: 1.12, 95% CI 1.05-1.20; OR: 0.97, 95% CI 0.94-0.99; OR: 1.03, 95% CI 1.00-1.06, respectively). CONCLUSIONS: Although higher CVP and lower MPP were associated with AKI progression, relative hypotension was not associated with AKI progression in patients after cardiac surgery. However, these findings were based on exploratory investigation, and further studies for validating them are required. Trial Registration UMIN-CTR, https://www.umin.ac.jp/ctr/index-j.htm , UMIN000037074.

Importance of blood pressure control in Kawasaki disease with expanded multiple giant coronary aneurysms with a 32 mm maximum diameter: a case report.

BACKGROUND: Ruptured coronary artery aneurysm is rare, but the most serious complications of an acute phase of Kawasaki disease (KD) with giant coronary artery aneurysm (GCAA). Progressive or super GCAA, which rapidly dilates and continue to increase over a diameter of 10 mm, are more susceptible to rupture. CASE SUMMARY: We report the case of a 6-year-old boy with KD who had multiple super GCAAs with a high risk of GCAA rupture. On admission to our hospital, he presented with fever, chest pain, and Stage II hypertension. Echocardiographic Z-scores adjusted for body surface area were used for measurements. The coronary artery diameter of segment 1 was 24.3 mm with a Z-score of 20.8; the diameter of segment 3 was 24.4 mm; the diameter of the left anterior descending branch was 32.6 mm with a Z-score of 20.1. The super GCAAs showed a tendency to expand compared to the latest echocardiography, and thrombus formation was observed in the super GCAA of segment 3. The patient was treated with anti-inflammatory therapy, antithrombotic therapy, and antihypertensive therapy with continuous arterial pressure monitoring with the goal of not exceeding the 5th percentile of the normal standard during the period when there was a risk of progressive coronary aneurysm expansion. He was discharged without any neurological complications. DISCUSSION: We speculated that the patient's hypertension was the cause of an expanding coronary artery aneurysm. In conclusion, KD patients with super GCAA may benefit from aggressive blood pressure control with continuous arterial pressure monitoring.

Delayed Obstructive Hydrocephalus After Cardiac Surgery With Cardiopulmonary Bypass in a Patient With Cerebellar Infarction: A Case Report.

Obstructive hydrocephalus caused by brainstem compression is a life-threatening complication and usually occurs within 6 days, with peak on day 3 after onset of cerebellar infarction. We present a case of obstructive hydrocephalus that developed on day 8 in a patient with cerebellar infarction. A 39-year-old man with cerebellar infarction caused by myocardial infarction-related intraventricular thrombus underwent left ventricular thrombectomy under cardiopulmonary bypass. He was lucid postoperatively, but his consciousness was diminished on day 8 because of obstructive hydrocephalus. Cerebral edema due to cardiopulmonary bypass may contribute to delayed onset of obstructive hydrocephalus, especially in patients with large-sized cerebellar infarction.

Cytotoxicity of propofol in human induced pluripotent stem cell-derived cardiomyocytes.

PURPOSE: Propofol infusion syndrome (PRIS) is a lethal condition caused by propofol overdose. Previous studies suggest that pathophysiological mechanisms underlying PRIS involve mitochondrial dysfunction; however, these mechanisms have not been fully elucidated. This study aimed to establish an experimental model of propofol-induced cytotoxicity using cultured human induced pluripotent stem cell (iPSC)-derived cardiomyocytes to determine the mechanisms behind propofol-induced mitochondrial dysfunction, and to evaluate the protective effects of coenzyme Q10 (CoQ10). METHODS: Human iPSC-derived cardiomyocytes were exposed to propofol (0, 2, 10, or 50 µg/ml) with or without 5 µM CoQ10. Mitochondrial function was assessed by measuring intracellular ATP, lactate concentrations in culture media, NAD+/NADH ratio, and the mitochondrial membrane potential. Propofol-induced cytotoxicity was evaluated by analysis of cell viability. Expression levels of genes associated with mitochondrial energy metabolism were determined by PCR. Intracellular morphological changes were analyzed by confocal microscopy. RESULTS: Treatment with 50 µg/ml propofol for 48 h reduced cell viability. High concentrations of propofol (≥ 10 µg/ml) induced mitochondrial dysfunction accompanied by downregulation of gene expression of PGC-1alpha and its downstream targets (NDUFS8 and SDHB, which are involved in the respiratory chain reaction; and CPT1B, which regulates beta-oxidation). Cardiomyocytes co-treated with 5 µM CoQ10 exhibited resistance to propofol-induced toxicity through recovery of gene expression. CONCLUSIONS: Propofol-induced cytotoxicity in human iPSC-derived cardiomyocytes may be associated with mitochondrial dysfunction via downregulation of PGC-1alpha-regulated genes associated with mitochondrial energy metabolism. Co-treatment with CoQ10 protected cardiomyocytes from propofol-induced cytotoxicity.

Perioperative Elevation in Cell-Free DNA Levels in Patients Undergoing Cardiac Surgery: Possible Contribution of Neutrophil Extracellular Traps to Perioperative Renal Dysfunction.

Background. This study aimed to determine the perioperative change in serum double-strand DNA (dsDNA) as a marker potentially reflecting neutrophil extracellular trap concentration in samples from patients undergoing cardiac surgery and to analyze a relationship between serum dsDNA concentrations and perioperative renal dysfunction. Methods. Serum dsDNA concentrations in samples that were collected during a previously conducted, prospective, multicenter, observational study were measured. Eighty patients undergoing elective cardiac surgery were studied. Serum samples were collected at baseline, immediately after surgery, and the day after surgery (POD-1). Results. Serum dsDNA concentration was significantly increased from baseline (median, 398 ng/mL [interquartile range, 372-475 ng/mL]) to immediately after surgery (median, 540 ng/mL [437-682 ng/mL], p < 0.001), and they were reduced by POD-1 (median, 323 ng/mL [256-436 ng/mL]). The difference in serum creatinine concentration between baseline and POD-1 was correlated with dsDNA concentration on POD-1 (rs = 0.61, p < 0.001). Conclusions. In patients undergoing cardiac surgery, serum dsDNA concentration is elevated postoperatively. Prolonged elevation in dsDNA concentration is correlated with perioperative renal dysfunction. Further large-scale studies are needed to determine the relationship between serum concentration of circulating dsDNA and perioperative renal dysfunction.

Polymyxin B hemoperfusion prevents acute kidney injury in sepsis model.

BACKGROUND: Direct hemoperfusion with a polymyxin B-immobilized column (PMX-DHP) adsorbs endotoxin and has been used for the treatment of septic shock. Yet, the mechanisms by which PMX-DHP acts on acute kidney injury are only partially understood. MATERIALS AND METHODS: Rats were anesthetized, tracheostomized, and placed on mechanical ventilation. The animals were randomized to three groups: a cecal ligation and puncture (CLP) + dummy-DHP group (n = 10), a CLP + PMX-DHP group (n = 10), and a sham group (n = 4). Four hours after CLP, a dummy-DHP or PMX-DHP was performed for 1 h. The heart rate, mean arterial pressure, arterial blood gases, and plasma concentrations of creatinine, lactate, potassium, interleukin (IL)-6, and IL-10 were measured at 0 h and 8 h. Eight hours after CLP, the kidney was harvested, and histopathologic examination was performed. The expressions of cleaved poly (ADP-ribose) polymerase (PARP) and nuclear factor (NF)-κB p65 were examined by immunohistochemistry. A terminal deoxynucleotide transferase dUTP nick-end labeling assay was performed to detect apoptotic nuclei in kidney sections. RESULTS: PMX-DHP maintained hemodynamics and the acid-base balance and significantly (P < 0.05) decreased the plasma concentrations of lactate, creatinine, potassium, IL-6, and IL-10 compared with dummy-DHP. PMX-DHP significantly (P < 0.001) attenuated the expressions of cleaved PARP and NF-κB p65 in renal tubular cells and renal tubular cell apoptosis compared with dummy-DHP. CONCLUSIONS: These findings suggest that PMX-DHP may protect against acute kidney injury not only by inhibiting the NF-κB signaling pathway but also by preventing renal tubular cell apoptosis.

[Anesthetic management for surgery of giant coronary aneurysms complicated with Churg-Strauss syndrome].

Few cases of Churg-Strauss syndrome (CSS) complicated by giant coronary aneurysms (CAs)have been reported thus far. We report a case of CSS in a 60-year-old man who underwent surgery for giant CAs, and was managed with anesthetics. The patient developed acute myocardial infarction, and was diagnosed with giant CAs in the right coronary artery (RCA, 11 cm) and circumflex artery (3 cm). The CA in RCA was communicating with the right ventricle. He had a history of pericardiectomy for pericarditis caused by the CSS and developed thrombocytopenia due to consumptive coagulopathy within the CAs. An operation, including ligation and excision of the CAs, and coronary artery bypass grafting was performed under general anesthesia and cardiopulmonary bypass. There was massive hemorrhage followed by hemodynamic instability while detaching the tight pericardial adhesion and fragile surface of the CAs. Massive transfusion was required along with inotropes administration and intraaortic balloon support. In this case, determination of the appropriate surgical timing was difficult because symptoms of the CSS became worse followed by rapid enlargement of the CAs, myocardial infarction, and thrombocytopenia. Steroids were administered for treating CSS, and the blood transfusion was sufficient. However, it was difficult to control the hemorrhage and maintain hemodynamic stability.

[A case of prolonged neuromuscular blockade possibly related to a high anti-acetylcholine receptor antibody level].

Prolonged neuromuscular blockade is a relatively common complication of general anesthesia. Some previous reports have shown that positive serum anti-acetylcholine receptor antibody (AChR Ab) might contribute to this complication. We experienced a case of a 69-year-old woman with prolonged neuromuscular blockade after laparoscopic sigmoid colectomy under general anesthesia using rocuronium. A high level of anti-AChR Ab (45 nmol x l-1) was found in postoperative examination and the patient had progressive muscle weakness for six months after the operation. Although this patient had mediastinal tumor diagnosed as thymic carcinoma two years before the operation, preoperative clinical evaluation was negative for myasthenia gravis (MG) and the tumor was in remission at the operation. These observations suggest that preoperative measurement of anti-AChR Ab level might be recommended for patients with mediastinal tumor regardless of symptoms of MG and that neuromuscular blocking agents should be administrated carefully in anti-AChR Ab positive patients under monitoring of the neuromuscular blockade.

[Ultrasound-guided peripheral nerve block for high-risk patients with arteriosclerosis obliterans in lower limb surgery--a report of nine cases].

Most patients with arteriosclerosis obliterans (ASO) have severe complications such as coronary artery disease, congestive heart failure and chronic kidney disease. They receive long-term antithrombotic therapy which is a contraindication to neuraxial anesthesia. In this retrospective study, we reviewed nine high-risk patients with ASO (revised cardiac risk index more than three) who underwent an urgent lower limb surgery under ultrasound-guided peripheral nerve block (PNB). In all cases, intraoperative hemodynamic changes remained minimized. In eight of the nine cases, analgesics are not required until 10 hours after the operation. No complication related to PNB occurred. Ultrasoundguided PNB for patients with ASO undergoing lower limb surgery can be a useful anesthetic technique, providing cardiovascular stability and good postoperative analgesia.