Postoperative intubation time is associated with acute kidney injury in cardiac surgical patients.

INTRODUCTION: Acute kidney injury (AKI) is a frequent complication after cardiac surgery and is associated with a poor prognosis. Mechanical ventilation is an important risk factor for developing AKI in critically ill patients. Ventilation with high tidal volumes has been associated with postoperative organ dysfunction in cardiac surgical patients. No data are available about the effects of the duration of postoperative respiratory support in the immediate postoperative period on the incidence of AKI in patients after cardiac surgery. METHOD: We performed a secondary analysis of 584 elective cardiac surgical patients enrolled in an observational trial on the association between preoperative cerebral oxygen saturation and postoperative organ dysfunction and analyzed the incidence of AKI in patients with different times to extubation. The latter variable was graded in 4 h intervals (if below 16 h) or equal to or greater than 16 h. AKI was staged according to the AKI Network criteria. RESULTS: Overall, 165 (28.3%) patients developed AKI (any stage), 43 (7.4%) patients needed renal replacement therapy. Patients developing AKI had a significantly (P <0.001) lower renal perfusion pressure (RPP) in the first 8 hours after surgery (57.4 mmHg (95% CI: 56.0 to 59.0 mmHg)) than patients with a postoperatively preserved renal function (60.5 mmHg ((95% CI: 59.9 to 61.4 mmHg). The rate of AKI increased from 17.0% in patients extubated within 4 h postoperatively to 62.3% in patients ventilated for more than 16 h (P <0.001). Multivariate logistic regression analysis of variables significantly associated with AKI in the univariate analysis revealed that the time to the first extubation (OR: 1.024/hour, 95% CI: 1.011 to 1.044/hour; P <0.001) and RPP (OR: 0.963/mmHg; 95% CI: 0.934 to 0.992; P <0.001) were independently associated with AKI. CONCLUSION: Without taking into account potentially unmeasured confounders, these findings are suggestive that the duration of postoperative positive pressure ventilation is an important and previously unrecognized risk factor for AKI in cardiac surgical patients, independent from low RPP as an established AKI trigger, and that even a moderate delay of extubation increases AKI risk. If replicated independently, these findings may have relevant implications for clinical care and for further studies aiming at the prevention of cardiac surgery associated AKI.

Simultaneous VEP and transcranial Doppler ultrasound recordings to investigate activation-flow coupling in humans.

Simultaneous assessment of electrical as well as hemodynamic responses in visual stimulation tasks is a relatively new approach to investigate activation-flow coupling in humans. To investigate the relation of both signals, we compared visually evoked potentials (VEP) with evoked flow velocity responses in the posterior cerebral artery by performing different visual stimulation tasks in healthy students. Check sizes and flickering frequency of a checkerboard pattern and the radial visual field section of a dartboard pattern were varied. VEPs were expressed in amplitude differences. Hemodynamic changes were given in terms of a control system model specifying the gain, attenuation, natural frequency and rate time parameters. From the typical VEP amplitude differences, we found the early N75-P100 amplitude difference significantly correlated to the gain parameter of the hemodynamic response. Both parameters increased with higher complexity of the checkerboard pattern and increasing visual field sections, whereas they remained nearly stable in the chosen frequency range. To corroborate the hypothesis of a tight coupling, further studies have to prove if the strength of this coupling could be used in clinical conditions.