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Original Article, Background: Acute kidney injury (AKI) is a common complication after cardiovascular surgery. The incidence of AKI after cardiovascular surgery is high, which worsens outcomes. We examined the incidence of AKI after aortic surgery without circulatory arrest and the effectiveness of AKI urinary biomarkers, including liver-type fatty acid-binding protein (L-FABP) and neutrophil gelatinase-associated lipocalin (NGAL). Methods: The participants were 60 adults who underwent surgery for a descending thoracic aortic aneurysm with left heart bypass technique under general anesthesia. Urinary L-FABP and NGAL levels were measured immediately and 24 hours after surgery and compared between patients with and without AKI. Results: Twenty-one patients (35%) developed AKI. Urinary L-FABP level significantly differed between the AKI group and non-AKI group at 24 hours after surgery. In contrast, urinary NGAL was not associated with AKI. Conclusions: After replacement of the descending aorta, which can cause mild reperfusion injury, L-FABP was better than NGAL in predicting postoperative AKI.

Aortobronchial fistula (ABF) is a rare and potentially lethal complication of thoracic aortic replacement surgery. Currently, thoracic endovascular aortic repair (TEVAR) has emerged as a less invasive alternative to open surgery for ABF to facilitate prompt hemostasis. However, there are no published reports of TEVAR for ABF, particularly for presentation with life-threatening respiratory failure from massive hemoptysis. A 48-year-old male patient, who had recently undergone aortic root and arch replacement due to aortic dissection, was transferred to the emergency department with massive hemoptysis and severe dyspnea. A single-lumen endotracheal tube was immediately placed in the right main bronchus to protect the nonbleeding lung from spillage of blood. Chest computed tomography (CT) showed leakage of contrast material from the distal anastomosis of the aortic graft and consolidated lung tissue adjacent to the leakage. He was diagnosed with an ABF following aortic arch replacement, and an emergency TEVAR was performed. After adequate hemostasis, severe hypercapnia remained uncorrected despite the maximum ventilatory support. Thus, venovenous extracorporeal membrane oxygenation (VV ECMO) was immediately initiated, and severe respiratory acidosis improved dramatically. Furthermore, VV ECMO facilitated prompt bronchoscopic washout of the remaining blood clot without any danger of respiratory collapse and was weaned off successfully after 5 days as ventilation improved. This case demonstrates that emergency TEVAR in combination with VV ECMO can be a rescue strategy for massive hemoptysis from an ABF.

Paraplegia is a serious complication after thoracoabdominal aortic aneurysm repair. Therefore, maintenance of spinal cord perfusion pressure, drainage of cerebrospinal fluid, and avoidance of opioids are important for prevention of paraplegia Management of acute post-thoracotomy pain is necessary not only to keep the patient comfortable but also to minimize postoperative complications. However, epidural analgesia, a common method of pain control, is hard to use because of existing postoperative coagulopathy and avoidance of spinal cord ischemia Although both paravertebral block and epidural analgesia provide comparable pain relief after thoracic surgery, paravertebral block has lesser detrimental effects on spinal cord perfusion and better preserves the possibility to monitor neurologic function than epidural analgesia. We report 7 cases in which paravertebral blockade was used for analgesia in patients who underwent thoracoabdominal aneurysm repair.

BACKGROUND Acute kidney injury (AKI) after surgery is associated with an increased risk of adverse events and death. Atrial natriuretic peptide (ANP) dilates the preglomerular renal arteries and inhibits the renin-angiotensin axis. A low-dose ANP infusion increases glomerular filtration rate after cardiovascular surgery, but it is not known whether it reduces the incidence of AKI or the mortality rate. OBJECTIVE To evaluate whether an intravenous ANP infusion prevents AKI in patients undergoing aortic arch surgery requiring hypothermic circulatory arrest. DESIGN A randomised controlled study. SETTING Operating room and intensive care unit at Kawasaki Saiwai Hospital, Kanagawa, Japan. PATIENTS Forty-two patients with normal preoperative renal function undergoing elective repair of an aortic arch aneurysm. INTERVENTION Patients were assigned randomly to receive a fixed dose of ANP (0.0125 μg (-1) kg(-1) min) or placebo. The infusion was started after induction of anaesthesia and continued for 24 h postoperatively. MAIN OUTCOME MEASURES The primary end-point was the incidence of AKI within 48 h after surgery. RESULTS AKI developed in 30% of patients who received ANP compared with 73% of patients who received placebo (P = 0.014). Intraoperative urine output was almost 1 l greater in patients who received ANP (1865 ± 1299 versus 991 ± 480 ml in the control group, P = 0.005). However, there were no differences in mean arterial pressure or number of episodes of hypotension between the groups. Length of hospital and intensive care stays were not significantly different, nor was there a difference in 30-day mortality. No patients required haemodialysis or continuous renal replacement therapy. CONCLUSION We found that an intravenous infusion of ANP at 0.0125 μg kg(-1) min(-1) is an effective intervention for reducing the incidence of postoperative AKI, and appears to afford a degree of renal protection during and after cardiovascular surgery. TRIAL REGISTRATION Kawasaki ANP trial, UMIN Clinical Trials Registry ID: UMIN000011650.

This case report describes a successful anesthetic management of a 74-year-old patient with a giant bulla and pulmonary dysfunction during off-pump coronary artery bypass grafting (OPCAB). BiPAP Vision with a laryngeal mask airway (LMA) was used for intraoperative respiratory management. General anesthesia was induced with propofol. After insertion of a LMA anesthesia was maintained with propofol and dexmedetomidine under spontaneous breathing with bilevel positive airway pressure. Epidural analgesia was used in combination with general anesthesia. The LMA was removed without coughing and bucking soon after the end of the surgery. There was no complication during and after anesthesia. This respiratory management may be beneficial for patients with a giant bulla and pulmonary dysfunction during OPCAB.

For a parturient with breech presentation, an external cephalic version is sometimes done to enable vaginal delivery. Usually external cephalic version has been done without anesthesiologist's management. However there have been several reports indicating a benefit of anesthesia for external cephalic version. We report successful case of external cephalic version under combined spinal-epidural anesthesia followed by vaginal delivery.

A novel echogenic insulated nerve block needle (CCR-needle: Echogenic Needle Type CCR; Hakko, Japan) is commercially available since 2006 in Japan. This needle has three echogenic dimples, namely corner cube reflectors (CCR) on its tip. The CCR-needle will potentially provide a significant advantage for detecting the needle tip. In this report, we firstly evaluated this new disposable echogenic needle in simulation phantom, and demonstrated improved visibility of the needle tip. Afterwards, an interscalene brachial plexus block was performed on a male patient undergoing shoulder surgery. The needle insertion procedure was the "out of plane" ultrasound-guided technique using simultaneous electrical nerve stimulation. The surgery was successfully conducted without any complications.