INTRODUCTION:Acute Stanford type A aortic dissection (ATAAD) is a lethal emergency. However, even with instant surgical repair, early mortality is up to 20%. ATAAD complicated by coronary artery involvement is considered rare but life-threatening because this can cause coronary artery malperfusion which results in acute myocardial infarction. In particular, left coronary artery malperfusion can bring worse outcomes than right coronary artery malperfusion, but there are few reports of left coronary artery involvement secondary to ATAAD. CASE PRESENTATION:We present a case of a woman who got emergency open heart surgery due to ATAAD. After the hemiarch replacement, the first weaning from bypass was relatively smooth. However, as soon as starting infusion protamine, we found out sudden regional wall motion abnormality at the diffuse anteroseptal to the lateral wall on echocardiography and ST depression on leads II and V5 electrocardiogram after several ventricular fibrillation. We recognized by echocardiography that intimal dissection flap extended to the left coronary artery ostium and dynamically obstructed left coronary artery blood flow, because the true lumen collapsed dynamically during the diastolic phase. Upon re-establishing bypass, proximal aortic false lumen was obliterated with BioGlue again. Smooth weaning from bypass proceeded at last. Finally, the blood flow to the left coronary artery ostium was good, and the wall motion abnormality was improved. CONCLUSION:Our report suggests the importance of the degree of myocardial damage caused by coronary artery malperfusion which is a major predictor of patient outcome. To reduce complications and minimize the mortality rate, an instant treatment plan is needed. However, limited options for exact surgical treatment directions or guidelines for coronary artery malperfusion secondary to ATAAD are available so far. We emphasize that we should not neglect any signs indicative of coronary artery malperfusion appear such as changes of electrocardiogram and echocardiography. Moreover, our report contributes to a profound understanding among clinicians regarding the necessity of practical treatment guidelines about coronary artery malperfusion due to ATAAD based on various surgical experiences and studies.

Background: Hypoalbuminemia is a marker of poor overall health with influences from protein energy malnutrition, systemic inflammation and hepatic and renal disease. Albumin has been reported to have a prognostic impact in various cohorts. This study investigated whether preoperative serum albumin levels could be used to predict mortality in patients with aortic aneurysms undergoing graft replacement of ascending aorta and aortic arch. Methods: We retrospectively reviewed 183 patients who underwent graft replacement of ascending aorta and aortic arch between January 2010 and December 2020. The exclusion criteria included patients with traumatic aortic injuries (n=2), previous aortic repair within 6 months (n=2), ruptured aortic aneurysms (n=14), or a lack of preoperative laboratory data or medical records (n=10). The remaining 87% eligible patients were divided into two groups based on their preoperative serum albumin levels. The lower albumin group was defined as having serum albumin levels ≤3.5 g/dL, while the higher albumin group was defined as having albumin levels >3.5 g/dL. The incidence of mortality was compared between the two groups, and a logistic regression analysis was performed to evaluate the predictors of mortality. Results: The incidence of 1-year mortality was higher in the lower albumin group than in the higher albumin group (3.4% vs. 23.5%, p=0.006). The optimal cut-off value of albumin to predict 1-year mortality was 4.0 g/dL (area under the curve 0.885, 95% CI 0.821-0.949, p<0.001), with a sensitivity and specificity of 90.0% and 80.3%, respectively. Preoperative serum albumin levels (OR = 0.116, 95% CI 0.021-0.641, p=0.014) and diabetes mellitus (OR = 5.757, 95% CI 1.018-32.565, p=0.048) remained independent predictors of mortality. Conclusion: Preoperative serum albumin levels were an independent predictor of 1-year mortality after the graft replacement of ascending aorta and aortic arch. These findings underscore that the optimization of patients' nutritional status before surgery may be warranted and should be further explored in this high-risk population.

Serum alkaline phosphatase (ALP) levels are related to high-turnover bone disease and reflect vascular calcification and inflammation. ALP has been reported to have a prognostic impact in various cohorts including chronic kidney disease. This study investigated whether preoperative serum ALP level could be used for predicting mortality in patients undergoing kidney transplantation. We retrospectively reviewed 1,718 patients who underwent kidney transplantation between November 2005 and June 2017. Finally, 1,533 patients who met the inclusion criteria were classified into tertiles based on preoperative serum ALP level (< 51, 51–72, > 72 IU/L). The incidence of mortality was compared among the three tertiles, and a stepwise logistic regression analysis was performed to evaluate the predictors for mortality. The incidence of 3-year mortality was the highest in the third tertile (1.0% vs. 2.5% vs. 4.4% in the first, second, and third tertile, respectively, p = 0.003). The third tertile of ALP level (odds ratio [OR] 1.855, 95% CI 1.192–2.886, p = 0.006), age (OR 1.052, 95% CI 1.022–1.082, p = 0.011), and history of hypertension (OR 0.401, 95% CI 0.210–0.765, p = 0.006) remained as independent predictors of mortality. Preoperative serum ALP level was significantly higher in the non-survivor group than in the survivor group (58.00 [44.00–76.00] vs. 75.00 [56.25–113.00], p = 0.003). The optimal cut-off value of serum ALP to predict 3-year mortality was 71 IU/L (area under the curve 0.636, 95% CI 0.554–0.719, p = 0.003). Therefore, preoperative serum ALP level was an independent predictor of 3-year mortality in patients undergoing kidney transplantation.

Objectives: To investigate if preoperative neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), or mean platelet volume (MPV) could be used to predict 1-year mortality in patients undergoing open abdominal aortic aneurysm (AAA) repair. Methods: We retrospectively reviewed 382 patients who underwent open AAA repair between January 2008 and July 2019. We divided the patients into two groups based on 1-year mortality and compared the preoperative NLR, PLR, and MPV. The patients were then classified into tertiles based on their preoperative NLR (first tertile: <2.41 (n = 111); second tertile: 2.41 ≤ NLR ≤ 6.07 (n = 111); and third tertile: >6.07 (n = 112)). We compared the incidence of mortality and morbidity across the aforementioned tertiles. We performed a stepwise logistic regression analysis to evaluate the predictors for mortality. An additional subgroup analysis was performed by dividing the cases into non-ruptured and ruptured cases. Results: The preoperative NLR was significantly higher in the non-survivor group than in the survivor group (10.53 ± 7.60 vs. 5.76 ± 6.44, respectively, p = 0.003). The PLR and MPV were similar between the groups (145.35 ± 91.11 vs. 154.20 ± 113.19, p = 0.626, 9.38 ± 1.20 vs. 9.11 ± 1.39, p = 0.267, respectively). The incidence of 1-year mortality was 2.7%, 9.0%, and 14.3% in the first, second, and third NLR tertiles, respectively (p = 0.009). Higher NLR (odds ratio 1.085, 95% confidence interval 1.016–1.159, p = 0.015) and ruptured AAA (odds ratio 2.706, 95% confidence interval 1.097–6.673, p = 0.031) were the independent predictors of 1-year mortality in all patients. Moreover, the preoperative NLR was significantly higher in the ruptured AAA than in the non-ruptured AAA group (11.17 ± 7.90 vs. 4.10 ± 4.75, p < 0.001). In subgroup analysis, preoperative NLR (odds ratio 1.144, 95% confidence interval 1.031–1.271, p = 0.012) and PLR (odds ratio 0.986, 95% confidence interval 16 0.975–0.998, p = 0.017) was an independent predictor for 1-year mortality in ruptured cases. Conclusions: We demonstrated an independent relationship between the preoperative NLR and 1-year mortality in patients undergoing open AAA repair, besides PLR and MPV. Furthermore, the NLR and PLR had predictive power for 1-year mortality in ruptured cases.

Dexmedetomidine has emerged as a promising organ protective agent. We performed prospective randomized placebo-controlled trial investigating effects of perioperative dexmedetomidine infusion on pulmonary function following thoracic aortic surgery with cardiopulmonary bypass and moderate hypothermic circulatory arrest. Fifty-two patients were randomized to two groups: the dexmedetomidine group received 1 µg/kg of dexmedetomidine over 20 min after induction of anesthesia, followed by 0.5 µg/kg/h infusion until 12 h after aortic cross clamp (ACC)-off, while the control group received the same volume of normal saline. The primary endpoints were oxygenation indices including arterial O 2 partial pressure (PaO 2 ) to alveolar O 2 partial pressure ratio (a/A ratio), (A–a) O 2 gradient, PaO 2 /FiO 2 and lung mechanics including peak inspiratory and plateau pressures and compliances, which were assessed after anesthesia induction, 1 h, 6 h, 12 h, and 24 h after ACC-off. The secondary endpoints were serum biomarkers including interleukin-6, tumor necrosis factor-α, superoxide dismutase, and malondialdehyde (MDA). As a result, dexmedetomidine did not confer protective effects on the lungs, but inhibited elevation of serum MDA level, indicative of anti-oxidative stress property, and improved urine output and lower requirements of vasopressors.

Age and acute hyperglycemia are known risk factors of myocardial ischemia-reperfusion injury. We investigated age-related difference in the effect of acute hyperglycemia on myocardial ischemia-reperfusion injury in Sprague-Dawley rats (young, 3 months; middle-aged, 10-12 months; and old, 22-24 months). The rats received 1.2 g/kg dextrose or normal saline and were subjected to coronary artery occlusion for 45 minutes followed by reperfusion for 240 minutes. Infarct size and ejection fraction were measured. The levels of apoptosis-related proteins (C-PARP, Bcl-2, Bax, and cytochrome c) and autophagy-related proteins (Bnip3, Beclin-1, Atg5, and LC3B-II) were evaluated. Infarct size increased with acute hyperglycemia in young and middle-aged rats but not in old rats, whereas the reduction of ejection fraction after ischemia-reperfusion was aggravated by acute hyperglycemia in all age groups. Acute hyperglycemia increased Bnip3 and Beclin-1 expressions after ischemia-reperfusion in young and middle-aged rats but not in old rats, whereas it increased the expression of Bax, cytochrome c, Atg5, and LC3B-II only in young or middle-aged rats. Conclusively, acute hyperglycemia does not aggravate myocardial ischemia-reperfusion injury in old rats, unlike in young and middle-aged rats. This heterogeneity may be due to attenuated changes in protein signaling after ischemia-reperfusion injury under acute hyperglycemia in old rats.

Several studies have reported that the neutrophil to lymphocyte ratio (NLR) and mean platelet volume (MPV) are associated with poor prognosis. This study investigated whether NLR and/or the MPV/platelet ratio could function as predictive markers of mortality in critically ill patients. We retrospectively reviewed 1,154 patients admitted to the intensive care unit (ICU) between January 2017 and December 2017. Patients were divided into 2 groups according to 1-year mortality. We compared the NLR and MPV/platelet ratio on each day of ICU admission. Patients were classified into tertiles based on their NLR and MPV/platelet ratios, and the incidence of 1-year mortality was compared. Kaplan–Meier survival curves were plotted to evaluate their potential as prognostic factors for 1-year mortality. The NLR and MPV/platelet ratio were higher in the non-survivor group than in the survivor group. The incidence of 1-year mortality was the highest in the third tertile for both the NLR and MPV/platelet ratio. The MPV/platelet ratio was an independent predictor for 1-year mortality based on the Kaplan–Meier survival analysis. Our data showed that the MPV/platelet ratio is a predictive factor for 1-year mortality in critically ill patients.

BACKGROUND:Serum alkaline phosphatase (ALP) is related to vascular calcification and is known to have a prognostic impact in various cohorts. However, evidence in patients undergoing thoracic endovascular aortic repair (TEVAR) is lacking. Thus, we hypothesized that preoperative serum ALP level could be used for predicting adverse events after TEVAR. METHODS:We retrospectively reviewed 167 patients who underwent TEVAR between February 2013 and December 2016. Patients were classified into tertiles according to preoperative ALP level (<69, 69-92, and >92 IU/L). The composite of morbidity and mortality (composite MM) was defined as the presence of one or more of the following: myocardial infarction, cerebrovascular accident, dialysis requirement, pulmonary complication, infection, and mortality within 1 year after TEVAR. The incidence of composite MM was compared among the 3 tertiles, and stepwise logistic regression analysis was performed to evaluate the predictors for composite MM. RESULTS:The incidence of composite MM was 14.5% in the first tertile group, 17.9% in the second tertile group, and 35.7% in the third tertile group (P = .016). The third tertile of ALP level (odds ratio [OR] 1.766, 95% confidence interval [CI] 1.074-2.904, P = .025) and emergency TEVAR (OR 2.369, 95% CI 1.050-5.346, P = .038) remained as independent predictors of composite MM. CONCLUSIONS:Our data showed an independent relationship between high preoperative ALP levels and adverse outcomes in patients undergoing TEVAR. This finding might suggest a potential role of ALP level as a risk stratification marker.

BACKGROUND:Cardiac and cerebrovascular complications are major causes of adverse outcomes following thoracic endovascular aortic repair (TEVAR). The benefits of statins have been established, but little is known about their impact on patients undergoing TEVAR. We investigated whether chronic statin use protected against early postoperative major adverse cardiac and cerebrovascular events (MACCEs) after TEVAR.METHODS:We retrospectively reviewed 211 patients who underwent TEVAR between February 2013 and March 2017 classified into two groups, those with acute aortic syndrome (AAS, N.=79) and those without (non-AAS, N.=132). Patients were subdivided according to preoperative statin therapy for ≥3 months or not. The primary endpoint was 30-day MACCE, defined as myocardial infarction, stroke, arrhythmia, cardiovascular death, or cerebrovascular death. Acute kidney injury (AKI) occurrence within 48 hours was also evaluated. Multivariate logistic regression analysis was performed to identify independent risk factors for MACCEs and AKI.RESULTS:Incidence of MACCEs (1% vs. 11%, P=0.019) was significantly lower in the statin group than in the no-statin group in non-AAS patients. Multivariate logistic regression analysis revealed statin use (odds ratio 0.85, 95% confidence interval 0.01-0.95, P=0.046) as an independent predictor for MACCE in non-AAS patients. The AKI incidence was significantly higher in the statin group than in the no-statin group in AAS patients (44% vs. 15%, P=0.018).CONCLUSIONS:In patients undergoing TEVAR, chronic statin use was associated with reduced 30-day MACCEs in non-AAS patients, but not in AAS patients. It might rather be associated with increased risk of AKI in AAS patients.

AIM: To compare the image quality of computed tomography angiography (CTA) reconstructed by sinogram-affirmed iterative reconstruction (SAFIRE) with that of advanced modelled iterative reconstruction (ADMIRE) in children with congenital heart disease (CHD). MATERIAL AND METHODS: Thirty-one children (8.23 +/- 13.92 months) with CHD who underwent CTA were enrolled. Images were reconstructed using SAFIRE (strength 5) and ADMIRE (strength 5). Objective image qualities (attenuation, noise) were measured in the great vessels and heart chambers. Two radiologists independently calculated the contrast-to-noise ratio (CNR) by measuring the intensity and noise of the myocardial walls. Subjective noise, diagnostic confidence, and sharpness at the level prior to the first branch of the main pulmonary artery were also graded by the two radiologists independently. RESULTS: The objective image noise of ADMIRE was significantly lower than that of SAFIRE in the right atrium, right ventricle, and myocardial wall (p<0.05); however, there were no significant differences observed in the attenuations among the four chambers and great vessels, except in the pulmonary arteries (p>0.05). The mean CNR values were 21.56 +/- 10.80 for ADMIRE and 18.21 +/- 6.98 for SAFIRE, which were significantly different (p<0.05). In addition, the diagnostic confidence of ADMIRE was significantly lower than that of SAFIRE (p<0.05), while the subjective image noise and sharpness of ADMIRE were not significantly different (p>0.05). CONCLUSION: CTA using ADMIRE was superior to SAFIRE when comparing the objective and subjective image quality in children with CHD. (c) 2017 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

Background: The i-gel has a gel-like cuff composed of thermoplastic elastomer that does not require cuff inflation. As the elimination of cuff inflation may shorten insertion time, the i-gel might be a useful tool in emergency situations requiring prompt airway care. This systematic review and meta-analysis of previous adult manikin studies for inexperienced personnel was performed to compare the i-gel with other supraglottic airways. Methods: We searched PubMed, the Cochrane Library, and EMBASE for eligible randomized controlled trials (RCTs) published before June 2015, including with a crossover design, using the following search terms: “i-gel,” “igel,” “simulation,” “manikin,” “manikins,” “mannequin,” and “mannequins.” The primary outcomes of this review were device insertion time and the first-attempt success rate of insertion. Results: A total of 14 RCTs were included. At the initial assessment without difficult circumstances, the i-gel had a significantly shorter insertion time than the LMA Classic, LMA Fastrach, LMA Proseal, LMA Unique, laryngeal tube, Combitube, and EasyTube. However, a faster insertion time of the i-gel was not observed in comparisons with the LMA Supreme, aura-i, and air-Q. In addition, the i-gel did not show the better results for the insertion success rate when compared to other devices. Conclusion: The findings of this meta-analysis indicated that inexperienced volunteers placed the i-gel more rapidly than other supraglottic airways with the exception of the LMA Supreme, aura-i, and air-Q in manikin studies. However, the quicker insertion time is clinically not relevant. The unapparent advantage regarding the insertion success rate and the inherent limitations of the simulation setting indicated that additional evidence is necessary to confirm these advantages of the i-gel in an emergency setting.

Purpose: Supraglottic airway devices have been widely utilized as an alternative to tracheal intubation in various clinical situations. The rotation technique has been proposed to improve the insertion success rate of supraglottic airways. However, the clinical efficacy of this technique remains uncertain as previous results have been inconsistent, depending on the variable evaluated.Materials and Methods: We systematically searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials in April 2015 for randomized controlled trials that compared the rotation and standard techniques for inserting supraglottic airways.Results: Thirteen randomized controlled trials (1505 patients, 753 with the rotation technique) were included. The success rate at the first attempt was significantly higher with the rotation technique than with the standard technique [ relative risk (RR): 1.13; 95% confidence interval (CI): 1.05 to 1.23; p = 0.002]. The rotation technique provided significantly higher overall success rates (RR: 1.06; 95% CI: 1.04 to 1.09; p < 0.001). Device insertion was completed faster with the rotation technique (mean difference: -4.6 seconds; 95% CI: -7.37 to -1.74; p = 0.002). The incidence of blood staining on the removed device (RR: 0.36; 95% CI: 0.27 to 0.47; p < 0.001) was significantly lower with the rotation technique.Conclusion: The rotation technique provided higher first-attempt and overall success rates, faster insertion, and a lower incidence of blood on the removed device, reflecting less mucosal trauma. Thus, it may be considered as an alternative to the standard technique when predicting or encountering difficulty in inserting supraglottic airways.

Size selection of the laryngeal mask airway (LMA) Classic based on actual body weight remains a common practice. However, ideal body weight might allow for a better size selection in obese patients. The purpose of our study was to compare the utility of ideal body weight and actual body weight when choosing the appropriate size of the LMA Classic by a randomized clinical trial. One hundred patients with age 20 to 70 yr, body mass index ≥25 kg/m(2), and the difference between LMA sizes based on actual weight and ideal weight were allocated to insert the LMA Classic using either actual body weight or ideal body weight in a weight-based formula for size selection. After insertion of the device, several variables including insertion parameters, sealing function, fiberoptic imaging, and complications were investigated. The insertion success rate at the first attempt was lower in the actual weight group (82%) than in the ideal weight group (96%), even it did not show significant difference. The ideal weight group had significantly shorter insertion time and easier placement. However, fiberoptic views were significantly better in the actual weight group. Intraoperative complications, sore throat in the recovery room, and dysphonia at postoperative 24 hr occurred significantly less often in the ideal weight group than in the actual weight group. It is suggested that the ideal body weight may be beneficial to the size selection of the LMA Classic in overweight patients (Clinical Trial Registry, NCT 01843270).

Thrombus-in-transit appears to increase the risk of mortality compared to pulmonary embolism alone and can require alteration in therapeutic plan. We present the case of a biatrial thromboembolus caught in transit across a patent foramen ovale diagnosed by intraoperative transesophageal echocardiogram in a 69-year-old female with acute pulmonary embolism and subsequent acute cerebral infarction. We suggest that echocardiography should be performed in a patient with suspected pulmonary thromboembolism to evaluate right heart function and diagnose emboli in transit.

Received: October 10, 2013. Revised: October 12, 2013. Accepted: November 14, 2013. Corresponding author: Sang Beom Nam, M.D., Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 146-92, Dogok-dong, Gangnam-gu, Seoul 135-720, Korea. Tel: 82-2-2019-6082, Fax: 82-2-3463-0940, E-mail: sbnam@yuhs.ac Effects of steep head-down position on pulse pressure variation

Intubation of patients with major intraoral arterial bleeding is a challenge for anesthesiologists. We succeeded orotracheal intubation with a lightwand, but the orotracheal intubation tube was exchanged with a nasotracheal intubation tube for a surgical approach. We successfully changed the orotracheal to the nasotracheal intubation tube with a fiberoptic bronchoscope (FOB). A 29-year-old man, 170 cm in height and 59 kg in weight, without any previous medical problems was admitted to the emergency room for the treatment of postoperative intraoral bleeding. Two days earlier, the patient underwent plastic surgery at a local clinic to revise his square jaw. During the operation, the right external carotid artery was lacerated. After the surgery, the surgeon applied gauze packing to the bleeding site for hemostasis and the wound was left open. The hemodynamic status of the patient was stable for one day at the local clinic. The surgeon had planned to close the wound site after hemostasis, however bleeding continued. When the patient arrived in the operating room, he was alert and without dyspnea. He could open his mouth fully despite postoperative pain. The patient's initial oxygen saturation was 100%. His heart rate was 123 beats/min, and his blood pressure was 108/63 mmHg. Before anesthesia induction, pre-oxygenation through an oxygen mask at a rate of 5 L/min was performed. Glycopyrrolate 0.004 mg/kg was administered intravenously as a premedication. We maintained the patient in the reverse Trendelenburg position to prevent aspiration. We did not perform awake intubation because of patient's anxiety and pain. Anesthesia was induced with propofol 0.6 mg/kg and sevoflurane at a concentration of 2% in oxygen. A small dose of propofol was administered to prevent hypotension. Fortunately, mask ventilation was partially possible and SpO2 remained at 100%. Upon laryngoscopic examination, no part of the glottis was visualized due to the presence of the packed gauze and intraoral hematoma. We were unable to identify the airway or normal anatomy of the pharynx. We attempted fiberoptic nasotracheal intubation. The FOB was passed through the pharynx, but the vocal cords were not visualized due to the hematoma and gauze in the oropharynx. Intubation with the FOB failed. Next, we considered administering a laryngeal mask airway (LMA), but LMA was not guaranteed to prevent aspiration. The lightwand was chosen to maintain ventilation and it provided a more secure airway than LMA [1]. We successfully intubated the patient in the second attempt with a lightwand. The surgeon requested nasal intubation for surgical approach. A nasal intubation tube was advanced through the naris and FOB was advanced through the nasotracheal tube and inserted close to the anterior commissure of the vocal cord along with the orotracheal tube. Under examination with the FOB, we checked the balloon of the orotracheal tube and deflated the balloon. Then, the FOB was advanced to the carina. After the orotracheal tube was carefully removed, the nasotracheal intubation tube was railroaded slowly over the FOB. After intubation, the tracheal tube position was verified by auscultating equal bilateral breath sounds as well as by monitoring EtCO2. The surgery involved controlling the patient's bleeding using an extra oral approach with electrocoagulation of the right external carotid artery and the use of topical hemostatic agents. When the surgery was finished, extubation was not performed due to intraoral edema and the possibility of rebleeding. The patient was sent to the intensive care unit (ICU). Two days later, he was extubated and discharged from the ICU without any complications. Although orotracheal intubation was successful in this difficult airway, we had to change the orotracheal tube to a nasotracheal tube for surgery. A new lightwand (Trachlight™) with a brighter light source and flexible stylet permitted oral and nasal intubation under ambient light. In a reported case, the soft lightwand was inserted easily and with a mild hemodynamic response into a double-curve nasotracheal tube [2]. However, we had not a soft, flexible lightwand, so we could not perform the nasal approach. We just performed orotracheal intubation with a lightwand, and decided to exchange the oral endotracheal tube with a nasal endotracheal tube using an FOB. There have been several methods described for the conversion of oral to nasal endotracheal tubes. One case report a cook airway exchange catheter being used successfully in a patient with mandibular atrophy [3]. However, the exchange catheter has the possibility of inadvertent dislodgement and can be dangerous in patients with a difficult airway. As a method that was reported previously, orotracheal tube to nasotracheal tube change with a FOB like a retrograde intubation method was reported [4]. The limitations of this method are the possibility of the optical fibers breaking, trauma, failure, and inadvertent extubation. The technique we used in our case is easy because it advances along with orotracheal intubation tube. It is also safe because we continuously monitored the tip of the FOB located in carina. Nevertheless, careful manipulation is required to go through the anterior commissure of vocal cord, because it has small room to pass due to preexisting orotracheal intubation tube (Fig. 1). Fig. 1 We advanced the fiberoptic bronchoscope (FOB), which was passed via the naris along the occupied orotracheal tube and inserted close to the anterior commissure of the vocal cords, to the carina. After the FOB reached the carina, the occupied orotracheal ... In conclusion, FOB is a reliable and safe method for changing to nasotracheal intubation tube in patients with preexisting orotracheal intubation tube.

BACKGROUND:Previous studies have reported a high incidence of acute kidney injury (AKI) after thoracic aortic surgery in heterogeneous patient cohorts, including various aortic diseases and the use of deep hypothermic circulatory arrest. Moderate hypothermia with cerebral perfusion makes deep hypothermia nonessential, but can make end organs susceptible to ischemia during circulatory arrest. We investigated the incidence and risk factors of AKI after thoracic aortic surgery with and without moderate hypothermic circulatory arrest for acute dissection.METHODS:We reviewed the medical records of 98 patients undergoing graft replacement of the thoracic aorta for acute dissection between 2008 and 2011 at a university hospital. Acute kidney injury was defined by RIFLE criteria, which is based on serum creatinine or glomerular filtration rate.RESULTS:The mean age was 55±15 years. The surgical procedures, 96% of which were emergencies, involved the ascending aorta (67%), aortic arch (41%), descending aorta (41%), and aortic valve (5%). Moderate hypothermic circulatory arrest was performed in 75%. The overall incidence of AKI was 54%, and 11% of 98 patients required renal replacement therapy. Thirty-day mortality increased with AKI severity (p=0.002). Independent risk factors for AKI were long cardiopulmonary bypass duration (>180 minutes; odds ratio, 7.50; p=0.008) and preoperative serum creatinine level (odds ratio, 8.43; p=0.016).CONCLUSIONS:Acute kidney injury was common after thoracic aortic surgery for acute dissection with or without moderate hypothermic circulatory arrest and worsened 30-day mortality. Prolonged cardiopulmonary bypass and increased preoperative serum creatinine were independent risk factors for AKI, but moderate hypothermic circulatory arrest was not.