Acute kidney injury frequently complicates critical illness and increases mortality; maintaining normoglycemia with insulin has been shown to reduce the incidence of intensive care unit (ICU)-acquired kidney injury. Here we tested the mechanisms by which this intervention might achieve its goal, using a rabbit model of burn-induced prolonged critical illness in which blood glucose and insulin were independently regulated at normal or elevated levels. Hyperglycemia caused elevated plasma creatinine and severe morphological kidney damage that correlated with elevated cortical glucose levels. Renal cortical perfusion and oxygen delivery were lower in hyperglycemic/hyperinsulinemic rabbits, compared to other groups, but this did not explain the elevated creatinine. Mitochondrial respiratory chain activities were severely reduced in the hyperglycemic groups (30-40% residual activity), and were inversely correlated with plasma creatinine and cortical glucose. These activities were much less affected by normoglycemia, and hyperinsulinemia was not directly protective. Mitochondrial damage, evident at day 3, preceded the structural injury evident at 7 days. Our study found that hyperglycemia evoked cellular glucose overload in the kidneys of critically ill rabbits, and this was associated with mitochondrial dysfunction and renal injury. Normoglycemia, independent of insulinemia, protected against this damage.

In a rabbit model of critical illness, HG evokes cellular glucose overload in liver and myocardium inducing mitochondrial dysfunction, which explained the HG-induced organ damage. Maintenance of normoglycemia, but not HI, protects against such mitochondrial and organ damage.

Adequate plasma concentrations of antibiotics during surgery are essential for the prevention of surgical site infections. We examined the pharmacokinetics of 1.5 g cefuroxime administered during induction of anaesthesia with follow-up doses every 2.5 hours until the end of surgery. We built a physiologically based pharmacokinetic model with the aim to ensure adequate antibiotic plasma concentrations in a heterogeneous population. Methods:A physiologically based pharmacokinetic model (PK-Sim ® /MoBi ® ) was developed to investigate unbound plasma concentrations of cefuroxime. Blood samples from 25 thoracic surgical patients were analysed with high-performance liquid chromatography. To evaluate optimized dosing regimens, physiologically based pharmacokinetic model simulations were conducted.Results: Dosing simulations revealed that a standard dosing regimen of 1.5 g every 2.5 hours reached the pharmacokinetic/pharmacodynamic target for Staphylococcus aureus. However, for Escherichia coli, >50% of the study participants did not reach predefined targets. Effectiveness of cefuroxime against E. coli can be improved by administering a 1.5 g bolus immediately followed by a continuous infusion of 3 g cefuroxime over 3 hours. Conclusion:The use of cefuroxime for perioperative antibiotic prophylaxis to prevent staphylococcal surgical site infections appears to be effective with standard dosing of 1.5 g preoperatively and follow-up doses every 2.5 hours. In contrast, if E. coli is relevant in surgeries, this dosing regimen appears insufficient. With our derived dose recommendations, we provide a solution for this issue.

Two grams of cefazolin at induction of anesthesia with a repeat dose after initiation of CPB ensures adequate drug levels to target a majority of pathogens of surgical site infections. Pharmacokinetic modeling demonstrated a significant influence of CPB on the volume of distribution and elimination of cefazolin. Other influences on pharmacokinetic parameters were albumin, protein, and creatinine clearance.

We agree with their strategy to avoid an invasive modality such as intraaortic balloon pump (IABP) to keep cerebral blood flow in cardiac surgery in moyamoya patients. We sometimes encounter difficult situations in which IABP is difficult to use owing to severe atherosclerosis in the descending aorta, stenosis of the iliac artery, and so on. In this situation, the strategy suggested by Santarpino and colleagues [1] is quite helpful. On the contrary, a strategy of keeping pulsatile flow and perfusion pressure higher by using IABP [2] has advantages in certainty and reproducibility because this strategy depends on mechanical support, not on pharmacologic treatment that is often influenced by many factors and is occasionally unpredictable. Several publications [3,4] support this strategy. Adoption of pulsatile flow with IABP is strongly influenced by familiarity with mechanical supports in a cardiovascular surgery unit. If surgeons are open to using mechanical supports, our strategy could be performed easily.As Santarpino and colleagues [1] mentioned, several strategies to manage moyamoya patients during cardiopulmonary bypass "lead to Rome," and it is difficult to strive for mastery. Regardless, the support strategies for cerebral perfusion and real-time monitoring of cerebral oxygenation give us important information during cardiopulmonary bypass. Monitoring of regional saturation of oxygen using near-infrared spectroscopy is one of the noninvasive methods to know the status of brain oxygenation. Visualization of cerebral oxygenation to enhance quick response to the change in the brain is a fundamental factor in the management of cardiac surgery for patients with a highrisk cerebral system. Further experience with brain protection during cardiopulmonary bypass in moyamoya patients and accumulation of scientific evidence to support treatment strategy are necessary. We believe our discussions will lead to a standardized treatment strategy for cardiac surgery in moyamoya patients.

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In the last decades, developing thoracic surgery raised the demands for sophisticated anesthesiological management. Especially patients with end-stage thoracic emphysema challenge the anesthesiologist to make modern surgery possible and to provide a safe and effective perioperative management. The development and scientific work-up of single lung ventilation (SLV) laid the cornerstone for surgery of the non-ventilated lung and hemi-thorax. However, modern medicine extended surgical options to extensive tracheal surgery and to patients suffering from severely insufficient lung-capacity precluding single-lung ventilation or artificial ventilation in se. For those critically ill, different techniques were thus developed and evaluated in recent research, among others, non-intubated surgery and surgery under extracorporeal perfusion support that temporarily avoids pulmonary gas exchange and ventilation via the trachea in any way. To tackle postoperative pain with its successive problems of immobilization, insufficient respiration and airway-clearance, regional anesthesia offers great advantages. Thoracic epidural anesthesia (TEA) is considered as the gold standard; complementary, modern ultrasound techniques make regional anesthesia possible even when contraindications prohibit neuraxial blocks. Especially paravertebral block, musculus serratus anterior block, intercostal block and the musculus erector spinae block provide good postoperative pain relief and appear to influence chronic post-thoracotmy pain positively. Careful preoperative preparation, intraoperative monitoring and patient-tailored, individual perioperative management by a well-trained team ensure good results, a good survival and favorable quality of life. This article provides a brief overview over state-of-the-art techniques and future perspectives to provide anesthesia in emphysema surgery.