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Background. A recent heat-balance study in volunteers suggested that greater efficacy of circulating-water garments (CWGs) results largely from increased heat transfer across the posterior skin surface since heat transfer across the anterior skin surface was similar with circulating-water and forced-air. We thus tested the hypothesis that the combination of a circulating-water mattress (CWM) and forced-air warming prevents core temperature reduction during major abdominal surgery no worse than a CWG does. Methods. Fifty adult patients aged between 18 and 85 yr old, undergoing major abdominal surgery, were randomly assigned to intraoperative warming with a combination of forcedair and a CWM or with a CWG (Allon ThermoWrap). Core temperature was measured in the distal oesophagus. Non-inferiority of the CWM to the CWG on change from baseline to median intraoperative temperature was assessed using a one-tailed Student’s t-test with an equivalency buffer of 20.58C. Results. Data analysis was restricted to 16 CWG and 20 CWM patients who completed the protocol. Core temperature increased in both groups during the initial hours of surgery. We had sufficient evidence (P¼0.001), to conclude that the combination of a CWM and forcedair warming was non-inferior to a CWG in preventing temperature reduction, with mean (95% CI) difference in the temperature change between the CWM and the CWG groups (CWM2CWG) of 0.468C (20.098C, 1.008C). Conclusions. The combination of a CWM and forced-air warming is significantly non-inferior in maintaining intraoperative core temperature than a CWG. Trial registry: This trial has been registered at clinical trials.gov, identifier: NCT 00651898.

Background: Risk factors for postoperative acute kidney injury (AKI) are well described in nontransplantation settings. Data regarding risks and consequences of AKI after cardiac transplantation are unclear. Methods: We analyzed 756 cardiac transplant recipients between 1993 and 2004. The primary outcome is postoperative AKI requiring dialysis therapy. Secondary outcomes are hospital mortality and postoperative morbidities, including cardiac, neurological, and serious infection. Wilcoxon rank-sum, chi-square, or Fisher exact tests were used for univariable comparison. A bootstrap-bagging procedure (1,000 repetitions) and multivariable logistic analysis with multiple imputation were used for the final model. Results: AKI frequency was 5.8% (44 of 756 patients). By means of univariable analysis, preoperative risk factors for AKI were diabetes, prior cardiac surgery, intra-aortic balloon pump use, albumin level, creatinine level, clinical severity score, and cold ischemia time. Intraoperative risk factors were cardiopulmonary bypass time and transfusion requirement. By means of multivariate analysis, serum creatinine level (odds ratio [OR], 2.7; 95% confidence interval [CI], 1.6 to 4.6), serum albumin level (OR, 0.34; 95% CI, 0.21 to 0.54), insulin-requiring diabetes (OR, 3.5; 95% CI, 1.4 to 9.0), and cardiopulmonary bypass time (OR, 1.29; 95% CI, 1.02 to 1.64) were independent predictors of postoperative AKI. The overall postoperative mortality rate was 4.2%; it was 50% in patients with AKI compared with 1.4% in patients without AKI. AKI was associated with greater frequencies of cardiac, neurological, and serious infection morbidities (43.2%, 18.2%, and 54.6% versus 5.5%, 2.3%, and 7.2%, respectively; P 0.001). Conclusion: AKI is associated with significant morbidity and mortality after cardiac transplantation. Predictors of AKI can be used to risk-stratify patients to ameliorate further kidney injury and offer a survival benefit. Am J Kidney Dis 48:787-796.

Objective: The purpose of this study was to assess the effect of preoperative dexamethasone (DEX) on the occurrence of postoperative atrial fibrillation (AF). Design: Prospective, randomized, double-blind, placebocontrolled clinical trial. Setting: Tertiary referral center. Participants: Seventy-eight adult patients undergoing combined valve and coronary artery bypass graft (CABG) surgery were randomized to receive either DEX or placebo. Interventions: The DEX group received dexamethasone, 0.6 mg/kg, after induction of anesthesia, and the placebo group received an equal volume of normal saline. Interleukin (IL)-6, -8, and -10; tumor necrosis factor
; and endothelin (ET)-1 were measured preoperatively and on postoperative days (POD) 1, 2, and 3. Complement (C-4) and C-reactive protein (CRP) were measured preoperatively and on POD 2. Exhaled nitric oxide (NO) was measured preoperatively, 15 minutes after aortic unclamping, and 1 hour after intensive care unit admission. Measurements and Main Results: No significant difference in the incidence of AF was found between the placebo (41%) and DEX groups (30%) (95% confidence interval [11%, 34%); p 0.31). DEX significantly reduced at least 1 postoperative level of IL-6, IL-8, IL-10, CRP, and exhaled NO. DEX did not affect ET-1 or C-4 levels. IL-10 on POD 3 was positively correlated with postoperative hospital length of stay (r 0.30, p 0.01). Increased levels of IL-8 and IL-10 on POD 1 were positively correlated with the intubation time (r 0.31, p 0.01; r 0.30, p 0.01, respectively). Conversely, C-4 on POD 2 was negatively correlated with the intubation time and intensive care unit length of stay (r 0.32, p 0.006; r 0.30, p 0.01, respectively). Conclusions: DEX did not affect the incidence of AF in patients undergoing combined CABG and valve surgery. However, it did modulate the release of several inflammatory and acute-phase response mediators that are associated with adverse outcomes.

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