Luis Baeza

Cardiac surgery-associated acute kidney injury (CS-AKI) increases short- and long-term mortality, progression to chronic kidney disease (CKD), and healthcare costs. Its pathogenesis is multifactorial—combining renal hypoperfusion, impaired oxygen delivery, hemodilution, inflammation, ischemia–reperfusion injury, and nephrotoxin exposure—so no single intervention confers universal protection. This narrative review appraises fourteen perioperative prevention strategies, grading each by study design, reproducibility, and concordance with contemporary guidelines. The strongest actionable evidence supports the preservation of renal oxygen delivery during cardiopulmonary bypass through goal-directed perfusion, perioperative amino acid infusion, and biomarker-guided Kidney Disease: Improving Global Outcomes (KDIGO) care bundles. Remote ischemic preconditioning, pulsatile flow, minimally invasive extracorporeal circulation, dexmedetomidine, N-acetylcysteine, levosimendan, hemoadsorption with the oXiris membrane, and natriuretic peptides show variable or subgroup-dependent signals limited by heterogeneous trial design and acute kidney injury (AKI) definitions. Prevention of CS-AKI is, therefore, best conceived as a multimodal, patient-centered process integrating preoperative risk stratification, intraoperative oxygen delivery optimization, patient blood management (PBM), and postoperative nephrotoxin avoidance and surveillance.

Electrical storm (ES) is a life-threatening clinical condition characterized by recurrent ventricular arrhythmias within a 24 h period, carrying a high mortality rate. Despite conventional therapies, including hemodynamic optimization, antiarrhythmic drugs, implantable cardioverter-defibrillator (ICD) reprogramming, and catheter ablation, a subset of patients develop refractory ventricular arrhythmias. In this setting, cardiac sympathetic neuromodulation can interrupt arrhythmic circuits by reducing efferent sympathetic outflow to the myocardium. Stellate ganglion block (SGB) with local anaesthetic (LA) is a temporary pharmacological blockade used as rescue therapy; in the largest prospective series (the STAR study), 92% of treated patients achieved at least a 50% reduction in arrhythmic events in the 12 h following the procedure. Because the effect of anaesthetic blockade is transient, more durable interventions have been explored, including percutaneous radiofrequency or chemical neurolysis and surgical cardiac sympathetic denervation (CSD), although current evidence is largely confined to small, uncontrolled case series. This narrative review synthesizes the available evidence on cardiac sympathetic neuromodulation—spanning SGB, percutaneous neurolysis, and surgical CSD—in refractory ES, positioning these interventions primarily as a means of stabilizing patients and bridging to definitive therapy rather than as established survival-modifying treatments. Furthermore, this review describes the primary anatomical foundations of the cervicothoracic sympathetic nervous system and the various techniques for SGB, along with their most relevant clinical indications. The risks and complications associated with these interventions are also addressed. Finally, clinical implications and potential future research directions in this field are discussed, with the aim of providing guidance for the comprehensive management of critically ill patients with refractory ES.

Objectives. To determine the pericapsular nerve group (PENG) block’s postoperative analgesic efficacy and safety compared to the suprainguinal fascia iliaca (SFI) block in patients undergoing primary hip arthroplasty using the same injectate volume. Material and Methods. Between January 2021 and March 2022, American Society of Anesthesiologists Physical Status (ASA-PS) classification I–III patients scheduled for hip arthroplasty were included in this study. After standard monitoring and subarachnoid anesthesia, an ultrasound-guided PENG or SFI block with 20 ml of 0.25% levobupivacaine was performed for postoperative analgesia. All patients were assessed with a numerical rating scale (NRS) at presurgery, upon arrival at the postanesthesia care unit (PACU), and in the postoperative period at 2, 4, 12, and 24 hours. The need for analgesic rescue and adverse effects was also assessed. Results. A total of 130 patients were included in the study (62 PENG block and 68 SFI block). Both blocks were equally effective in managing postoperative pain without any statistically significant differences except at 12 h ( ), where the deviation found was not clinically relevant. The median total morphine consumption was 0 mg [0–2] in the PENG block group and 0 mg [0–2] in the SFI block group. A more significant motor block was found in the first 6 hours in the SFI block group ( ). There was no significant difference in the ease of performing PENG (79%) or SFI (85%) blocks. No major complications were recorded in both groups, and patient satisfaction was high (83.9% for the PENG block group vs. 91.2% for the SFI block group). Discussion. Both blocks have been demonstrated to be effective for postoperative analgesia in hip arthroplasty and should be integrated as a multimodal analgesic strategy. The lesser degree of motor block recorded in the first hours with the PENG block makes it the most suitable option for early recovery. Both techniques were easy and safe to perform.