Online ISSN: 2515-8260

Keywords : surgery


Onset and Intubating Conditions with Succinylcholine and Rocuronium

N. Syama Kumar, Gangula Chandra Sekhar, K. Nagabhushanam, K. Deepthi

European Journal of Molecular & Clinical Medicine, 2022, Volume 9, Issue 5, Pages 321-333

Background: Rocuronium, like succinylcholine, has a rapid onset of neuromuscular blockade; but, unlike succinylcholine, rocuronium does not have the deleterious effects that are associated with the use of the latter. Nevertheless, its usage is restricted because of its protracted activity. The purpose of this study was to determine whether or not lowering the intubating dose of rocuronium shortened its duration of action while still providing intubating conditions that were clinically acceptable. This was a prospective, randomised, and blinded study for both participants and observers.
Material and Methods: One hundred Indian patients aged between 18 and 65 years who were scheduled for elective surgery were randomly assigned to one of the four rocuronium groups (rocuronium dose of 0.6 mg/kg intubated at 60 s or at 90 s, rocuronium 0.9 mg/kg intubated at 60 s or at 90 s) or succinylcholine group (succinylcholine dose of 1.5 mg/kg intubated at 60 s). Intubating conditions Analysis of variance (ANOVA), Chi-square test, repeated measures analysis of variance (ANOVA), and Mann–Whitney U test were the four statistical tests that were carried out.
Results: Intubating conditions were deemed clinically acceptable in 35% of subjects at 60 seconds and 60% of subjects at 90 seconds when rocuronium was administered in a dosage of 0.6 mg/kg; however, when rocuronium was administered in a dosage of 0.9 mg/kg, intubating conditions were deemed clinically acceptable in 80% of subjects at 60 seconds and 100% of subjects at 90 seconds.
Conclusion: When administered at a dose of 0.6 mg/kg, rocuronium did not produce clinically acceptable intubating circumstances at either 60 or 90 seconds, although it has a shorter duration of action. It takes approximately the same amount of succinylcholine, 0.9 mg/kg, for rocuronium to provide clinically acceptable intubating circumstances as it does for succinylcholine, 1.5 mg/kg.

AIRWAY MANAGEMENT IN PATIENTS WITH THYROID SWELLING UNDERGOING THYROID SURGERY: A PROSPECTIVE STUDY

Mayank Rastogi, Shubhra Srivastava, Amala G. Kudalkar

European Journal of Molecular & Clinical Medicine, 2022, Volume 9, Issue 6, Pages 56-66

Aim: Airway management in patients with thyroid swelling undergoing thyroid  surgery.
Methodology: After approval from Institutional ethics committee, we conducted a prospective observational study including 60 consenting patients with thyroid swelling undergoing thyroidectomy. A standard OT protocol for routine pre anaesthetic check up was followed. The usual airway parameters such as mouth opening, MPC, slux, thyromental distance (TMD), neck movement were assessed. The euthyroid status of the patient was confirmed.
Results: In 54 (88.3%) patients propofol was used as induction agent. In 3 (5%) patients combination of dexmedetomidine & propofol was used as induction agent. In 2 (3.3%) patients sevoflurane and propofol was used as induction agent. In 1 (1.4%) patient etomidate was used as induction agent. 16 (26.7%) of patients required external laryngeal manoeuvre whereas 44 (73.3%) didn’t require external laryngeal manoeuvre. Highest percentage of patients 48.3% (29) were intubated in 15-30sec, 13 (21.6%). patients required 30-45 sec, 12 (20%) required less than 15 sec, while 6 (10%) patients required more than 45 sec. Maximum time required for intubation was 58 sec. 1 (1.7%) patient had complaint of hoarseness of voice post-operatively. 1 (1.7%) patient had tracheomalacia for which tracheostomy was done. 1 (1.7%) patient was not extubated due to prolonged surgery. no patient had post-extubation desaturation.
Conclusion: From this study we concluded that thyroid swelling accompanied with airway deformity is a risk factor for difficult intubation. A thorough preoperative history in all patients with thyroid swelling is mandatory and should include duration of thyroid swelling, pressure symptoms and radiological investigations of the neck and thorax.

Surgical management of posterior fossa tuberculosis

Dr. K Narasimha, Dr. Sujay Kumar Parasa, Dr. Ashok Kumar Kothapalli

European Journal of Molecular & Clinical Medicine, 2022, Volume 9, Issue 4, Pages 3131-3137

Tuberculoma of the brain is a dangerous disease that is becoming more common in developed countries as tuberculosis continues to spread. At first, antimycobacterial drugs are used to treat brain tuberculoma. But neurosurgery is the main part of treatment. Surgery is needed if the tuberculoma does not respond to medical treatment, if it is causing symptoms, or if there is no other way to find out what is wrong. In this paper, we talk about four cases of posterior fossa tuberculomas in people who had never had tuberculosis or a weak immune system before. Brain tuberculosis had to be treated with surgery in all cases for it to go away safely and effectively.

To distinguish between the results of early and delayed arthroscopic reconstruction of anterior cruciate ligament tears

Dr. Venugopal Palakurthi, Dr. Srimukthi Madhusudan, Dr. B Srinivas, Dr. V Krishna Kumar

European Journal of Molecular & Clinical Medicine, 2022, Volume 9, Issue 4, Pages 3156-3169

Objective of the Study: This study's main goal is to evaluate the functionality of early and delayed arthroscopically reconstructed ACLs using the IKDC score, Lysholm-Tegner score, KOOS scoring, as well as clinical testing such as the pivot shift test, anterior drawer test, Lachmann test, and range of motion both before and after surgery.
Need for the Study: Reconstructing the anterior cruciate ligament (ACLR) increases the stability and functionality of the knee. Numerous contentious concerns, including graft selection, surgical technique, and scheduling of operation, are present and the surgical approach is still evolving. The best moment for reconstructive surgery following injuries is a topic of debate. Few authors have advocated for reconstruction within 12 weeks. Early surgical intervention may reduce the likelihood of meniscal and chondral damage and prevent the knee from becoming more unstable. Other studies concluded that early repair would have unexpected results because of discomfort, arthrofibrosis, and patellar contracture syndrome and advised waiting until 12 weeks had passed before having surgery. This research will assist the surgeon in arthroscopically reconstructing the anterior cruciate ligament at the ideal time.
Methods: After receiving informed consent, 60 patients with ACL injuries who were admitted to Govt. Medical College & Hospital were enrolled in this study. There was a thorough clinical examination and history taken. Magnetic Resonance Imaging (MRI) and routine clinical tests were used to confirm the diagnosis (Sigma HDxT-GE 1.5 Tesla). Depending on the time of hospital presentation, patients with total or partial ACL Tears having ACL reconstruction were randomly assigned to early 12-week groups x. These patients had arthroscopic ACL reconstruction using semitendinosis and gracilis triple grafts in order to repair their established ACL tears, either partial or total. IKDC score, Lysholm-tegner score, and KOOS scoring were used to evaluate the functional performance of the rebuilt ACL over a period of 6 to 1 year.
Results: Clinical and functional scores post-operatively improved statistically significantly in both the Early and Delayed groups. In both groups, the score improvement was comparable. The improvement in pain ratings, range of motion, anteroposterior stability, and functional scores between the early and delayed groups did not vary statistically. There were no notable variations between the two groups' improvements.

Clinical study of venous ulcers occurring in patients with varicose veins & response to various modalities of treatment

Dr. Shajee Ganesh, Dr. Hareeshwaran

European Journal of Molecular & Clinical Medicine, 2022, Volume 9, Issue 2, Pages 1789-1794

Background: Varicose veins of the lower limbs are the most common vascular disorder affecting human beings. Although venous ulceration is a benign condition, there is considerable morbidity due to recurrent cellulitis, phlebitis and stiffness of joints. Present study was aimed to study venous ulcers occurring in patients with varicose veins & response to various modalities of treatment at a tertiary hospital.
Material and Methods: Present study was hospital based, prospective, observational study, conducted in patients with venous ulceration in the leg due to varicose veins, willing to participate & follow up.
Results: In present study 32 patients were included. All patients were male. age ranged between 28 to 70 yrs. Majority of were from 40-49 years age group (31.25%) & duration of illness was 1-5 years (53.13%). Apart from ulcer & varicose veins (100.00%), common complaints were itching (31.25%), pain (28.13%) & pedal oedema (9.38%). Four patients (12.50%) had bilateral disease Fascial defects due to perforator incompetence was clinically well palpable in all patients with below knee perforators. Perthes’ test was negative in all patients and doppler (Duplex) assessment showed patent deep veins in all patients. All 32 patients (36 limbs) underwent Trendelenburg operation. Treatment modalities were Trendelenburg operation with stripping with stab avulsion (52.78%), Trendelenburg operation with stripping with subfascial ligation (36.11%), short saphenous vein ligation and stripping (5.56%) & excision of fibrous tissue and split skin grafting (5.56%).Post-operative complications in present Wound infection of the transverse groin incision was present in 2 patients.
Conclusion: In cases of venous ulcers occurring in patients with varicose veins, meticulous clinical assessment leads to successful treatment. Conservative treatment of venous ulceration should be tried before embarking on surgery which is the definitive treatment.

STUDY OF FIBROID UTERUS

DR VIJAY Y KALYANKAR,2.DR BHAKTI VIJAY KALYANKAR, DR SRINIVAS N GADAPPA, DR REVATI RAMESHWAR GHAYAL, DR MEGHA CHAUHAN, DR SHIVANGI S VERMA .

European Journal of Molecular & Clinical Medicine, 2022, Volume 9, Issue 3, Pages 4974-4980

INTRODUCTION-uterine fibroids are common tumor of uterus, seen in reproductive age group. Fibroids during pregnancy produce special challenges during labour. Small fibroids with minimal symptoms treated with medical management, while large, multiple fibroids with pressure symptoms require surgical management. Fibroids during pregnancy produces special challenges during labour.
AIMS & OBJECTIVES –To study and analyse the Risk factors associated withfibroids, Clinical features according to different type offibroid, Different types of management of fibroid.
METHODOLOGY- fibroid cases were diagnosed clinically and with ultrasonography. Details of clinical examination findings, investigations and treatment modalities used were noted. Difficulties during surgery and methods to overcome were studied.
Histopathology details of specimen and other associated findings were studied.
RESULTS- Fibroids are Commonly seen in reproductive age group showing 45.5% cases. Majority cases are multipara seen in 79.35% cases and 5.14% cases are pregnant patients with fibroid. Intramural fibroid was seen in 60% and presented with menorrhagia (73%) and dysmenorrhea (50.5%). Fibroids presented with menstrual symptoms were seen in 96.15% cases. 61.7% cases underwent surgical management in that Total Abdominal Hysterectomy alone constitute 76.19%. neglected fibroids were common in rural areas making surgical management more common.
CONCLUSIONS- Pre-operative adequate preparations with general build-up for anesthesia and surgery, imaging studies, ureteric stenting where-ever required, use of GNRH analogues and following the principles of Fibroid surgery, made successful surgeries with no surgical morbidity and mortality. Caesarean section is common mode of delivery in fibroids in pregnancy with no complications.

Clinical study of venous ulcers occurring in patients with varicose veins & response to various modalities of treatment.

Dr. Shajee Ganesh, Dr. Hareeshwaran

European Journal of Molecular & Clinical Medicine, 2022, Volume 9, Issue 2, Pages 1795-1800

Background: Varicose veins of the lower limbs are the most common vascular disorder affecting human beings. Although venous ulceration is a benign condition, there is considerable morbidity due to recurrent cellulitis, phlebitis and stiffness of joints. Present study was aimed to study venous ulcers occurring in patients with varicose veins & response to various modalities of treatment at a tertiary hospital.
Material and Methods: Present study was hospital based, prospective, observational study, conducted in patients with venous ulceration in the leg due to varicose veins, willing to participate & follow up.
Results: In present study 32 patients were included. All patients were male. age ranged between 28 to 70 yrs. Majority of were from 40-49 years age group (31.25%) & duration of illness was 1-5 years (53.13%). Apart from ulcer & varicose veins (100.00%), common complaints were itching (31.25%), pain (28.13%) & pedal oedema (9.38%). Four patients (12.50%) had bilateral disease Fascial defects due to perforator incompetence was clinically well palpable in all patients with below knee perforators. Perthes’ test was negative in all patients and doppler (Duplex) assessment showed patent deep veins in all patients. All 32 patients (36 limbs) underwent Trendelenburg operation. Treatment modalities were Trendelenburg operation with stripping with stab avulsion (52.78%), Trendelenburg operation with stripping with subfascial ligation (36.11%), short saphenous vein ligation and stripping (5.56%) & excision of fibrous tissue and split skin grafting (5.56%).Post-operative complications in present Wound infection of the transverse groin incision was present in 2 patients.
Conclusion: In cases of venous ulcers occurring in patients with varicose veins, meticulous clinical assessment leads to successful treatment. Conservative treatment of venous ulceration should be tried before embarking on surgery which is the definitive treatment.

Anaesthetic management of adrenal tumours presenting with combination of rare syndromes during a pandemic: experience from a tertiary cancer care centre in Northeast India

Dr.Sonai Datta Kakati, Dr. Biplob Borthakur, Dr.Barnali Kakati, Dr. Marie Ninu, Dr. Dokne Chintey .

European Journal of Molecular & Clinical Medicine, 2022, Volume 9, Issue 3, Pages 10682-10692

Background and Aims: Perioperative management of functional adrenal tumours is resource intensive. Due to the covid 19 pandemic, there has been sizeable delay in preparing and conducting these time sensitive surgeries.Quality of care andresource utilisation may worsen. This retrospective review was aimed at finding if care quality deteriorated due to covid 19 related restrictions, from anaesthetic perspective.
Methods:Three cases of hormone-secreting adrenal tumours operated during a two year period in a tertiary cancer centre in India were retrospectively reviewed.Summary of the demographic profile, tumour characteristics, and the perioperative care were described using tables and analysed in the discussion.
Results: Out of the three cases operated for adrenal gland tumour, pheochromocytoma tumour type with distant metastasis had prolonged hospital stay. One patient developed covid 19 infection in hospital. Cases were adequately managed during the perioperative period and the covid 19 related constraints didn’t affect the quality of care.
Conclusion:As in any other major surgery, adhering to a unique checklist, multidisciplinary approach, clear communication, knowledge sharing and establishing a care pathway helps to maintainquality care in high risk cases and at times of crisis.
 

VARIATION IN PRACTICE AND OUTCOMES AFTER INGUINAL HERNIA REPAIR

DR.OMRANESSAOBAID .

European Journal of Molecular & Clinical Medicine, 2022, Volume 9, Issue 3, Pages 12070-12076

Background: Inguinal hernia repair has often been used as a showcase to illustrate practice variation in surgery. This study determined the degree of hospital variation in proportion of patients with an inguinal hernia undergoing operative repair and the effect of this variation on clinical outcomes.
Method: An unselected cohort of 223 patients who underwent laparoscopic totally extraperitoneal (TEP) inguinal hernia repair before March 2022 were included in this study, thus ensuring a minimum 5-year follow-up. Patient demographic data, clinical notes, operating notes and outpatient follow-up notes were studied. Patients were interviewed telephonically regarding hernia recurrence, chronic pain and technique preference if they had previously undergone an open repair. All data collected were recorded on an electronic spreadsheet.The primary outcome parameter was recurrence. The secondary outcome parameters were postoperative and long-term complications.
Results: This nationwide database study shows that practice variation in inguinal hernia repair is modest in the Babel province. Operation-rates vary by less than two-fold, and variation is stable over the years 2020-2022. A more thorough analysis illustrates that the type of hospital (academic, teaching, or private) is the most relevant factor contributing to the observed variation. An addition to previous reports on practice variation in hernia surgery is the present finding that adjusted rates in surgery in general hospitals are associated with the type of financial reimbursement for diagnosis and the percentage of self-employed staff. These non-clinical factors related to variation may not only contribute to practice variation in hernia surgery,
Conclusion :Hospital variation in inguinal hernia repair in the Al-hila city is modest, operation-rates vary by less than two-fold, and variation is stable over time. Hernia repair in hospitals with high adjusted rates of inguinal hernia repair are associated with improved outcomes.

A comparative study of acute ligamentous repair and functional treatment in patients with simple elbow dislocation

Dr. Vinod Kumar

European Journal of Molecular & Clinical Medicine, 2021, Volume 8, Issue 4, Pages 1642-1646

Background: The elbow is the second most commonly dislocated major joint in adults. Simple
dislocations are those where there had been no concomitant fracture apart from small
periarticular avulsions 1 mm or 2 mm in diameter. The present study compared acute
ligamentous repair with functional treatment in patients with simple elbow dislocation.
Materials & Methods:80 patients with elbow dislocation were divided into 2 groups of 40 each.
Group I patients were treated with closed reduction of elbow and group II patients were
treated with closed elbow reduction and subsequent reconstruction of torn collateral
ligaments. Outcome of the treatment was compared.
Results: Side of dislocation was left side in 17 in group I and 14 in group II and on right side
seen in 23 in group I and 26 in group II. Type of dislocation was posterior seen in 15 in group
I and 16 in group II, postero- lateral seen 12 in group I and 11 in group II, postero- medial
seen 7 in group I and 8 in group II and lateral seen 6 each in group I and 5 in group II.
Clinical outcome was excellent seen in 30 in group I and 22 in group II, good in 6 in group I
and 14 in group II, fair seen in 4 in group I and 3 in group II and poor seen 1 in group II.
The difference was significant (P< 0.05).
Conclusion:Closed reduction of elbow repair found to be better than closed elbow reduction
and subsequent reconstruction of torn collateral ligaments.

Recurrent laryngeal nerve identification in thyroidectomy by intraoperative staining with methylene blue

Ahmed Emad Eldeen Sebaey; Alaa Mohamed Khalil; Mohamed Mahmoud Elkilany; Ramadan Mahmoud Ali

European Journal of Molecular & Clinical Medicine, 2021, Volume 8, Issue 2, Pages 644-649

Background: Unrecognized transection of the recurrent laryngeal nerve (RLN) or its motor branch could result in an unexpected permanent palsy. So, for a safe thyroid operation, intraoperative assurance of anatomical and functional RLN integrity is a necessity. Aim of work: To evaluate the recognition and protection of RLN by staining the RLN intraoperatively with methylene blue (MB) in one side and comparing it with the identification alone in the other side visually during total thyroidectomy. Subjects and methods: A case control study (retrospective study) carried out in the department of surgical oncology Zagazig university hospitals and Ismailia teaching oncology hospital during the period from November 2018 to August 2019. The study included 112 patients with bilateral thyroid disease who will do total thyroidectomy. The patients were subdivided into two groups depending on the MB use. Complete history taking was taken from all subjects. General examination of all body systems and local examination of the neck were done. We also did full lab investigations, neck U/S then the operations were performed. Results: We detected transient vocal cord palsy 10 sides (8.6%) of visual  identification alone, while in MB sides no case was detected with the same lesion. Conclusion: Recognition of RLN intraoperatively by MB staining is cheap and widely available technique and can decrease the stress during thyroidectomy, especially when Intra Operative Nerve Monitoring (IONM) is absent.

The aesthetic out come of primary Cheilo-Rhinoplasty

Ehab Wagdy Ragy; Raafat Abd Allatif Anany; Ahmed Abohashim Azzab; Mohammed Ali Nasr

European Journal of Molecular & Clinical Medicine, 2021, Volume 8, Issue 2, Pages 346-354

The earliest procedure in unilateral cleft lip nose management was concenterated by Victor Veau in his book at 1938. He used simple coaptation of the margins of the cleft after they had been surgically exposed. The results obtained with this technique were unfortunately consistently bad for many reasons but mainly because of poor surgical reconstruction of the labial musculature. Through the principles done by Veau and more recently by Delaire, there has been a re-appraisal to concept of primary cheilorhinoplasty in unilateral cleft lip management. Senior cleft surgeons as Millard, McComb and Salyer provided encouraging results after reviewing the long term results of simultaneous repair. They proved that there was no interruption of growth by early surgery and reported stable results up to 18 years after surgery

GOSSYPIBOMA

M.Pauline Nivetha

European Journal of Molecular & Clinical Medicine, 2020, Volume 7, Issue 7, Pages 6018-6020

The term “gossypiboma” is derived from the latin word “gossypium” cotton wool or cotton and the suffix “oma” meaning a tumor or growth and describe a collection within a patients’s body comprising a cotton matrix enclosed by a granuloma. A surgical instruments accidentally left inside the body during surgery is called a foreign body granuloma or a retainted foreign body. In many studies found that the majority common threat factors associated with “retained foreign bodies” are emergency operations, unexpected changes in operating procedures, and when operating on patients with “higher body-mass index.

SYSTAMATIC REVIEW ON DIFFERENT ORTHODONTIC IMPLANTS CURRENTLY USED IN DENTISTRY

Dr. Anand V; Dr.Monisha S

European Journal of Molecular & Clinical Medicine, 2020, Volume 7, Issue 7, Pages 5745-5751

It is important, considering the wide range of orthodontic devices currently available on the market, to select the most biocompatible orthodontic implant available on the market. Current science data have shown that in vitro measurements of the toxicity of residual particles produced by various orthodontic apparatuses with oral cell lines provide accurate data. In this relation, three commercially available implants, i.e., stainless steel and titanium implants have been tested for in vitro biocompatibility. Methods: Human gingival fibroblasts (HGFs) have been used as the in vitro model to determine cellular morphology, viability of the cells, and cytotoxicity via a 24-hour and 72-hour test for celular implant exposure with 3-(4,5-dimethythiazol-2-yl)-, 2-5,5-diphenyltetrazolium bromide (MT) and LDH test. Results: The results compare implant surface structure and topography with biological, laboratory assessments related to the direct cells (genetic fibroblasts) and blood vessel toxicology (HET-CAM) trial. A relative cytototoxicity of HGF cells occurs for the stainless steel implant, while the other two tests did not produce substantial alteration in HGF cells. Conclusion: The stainless steel implant caused mild cytotoxic effects among the three orthodontic implants samples. This calls for improved alertness in their clinic usage, especially in patients with a strong sensitivity to nicke 1,2.

OPEN BITE: ETIOLOGY, DIAGNOSIS AND MANAGEMENT

S.Vaibava Keerthana; Dr. Thulasiram; Dr.M.S. Kannan

European Journal of Molecular & Clinical Medicine, 2020, Volume 7, Issue 4, Pages 1753-1756

Anterior open bite is one of the most difficult malocclusions to treat with its varied characterizations. Appropriate etiology should be identified for effective management of open bite. Anterior Open Bite can irrespectively occur in all kinds of malocclusion. Aesthetics, speech, mastication and tooth wear are some of the common concerns for the patients. Thorough apprehension of the anomaly is important in determining the appropriate corrective measures. This review will throw more light on the etiology of open bite, diagnosis and treatment enabling the clinicians for better understanding of the malocclusion.

Systematic Review And Meta-Analysis: Risk Factors Of Acute Kidney Injury In Major Abdominal Surgery

Emminarty .; Hasyim Kasim; Haerani Rasyid; Syakib Bakri; Andi Makbul Aman; Husaini Umar; Muh. Ilyas; Arifin Seweng; Gita vita soraya

European Journal of Molecular & Clinical Medicine, 2020, Volume 7, Issue 8, Pages 944-952

Background and objective: Acute kidney injury (AKI) is a common complication in patients undergoing major abdominal surgery. Various recent studies reported an incidence of AKI after surgery ranging from 6.7 to 32%. Risk factors for AKI in this setting may be procedure-related factors, post-operative complications and several patient-related include age, gender, comorbid disease Diabetes Melitus (DM), Hypertension (HT), Cardiovascular disease (CVD), and physical status. This study aimed to explore the risk factors of AKI in major abdominal surgery
Methods: We conducted a systematic literature search from PubMed and Cochrane Library. We included articles describing AKI in the setting of major abdominal surgery, published from 2015 until now, and cohort study design. This review was registered with PROSPERO (CRD42020216405)
Results: From 478 articles, 4 articles met our inclusion criteria describing AKI outcomes in varied population 683-3751. Prevalence of AKI 8,8 %. Age patient risk AKI in major abdominal surgery with Mean difference was 3.04 (95% CI = 1.83-4.25; P <0.00001). Meta-analysis of the four studies showed that Male had a pooled Odds ratio (OR) of 1.79 (95% CI = 1.04-3.08; P = 0.04) , DM OR 1.64 (95% CI 1.36-2.03; P <0.00001), HT pooled OR 1.90 (95% CI = 1.30-2.78; P = 0.0009), CVD has an OR of 1.58 (95% CI = 0.91-2.75; P = 0.10), physical status ASA≥ 3 (The American Society of Anesthesiologists) score has pooled OR 1.70 (95% CI = 1.16-2.49; P = 0.007)
945
Conclusion: Risk factors of AKI in major abdominal surgery setting are higher significantly in male, and patient with comorbid disease DM and HT had a significantly high risk of AKI, as well as physical status score ASA > 3.