Acute kidney injury is a disease spectrum that can present with from mild renal dysfunction to complete renal failure that would require renal replacement therapy. Cardiac surgery-associated acute kidney injury is a complication that carries a grave disease burden. Risk factors are identified as being either modifiable or non-modifiable. This literature review aims to define the pathophysiology of cardiac surgeryassociated acute kidney injury, the current definition and classification of acute kidney injury and the available diagnostic modalities, especially the use of biomarkers

Cardiac surgery with cardiopulmonary bypass (CPB) is known to contribute towards the incidence of acute kidney injury (AKI) and peri-operative morbidity and mortality. There are several patient, anaesthetic and surgical factors that contribute to its occurrence. It is imperative to know the profile of a patient who is likely to develop this complication to mitigate for modifiable risks. This study aimed at describing a profile of AKI in an adult patient (over the age of 18 years) following cardiac surgery on CPB. Factors associated with the development of cardiac surgery-associated acute kidney injury (CSA-AKI) are described, as well as the relationship between CSA-AKI and in-hospital mortality. This was a contextual, descriptive and retrospective single-centre study with data of 476 adult patients admitted post cardiac surgery between January 2016 and December 2017. Data were collected from Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) in South Africa. All adult patients who presented for elective cardiac surgery (coronary artery bypass graft), valvular, aortic and other cardiac surgery on CPB were included. Peri-operative factors such as patient demographics, baseline renal function, co-morbid factors, length of CPB and aortic cross-clamp time, degree of hypothermia, use of assist devices, and post-operative serum creatinine (SCr) levels were collected. Incomplete essential peri-operative data and data for patients who presented on renal replacement therapy (RRT) already were excluded. AKI was defined by Kidney Disease Improving Global Outcomes (KDIGO) criteria. One hundred and thirty-five (28%) patients developed CSA-AKI and 20, 5 and 3% were in KDIGO 1, 2 and 3, respectively. Older age (p = 0.024), female gender (p = 0.015), higher serum creatinine level (p = 0.025), and lower estimated glomerular filtration rate (eGFR) (p = 0.025) were associated with the development of CSA-AKI, while a history of hypertension was predictive. Forty-six of the 476 patients died. Mortality rates were significantly higher in those with AKI compared to those without [28 (21%) vs 18 (5%), respectively (p = 0.001)]. The incidence was significantly worse in those with severe kidney injury, as evidenced by mortality rates of 44 versus 5% between KDIGO 3 and KDIGO 1 (p < 0.001). Pre-operative eGFR and CSA-AKI requiring RRT were significantly associated with mortality, while pre-operative eGFR was an independent predictor of mortality (hazard ratio 0.99, 95% confidence interval: 0.97–0.99, p = 0.019). A history of hypertension was predictive of the development of CSA-AKI, and pre-operative eGFR was an independent predictor of mortality in this cohort. Both factors are modifiable.

Open-heart surgery is the leading cause of neuronal injury in the perioperative state, with some patients complicating with cerebrovascular accidents and delirium. Neurological fallout places an immense burden on the psychological well-being of the person affected, their family, and the healthcare system. Several randomised control trials (RCTs) have attempted to identify therapeutic and interventional strategies that reduce the morbidity and mortality rate in patients that experience perioperative neurological complications. However, there is still no consensus on the best strategy that yields improved patient outcomes, such that standardised neuroprotection protocols do not exist in a significant number of anaesthesia departments. This review aims to discuss contemporary evidence for preventing and managing risk factors for neuronal injury, mechanisms of injury, and neuroprotection interventions that lead to improved patient outcomes. Furthermore, a summary of existing RCTs and large observational studies are examined to determine which strategies are supported by science and which lack definitive evidence. We have established that the overall evidence for pharmacological neuroprotection is weak. Most neuroprotective strategies are based on animal studies, which cannot be fully extrapolated to the human population, and there is still no consensus on the optimal neuroprotective strategies for patients undergoing cardiac surgery. Large multicenter studies using universal standardised neurological fallout definitions are still required to evaluate the beneficial effects of the existing neuroprotective techniques.

Background: Acute kidney injury remains one of the most prevalent complications in hospitalised patients, with an especially high incidence in the paediatric population. Its diverse pathophysiological aetiologies present significant challenges in its clinical diagnosis. Relying solely on serum creatinine levels and urine output measurements for diagnosis has been shown to be inadequate, particularly for early detection of the disease. The wide range of disease manifestations highlights the importance of exploring diagnostic techniques that can identify patients at risk before disease progression occurs, thereby allowing for the implementation of timely corrective measures. Point-of-care ultrasound is a valuable technique with the potential to aid in the early identification of at-risk patients. Objective: To describe ultrasound parameters associated with the development of acute kidney injury or renal dysfunction in the hospitalised paediatric patient, and to examine their association with its development. This will include an analysis of the specific ultrasound features that may predict or be associated with the occurrence of acute kidney injury, as well as their potential role in identifying at-risk paediatric patients, facilitating timely interventions to mitigate further kidney damage. Methods: A systematic review of existing literature will be performed to assess ultrasound modalities currently associated with the diagnosis of acute kidney injury in the paediatric population. The protocol for this review has been registered with PROSPERO (CDR42024547614) and was developed in accordance with the guidelines set forth by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA). A comprehensive search of scientific literature will be conducted across PubMed, Scopus, Cochrane Library, and CINAHL databases. The data search will be performed independently by the primary researchers (GL and NA), with any disagreements resolved by the third and fourth researchers (MK, PMC). The COVIDENCE Systematic Review Software® 2024 will be utilised for article exportation, review, and data extraction. The QUADAS-2 tool will be applied to assess the risk of bias in the diagnostic accuracy of the studies included in the review. Conclusion: This protocol outlines a systematic review designed to evaluate the application of ultrasonography in identifying paediatric patients at risk of developing acute kidney injury and other forms of renal dysfunction. The review will critically assess the effectiveness of ultrasound techniques, including point-of-care ultrasound, in identifying acute kidney injury in children, with a particular emphasis on early detection. The findings from this review will contribute to a deeper understanding of the role of ultrasonography in clinical practice, with the potential to improve patient outcomes through earlier intervention. The ultrasound techniques identified, including Doppler imaging and flow measurements, will be employed in a subsequent prospective study within the paediatric population to evaluate their role, sensitivity, and accuracy.

Background. Anaesthetic drug wastage negatively impacts the already constrained economy in developing countries such as South Africa (SA). However, safe anaesthetic drug administration during both elective and emergency surgeries can be achieved without increasing wastage or costs. Drugs frequently wasted include those required in emergencies. Cost-reduction strategies, particularly in drug wastage, represent a potential area for short-term savings in hospital drug budgets. Increasing clinician awareness of drug wastage can help modify practices, leading to reduced waste while maintaining high-quality patient care. Objective. To evaluate wastage of commonly administered anaesthetic drugs, and to evaluate preventable and routine drug wastage and its cost. Methods. A prospective observational study was conducted in the operating theatre of Chris Hani Baragwanath Academic Hospital, a tertiary hospital in SA. Prospective data were collected for all patients who presented for elective and emergency surgical procedures at this institution over a 2-week period. Drug preparation and administration were determined by the treating anaesthesiologist. The amount of remaining drug in syringes and opened ampoules was considered as wasted. Routine drug wastage was defined as the remaining drug after the required dose was administered, while preventable drug wastage referred to drugs drawn but not administered to the patient. Results. Data were collected from 373 participants, of whom 58% were undergoing elective surgery. The average drug wastage was 29.7%, comprising 21.3% routine wastage and 8.4% preventable wastage, with an effect size of 0.47 (p<0.001). Propofol accounted for the highest frequency of routine drug wastage, while preventable wastage was predominantly attributed to adrenaline, atropine and suxamethonium (emergency pharmacological agents). The average cost of routine wastage was ZAR3.85, significantly higher than the ZAR1.32 for preventable drug wastage (p<0.001). Multivariate regression analysis revealed a significant association between paediatric surgical cases and increased anaesthetic drug wastage (p=0.004). Conclusion. The cost and wastage of anaesthetic drugs pose significant challenges in healthcare institutions, particularly in developing countries with limited resources. Implementing cost-effective strategies, such as using smaller ampoules and prefilled syringes, has been demonstrated to reduce drug wastage without compromising patient care.

Background: Neonatal anaemia is common, particularly in preterm and critically ill infants, and is frequently managed with red blood cell transfusion despite well-recognised associated morbidity. Patient blood management strategies aim to reduce transfusion exposure, and tranexamic acid (TXA) has emerged as a potential pharmacological adjunct. However, evidence supporting the use of TXA in neonates remains limited. Methods: We conducted a comprehensive narrative review of peer-reviewed literature published between January 2015 and December 2025. Searches were performed in PubMed/MEDLINE, Scopus, and Web of Science using Medical Subject Headings and keyword combinations related to neonates, children, blood conservation strategies, and TXA. Eligible studies included systematic reviews, randomised controlled trials, observational cohort studies, and case reports evaluating TXA use in paediatric and neonatal populations across surgical, critical care, and selected medical contexts. Adult-only and animal studies were excluded. Findings were synthesised qualitatively. Results: Seventeen studies met the inclusion criteria. Evidence consistently supports the use of TXA as part of multimodal blood-conservation strategies in elective paediatric surgery with predictable bleeding, particularly in craniosynostosis surgery, where reductions in blood loss and transfusion requirements were observed. In paediatric cardiac surgery and life-threatening haemorrhage, TXA may reduce bleeding and early mortality; however, benefits were less consistent in neonates. Evidence for TXA use in neonatal medical indications was sparse and inconclusive. Safety data suggest a dose- and context-dependent risk of seizures, with limited neonatal-specific adverse event reporting. Conclusion: TXA shows promise as a pharmacological blood conservation strategy in selected paediatric surgical populations, but evidence supporting its routine use in neonates remains limited. The unique haemostatic physiology, immature renal clearance, and neurological vulnerability of neonates necessitate cautious use. High-quality neonatal pharmacokinetic studies and prospective trials are urgently needed to define optimal dosing, safety, and efficacy before widespread adoption in neonatal practice.