Anesthesiology and Perioperative Science最新文献

Purpose

Dexmedetomidine is commonly used for its sedative and neuroprotective effects, but its impact on brain activity and sleep architecture is not fully understood. Emerging evidence suggests it may improve postoperative outcomes, particularly in older adults, by promoting sleep-like states with stable hemodynamics, reducing posttraumatic stress, and decreasing delirium. This study aims to better characterize the neurophysiological profile of dexmedetomidine-induced sedation by comparing it to natural sleep in both young and aged mice.

Methods

Twelve 4–5 month old and six 10–18-month-old C57BL/6 J male mice were used. Animals were implanted with electroencephalography/electromyography electrodes. After at least 7 days of recovery, animals received intraperitoneal injections of saline or dexmedetomidine (50–400 µg/kg) and sleep–wake states were recorded for 5–12 h.

Results

Dexmedetomidine significantly increased delta (0.5–4 Hz) power beyond levels observed during natural non-rapid eye movement (NREM) sleep, followed by suppression of both high frequency (> 10 Hz) electroencephalography activity and REM sleep in a dose dependent manner. Body posture was sprawled during dexmedetomidine versus curled as during natural sleep. Notably, at the transition into sedation, dexmedetomidine induced high-voltage spikes resembling high-voltage spindles and spike wave discharges. These spikes were more prominent in the prefrontal cortex compared to the parietal cortex and aged animals exhibited more high voltage spikes than young adult animals.

Conclusion

The combination of elevated delta power, high-voltage spikes, suppression of high-frequency activity, and sprawled body posture during dexmedetomidine-induced sedation indicates a state of unconsciousness that is neurophysiologically distinct from natural NREM sleep in mice. These findings highlight important age-related differential responses to dexmedetomidine and help inform its safe and effective use in vulnerable patient populations.

Preoperative medicine which includes comprehensive medical evaluations and optimizations of medical conditions before surgeries is an evolving specialty of medicine. Preoperative medicine is practiced by a variety of specialists, varies widely in efficacy, but should be evidence based and individualized based on the patient, and the planned anesthetic and surgery. Innovations in procedural and surgical care are evolving rapidly. And, the demand for anesthesia for even minor procedures continues to expand. Specialized services are increasing, but often lead to fragmented care. These confluences predispose to complications and poor outcomes. Preoperative medicine is filling a gap to meet the needs of perioperative physicians to evaluate and prepare patients for anesthesia, surgeries and procedures. Increasing age, numbers of comorbidities and the extent of surgery combine to increase the risk of perioperative morbidity and mortality. This review cannot address every factor that predicts risk, but is designed to be highlight some of the most common or controversial conditions.

Purpose

Sepsis, a potentially fatal condition resulting from a dysregulated immune response to infection, is often associated with immunosuppression. Interferon regulatory factor 4 (IRF4), a key regulator of T-cell function, plays an important role in this process. This study aimed to investigate the effects of IRF4 on splenic CD4⁺ T lymphocytes in the spleens of septic mice during the immunosuppressed phase and to elucidate the mechanisms regulating its expression.

Methods

An immunosuppressed state was induced in mice using the cecal ligation and puncture model. The MEK inhibitor trametinib was administered to suppress IRF4 expression, enabling evaluation of its role in immunosuppression. MeRIP–qPCR, RIP–qPCR, and dual-luciferase reporter assays were performed to investigate the regulatory mechanisms underlying IRF4 upregulation.

Results

IRF4 was upregulated in immunosuppressed septic mice. Treatment with trametinib suppressed IRF4 expression, thereby alleviating the immunosuppressed state. Methyltransferase-like 3 (METTL3)-mediated N6-methyladenosine (m6A) modification enhanced the binding of YTH N6-methyladenosine RNA-binding protein 1 to IRF4 mRNA, promoting its translation. METTL3 depletion reduced IRF4 expression, alleviated immunosuppression, and improved survival.

Conclusion

Our findings highlight the critical regulatory role of IRF4 in sepsis-induced immunosuppression. The identification of m6A modification as a mechanism regulating IRF4 expression reveals a novel potential avenue for therapeutic intervention.

Purpose

To compare ChatGPT, a general-purpose large language model (LLM), with OpenBioLLM, a domain-specific biomedical model, in generating clinically appropriate anesthesia plans, and to assess the impact of advanced prompt engineering (PE).

Methods

A comparative observational study analyzing anonymized clinical records of 100 cardiac surgery patients using three LLMs under simple querying and PE. Plans were evaluated by anesthesiologists using a double-blind approach. The main outcome measures included clinical alignment, reasoning quality, medication selection, dosage accuracy, omissions, and risk of harm. Scores were rated on a 5-point Likert scale by both experienced and trainee anesthesiologists, and differences analyzed via paired t-tests and analysis of variance.

Results

In clinical matching accuracy, logical reasoning, medication selection, and safety evaluation metrics, ChatGPT consistently outperformed OpenBioLLM. GPT-4o demonstrated superior performance compared to GPT-3.5, with significant performance enhancements achieved through prompt optimization. Both physician groups reported notable improvements in their average scores for the ChatGPT model when utilizing advanced PE, whereas OpenBioLLM showed comparatively smaller score improvements.

Conclusion

ChatGPT’s adaptability and clinical accuracy, enhanced by PE, make it a valuable tool for anesthesia planning, especially in resource-limited settings. However, over-reliance on AI by less experienced clinicians poses risks, underscoring the need for physician oversight and tailored training. Further research is necessary to validate these findings across diverse clinical scenarios.

Since its introduction in 2002, transcatheter aortic valve replacement (TAVR) has gained rapid worldwide adoption, significantly increasing the survival rates of high-risk surgical patients. As key members of the multidisciplinary TAVR team, anesthesiologists play a crucial role in perioperative care. Initially, anesthesiologists administered general endotracheal anesthesia, maintained hemodynamic stability, monitored cardiac function with transesophageal echocardiography, and managed adverse events. Improvements in techniques and valve design have expanded TAVR indications, enabling minimally invasive procedures. As a result, anesthesia practices have shifted from general anesthesia to monitored anesthesia care or local anesthesia. Today, anesthesia efforts focus on refining perioperative strategies to improve patient comfort while reducing complications, length of hospital stay, costs, and mortality. These developments highlight the essential role of anesthesiologists in optimizing TAVR outcomes.

Ancient China has a rich history of acupuncture anesthesia (AA), with both theoretical and clinical foundations that were notably effective in the 1970s. This paper provides an in-depth analysis of AA's historical context and clinical applications, juxtaposing it with conventional anesthesia methods. It also aims to forecast the future trajectory of AA and examine the factors influencing its evolution. Despite experiencing a decline after its peak—primarily due to the precision, effectiveness, visibility, and cost-effectiveness of conventional anesthesia—AA's potential remains significant. Its application in perioperative period has been demonstrated to significantly reduce side effects associated with traditional methods, leading to improved clinical outcomes. However, in recent years, the concept of AA has been associated with perioperative acupuncture. There are numerous successful AA cases reported worldwide, and the field is in urgent need of continuously being evaluated and refined to keep pace with modern medical advancements and societal needs. This nonsystematic narrative review manifests the potential for further development in AA is considerable, and ongoing research and integration efforts suggest a promising future for this ancient practice in contemporary medicine.

Patients with chronic liver disease (CLD) are at increased risk of adverse perioperative outcomes. Effective preoperative risk stratification and optimization are critical to minimizing perioperative complications. This article summarizes key aspects of perioperative care in patients with CLD, including pathophysiology, preoperative risk assessment, and evidence-based perioperative care strategies. For patients with hepatocellular carcinoma require liver resection, a multidisciplinary approach is recommended to optimize surgical candidacy and outcomes. In addition, altered bioavailability of opioids and other analgesics necessitates individualized postoperative pain management, emphasizing multimodal approaches tailored to hepatic function.

Graphical Abstract

Purpose

Patients undergoing transurethral prostate surgery often experience catheter-related bladder discomfort (CRBD), which can significantly impairs postoperative recovery. The anatomical convergence between the ilioinguinal and iliohypogastric (II-IH) nerve pathways (T12–L2) and the bladder innervation provides a rationale for evaluating the II-IH nerve block as a potential treatment. This study aimed to investigate the efficacy of ultrasound-guided II-IH nerve block versus intravenous tramadol in reducing postoperative CRBD.

Methods

Ninety-four patients undergoing transurethral prostate surgery were equally randomized to receive either 1.5 mg/kg intravenous tramadol or bilateral ultrasound-guided II-IH nerve block with 15 mL of 0.375% ropivacaine per side before extubation. Intravenous tramadol was used as rescue medication for moderate-to-severe CRBD. The primary outcome was the overall incidence of CRBD within postoperative 24 h. Secondary outcomes included CRBD severity, pain scores, adverse events, patient satisfaction, hospitalization duration, and International Prostate Symptom Scores (IPSSs).

Results

The overall incidence of CRBD within postoperative 24 h was 56.5% in the II-IH block group versus 65.2% in the tramadol group, with an absolute risk difference of −8.70% (95% confidential interval: −24.71% to 10.92%; p = 0.393). Secondary outcomes, including the incidence of moderate-to-severe CRBD, pain scores at all assessed timepoints, rescue tramadol use, length of hospitalization, and IPSSs were comparable between the two groups (all p > 0.05). However, the II-IH block group demonstrated significantly lower incidences of adverse events (including nausea and vomiting, headache, dizziness, and dry mouth) and a higher proportion of extremely satisfied patients (all p < 0.05). Importantly, no nerve block-related complications were observed in the II-IH block group.

Conclusions

Ultrasound-guided II-IH nerve block appeared to be a comparable alternative to intravenous tramadol for reducing CRBD after transurethral prostate surgery, while offering a more favorable safety profile and higher patient satisfaction.

Trial registration

Chinese Clinical Trial Registry, ChiCTR2300078552. Registered 12 December 2023, https://www.chictr.org.cn/showproj.html?proj=209712

Purpose

Postoperative delirium (POD) is common in older adults following major surgery. Ketamine has opioid-sparing properties and potential neuroprotective effects, yet whether intraoperative ketamine reduces the incidence of postoperative delirium remains uncertain. This systematic review aims to determine whether ketamine use is associated with a lower incidence of POD in older patients undergoing spine or orthopedic surgery.

Methods

We conducted comprehensive searches in PubMed, Web of Science, EMBASE, Cochrane CENTRAL, and CINAHL Complete from inception to June 26, 2025. Both keywords and index terms (Mesh/EMTREE) were used to develop broad and sensitive searches tailored to each database to retrieve all relevant articles. EMBASE results were limited to articles and articles in press. Eligible studies included patients aged ≥ 60 years undergoing surgery with intraoperative ketamine administration and reporting POD as an outcome. Two reviewers independently screened studies, extracted data, assessed risk of bias, and performed quality appraisal using RoB 2 for randomized controlled trials (RCTs) and ROBINS-I for observational studies. Random-effects meta-analyses were performed to calculate odds ratios (ORs) with 95% confidence intervals (CIs).

Results

We included 24 studies in the final analysis and five specifically studied patients undergoing spine or orthopedic surgery. The effect of ketamine on POD showed an OR of 1.50 (95% CI 0.38–5.91, P = 0.56 random effects model) for the two RCTs. Including the additional three cohort studies was marginally associated with an increase in the occurrence of postoperative delirium, OR 1.30 (95% CI 1.01–1.67), P = 0.0425. However, the imprecision of the studies was deemed to be serious due to small sample sizes, and only two were RCTs.

Conclusions

This systematic review and meta-analysis did not find a statistically significant association between intraoperative ketamine use and POD in older patients undergoing spine or orthopedic surgery in the RCTs. However, because of the small number of available studies together with imprecision, this conclusion should only be considered as preliminary. Larger, high-quality randomized trials are needed to determine whether ketamine influences POD risk and to assess different dosing strategies for their effects on postoperative cognitive outcomes in older adults.