Anesthesiology and Perioperative Science最新文献

The ependymal epithelium forms the cerebrospinal fluid barrier, separating the brain and spinal cord from the cerebrospinal fluid. However, in specific regions of the central nervous system, there are neurons that directly interface with the cerebrospinal fluid, including neuronal bodies, dendrites, or axons, This constitutes what is referred to as the "cerebrospinal fluid contacting neurons system (CSF-CNS)". The research team led by Professor Zhang has successfully utilized cholera toxin subunit B coupled horseradish peroxidase complex (CB-HRP) to selectively label the specialized neuron system that interfaces with cerebrospinal fluid, pioneeringly designating it as the "cerebrospinal fluid-contacting nucleus", commonly referred to as the "CSF-contacting nucleus". For the first time, the discovery of the CSF-contacting nucleus provides compelling morphological evidence for the existence of a distinct neural structure within the brain parenchyma that establishes a connection with the cerebrospinal fluid, thereby suggesting its potential significance in facilitating material and information exchange between the brain parenchyma and cerebrospinal fluid. After conducting a comprehensive series of studies on the morphological structure, material expression, gene analysis and functional aspects of the CSF-contacting nucleus in rodents and non-human primates, it has been revealed that there are fibrous connections between the CSF-contacting nucleus and the cerebral cortex and subcortical nuclei being involved in the regulatory mechanisms of pain, cognition, learning and memory, emotion, addiction, stress and anxiety responses, visceral activity, olfaction, vision processing and perception, auditory processing, perception, motor control and coordination, homeostasis regulation including maintenance of body energy and fluid balance, as well as the control of sleep–wake cycles and synchronization of biological rhythms. Current experiments have confirmed that the CSF-contacting nucleus is related to pain, morphine dependence and withdrawal, learning and memory, as well as stress. This present article offers a comprehensive review of the neurobiological characteristics and recent advancements in pain regulation of the CSF-contacting nucleus. The aim is to provide novel insights into the investigation of pain regulation within bidirectional regulatory pathway between the brain and cerebrospinal fluid, with a specific focus on elucidating the role of the CSF-contacting nucleus as a bridge structure. Additionally, the objective of this research is to propose innovative strategies for pain management and associated disorders in the future.

To summarize the existing evidence on the effects of ultrasound-guided recruitment maneuver (RM) during perioperative period on atelectasis, oxygenation and other clinical outcomes in adult patients undergoing abdominal surgery. In this systematic review and meta-analysis, PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure, and WanFang databases were searched from inception to May 2023 for relevant randomized controlled trials (RCTs) comparing the perioperative use of ultrasound-guided RM with a control group in adult patients undergoing abdominal surgery. The primary outcome was the incidence of early postoperative atelectasis (within 24 h after surgery). A total of 12 RCTs with 895 patients were included. The ultrasound-guided RM significantly reduced the incidence of postoperative atelectasis (RR [risk ratio]: 0.44, 95% CI [confidence interval]: 0.34 to 0.57, P < 0.001), with a median fragility index of 4. Prespecified subgroup analyses demonstrated the consistent findings. Additionally, ultrasound-guided RM could decrease postoperative lung ultrasound score (MD [mean difference]: − 3.02, 95% CI: − 3.98 to − 2.06, P < 0.001), reduce the incidence of postoperative hypoxemia (RR: 0.32, 95% CI: 0.18 to 0.56, P < 0.001), improve postoperative oxygenation index (MD: 45.23 mmHg, 95% CI: 26.54 to 63.92 mmHg, P < 0.001), and shorten post-anesthesia care unit (MD: − 1.89 min, 95% CI: − 3.14 to − 0.63 min, P = 0.003) and hospital length of stay (MD: − 0.17 days, 95% CI: − 0.30 to − 0.03 days, P = 0.02). However, there was no significant difference in the incidence of atelectasis at the end of surgery between two groups (RR: 0.99, 95% CI: 0.86 to 1.14, P = 0.89). The use of ultrasound-guided RM perioperatively reduced the risk of atelectasis and improve oxygenation after abdominal surgery. Strategies to reduce the development of perioperative atelectasis are presented to highlight areas for future research.

Purpose

This study aims to provide a comprehensive overview of anesthesia management strategies employed in pediatric lung transplantation.

Methods

A retrospective analysis was conducted on data from 14 pediatric patients who underwent lung transplantation at the Wuxi Center between September 2019 and November 2022. Patient demographics, surgical particulars, airway management, utilization of extracorporeal support, fluid administration, blood gas and electrolyte profiles, and postoperative outcomes were systematically documented and subsequently summarized.

Results

Of the 14 patients, 7 received extracorporeal membrane oxygenation (ECMO) and 1 received cardiopulmonary bypass (CPB). The average operation time was 303 ± 53 min, with the median extubation time of 26 h. The entirety of pediatric lung transplant procedures was executed successfully, resulting in the discharge of thirteen patients postoperatively. Regrettably, one patient died due to infectious shock on the fourth postoperative day.

Conclusion

The achievement of successful pediatric lung transplantation necessitates effective perioperative anesthesia management, with a focal emphasis on circulatory control. Real-time measurements serve as the cornerstone for decision-making. Proactive administration of vasoactive agents is integral to sustaining hemodynamic stability. The judicious assessment of ECMO necessity is paramount, favoring central ECMO during the surgical intervention.

Taurine is a conditionally essential amino acid that has been reported to have antioxidative and immunomodulatory effects either directly or through its interactions with gut microbiome. Although taurine has been widely used as a health supplement and also for treatment of congestive heart failure in Japan, its roles in the perioperative setting have not been well characterized. The purpose of this systematic review and meta-analysis was to assess whether oral or intravenous taurine, or its derivatives such as taurolidine, can offer benefits compared to placebo in the perioperative setting. Non-randomized studies, trials assessed topical taurine or taurolidine, or trials did not report clinical outcomes were excluded. Six randomized-controlled-trials (RCTs) involving a total of 596 adult surgical patients, in PubMed, MEDLINE and EMBASE databases on September 14, 2023 were identified and meta-analyzed using a fixed-effect model. Biases were assessed by reporting individual trial elements. Taurine or taurolidine (which is readily metabolized by hydrolysis to taurine) supplementation was associated with a reduction in all-cause infection (5 trials: pooled odds ratio (OR) 0.59; 95% confidence interval (CI) 0.38–0.92; p = 0.020) but not delirium (2 trials: OR 0.63, 95% CI 0.38–1.04; p = 0.071) or mortality (4 trials: OR 0.82, 95% CI 0.43–1.58; p = 0.557) compared to placebo. Using the ‘trim and fill’ technique to adjust for publication bias did not change the favorable effect of taurine on risk of infection (OR 0.61, 95% CI 0.40–0.95). Because the number of studies included was small, the promising benefits of taurine on risks of perioperative infection should be confirmed by adequately-powered RCTs.

Purpose

Submaximal exercise tests (SET) are an easier to conduct and less physically demanding alternative to cardiopulmonary exercise testing for assessment of pre-operative fitness. Assessment of heart rate recovery (HRR) following SETs offers an easily obtained marker of vagal reactivation and sympathetic withdrawal and therefore provides an indication of an individual’s fitness. This study sought to assess the reproducibility of HRR across different workloads and modalities of SET.

Methods

Thirty-four healthy volunteers were recruited to undergo two SETs at 40% and 60% of their predicted maximal workload. A second group of thirty-one healthy volunteers were recruited to undergo three SETs of differing modalities; Cycle ergometry, Step and Shuttle Walk tests. HRR was quantified using the conventional indices HRR1 and HRR2 (calculated as heart rate (HR) on exercise cessation minus HR at 1 and 2 min of rest) and a novel area under the HRR vs. time curve (HRR_AUC) method. Reproducibility of results was assessed using intra-class correlation coefficient (ICC) and limits of agreements.

Results

The results showed that HRR1 and HRR2 were poorly reproducible across differing workloads and exercise modalities (ICC < 0.45 for all comparisons) whereas HRR_AUC proved to be at least moderately reproducible (ICC > 0.52 for all comparisons).

Conclusions

These results suggest that HRR_AUC may be a superior way of quantifying HRR following SETs, adding objectivity to SET results. Quantifying HRR_AUC could prove to have useful clinical applications for pre-operative risk assessment, assessing fitness to undergo treatment and monitoring disease progression.

Mechanical ventilation is an important life-saving therapy for general anesthesia and critically ill patients, but ventilation itself may be accompanied with lung injury. Ventilator-induced lung injury (VILI) exacerbates pre-existing lung disease, leading to poor clinical outcomes. Especially for patients undergoing cardiothoracic surgery and receiving one-lung ventilation (OLV), optimizing the parameters of OLV is closely related to their prognosis. It is not clear what is the best strategy to minimize VILI through adjusting ventilation parameters, including tidal volume, positive end expiratory pressure and driving pressure, etc. Different parameters, in combination, are responsible for VILI. Protective ventilation strategies, aiming to reduce postoperative pulmonary complications, have been discussed in many clinical studies and different opinions have been raised. This review addresses the pathogenesis of VILI and focus on the OLV management and better protective OLV strategies during thoracic surgery.

Pain in the postoperative period is a common patient experience that can subsequently lead to other postoperative complications if not managed appropriately. While opioids are a common pharmacologic tool for managing pain, there are risks associated with liberal opioid use. Multimodal analgesic strategies, however, can adequately manage postoperative pain and minimize the risks associated with opioids. In this review, common pharmacological treatments for multimodal analgesia will be reviewed for efficacy, risks, and benefits, including gabapentinoids, opioids, alpha-2 agonists, ketamine, Non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids. While this may not be a comprehensive list of medication options, it represents some of the most commonly used pharmacologic techniques for managing pain in the perioperative period. In addition, newer regional anesthetic techniques will be discussed to review their efficacy, risks, and benefits as well. The goal of this review is to summarize the various options for a multimodal analgesic protocol that we encourage providers to utilize when managing postoperative pain to facilitate conservative opioid usage and improve patient outcomes overall.

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