Anesthesiology and Perioperative Science最新文献

Cognitive training (CT) has been shown to reduce the risk of postoperative cognitive dysfunction (POCD) in surgical patients undergoing general anesthesia, but the evidence is controversial. Additionally, whether different timings of CT have diverse effects and which surgical populations benefit most are unclear. To answer these questions, we searched Medline, Embase, Web of Science and Cochrane Library through July 18, 2022, for randomized controlled trials (RCTs) of CT in surgical patients with general anesthesia reporting cognitive outcomes, and found 13 studies including 989 patients. Pooled analysis showed that CT could significantly reduce the incidence of POCD (k=7, RR=0.52, 95% confidence interval (CI)=[0.34–0.78]), especially for the noncardiac surgery population (k=4, RR=0.43 [0.29–0.63], P<0.01, I² =0%). The pooled RRs for preoperative CT and postoperative CT were both low and statistically significant, while that for perioperative CT was not (k=2, RR=0.42 [0.25–0.70], P<0.01, I²=0% vs k=4, RR=0.43 [0.28–0.67], P<0.01, I²=0% vs k=1, RR=1.44 [0.69–3.01], P=0.34, I²=0%). Small to moderate effects were found for executive function, speed, language and verbal memory, while no statistically significant effects were found for postoperative delirium (POD), global cognition, working memory, and psychosocial functioning, including depressive symptoms and anxiety symptoms. Although RCT evidence remains sparse, current evidence suggests that preoperative and postoperative CT may help reduce the incidence of POCD, particularly in the noncardiac surgery population, and improve specific cognitive domains in surgical patients. This intervention therefore warrants longer-term and larger-scale trials to examine the effects on the risk of POD and application to the cardiac surgery population.

Graphical Abstract

The short acting benzodiazepine remimazolam has been well characterised for use during procedural sedation. Onset of hypnotic effect is swifter than midazolam and recovery is faster with a period of antegrade amnesia. Haemodynamic changes associated with remimazolam sedation are modest and there is no pain on injection. General anaesthesia may be induced and maintained by infusion of remimazolam in combination with a suitable opioid. Hypotension is less frequent than when propofol is used. In addition, remimazolam may be a suitable alternative to propofol or etomidate for inducing anaesthesia in haemodynamically compromised patients prior to maintenance with a volatile agent. A small proportion of patients are slow to recover consciousness after total intravenous anaesthesia (TIVA) with remimazolam/opioid combinations. Preliminary experience suggests that flumazenil may be useful in this group however studies are required to define the appropriate dosage and timing for flumazenil administration. Future developments may include sedation and anaesthesia for infants and children as well as intensive care sedation for all age groups. These indications require demonstration in well designed clinical trials.

Graphical Abstract

Purpose

Glial cells play a crucial role in regulating physiological and pathological functions, such as sensation, infections, acute injuries, and chronic neurodegenerative disorders. Despite the recent understanding of glial subtypes and functional heterogeneity in central nervous system via single-cell/nucleus RNA sequencing, the transcriptomic profiles of glial cells in the adult human dorsal root ganglia (DRG) have not yet been characterized at single-cell resolution.

Methods

We used high-throughput single-nucleus RNA sequencing to map the cellular and molecular heterogeneity of satellite glial cells (SGCs) and Schwann cells (SCs) in the human DRG, and further compared these human findings with those from mice. The expression profiles of classical marker genes of peripheral somatosensory system in glial cells were examined in human and mouse DRG. Additionally, the functional properties of the enriched genes in glial cells and their subtypes were also explored by Gene Ontology (GO) term analysis.

Results

Human DRG cells were initially classified into 11 clusters based on their distinct transcriptional characteristics. SGCs and SCs were identified through their representative marker genes. SGCs were further classified into six subclusters, while SCs were classified into seven subclusters. The comparison with mouse transcriptomic profiles revealed an overall similarity between the two species, while simultaneously highlighting some degree of heterogeneity in specific genes.

Conclusions

This atlas comprehensively profiled glial cell heterogeneity and provides a powerful resource for investigating the cellular basis of physiological and pathological conditions associated with DRG glial cells.

Graphical Abstract

Patients awaiting surgical procedures often experience obvious anxiety due to discomfort and uncertain events, which is one of the most common clinical manifestations in perioperative patients. Numerous studies have confirmed that preoperative anxiety is closely related to the occurrence of postoperative adverse events, such as insomnia, pain, nausea and vomiting and neurocognitive dysfunction. Appropriate intervention or treatment for preoperative anxiety may contribute to reducing the incidence of postoperative adverse events. Although people have long known about the negative effects of preoperative anxiety and have taken certain measures, the underlying mechanism has yet to be fully elucidated. In this paper, we focus on several typical postoperative adverse events that are, particularly concerning to anesthesiologists, review their relationships with preoperative anxiety, describe the intervention strategies and provide a certain summary and outlook.

Purpose

Congenitally corrected transposition of the great arteries (ccTGA) is a rare disease that is complicated by a variety of tachyarrhythmias or atrioventricular blocks and cardiac malformations. Anesthesia management is a challenge, especially in ccTGA patients with complications. Herein, we reported a case of ccTGA.

Methods

Multimodal general anesthesia combined with transversus thoracic muscle plane block (TTMPB), use of low-dose opioids and adjuvant medications, lung protective ventilation, use of vasoactive drugs and close perioperative monitoring were employed for the peri-operative management of this patient.

Results

The patient was safely returned to the ward and did not develop serious complications. Fourteen days after surgery, the patient recovered well and was discharged.

Conclusions

For patients undergoing a secondary cardiac surgery for ccTGA, preoperative evaluation of etiology of ccTGA is very important. Anesthesia management based on the surgical method and intraoperative vital signs and the postoperative real-time monitoring are also crucial for the post-operative recovery of these patients.

Effective management of pediatric perioperative pain is typically goal-directed and multimodal, requiring various imperfect agents in combination to provide analgesia and support recovery. Gabapentinoids are one such class of agents often used in pediatric analgesic and enhanced recovery pathways. In adults, gabapentinoids have been associated with a modest reduction in pain scores but are often avoided due to undesired side effects. Children may be less susceptible to these unwanted effects, and the reduction in pain, agitation, and post-operative nausea and vomiting seen with these medications may confer significant benefit. While further studies are needed, to date there is no evidence to suggest a significantly increased risk of adverse effects in generally healthy children treated with gabapentinoids in the perioperative period. Although current evidence does not support their indiscriminate use, there appears to be a subset of pediatric surgical patients who stand to benefit from perioperative gabapentinoids. Pediatric use should not be abandoned, but rather further investigated to support thoughtful goal-directed application.

Graphical Abstract

Purpose

To present a review of insights gained from investigating the question as to whether red haired individuals have altered sensitivity to pain.

Methods

A narrative review of the literature.

Results

Anecdotal observations from anaesthesiologists have suggested that individuals with red hair require more analgesia on average than members of the general population. This observation has been confirmed and the redheaded phenotype is associated with an altered sensitivity to pain across a wide range of different pain types. Through the use of mouse models, a central mechanism for this altered pain sensitivity has been proposed involving both the melanocortin and opioid receptor systems, despite the causative mutation for this phenotype occurring in melanocortin 1 receptors (MC1Rs) on peripheral melanocytes.

Conclusions

Understanding the endocrine imbalance caused by this loss of function mutation helps us to further explore the mechanisms behind pain sensitivity. It also facilitates a discussion about how pharmacogenomics can be exploited to personalise and subsequently optimise treatment.

Graphical Abstract