Anesthesiology and Perioperative Science最新文献

This article provides an overview of perioperative strokes—a pressing concern given the rising number of surgical or interventional procedures performed worldwide. Mechanisms underlying perioperative stroke include atherosclerotic plaque instability, induction of a pro-inflammatory state (aggravated by vascular risk factors), hemodynamic dysfunction through hypotension and blood loss, and disruption of the endothelial glycocalyx. The frequency of perioperative stroke varies considerably depending on the type of procedure, being higher with aortic valve and neurovascular procedures. Covert or silent strokes are commonly seen on post-operative magnetic resonance imaging in as many as one in two patients after procedures like brain aneurysm coiling. Risk factors for perioperative stroke include patient factors such as age, sex, race, and comorbidities, as well as operator and procedural factors such as operator experience, institutional procedural volume, use of certain devices, and vascular access site. Overt periprocedural stroke is associated with higher mortality, longer hospital stays, and higher long-term disability. The long-term sequelae of covert strokes are still being characterized, but recent studies have indicated that a higher burden of such infarcts is associated with worse functional and cognitive outcomes. Key considerations to prevent perioperative strokes include screening plus risk factor control, pre-medication, and procedural considerations including anesthetic choice. The management of perioperative ischemic stroke has been aided by advancements in reperfusion therapies and stroke systems of care that allow rapid treatment of major stroke. Ongoing work seeks to address the enduring need for evidence-based therapeutic strategies to prevent these strokes and mitigate their adverse impact.

Purpose

The mechanisms underlying reversible unconsciousness induced by general anesthetics remain unclear. This study aimed to investigate the effects of four commonly used anesthetics on neuronal spiking patterns in layer 5 of the medial prefrontal cortex (mPFC).

Methods

In vivo multi-channel recordings were performed in layer 5 of the mPFC in a mouse model. Neuronal spiking patterns of regular-spiking and fast-spiking neurons were measured and compared across wakefulness loss of the righting reflex (LORR), and recovery of the righting reflex (RORR). Four anesthetic/sedative drugs (sevoflurane, propofol, ketamine, and dexmedetomidine) were tested.

Results

During LORR, most cortical regular-spiking neurons were inhibited, while a small subset was excited. Fast-spiking neurons exhibited significant suppression across all anesthetics. Among these, the firing rate of inhibited regular-spiking neurons was closely associated with the transitions between LORR and RORR. Sevoflurane, propofol, and dexmedetomidine exhibited similar modulatory effects on mPFC neurons, whereas ketamine induced stronger excitatory effects on both regular- and fast-spiking neurons.

Conclusions

Sevoflurane, propofol, and dexmedetomidine exert comparable effects on neuronal spiking in the mPFC, while ketamine induces distinct excitatory effects. Inhibited regular-spiking neurons in layer 5 of the mPFC are closely associated with the reversible transitions between LORR and RORR.

Purpose

Sarcoidosis is a rare systemic granulomatous disorder characterized by lung involvement but frequently involves the heart, gastrointestinal and lymphatic organs. Few studies have investigated sarcoidosis-related postoperative cardiopulmonary complications, creating a significant knowledge gap. Using a comparative cohort analysis, the authors hypothesized that sarcoidosis would be associated with higher risk for 30-day postoperative pulmonary complications (PPC).

Methods

This retrospective study examined hospital system data between January 1, 2013, and January 1, 2022, for patients over 18 years, admitted for procedural intervention. 389 sarcoidosis patients and controls (N = 48,823) were identified. The primary endpoint of PPC, as measured by the Agency for Healthcare Research and Quality PPC composite, and secondary endpoints of major adverse cardiovascular events (MACE), PPC subcomposites, and length of stay (LOS) were analyzed. A Mahalanobis distance matching (MDM) was used to match sarcoidosis and control patients (N = 389) on clinically relevant baseline covariates.

Results

After MDM and adjustment for surgical time and anesthesia type, sarcoidosis diagnosis corresponded to higher composite 30-day PPC (18.5% vs. 9.3%, adjusted odds ratio [OR_adj] = 3.32, 95% confidence intervals [CI] 1.8–5.8; p < 0.001), sub-composite respiratory failure/insufficiency (10.5% vs. 5.1%, OR_adj = 3.31, 95% CI 1.6–6.7; p < 0.001) but not pneumonia (5.7% vs. 3.9%, OR_adj = 2.0, 95% CI 0.8–4.8; p = 0.117). The sarcoidosis cohort had longer LOS (OR_adj = 2.33, 95% CI 2.0–2.7; p < 0.001). Sarcoidosis diagnosis was not associated with 30-day MACE (12.3% vs. 12.9%, OR_adj = 1.43, 95% CI 0.8–2.4; p = 0.192), atrial fibrillation (6.9% vs. 5.7%; p = 0.931), or congestive heart failure events (5.9% vs. 7.2%; p = 0.526).

Conclusions

Sarcoidosis is associated with a twofold increased risk of 30-day PPC, primarily related to an increased incidence of 30-day respiratory failure/insufficiency. This risk appears to be independent of disease staging, but is associated with the presence of sarcoidosis features on preoperative chest radiography. Postoperatively, sarcoidosis patients experience longer hospital LOS, suggesting that when complications occur, they are more resource-intensive, when compared to controls. These findings highlight opportunities to enhance preoperative multi-disciplinary optimization, and suggest that tailored perioperative care strategies for sarcoidosis patients would be beneficial.

Graphical Abstract

Purpose

An increased incidence of delirium was reported in patients especially in elderly patient during the acute phase of coronavirus disease 2019 (COVID-19). However, whether COVID-19 history increases the risk of postoperative delirium (POD) in elderly patients remains unclear. This study aims to investigate the association between COVID-19 history and POD in elderly patients undergoing elective surgeries.

Methods

In this prospective, two center cohort study, 500 elderly patients undergoing elective surgeries from March to May 2023 were analyzed. The primary exposure was a history of COVID-19. The primary outcome was POD assessed with 3-min diagnostic confusion assessment method or confusion assessment method for the intensive care unit within three days after surgery. We used inverse probability of treatment weighting (IPTW) to balance the differences between patients with or without a history of COVID-19. The association between COVID-19 history and POD was estimated using a logistic regression model with IPTW. Additionally, we next exploringly conducted subgroup analysis and assessed interaction effects to evaluate the impact of COVID-19 history on POD based on frailty/pre-frailty, cancer, surgical type/classification, sex, profession, and residence type.

Results

In this cohort, 412 patients had a history of COVID-19 with an incidence 16% of POD while 88 were uninfected with 15.9% of POD incidence. There was no association between COVID-19 history and POD [adjusted odds ratio (OR_adj) 1.20 (0.80–1.79), P = 0.378] in elderly patients undergoing elective surgery. However, POD was significantly increased in patients with COVID-19 history who were pre-frailty/frailty or with cancers [OR_adj 2.41 (1.19–5.10) and OR_adj 2.29 (1.23–4.39), respectively].

Conclusion

This preliminary exploratory study found no association between a history of COVID-19 and POD in elderly patients undergoing elective surgery.

Trial registration

Registered at the Chinese Clinical Trial Center (https://www.chictr.org.cn/showproj.html?proj=192846) with No. ChiCTR2300069308 on Mar 13, 2023.

Remimazolam is a novel ultra-short-acting benzodiazepine gaining attention for its rapid onset, predictable pharmacokinetics, and favorable safety profile in adult procedural sedation and anesthesia. Early pediatric data suggest it may offer significant advantages over traditional sedatives, including enhanced predictability, improved safety, and faster recovery times. Despite these promising attributes, its routine use in pediatric populations remains underexplored and unestablished. This narrative review examines remimazolam’s pharmacological properties, including its mechanism of action, metabolism, and elimination, and evaluates its safety and efficacy in pediatric sedation. Potential clinical applications are highlighted, such as procedural sedation, intensive care, and anesthesia induction, with comparisons to conventional agents. While initial studies suggest benefits, critical gaps remain in understanding its use in children. These include age-specific dosing strategies, long-term safety considerations, and its efficacy in children with comorbid conditions or undergoing complex procedures. Addressing these gaps will require robust clinical trials and large-scale observational studies. This review synthesizes current evidence and explores the potential of remimazolam to enhance pediatric sedation and anesthesia practices. By identifying key knowledge gaps and proposing future research directions, it aims to inform clinicians and researchers about the role of remimazolam in improving safety and outcomes in pediatric anesthesia.

Pharmacological interventions with the inhaled anesthetic sevoflurane, widely used in cardiac surgery, have been reported to mimic the cardioprotection produced by ischemic conditioning against myocardial ischemia–reperfusion injury. Beneficial effects of sevoflurane conditioning vary with dose, time window and duration and have been reported in a variety of studies involving both laboratory experiments and clinical trials. However, sevoflurane conditioning effects are impaired or lost in subjects with diabetes in both laboratory and clinical settings with mechanisms incompletely understood. This article summarizes the major findings investigating sevoflurane-induced myocardial protection. Our aim is to provide a better understanding of the interrelated but poorly described sevoflurane conditioning signaling pathways. Moreover, this may facilitate the development of more effective therapeutic or preventive strategies for myocardial ischemia-reperfusion injury.

Anesthesia is a fundamental aspect of modern medical practice, ensuring patient safety and comfort during surgical procedures by effectively managing hypnosis and analgesia. The rapid advancement of artificial intelligence (AI) has facilitated the emergence of automated anesthesia systems, significantly enhancing the precision, efficiency, and adaptability of anesthesia management in complex surgical environments. This review provides a comprehensive survey of the existing literature on automated anesthesia, focusing on three key areas: physiological modeling, automatic anesthesia control, and performance evaluation. It critically examines the strengths and limitations of current methodologies, including traditional statistical learning, machine learning and deep learning approaches, while discussing future development trends in the field. By synthesizing recent technological advancements and clinical applications, this work aims to provide valuable insights for researchers and clinicians, promoting the evolution of intelligent and automated anesthesia practices. Ultimately, this review underscores the transformative potential of AI-driven solutions in delivering personalized anesthesia care, optimizing both hypnosis and analgesia, and enhancing surgical outcomes.