Anesthesiology and Perioperative Science最新文献

The erector spinae plane block remains a divisive regional technique which has split the regional anesthesia community into believers and non-believers. Its main mechanism of action remains controversial and this has been pivotal in the controversy. We explore our current understanding of fascial plane blocks and erector spinae blocks as well as explore the gaps in knowledge. This opinion paper is meant to give a balanced view of the current state of this block in regard to guidelines, research and future. The viewpoint of the authors may not necessarily align with current ideas, however, hopefully will guide subsequent trials to more robust evidence.

To characterize the fragility index (FI) of statistically significant results reported in randomized controlled trials (RCTs) investigating the incidence of hemidiaphragmatic paralysis (HDP) after brachial plexus blocks. A systematic review of RCTs retrieved from the PubMed-Medline, Embase, and Web of Science electronic databases was conducted. All alternative RCTs published between January 2012 and October 2022 were identified. Only RCTs with two parallel arms designs, and reporting HDP as the primary outcome, statistical significance, and superiority results were selected. The FI was calculated according to Fisher’s exact test using previously described methods. In addition, the risk of bias was evaluated using the Cochrane Risk-of-Bias tool for randomized trials. The 23 RCTs that fulfilled the inclusion criteria had a median FI of 4 (interquartile range [IQR]2–8) and a median Fragility Quotient of 0.077 (IQR 0.038- 0.129). However, in 13 (56.5%) trials, the calculated FI value was ≤ 4. In 3/23 (13.0%) trials, the number of patients who dropped-out exceeded the FI value. Most trials (91.3%) had an overall low risk of bias. This systematic review revealed that the statistical results of RCTs investing HDP after brachial plexus blocks have tended to be fragile in the past decade. The FI should be an important aid in the interpretation of clinical results in combination with the P-value, particularly when statistically significant results are dependent on a small number of events. Future RCTs with larger sample sizes are needed to obtain more robust results in this field.

Exogenous catecholamines may have pronounced side effects and affect physiological cascades. The aim of this study was to investigate the effect of vasopressors on mortality of critically ill patients with coronavirus disease 2019 (COVID-19). A systematic search of PubMed, Scopus, and ClinicalTrials.gov was conducted for relevant articles until December 2022. Eligibility criteria were randomized controlled and non-randomized trials. The primary outcome was in-hospital and 30-day mortality. The quality of studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS) tool, while paired meta-analysis was used to estimate the pooled risk ratios (RR) along with their 95% Confidence Interval (95% CI). Analyses of 22 studies (n = 8034) revealed that vasopressor use is associated with mortality compared to no vasopressor therapy [RR (95%CI): 4.30 (3.21, 5.75); p < 0.001]. In-hospital and 30-day mortality are significantly higher in patients who receive vasopressors [RR (95%CI): 4.60 (2.47, 8.55); p < 0.001 and RR (95%CI): 2.97 (1.72, 5.14); p < 0.001, respectively]. Also, analyses of data from 10 studies (n = 3519) revealed that vasopressor use is associated with acute kidney injury [RR (95%CI): 3.17 (2.21, 4.54); p < 0.001]. In conclusion, current use of vasopressors in critically ill patients with COVID-19 may be associated with higher in-hospital mortality, 30-day mortality, and incidence rate of acute kidney injury. Further research is required to estimate the correlation of specific vasopressor characteristics (type, timing, dose, combination) with adverse effects and mortality in this population.

Graphical Abstract

The development of acute kidney injury after surgery is associated with significant mortality and morbidity and with worse short and long-term outcomes. Patients who develop acute kidney injury are at an increased risk of developing long-term renal dysfunction, which leads to lower quality of life and greater financial burden on the healthcare system. Although there are various systems to classify the severity of acute kidney injury, most systems only measure components that deteriorate after significant renal damage, such as urine output and serum creatinine. Surgical trauma and stress trigger acute kidney injury development, in addition to multiple co-morbidities, cardiovascular disease, and postoperative factors. The pathophysiology of acute kidney injury is complex, and this is reflected in the heterogenous population that is affected. Treatment is largely supportive and focuses on ensuring adequate renal perfusion, correcting electrolyte abnormalities and avoiding further renal injury. Current research focuses on novel biomarkers that detect decreased renal function earlier and that the deteriorating renal function can be treated before long-lasting damage occurs. This review discusses the epidemiology, aetiology, risk factors, and short and long-term surgical outcomes of acute kidney injury. Treatment, prevention, and recent developments in future research are also discussed.

Graphical Abstract

Purposes

SARS-CoV-2 have become widespread worldwide since the outbreak. Respiratory function deteriorates rapidly in critically ill patients infected with SARS-CoV-2. Endotracheal intubation is an indispensable therapeutic measure during the development of the disease. This study was intended to describe the experience of endotracheal intubation from front-line anesthesiologists and clinical prognosis of patients infected with Coronavirus disease-19 (COVID-19).

Methods

Fourteen critical patients infected with COVID-19 who underwent endotracheal intubation were included in this study. We collate and analyze the blood gas results before and after tracheal intubation of patients and clinical prognostic indicators such as length of stay and. mortality. The experience of anesthesiologists who intubated patients has also been recorded in detail.

Results

Patients had a mean time of 10.6 days from initial symptoms to endotracheal intubation. Most intubated patients had one or more underlying conditions: hypertension (8, 57.14%), diabetes (5, 35.71%), and cardiovascular and cerebrovascular diseases (2, 14.29%). The oxygenation index increased significantly after intubation compared with before intubation (148.80 ± 42.25 vs 284.43 ± 60.17 p < 0.001). 85.72% of patients required extra-corporeal membrane oxygenation (ECMO) due to inability to maintain oxygen saturation with standard therapeutic measures. Two patients underwent lung transplantation because their lungs were essentially nonfunctional, and they recovered well after surgery. As of this writing, all patients were discharged after satisfactory recovery.

Conclusions

Reasonable selection of intubation timing is particularly important. It is crucial to increase the patient's oxygen supply and reduce oxygen consumption as much as possible during endotracheal intubation. In addition, the personal protective measures of medical personnel participating in treatment should be scientific and standardized.

Graphical Abstract

Background

Homer1, an immediate early gene, is related to sleep deprivation (SD), and its protein products are involved in synaptic plasticity affecting the cognitive process. This study aimed to identify the SD-associated key Homer1 gene in the brain and explore the value of Homer1 proteins acting on synaptic plasticity in SD.

Methods

GSE9441 was extracted from Gene Expression Omnibus (GEO) database. Differentially expressed genes (DEGs) between SD and Control samples were achieved by R software and were analyzed by the Gene Ontology (GO), Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway, and gene set enrichment analysis (GSEA). Protein–protein interactions (PPI) network was built by the GeneMANIA databases. In animal experiments, male C57BL/6 J mice (aged 12–13 weeks) were sleep deprived for 6 h, followed by independent behavioral tests and in vitro assays. Morris water maze (MWM) was used to evaluate learning and memory function. The expression of hippocampal Homer1 proteins was detected by Western blot analysis and its distribution in CA1 by immunohistochemistry and immunofluorescence staining. Synaptic plasticity was assessed by Golgi staining and long-term potentiation (LTP) testing in the hippocampal CA1 region.

Results

Homer1 was the hub gene most associated with SD, and its protein products specifically acted on the regulation of synaptic plasticity in bioinformatics. SD mice exhibited spatial memory impairment accompanied by increased Homer1a expression in hippocampal tissue and CA1 region. SD did not induce Homer1b/c overexpression of mice in the hippocampus. SD impaired the hippocampal synaptic plasticity of mice by reducing the density of dendritic spines and inhibiting LTP in the hippocampal CA1 region, which may involve the overexpression of Homer1a in the hippocampus.

Conclusion

Homer1 gene is a core brain molecule associated with acute SD, and its protein product Homer1a is involved in the changes in cognitive brain function following short-term SD, especially the impact on hippocampal synaptic plasticity.

With the surge of critically ill COVID-19 patients in China, numerous anesthesiologists from anesthesia intensive care units (AICU) or reallocated to other ICUs were devoted to the treatment of COVID-19. Besides the standard protocols to treat COVID-19 cases, anesthesiologists also have their own experience to treat COVID-19 cases based on professional expertise and practice. Here, we propose some viewpoints to treat critically ill COIVD-19 patients from the perspective of anesthesiologists.

Purpose

To provide an expert commentary on the impact of prior COVID-19 infection on patient’s surgical outcomes and postoperative recovery. To highlight the need for greater focus on peri-operative care of patients who have recovered from COVID-19.

Methods

A narrative review of the literature was conducted by searching Pubmed and EMBASE for relevant articles using keywords such as “COVID-19”, “Coronavirus”, “surgery” and “peri-operative infection”.

Results

Post-COVID-19 condition also known as long COVID has an estimated incidence of between 3.0 to 11.7%. COVID-19 has been shown to cause a series of short and long-term sequelae including cardiopulmonary complications, renal impairment, chronic fatigue and muscular deconditioning. Peri-operative infection with COVID-19 is associated with increased peri-operative mortality. Elective surgery patients who developed COVID-19 were 26 times more likely to die whilst in hospital compared to controls without COVID-19 infection, and for emergency surgery patients with COVID-19 infection were six times more likely to die. A large international prospective cohort study identified that patients who had surgery delayed over 7 weeks from the date of COVID-19 infection had no increased 30-day postoperative mortality, except those with ongoing symptoms.

Conclusions

COVID-19 infection and its complications have been shown to adversely affect surgical outcomes. Further research is required to better characterise long COVID and the long-term sequelae that develop, which should be used to guide comprehensive peri-operative assessment of patients.

Graphical Abstract

Purpose

Repeated exposures to sevoflurane could induce epigenetic modifications in specific brain regions and cognitive impairments in the immature mice. Conflicting findings make neurobehavioral manifestations intricate and potential mechanisms elusive. Influence of neonatal anesthesia with sevoflurane on the expression of synaptic scaffold proteins and neuronal activity remains to be determined.

Methods

C57BL/6 male and female mice in breeding ages were used to produce next generation. The offspring male mice were randomly scheduled to receive 3.0% sevoflurane plus 60% oxygen for 2 h daily at postnatal day (P) 6–8. Three-chambered social paradigm was used to test social affiliation and social memory. Morris water maze was used to test learning and memory. Whole genome bisulfite sequencing (WGBS), differentially methylated regions (DMRs) and KEGG enrichment analysis were performed to screen target gene in sequence context of CG. RT-PCR and immunoblotting analysis were used to assess expression of the Shank gene family, as well as DNA methylases.

Results

The male mice undergoing sevoflurane anesthesia at P6-8 showed diminished preference for novel conspecific and prolonged escape latency and decreased platform-crossing times. The sevoflurane-exposed mice showed reduced mRNA and protein levels of the Shank2 gene. KEGG analysis disclosed the role of DNA hypermethylation of Shank2 gene in the pathway of glutamatergic synapse. In addition, sevoflurane anesthesia reduced mRNA and protein levels of the TET3 enzyme.

Conclusion

Repeated exposures to sevoflurane in neonatal period could impair social recognition memory and spatial reference memory in the male mice. Reduction of hippocampal SHANK2 protein could contribute to sevoflurane-induced neurotoxicity in the immature mice. Reduction of the TET3 enzyme should be responsible for DNA hypermethylation-related silencing of the Shank2 gene.

Graphical Abstract