Neuroinflammation: The central enabler of postoperative cognitive dysfunction.

The proportion of advanced age patients undergoing surgical procedures is on the rise owing to advancements in surgical and anesthesia technologies as well as an overall aging population. As a complication of anesthesia and surgery, older patients frequently suffer from postoperative cognitive dysfunction (POCD), which may persist for weeks, months or even longer. POCD is a complex pathological process involving multiple pathogenic factors, and its mechanism is yet unclear. Potential theories include inflammation, deposition of pathogenic proteins, imbalance of neurotransmitters, and chronic stress. The identification, prevention, and treatment of POCD are still in the exploratory stages owing to the absence of standardized diagnostic criteria. Undoubtedly, comprehending the development of POCD remains crucial in overcoming the illness. Neuroinflammation is the leading hypothesis and a crucial component of the pathological network of POCD and may have complex interactions with other mechanisms. In this review, we discuss the possible ways in which surgery and anesthesia cause neuroinflammation and investigate the connection between neuroinflammation and the development of POCD. Understanding these mechanisms may likely ensure that future treatment options of POCD are more effective.

Anesthetic Management of Patients With Kartagener Syndrome: A Systematic Review of 99 Cases.

KARTAGENER SYNDROME (KS) is characterized by the triad of chronic sinusitis, bronchiectasis, and situs inversus. The mirrored anatomy and respiratory infections in patients with KS patients pose great challenges for anesthetic management. The aim of this review is to summarize published cases with the hope of helping anesthesiologists perform anesthesia in patients with KS more safely. A comprehensive literature search for all cases of anesthetic management of KS patients was performed in Pubmed, EMBASE, CNKI, and Wanfang Database. The extracted data included age, sex, type of surgery, preoperative treatment, type of anesthesia, anesthetic agents, airway management, central venous catheterization, transesophageal echocardiogram, reversal of neuromuscular blockade, adverse events during the surgery, and postoperative complications. The study authors included 82 single-case reports, 3 case series, and 1 case cohort, with a total number of 99 patients. The most common surgical procedures were thoracic surgery (51.5%), which was followed by ear, nose, and throat surgery (16.5%), and general surgery (14.5%). The preoperative treatment of the patients was reported in only 20 patients, and included antibiotics, bronchodilators, steroids, chest physiotherapy, and postural drainage. General anesthesia was performed for 85.4% of the surgeries, and regional anesthesia was performed in 14.6% of the cases. For nonthoracic surgery, an endotracheal tube was the most commonly used airway device. For thoracic surgery, a double-lumen tube was the most commonly used airway device. The intraoperative process was uneventful in most patients, and most patients recovered smoothly in the postoperative course.

Comparison of LPS and MS-induced depressive mouse model: behavior, inflammation and biochemical changes.

Depression is a mental disease involving complex pathophysiological mechanisms, and there are many ways to establish depressive mouse models. The purpose of this study is to comprehensively compare the behavioral changes and its mechanism induced by two different models. This study established two depressive mouse models by maternal separation (MS) or lipopolysaccharide (LPS) administration, and added fluoxetine treatment group respectively for comparison. MS induced more apparent anxiety-like behavior while LPS induced more apparent depressive-like behavior. LPS increased peripheral inflammatory factors more apparent, which were mitigated by fluoxetine. MS inhibited the 5-HT system more obviously and was relieved by fluoxetine. LPS triggered stronger immune response in the hippocampus and prefrontal cortex (PFC). MS significantly reduced the expression of neurotrophic proteins and was alleviated by fluoxetine. Overall, LPS induced stronger system inflammation, while MS impaired the function of HPA axis and 5-HT system. Our results will contribute to a deeper understanding of the pathophysiology of different stress-induced depression and will also help researchers select appropriate models of depression for their own needs.

Acute left heart failure with pulmonary edema during resection of pediatric neuroblastoma: case report.

Resection of an unknown neck mass in a 6-year-old child triggered acute left-sided heart failure and pulmonary edema. The lesion was confirmed as neuroblastoma by postoperative tissue examination. Such tumors regularly synthesize and secrete catecholamines, warranting caution in advance of surgical manipulation.

Hydrogen-rich saline regulates the polarization and apoptosis of alveolar macrophages and attenuates lung injury via suppression of autophagy in septic rats.

BACKGROUND: Hydrogen-rich saline (HRS) has a protective effect on sepsis-induced lung injury. However, the underlying mechanisms are still unclear. Polarization and apoptosis of macrophages are essential factors in the pathogenesis of acute lung injury (ALI). Moreover, autophagy is involved in the regulation of both macrophage polarization and apoptosis. Therefore, this study investigated the ability of HRS to attenuate ALI through regulation of the polarization and apoptosis of alveolar macrophages (AMs) during sepsis by modulating autophagy. METHODS: Male Sprague-Dawley (SD) rats were used to prepare the sepsis-induced lung injury animal model. Rat lung tissue was harvested after lipopolysaccharide (LPS) treatment, in the presence or absence of HRS, and the AMs were analyzed for changes in polarization, apoptosis, and autophagy. The rat AM cell line NR8383 was used to examine these processes in vitro using Western blot analysis, flow cytometry, and transmission electron microscopy. RESULTS: LPS-induced ALI in rats was associated with an increase in autophagy, apoptosis, and M1 polarization but a decrease in M2 polarization in AMs. These effects were reversed by administration of HRS. Inhibition of AM autophagy with 3-methyladenine (3-MA) decreased apoptosis and M1 polarization and increased M2 polarization, paralleling the effects of HRS. CONCLUSIONS: HRS could attenuate ALI in septic rats through regulation of AM polarization and a reduction in apoptosis by suppressing autophagy. This may represent a potential novel therapeutic target for the treatment of ALI caused by sepsis.

Exosome: The Regulator of the Immune System in Sepsis.

Sepsis is a syndrome comprised of a series of life-threatening organ dysfunctions caused by a maladjusted body response to infection with no effective treatment. There is growing evidence that the immune system plays a core role in sepsis. Pathogens cause abnormal host immune response and eventually lead to immunosuppression, which is an important cause of death in patients with sepsis. Exosomes are vesicles derived from double invagination of plasma membrane, associating with immune responses closely. The cargos delivered by exosomes into recipient cells, especially immune cells, effectively alter their response and functions in sepsis. In this review, we focus on the effects and mechanisms of exosomes on multiple immune cells, as well as the role of immune cell-derived exosomes in sepsis. This is helpful for us to have an in-depth understanding of the mechanism of immune disorders in sepsis. Exosomes is also expected to become a novel target and therapeutic approach for sepsis.

Individualized positive end-expiratory pressure in patients undergoing thoracoscopic lobectomy: a randomized controlled trial.

BACKGROUND AND OBJECTIVES: With the intensive study of lung protective ventilation strategies, people begin to advocate the individualized application of positive end-expiratory pressure (PEEP). This study investigated the optimal PEEP in patients during one-lung ventilation (OLV) and its effects on pulmonary mechanics and oxygenation. METHODS: Fifty-eight patients who underwent elective thoracoscopic lobectomy were randomly divided into two groups. Both groups received an alveolar recruitment maneuver (ARM) after OLV. Patients in Group A received optimal PEEP followed by PEEP decremental titration, while Group B received standard 5 cmH2O PEEP until the end of OLV. Relevant indexes of respiratory mechanics, pulmonary oxygenation and hemodynamics were recorded after entering the operating room (T0), 10 minutes after intubation (T1), pre-ARM (T2), 20 minutes after the application of optimal PEEP (T3), at the end of OLV (T4) and at the end of surgery (T5). Postoperative outcomes were also assessed. RESULTS: The optimal PEEP obtained in Group A was 8.8 ± 2.4 cmH2O, which positively correlated with BMI and forced vital capacity (FVC). Group A had a higher CPAT than Group B at T3, T4, T5 (p < 0.05) and a smaller ΔP than Group B at T3, T4 (p < 0.01). At T4, PaO2 was significantly higher in Group A (p < 0.01). At T3, stroke volume variation was higher in Group A (p < 0.01). Postoperative outcomes did not differ between the two groups. CONCLUSIONS: Our findings suggest that the individualized PEEP can increase lung compliance, reduce driving pressure, and improve pulmonary oxygenation in patients undergoing thoracoscopic lobectomy, with little effect on hemodynamics.

Prediction of Double-Lumen Tube Size By Ultrasonography for Asian Women: A Prospective Observational Study.

OBJECTIVE: To assess the agreement of the diameter of the cricoid cartilage by computed tomography and ultrasonography and to compare the accuracy of the left double-lumen tubes (DLTs) and right DLTs predicted by ultrasonography for Asian women. DESIGN: Prospective observational study. SETTING: Academic, tertiary care hospital. PARTICIPANTS: Fifty female patients intubated with a left DLT and 50 female patients intubated with a right DLT. INTERVENTIONS: No intervention. MEASUREMENTS AND MAIN RESULTS: A radiologist measured the transverse cricoid diameter by computed tomography (CT), and an independent echographer measured the transverse cricoid diameter using ultrasonography. The size of the DLT was selected based on the cricoid diameter by ultrasonography. The agreement of the transverse cricoid diameter was assessed by computed tomography and ultrasonography. The accuracy of the DLT, the tracheal segment, and the bronchial segment were compared between the left intubation group and right intubation group. There was a good agreement between the transverse cricoid diameter measured by ultrasonography and CT (r = 0.946, p < 0.001). The overall accuracy of the DLTs was similar between the groups (86.0% v 92.0%, p = 0.318). There were no significant differences in the accuracy of the tracheal segment (96.0% v 94.0%; p = 1.000) and the bronchial segment (90.0% v 98.0%, p = 0.056). CONCLUSIONS: The transverse diameter of the cricoid cartilage in most Asian women can be accurately measured by ultrasonography. The size of the DLT for Asian women can be predicted by ultrasonography measurement of the cricoid diameter.

Age-related Change of the Dimensions of the Cricoid Cartilage in Adults.

OBJECTIVES: To measure the dimensions of the cricoid cartilage in adults and to investigate the age-related change of the dimensions of the cricoid cartilage. METHODS: After performing the multiplanar reconstruction and correcting the slant of the cervical computed tomography scans, the transverse and anteroposterior internal diameters of the inlet (TD-in and APD-in) and outlet (TD-out and APD-out) of the cricoid cartilage were measured, respectively. The angle between the arch and lamina of the cricoid cartilage in the middle sagittal plane was measured. The ratios of transverse to anteroposterior diameter for the inlet (Ratio-in) and outlet (Ratio-out) of the cricoid cartilage were calculated, respectively. RESULTS: A total of 1200 adults were included in this study, with 600 males and 600 females. The TD-in is the smallest cricoid diameter and the APD-in is the largest cricoid diameter. The mean cricoid diameters and the cricoid angle in males were larger than those in females. The cricoid inlet is oval shaped and the cricoid cartilage is "funnel-shaped" in the middle sagittal plane. The shape of the outlet of the cricoid cartilage varies greatly among individuals. In males, the APD-in and APD-out were negatively correlated with age while the Ratio-in and Ratio-out was positively correlated with age. In females, the APD-out were negatively correlated with age while the Ratio-out was negatively correlated with age. CONCLUSIONS: The dimensions of the cricoid cartilage change as age advances in adult population and the sexual dimorphism of the cricoid outlet occurs after 50 years old.

Airway Rupture Caused by Double-Lumen Tubes: A Review of 187 Cases.

The double-lumen tubes (DLTs) are the most widely used devices to provide perioperative lung isolation. Airway rupture is a rare but life-threatening complication of DLTs. The primary aim of this review was to collect all cases reported in the literature about airway rupture caused by DLTs and to describe the reported possible contributors, diagnosis, treatment, and outcomes of this complication. Another aim of this review was to assess the possible factors associated with mortality after airway rupture by DLTs. A comprehensive literature search for all cases of airway rupture caused by DLTs was performed in the PubMed, EMBASE, Ovid, Wanfang Database, and CNKI. The extracted data included age, sex, height, weight, type of operation, type and size of DLT, site of airway rupture, possible contributors, clinical presentation, diagnosis timing, treatment, and outcome. We included 105 single case reports and 22 case series with a total number of 187 patients. Most of the ruptures were in the trachea (n = 98, 52.4%) and left main bronchus (n = 70, 37.4%). The common possible contributors include use of a stylet, cuff overdistention, multiple attempts to adjust the position of a DLT, difficult intubation, and use of an oversized DLT. Most of the airway ruptures were diagnosed intraoperatively (n = 138, 82.7%). Pneumomediastinum, air leakage, hypoxemia, and subcutaneous emphysema were the common clinical manifestations. Most patients were treated with surgical repair (n = 147, 78.6%). The mortality of the patients with airway rupture by DLTs was 8.8%. Age, sex, site of rupture, diagnosis timing, and method of treatment were not found to be associated with mortality.

The Incidence of Tracheal Bronchus in Thoracic Surgery Patients and Its Implication for Lung Isolation: A Retrospective Cohort Study.

OBJECTIVE: To investigate the incidence of tracheal bronchus (TB) and explore its implication for lung isolation. DESIGN: Retrospective cohort study. SETTING: Academic, tertiary care hospital. PARTICIPANTS: The study comprised 7,102 thoracic patients with- one lung ventilation. INTERVENTIONS: No intervention. MEASUREMENTS AND MAIN RESULTS: Two independent anesthesiologists reviewed the computed tomography images to identify the presence of a TB, and their results were confirmed by a radiologist. The clinical data of patients with a TB were obtained from the electronic medical record. Data regarding the device used to provide lung isolation, preoperative oxygen saturation (SpO2), and intraoperative SpO2 during one- lung ventilation were obtained from the electronic anesthesia record. The incidence of TB was 1.08% (77 of 7,102). The TB arose from the right side of the trachea in all 77 patients, including 70 type Ⅲ TBs and 7 type Ⅱ TBs. Left- and right-sided double-lumen tubes (DLTs) were used in 54 and 23 patients, respectively. For patients with a left-sided DLT, the median SpO2 and incidence of hypoxemia (SpO2 <90%) were 97% and 6 of 54 (11.1%), respectively. For patients with a right DLT, the median SpO2 and incidence of hypoxemia were 95% and 7 of 20 (35.0%), respectively. There were significant differences in the mean SpO2 and the incidence of hypoxemia between patients intubated with left- and right-sided DLTs (p = 0.014 and p = 0.016, respectively). CONCLUSIONS: Preoperative diagnosis of TB is important when lung isolation is needed. The left-sided DLT can be used for most patients with a TB.

The development of the cricoid cartilage and its implications for the use of endotracheal tubes in the pediatric population.

BACKGROUND: The rigid cricoid cartilage is functionally the narrowest portion of the larynx. There is some controversy over the shape of the pediatric cricoid cartilage in the transverse plane. It is important to understand the development of the cricoid cartilage so that endo-traceheal tubes can be used more safely. AIM: To determine changes in the internal diameter and shape of the cricoid cartilage during development and explore the implications of those changes for the selection of ETT type and size for children. METHODS: The cervical computed tomography scans were reviewed in patients aged 1-20 years. After performing the multiplanar reconstruction and correcting the slant, the transverse and anteroposterior internal diameters of the inlet and outlet of the cricoid cartilage were measured, respectively. The angle between the arch and the lamina of the cricoid cartilage in the middle sagittal plane was measured. The ratios of transverse to anteroposterior diameter for the inlet and outlet of the cricoid cartilage were calculated, respectively. RESULTS: In females, the internal diameters of the cricoid cartilage increased linearly with age. In males, the internal diameters of the cricoid cartilage exhibited a growth spurt during adolescence. The transverse diameter of the inlet was the smallest diameter of the cricoid cartilage, and the predicting formula of the transverse diameter of the inlet for children aged 1-12 was 0.4 × age (year) + 5.1, R2  = .758. The angle between the arch and lamina of the cricoid cartilage and the ratios of transverse to anteroposterior diameter correlated weakly with age. CONCLUSION: The transverse inner diameter of the inlet is the smallest diameter of the cricoid cartilage. The "funnel shape" of the cricoid cartilage remains unchanged during development. The outer diameter should be considered when selecting an endotracheal tube.

Therapeutic Effect of Long-Term Epidural Block in Rats with Pregnancy Induced Hypertension.

BACKGROUND: Pregnancy induced hypertension (PIH) causes a variety of systemic disorders that negatively affect the maternal placenta and fetal growth. Epidural sympathetic block elicits symptoms of decreased blood pressure. This study was designed to determine the therapeutic effect of long-term epidural block in rats with PIH. METHODS: Forty healthy pregnant Sprague Dawley rats were randomized into four groups with each group consisting of 10 rats. On gestation day (GD) 14, rats in control group underwent a sham procedure; rats in RUPP group were operated on to obtain reduced uterine perfusion pressure (RUPP); rats in RUPP plus normal saline (NS) group were also subjected to the RUPP procedure and underwent epidural block with 25 µl normal saline twice daily until delivery; rats in RUPP plus epidural block (EB) group were treated as those in RUPP plus NS group except that an epidural block with 25 µl of 0.125% bupivacaine was administered two times per day until delivery. On GD 20, blood pressure was measured in all groups before delivery, and blood samples were collected in order to quantify the serum concentrations of vascular endothelial growth factor (VEGF) and soluble fms-like tyrosine kinase 1 (sFlt-1). RESULTS: The mean arterial pressure (MAP) of rats in RUPP group (147.6 ± 6.0 mmHg) was markedly increased when compared with control group (80.8 ± 4.6 mmHg) (p < 0.05). The MAP of rats in RUPP plus EB group (114.4 ± 7.2 mmHg) was clearly decreased in contrast with RUPP group but was still higher than in control group (p < 0.05). The variation of fetal weight in all groups followed a similar trend to that of MAP. However, there were no significant differences between control group and RUPP plus EB group with respect to placental weight (p = 0.186). Variation in MAP was positively correlated with the expression of sFlt-1 in each group but was negatively correlated with VEGF. CONCLUSION: This study demonstrates that long-term epidural block decreases blood pressure in PIH rats and improves the serum concentrations of VEGF and sFlt-1. Taken together, long-term epidural block may have a potential role in PIH treatment.

Perioperative psychological and music interventions in elderly patients undergoing spinal anesthesia: effect on anxiety, heart rate variability, and postoperative pain.

PURPOSE: The aim of this study was to evaluate the effects of perioperative psychological and music interventions in elderly patients undergoing elective surgery on anxiety, post-operative pain, and changes in heart rate variability (HRV) to ascertain if perioperative psychological and music interventions can affect overall anxiety levels. MATERIALS AND METHODS: Fourty elderly patients undergoing elective surgery were randomized to two groups; one group received psychological and music intervention, and the other was the control. The intervention group underwent psychological intervention and listening to music for 30 min before surgery. RESULTS: The mean change in HRV as determined by low frequency (LF) power measurements. After the intervention, the ratio of mean LF to high frequency (HF) power decreased significantly in the intervention group compared to before the intervention (p<0.05). In the control group, mean LF measurements and the ratio of LF:HF did not change significantly. In the intervention group, mean HF power was significantly higher after the procedure than before (p<0.01). Moreover, the mean self-rating anxiety score of the intervention group decreased after the procedure compared to before (p<0.05). The mean visual analogue score of the intervention group 6 hours after surgery was significantly lower than that of the control group (p<0.01). CONCLUSION: Perioperative psychological and music interventions can reduce anxiety and postoperative pain in elderly patients.

Preoperative music intervention for patients undergoing cesarean delivery.

OBJECTIVE: To evaluate the effects of music played preoperatively in women undergoing elective cesarean delivery. METHODS: Sixty women undergoing elective cesarean delivery were randomized to a study group or a control group. Those in the study group listened to music for 30 minutes before surgery. All women underwent heart rate variability analysis and scored their anxiety and pain levels using the Self-Rating Anxiety Scale and a visual analog pain scale. RESULTS: In the study group the mean HRV, as measured by the low frequency power (LF) value and the LF to high frequency power (LF/HF) ratio during Holter assessment, was significantly less after the music intervention but was not significantly changed in the control group. Moreover, the mean HF value was significantly increased and the mean anxiety score was significantly decreased after the music intervention but not in the control group. Finally, the mean pain score obtained 6 hours after surgery was significantly lower in the study than in the control group. CONCLUSION: A preoperative music intervention can reduce anxiety and pain in women undergoing cesarean delivery.

Effect of epidural block on 24-hour urine protein in pregnant rat models with preeclampsia.

OBJECTIVE: To investigate the effects of epidural block on 24-hour urine protein in rat with preeclampsia (PE). METHODS: Thirty healthy pregnant Wistar rats were randomly divided into three groups (each group with 10 rats). From the 14th day of pregnancy, the rats in Group A were given subcutaneous normal saline (0.5 ml) every day in a total of 7 days; the rats in Group B were given subcutaneous L: -nitroarginomethyl ester (L: -NAME) (50 mg) every day in a total of 7 days; and the rats in Group C both were given subcutaneous L: -NAME (50 mg) every day and underwent epidural block with 25 µl of 0.125 % bupivacaine twice every day all in a total of 7 days. The 24-hour urine protein and systolic blood pressure on the 13th and 20th day of pregnancy were measured. RESULTS: On the 13th day of pregnancy, there was no statistical significant difference in 24-hour urine protein and systolic blood pressure between the three groups (P > 0.05). On the 20th day of pregnancy, 24-hour urine protein and systolic blood pressure all were higher in Group B and C than in Group A (P < 0.01 and P < 0.05)) and all were lower in Group C than in Group B (P < 0.01 and P < 0.05). CONCLUSION: Epidural block can decrease 24-hour urine protein and systolic blood pressure in pregnant rat models with PE. This study provides a potential strategy for treatment of PE.

Comparative study on the pharmacodynamics of cisatracurium: continuous infusion or intermittent bolus injection.

OBJECTIVE: To explore a better administration way through comparison of the pharmacodynamics of cisatracurium administered by continuous infusion or intermittent bolus injection. METHODS: Thirty patients (ASAI-II) who had no neuromuscular disease and underwent selective surgery under general anesthesia were randomly divided into group I and II (each group with 15 patients). In group I, patients received cisatracurium by continuous infusion and in group II, by intermittent bolus injection. The responses of adductor pollicis to train-of-four (TOF) stimulation were monitored. The duration of neuromuscular blockade, recovery index and total dose of cisatracurium consumption were recorded in the two groups. Intravenous anesthesia was used for anesthesia induction and sevoflurane inhalation for maintenance of anesthesia. RESULTS: The mean infusion rate was significantly lower in group I (0.78 ± 0.15 µg.kg(-1).min(-1)) than in group II (1.09 ± 0.33 µg.kg(-1).min(-1)) (P<0.05). There was no significant difference in duration of neuromuscular blockade between the two groups (P>0.05). The recovery index was 13.13 ± 3.36 min in group I and 14.38 ± 4.48 min in group II, which indicated that the recovery was faster in group I than in group II, but without statistical significance (P>0.05). During the duration of neuromuscular blockade, 8 patients had T(1)<3%, 4 T(1) of 3%-7% and 3 T(1) of 7%-10% in group I; T(1) was maintained between 0 and 20% in group II. CONCLUSIONS: Although cisatracurium consumption was significantly lower in continuous infusion than in intermittent bolus injection, continuous infusion can obtain more stable neuromuscular blockade than intermittent bolus injection.