Ultrasound-Guided Posterior Quadratus Lumborum Block for Acute Postoperative Analgesia in Adult Patients: A Meta-Analysis of Randomized Controlled Trials.

Objective: The quadratus lumborum block provides postoperative analgesia for patients undergoing abdominal surgery, although there are three common approaches to perform this block. The present meta-analysis investigated the effectiveness of posterior quadratus lumborum block (QLB2) after surgery. Methods: PubMed, Embase, and the Cochrane Central Register were searched from inception to 26 August 2021 for randomized controlled trials that evaluated the analgesic efficacy of QLB2 vs control (placebo or no block). The primary outcomes were pain scores at 6 h, 12 h, and 24 h after surgery. The secondary outcomes were morphine consumption at 24 h after surgery and the postoperative complications. Results: The present meta-analysis included 14 studies conducted with a total of 1001 patients. In comparison to control group, the QLB2 group presented significantly lower rest pain scores at 6 h (SMD -0.59; 95% CI: -1.05, -0.12; p = 0.01, I2 = 84%; GRADE = moderate), 12 h (SMD: -0.83; 95% CI: -1.47, -0.19; p = 0.01; I2 = 88%; GRADE = low), and 24 h (SMD: -0.37; 95% CI: -0.71, -0.03; p = 0.03; I2 = 80%; GRADE = moderate) after surgery. The dynamic pain scores were significantly reduced, compared to control, in the QLB2 group at 12 h (SMD: -0.93; 95% CI: -1.52, -0.33; p = 0.002; I2 = 83%; GRADE = low) and 24 h (SMD: -0.52; 95% CI: -0.93, -0.11; p = 0.01; I2 = 83%; GRADE = moderate) after surgery. In addition, the QLB2 group presented reduced postoperative opioid consumption at 24 h (SMD: -0.45; 95% CI: -0.86, -0.03; p = 0.03; I2 = 78%; GRADE = moderate). The subgroup analyses revealed that the analgesic benefit of QLB2 did not persist beyond 24 h when the patients were under spinal anesthesia. Conclusion: Ultrasound-guided QLB2 could provide effective analgesia for patients under general anesthesia by decreasing the intensity of pain and opioid requirement when used within 24 h after abdominal surgery.

Remifentanil pretreatment attenuates brain nerve injury in response to cardiopulmonary bypass by blocking AKT/NRF2 signal pathway.

OBJECTIVE: This study aimed to explore the effect and mechanism of remifentanil on cardiopulmonary bypass (CPB)-induced cerebral nerve injury. METHODS: After pretreating with remifentanil, or dexmedetomidine (DEX), SD rats were subjected to the CPB for 2 h. The data of body temperature, blood gas and mean arterial pressure (MAP) and hematocrit (HCT) were recorded at different time points. The cerebral tissue water content of rats was determined and immunohistochemical (IHC) and H&E assays on the hippocampal CA1 region of rats was performed. The levels of interleukin (IL)-6, IL-10, soluble protein-100ß (S100ß) and neuron-specific enolase (NSE) were analyzed by ELISA, and those of the indexes for oxidative stress (malondialdehyde (MDA) and superoxide dismutase (SOD)) were detected by the commercial kits. Morris water maze was used to evaluate the learning and memory abilities. Western blot/qRT-PCR were used to detect the protein/mRNA expressions in hippocampus. RESULTS: CPB increased the levels/expressions of IL-6, IL-10, S100ß, NSE, MDA, cleaved caspase-3, Bax and decreased those of Bcl-2, SOD, p-AKT, HO-1, in serum and parietal cortex tissue, with increased brain water content, lesions in the hippocampal CA1 area, swimming distance, brain nerve injury and decreased escape latency, retention time on platform and times of crossing the platform of rats. The preconditioning of remifentanil or DEX partially attenuated CPB-induced injury and -decreased expressions on p-AKT and HO-1, while further promoting CPB-induced expression of nuclear Nrf2 expression and inhibiting that of cytoplasm Nrf2. CONCLUSION: This paper demonstrates that remifentanil preconditioning could partially attenuate CPB-induced brain nerve injury of rats.

Perioperative dexmedetomidine administration to prevent delirium in adults after non-cardiac surgery: A systematic review and meta-analysis.

STUDY OBJECTIVE: To evaluate the efficacy of perioperative dexmedetomidine (DEX) administration for preventing delirium in adults after non-cardiac surgery. DESIGN: Systematic review and meta-analysis of randomized controlled trials (RCTs). INTERVENTIONS: Perioperative administration of DEX to prevent delirium in adults following non-cardiac surgery. MEASUREMENTS: The incidence of postoperative delirium (POD). METHODS: The databases of PubMed, Embase and Cochrane Central Register were searched from inception to Mar 4, 2021 for all available RCTs that assessed DEX for POD in adults after non-cardiac surgery. Risk ratio (RR) with a 95% confidence interval (CI) was calculated for dichotomous data. Standardized mean difference (SMD) was calculated for continuous data. Risk of bias was assessed using the second version of the Cochrane risk-of-bias tool for RCTs (RoB 2.0), and the level of certainty for main outcomes were assessed by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. MAIN RESULTS: Thirteen studies, including the meta-analysis with a total of 4015 patients (DEX group: 2050 patients; placebo group: 1965 patients), showed that DEX significantly reduced the incidence of POD in adults after non-cardiac surgery compared with control group (RR: 0.60; 95%CI: 0.46 to 0.77, P = 0.0001, I2 = 55%, GRADE = moderate). Meanwhile, there was a statistical difference by the subgroup analysis between the mean age ≥ 65 years group and the mean age<65 years group. There were no statistical differences in length of hospital stay following surgery (SMD: -0.36; 95%CI: -0.80 to 0.07, P = 0.1, I2 = 97%, GRADE = low) and all-cause mortality rate (RR:0.57; 95%CI: 0.25 to 1.28, P < 0.17, I2 = 0%, GRADE = moderate) compared with placebo group. However, Meta-analysis showed that DEX administration significantly resulted in intraoperative bradycardia when compared with placebo group (RR: 1.39; 95%CI: 1.14 to 1.69, P = 0.0009, I2 = 0%, GRADE = high), and as well as intraoperative hypotension (RR: 1.25; 95%CI: 1.11 to 1.42, P = 0.0004, I2 = 0%, GRADE = high). CONCLUSION: This systematic review and meta-analysis suggests that perioperative administration of DEX could significantly reduce the incidence of POD in patients elder than 65 years following non-cardiac surgery. However, there was no definite evidence that perioperative DEX could reduce the incidence of POD in patients younger than 65 years of age after non-cardiac surgery. In addition, perioperative DEX administration was associated with an elevated risk of bradycardia and hypotension.

Venoarterial Extracorporeal Membrane Oxygenation as an Effective Therapeutic Support for Refractory Cardiac Arrest in the Setting of Spinal Anesthesia: A Case Report and Literature Review.

Cardiac arrest is the most serious event among the complications associated with spinal anesthesia. Spinal anesthesia reduces the release of catecholamines and impairs neuroendocrine response following cardiac arrest, which contributes cardiopulmonary resuscitation (CPR) more difficult. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) may be a bridge to provide a more effective and durable mechanical solution under this extremely critical condition. This study reports a 50-year-old man who was scheduled to undergo surgical great saphenous vein varices under spinal anesthesia. A sudden cardiac arrest occurred after spinal anesthesia. Standard CPR was performed and large doses of vascular drugs are administered, but the effect of resuscitation was still poor. We fastly initiated VA-ECMO to provide cardiopulmonary support for this refractory cardiac arrest. Fortunately, the patient was successfully resuscitated with complete recovery. In summary, standard CPR might more difficult during spinal block anesthesia. Quick-started VA-ECMO is a potential option under this situation, which protects the patient from further harm from repeated prolonged CPR, refractory hypotension and deteriorated desaturation, and therefore benefit for patient in this critical condition.

The analgesic efficacy compared ultrasound-guided continuous transverse abdominis plane block with epidural analgesia following abdominal surgery: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: This review and meta-analysis aims to evaluate the analgesic efficacy of continuous transversus abdominis plane (TAP) block compared with epidural analgesia (EA) in adults after abdominal surgery. METHODS: The databases PubMed, Embase and Cochrane Central Register were searched from inception to June 2019 for all available randomized controlled trials (RCTs) that evaluated the analgesic efficacy of continuous TAP block compared with EA after abdominal surgery. The weighted mean differences (WMDs) were estimates for continuous variables with a 95% confidence interval (CI) and risk ratio (RR) for dichotomous data. The pre-specified primary outcome was the dynamic pain scores 24 h postoperatively. RESULTS: Eight trials including 453 patients (TAP block:224 patients; EA: 229 patients) ultimately met the inclusion criteria and seven trials were included in the meta-analysis. Dynamic pain scores after 24 h were equivalent between TAP block and EA groups (WMD:0.44; 95% CI: 0.1 to 0.99; I2 = 91%; p = 0.11). The analysis showed a significant difference between the subgroups according to regularly administering (4 trials; WMD:-0.11; 95% CI: - 0.32 to 0.09; I2 = 0%; p = 0.28) non-steroidal anti-inflammatory drugs (NSAIDs) or not (3 trials; WMD:1.02; 95% CI: 0.09 to 1.96; I2 = 94%; p = 0.03) for adjuvant analgesics postoperatively. The measured time of the urinary catheter removal in the TAP group was significantly shorter (3 trials, WMD:-18.95, 95% CI:-25.22 to - 12.71; I2 = 0%; p < 0.01), as was time to first ambulation postoperatively (4 trials, WMD:-6.61, 95% CI: - 13.03 to - 0.19; I2 = 67%; p < 0.05). CONCLUSION: Continuous TAP block, combined with NSAIDs, can provide non-inferior dynamic analgesia efficacy compared with EA in postoperative pain management after abdominal surgery. In addition, continuous TAP block is associated with fewer postoperative side effects.

Dexmedetomidine Exerts Brain-Protective Effects Under Cardiopulmonary Bypass Through Inhibiting the Janus Kinase 2/Signal Transducers and Activators of Transcription 3 Pathway.

Brain injury is a major complication resulted from cardiopulmonary bypass (CPB). Dexmedetomidine (DEX) has potential brain-protective effects; however, the mechanism is unclear. The aim of this study is to investigate the effect of DEX on brain injury in CPB rats and its mechanism. The levels of interleukin-6 (IL-6), interleukin-10 (IL-10), S100ß, and neuron-specific enolase (NSE) were measured by enzyme-linked immunosorbent assay. The hippocampus CA1 region in rats was observed by hematoxylin-eosin staining. Western blot and quantitative real-time polymerase chain reaction were performed to detect related proteins and mRNA expressions in the hippocampus tissues. We found that after CPB, the neuron cells in hippocampus CA1 region of rats were randomly arranged, and that the levels of IL-6, IL-10, S100ß, NSE, Cleaved Caspase-3, and Bax were upregulated, while Bal-2 level was downregulated. However, after DEX treatment, the neuron cells arranged in an orderly manner, and the levels of IL-6, IL-10, S100ß, NSE, Cleaved Caspase-3, and Bax were downregulated, but Bal-2 level was upregulated. DEX suppressed Janus kinase 2 (JAK2)/signal transducers and activators of transcription 3 (STAT3) pathway activated by CPB, ameliorated CPB-induced brain injury in rats by reducing inflammatory response, and inhibited neuronal apoptosis. The brain-protective effect of DEX may be related to the inhibition of the activation of JAK2/STAT3 pathway.