The impact of pre-rehydration guided by carotid corrected flow time on hypotension prevention following general anesthesia induction in patients undergoing gastrointestinal surgery: a prospective randomized controlled trial.

Background: Patients undergoing gastrointestinal surgery often experience hypotension following general anesthesia induction due to insufficient volume. This study aimed to assess whether pre-rehydration guided by carotid corrected flow time (FTc) could mitigate post-induction hypotension induced by general anesthesia. Methods: Patients undergoing resection of gastrointestinal tumors were assigned to either the conventional treatment group (Group C) or the fluid treatment group based on FTc (Group F). Within Group F, patients were further divided into Group A (carotid FTc <340.7 ms) and Group B (carotid FTc ≥340.7 ms) based on pre-rehydration carotid FTc values. Group A patients received pre-rehydration with 250 mL of colloids (hydroxyethyl starch-HES) administered within 15 min until carotid FTc reached ≥340.7 ms to counteract hypovolemia prior to induction. Patients in Group B and Group C received a continuous HES infusion at a rate of 6 mL/kg/h 30 min before induction to compensate for physiological fluid loss. All patients received a perioperative background infusion of 3 mL/kg/h compound sodium chloride, with infusion rates optimized based on mean arterial pressure (MAP) and heart rate (HR). The incidence of post-induction hypotension was compared between Group C and Group F, as well as between Group A and Group B. Results: The incidence of hypotension after induction was significantly lower in Group F compared to Group C (26.4% vs. 46.7%, respectively; p < 0.001). Patients in Group A received significantly more pre-rehydration, leading to a greater increase in carotid FTc values compared to Group B (336.5 ± 64.5 vs. 174.3 ± 34.1 ms, p = 0.002). However, no significant difference in carotid FTc values after pre-rehydration was observed between the groups. There was no significant difference in the incidence of hypotension after general anesthesia induction between Group A and Group B (22.9% vs. 28.8%, p = 0.535). Conclusion: Pre-rehydration based on FTc can effectively reduce the occurrence of post-induction hypotension in patients undergoing gastrointestinal surgery who present with insufficient volume. Clinical trial registration: https://www.chictr.org.cn/showprojEN.html?proj=201481.

Value of carotid corrected flow time or changes value of FTc could be more useful in predicting fluid responsiveness in patients undergoing robot-assisted gynecologic surgery: a prospective observational study.

Background: The aim of this study was to evaluate the ability of point-of-care Doppler ultrasound measurements of carotid corrected flow time and its changes induced by volume expansion to predict fluid responsiveness in patients undergoing robot-assisted gynecological surgery. Methods: In this prospective study, carotid corrected flow time was measured using Doppler images of the common carotid artery before and after volume expansion. The stroke volume index at each time point was recorded using noninvasive cardiac output monitoring with MostCare. Of the 52 patients enrolled, 26 responded. Results: The areas under the receiver operating characteristic curves of the carotid corrected flow time and changes in carotid corrected flow time induced by volume expansion were 0.82 and 0.67, respectively. Their optimal cut-off values were 357 and 19.5 ms, respectively. Conclusion: Carotid corrected flow time was superior to changes in carotid corrected flow time induced by volume expansion for predicting fluid responsiveness in this population.

Modified combined short and long axis method versus oblique axis method in adult patients undergoing right internal jugular vein cannulation: A randomized controlled non-inferiority study.

BACKGROUND: Modified combined short and long axis method (MCSL) can replace oblique axis in-plane method (OA-IP) for internal jugular vein cannulation (IJVC). This randomized, non-inferiority study estimated the efficacy of MCSL compared with OA-IP in right IJVC. METHODS: Patients (18-75 yr. old) undergoing right IJVC under local anesthesia were randomly assigned to MCSL or OA-IP group. The primary outcome is the event of first needle pass without posterior vessel wall puncture (PVWP). Secondary outcomes included needle attempts, success rate, puncture and cannulation time, needle visualization, probe placement difficulty and complications. RESULTS: Among 190 randomized patients, 187 were involved in the analysis. The first needle pass without PVWP was 85(89.47%) in the MCSL and 81 (85.26%) in the OA-IP (p = 0.382), with a mean rate difference of 4.2% (95% confidence interval: -5.2-13.6), which confirmed the non-inferiority with the margin of -8%. MCSL group exhibited shorter procedure time and lower complications than OA-IP group. No significant differences were discovered between groups in needle attempts, success rate, incidence of probe placement difficulty and needle visualization. CONCLUSIONS: MCSL is non-inferior to OA-IP in first needle pass without PVWP in adults who underwent elective right IJVC and associate with less complications and shorter operating time. CLINICAL TRIAL REGISTRATION: ChiCTR, ChiCTR2100046899.

Comparison of the carotid corrected flow time and tidal volume challenge for assessing fluid responsiveness in robot-assisted laparoscopic surgery.

We aimed to compare the ability of carotid corrected flow time assessed by ultrasound and the changes in dynamic preload indices induced by tidal volume challenge predicting fluid responsiveness in patients undergoing robot-assisted laparoscopic gynecological surgery in the modified head-down lithotomy position. This prospective single-center study included patients undergoing robot-assisted laparoscopic surgery in the modified head-down lithotomy position. Carotid Doppler parameters and hemodynamic data, including corrected flow time, pulse pressure variation, stroke volume variation, and stroke volume index at a tidal volume of 6 mL/kg predicted body weight and after increasing the tidal volume to 8 mL/kg predicted body weight (tidal volume challenge), respectively, were measured. Fluid responsiveness was defined as a stroke volume index ≥ 10% increase after volume expansion. Among the 52 patients included, 26 were classified as fluid responders and 26 as non-responders based on the stroke volume index. The area under the receiver operating characteristic curve measured to predict the fluid responsiveness to corrected flow time and changes in pulse pressure variation (ΔPPV6-8) after tidal volume challenge were 0.82 [95% confidence interval (CI) 0.71-0.94; P < 0.0001] and 0.85 (95% CI 0.74-0.96; P < 0.0001), respectively. The value for pulse pressure variation at a tidal volume of 8 mL/kg was 0.79 (95% CI 0.67-0.91; P = 0.0003). The optimal cut-off values for corrected flow time and ΔPPV6-8 were 357 ms and > 1%, respectively. Both the corrected flow time and Changes in pulse pressure variation after tidal volume challenge reliably predicted fluid responsiveness in patients undergoing robot-assisted laparoscopic gynecological surgery in the modified head-down lithotomy position. And pulse pressure variation at a tidal volume of 8 mL/kg maybe also a useful predictor.Trial registration: Chinese Clinical Trial Register (CHiCTR2200060573, Principal investigator: Hongliang Liu, Date of registration: 05/06/2022).

Anesthetic Spread of Ultrasound-Guided Paraspinal Blocks in Video-Assisted Thoracoscopic Surgery: A Three-Dimensional Reconstruction Image Study.

BACKGROUND: Anesthetic spread of ultrasound-guided paraspinal blocks is still unknown. OBJECTIVES: To compare the drug diffusion qualities of intertransverse process block (ITPB) and erector spinae plane block (ESPB) in clinical practice. STUDY DESIGN: Prospective computed tomography (CT)-3-dimensional (3D) reconstruction image study. SETTING: Operation room in hospital. METHODS: Twenty patients undergoing thoracoscopic pulmonary wedge resection or segmentectomy were enrolled. These procedures require localization of pulmonary nodules using CT-guided needle puncture immediately before surgery. The patients were divided into 2 groups, each consisting of 10 patients. Group I underwent ITPB, while group E underwent ESPB. These interventions were performed 30 minutes before surgery using 20 mL of 0.25% bupivacaine with 2 mL iohexol. Sensory loss of the thoracic dermatomes was assessed using cold stimulation before general anesthesia. Patients' CT localization images were used for 3D reconstruction after surgery, and the diffusion of the drug in each cross-section of the CT images was evaluated. RESULTS: Three-dimensional imaging of the drug showed that in group E, drug diffusion was improved in the cephalocaudal area compared to group I (10 vs 4.5 segments). Drug diffusion in group I was improved anteriorly and laterally ([10/10, 100%] in the paravertebral and intercostal spaces) and reached the front of the vertebral body along the thoracic fascia in certain segments (6/10, 60%). In group E, very few segments of the drug reached the paravertebral (2/10, 20%) and intercostal (3/10, 30%) spaces. All patients in group I had clear signs of loss of cold sensation on the lateral and anterior chest walls, with an average of 4 thoracic dermatomes. In group E, 3 patients had definite lateral and anterior chest wall cold stimulation signs, the thoracic dermatome was discontinuous, and the effect was only present between 1-2 segments. The blocking effect of the paraspinal zone was excellent (100%) in both groups. LIMITATIONS: However, this study has some limitations. First, the sample size was small, and clinical trials with larger samples are required to further verify the effects of ITPB and ESPB. Second, the same local anesthetic drug concentration and volume were used for both techniques in this study, and the effect of volume or concentration on drug diffusion was not further explored. CONCLUSIONS: Compared with ESPB, ITPB yielded increased stability in lateral and anterior chest wall block with improved anterior and intercostal spread, but reduced cephalocaudal spread.

Effect of internal jugular vein catheterization on intracranial pressure and postoperative cognitive function in patients undergoing robot-assisted laparoscopic surgery.

Background: We aimed to evaluate the effects of internal jugular vein (IJV) catheterization on intracranial pressure (ICP) and postoperative delirium (POD) during robot-assisted laparoscopic surgery by measuring the optic nerve sheath diameter (ONSD). Methods: Data from a prospective single-center cohort study, conducted from October 2021 to February 2022, were used. Forty out of 80 patients scheduled for laparoscopic radical hysterectomy or prostatectomy were assigned to the group receiving IJV catheterization (Group I), and the other 40 only received peripheral venous cannulation (Group C) according to clinical need of patients. Ultrasonography of ONSDs, the proportion of regurgitation time in a cardiac cycle, and hemodynamic parameters were measured at four time points: immediately after induction of anesthesia in the supine position (T0), 30 min (T1), 60 min (T2) after orienting to the Trendelenburg position, and before returning to the supine position at the end of surgery (T3). Time to eye opening and emergence stay, POD, and QoR-15 were compared. Results: The ONSDs increase gradually as the surgery progressed. Group I showed a higher value of ONSD at T1 (4.72 ± 0.29 mm vs. 4.5 ± 0.33 mm, p = 0.0057) and T3 (5.65 ± 0.33 mm vs. 5.26 ± 0.31 mm, p < 0.0001). The proportions of the regurgitation time of IJVV were greater in Group I than those in Group C at T1 (14.95, 8.5%-18.9% vs. 9.6%, 0%-17.2%, p < 0.0001) and T3 (14.3, 10.6%-18.5% vs. 10.4%, 0%-16.5%, p = 0.0003). Group I had a delayed time to eye opening (10.7 ± 1.72 min vs. 13.3 ± 2.35 min, p < 0.0001) and emergence stay (32.2 ± 5.62 min vs. 39.9 ± 6.7 min, p < 0.0001). There were no significant differences in POD and QoR-15 between the two groups on day three. Conclusion: IJV cannulation may not be the preferred approach in robot-assisted laparoscopic surgery as it was risk factor for IJVV regurgitation, ICP elevation, emergence delayed.

Comparison of the effect of double-lumen endotracheal tubes and bronchial blockers on lung collapse in video-assisted thoracoscopic surgery: a systematic review and meta-analysis.

OBJECTIVE: This meta-analysis compared the quality of lung collapse and the resultant adverse reactions between the use of double-lumen endotracheal tubes (DLT) and bronchial blockers (BB) in minimally invasive thoracic surgery. METHODS: A search was performed in five bibliographic databases, namely PubMed, Springer, Medline, EMBASE, and Cochrane Library ignoring the original language, which identified five randomized controlled trials (RCTs) published on or before December 31, 2021. These studies were subsequently analyzed. All included studies compared the efficacy and safety of DLT and BB as a lung isolation technique in surgery. The methodological quality of each study was assessed by the Cochrane Collaboration's risk of bias tool. The quality of lung collapse and the malposition rate were adopted as the main outcome indicators. Alternatively, the intubation time and the incidence of postoperative sore throat were adopted as secondary indicators. RESULTS: When either DLT or BB were utilized in minimally invasive thoracic surgery, no differences were observed in the quality of lung collapse (odds ratio [OR], 1.00; 95% confidence interval [CI], 0.63 to 1.58), the intubation time (mean difference [MD], 0.06; 95% CI, -1.02 to 1.14), or the malposition rate (OR, 0.88; 95% CI, 0.37 to 2.06). However, the incidence of postoperative sore throat among patients treated with BB was significantly lower than that among patients treated with DLT (OR, 5.25; 95% CI, 2.55 to 10.75). CONCLUSION: When utilized in minimally invasive thoracic surgery, the quality of lung collapse with DLT was identical to that with BB. However, patients treated with the latter demonstrated a significantly lower incidence of postoperative sore throat.

Compare the Efficacy and Safety of Modified Combined Short and Long Axis Method versus Oblique Axis Method for Right Internal Jugular Vein Catheterization in Adult Patients (The MCSLOA Trial): Study Protocol of a Randomized Controlled Trial.

Background: Ultrasound-guided internal jugular vein (IJV) catheterization has become a standard procedure as it yields a higher success rate and fewer mechanical complications compared with an anatomical landmark technique. There are several common methods for ultrasound guidance IJV catheterization, such as short-axis out-of-plane, long-axis in-plane and oblique axis in-plane, but these technologies are still developing. It is important to further study the application of different ultrasound-guided IJV puncture techniques and find an effective and safe ultrasound-guided puncture technique. Methods: A China randomized, open-label, parallel, single center, positive-controlled, non-inferiority clinical trial will evaluate 190 adult patients undergoing elective surgery and need right jugular vein catheterization. Study participants randomized in a 1:1 ratio into control and experimental groups. The control group will take the oblique axis in-plane method for IJV catheterization. The experimental group will take the Modified combined short and long axis method. The primary endpoint of the trial is the rate of one-time successful guidewire insertion without posterior wall puncture (PWP). Secondary endpoints are the number of needle insertion attempts, the total success rate, the procedure time, and mechanical complications. Conclusion: This randomized controlled trial will evaluate the effectiveness and safety of Modified combined short and long axis method and oblique axis in-plane method for right IJV catheterization in adult patients.

Asymptomatic carbon dioxide embolism during transoral vestibular thyroidectomy: A case report.

BACKGROUND: Endoscopic thyroidectomy has obvious advantages over conventional surgical techniques in terms of postoperative cosmetic outcome. Although the incidence of carbon dioxide embolism (CDE) during endoscopic thyroidectomy is very low, it is potentially fatal. The clinical manifestations of CDE vary, and more attention should be paid to this disorder. CASE SUMMARY: A 27-year-old man was scheduled for thyroidectomy by the transoral vestibular approach. The patient had no other diseases or surgical history. During the operation, he developed a CDE following inadvertent injury of the anterior jugular vein. The clinical manifestation in this patient was a transient sharp rise in end-tidal carbon dioxide, and his remaining vital signs were stable. In addition, loud coarse systolic and diastolic murmurs were heard over the precordium. The patient was discharged on day 4 after surgery without complications. CONCLUSION: A transient sharp rise in end-tidal carbon dioxide is considered a helpful early sign of CDE during endoscopic thyroidectomy.

Aspiration pneumonia during general anesthesia induction after esophagectomy: A case report.

BACKGROUND: Esophageal cancer is a common malignant tumor of the digestive system. At present, surgery is the most important treatment strategy. After esophagectomy and gastric esophagoplasty, the patients are prone to regurgitation. However, these patients currently do not receive much attention, especially from anesthesiologists. CASE SUMMARY: A 55-year-old woman was scheduled for right lower lung lobectomy. The patient had undergone radical surgery for esophageal cancer under general anesthesia 6 mo prior. Although the patient had fasted for > 17 h, unexpected aspiration still occurred during induction of general anesthesia. Throughout the operation, oxygen saturation was 98%-100%, but the airway pressure was high (35 cmH2O at double lung ventilation). The patient was sent to the intensive care unit after surgery. Bedside chest radiography was performed, which showed exudative lesions in both lungs compared with the preoperative image. After surgery, antibiotics were given to prevent lung infection. On day 2 in the intensive care unit, the patient was extubated and discharged on postoperative day 7 without complications related to aspiration pneumonia. CONCLUSION: After esophagectomy, patients are prone to regurgitation. We recommend nasogastric tube placement followed by rapid sequence induction or conscious intubation.

Construction of an Inducible CRISPR/Cas9 System for CXCR4 Gene and Demonstration of its Effects on MKN-45 Cells.

The CRISPR/Cas9 system is an effective tool for gene editing. However, this conventional expression system cannot control the timing of gene editing and does not utilize resistance screening markers. Therefore, carrying out CRISPR/Cas9 experiments is extremely inconvenient. Our aim is to develop an inducible lentiviral vector-based gene-editing system for C-X-C chemokine receptor 4 (CXCR4) by CRISPR/Cas9, and to demonstrate its function in MKN-45 cell. The DNA fragments of Blasticidin and T2A-GFP were produced using the lenti-Cas9-BLAST and PX458 plasmids as templates. The PCR products were harvested and cloned into the lenti-guide-puro plasmid to yield the lenti-guide-BLAST-GFP plasmid. Three double-stranded guide RNA (gRNA) sequences targeting the exon 2 of CXCR4 gene were designed online (http://crispr.mit.edu), synthesized, and recombined into the lenti-guide-BLAST-GFP plasmid, to yield the lenti-guide-BLAST-GFP-gRNA plasmid. The pCW-Cas9 and lenti-guide-BLAST-GFP-gRNA plasmids were packaged with lentiviral vectors, which were then transfected into MKN-45 cells, to identify the CXCR4 gene-editing effects using the T7 endonuclease 1 (T7E1) and Western blot assays. The lenti-guide-BLAST-GFP and lenti-guide-BLAST-GFP-gRNA plasmids were successfully constructed and packaged, to yield lentiviral particles. Transfection of the pCW-Cas9 and lenti-guide-BLAST-GFP-gRNA viral vectors could decrease the expression of CXCR4 protein, and lead to gene editing in MKN-45 cells. The efficiencies of gRNA-1, gRNA-2, and gRNA-3 were 45.6%, 53.6%, and 56.7%, respectively. Furthermore, the chemotactic efficiency of the dual viral vector-infected MKN-45 cells was significantly decreased in response to SDF-1. The numbers of migratory cells in the lower chamber of the transwell system were 30.0 ± 0.23, 29.7 ± 1.55, 28.2 ± 1.11 and 36.1 ± 2.00 cells per field (400×) for gRNA-1, gRNA-2, gRNA-3 and the control, respectively (P < 0.05). We constructed an inducible CXCR4 gene-editing, dual-vector CRISPR/Cas9 system, which could induce CXCR4 gene editing in MKN-45 cells in a doxycycline-dependent manner and thus reduce the migration of MKN-45 cells.

The stromal cell-derived factor 1/C-X-C chemokine receptor type 4 axis is important in neutrophil migration caused by cardiopulmonary bypass in children.

OBJECTIVES: Acute lung injury caused by cardiopulmonary bypass (CPB) is characterized by massive neutrophil migration to the lungs. Neutrophil migration may be closely related to stromal cell-derived factor 1 (SDF-1)/C-X-C chemokine receptor Type 4 (CXCR4) axis activation, which plays an essential role in modulating the trafficking of neutrophils. We investigated the changes in the expression of SDF-1/CXCR4 axis components before and after CPB as well as the role of the axis in driving the migration of neutrophils in patients with congenital heart disease. METHODS: Fifteen children undergoing elective open-heart surgery under CPB (CPB group) and 15 children undergoing minimally invasive ultrasound-guided closure of a ventricular septal defect (control group) were enrolled in this non-randomized clinical trial. Neutrophil CXCR4 expression was evaluated using quantitative reverse transcription polymerase chain reaction and flow cytometry. An enzyme-linked immunosorbent assay was used to measure plasma SDF-1 levels. The migration characteristics of neutrophils under 8 different combinations designated A-H were assayed with and without a specific CXCR4 antagonist, AMD3100, to evaluate the functional significance of the SDF-1/CXCR4 axis. RESULTS: Both CXCR4 gene and protein expressions were elevated in the CPB group compared with the control group after CPB (0.81 ± 0.55 vs 1.76 ± 1.32; P < 0.05, 1.96 ± 0.86 vs 2.65 ± 0.79; P < 0.05), and plasma SDF-1 levels were also increased in the former compared with the latter (197.84 ± 19.96 pg/ml vs 539.13 ± 99.83 pg/ml; P < 0.05). The in vitro experiments showed that plasma isolated post-CPB exhibited the strongest chemotactic effect on neutrophils. The CPB group showed a higher chemotaxis index, which serves as a marker for the effects of plasma on neutrophils, than that for the control group after CPB (37.38 ± 9.39 vs 13.61 ± 2.59; P < 0.05). In addition, the CXCR4 antagonist AMD3100 significantly abrogated the increase in neutrophil migration in the CPB group. CONCLUSIONS: Exposure to CPB, which activates the SDF-1/CXCR4 axis, using an antagonist to prevent neutrophil trafficking, may be a beneficial therapy for the related complications.