Effect of depth of neuromuscular blockade on the abdominal space during pneumoperitoneum establishment in laparoscopic surgery.

STUDY OBJECTIVE: To evaluate the effect of neuromuscular blockade (NMB) upon the abdominal space during pneumoperitoneum establishment in laparoscopic surgery, comparing moderate NMB and deep NMB. DESIGN: Prospective, randomized, crossover clinical trial. SETTING: Operating room. PATIENTS: Seventy-six American Society of Anesthesiologists 1 to 2 patients scheduled for elective laparoscopic surgery. INTERVENTIONS: Two independent evaluations were performed at the establishment of pneumoperitoneum for a preset intraabdominal pressures (IAPs) of 8 and 12 mm Hg, both during moderate NMB (train-of-four count, 1-3) and deep NMB (posttetanic count, <5). Rocuronium was used to induce NMB, and sugammadex was used for reversal. MEASUREMENTS: We evaluated (i) the volume of CO2 introduced in 41 patients and (ii) the skin-sacral promontory distance in 35 patients, at pneumoperitoneum establishment. RESULTS: Compared to moderate NMB, deep NMB increased, in a significant manner, both the intraabdominal volume of CO2 insufflated (mean [SD], 2.24 [1.10] vs 2.81 [1.13] L at 8 mm Hg IAP, P<.001, and 3.52 [1.31] vs 4.09 [1.31] L at 12 mm Hg IAP, P<.001) and the skin-sacral promontory distance (11.78 [1.52] vs 12.16 [1.51] cm at 8 mm Hg IAP, P=.002, and 13.34 [1.87] vs 13.80 [1.81] cm at 12 mm Hg IAP, P<.001). Increase in intraabdominal volume after inducing deep NMB was observed in 88% and 81.7% of patients at 8 and 12 mm Hg pneumoperitoneum, with a volume increase of mean of 36.8% (95% confidence interval [CI], 22.8-50.8) and 25% (95% CI, 13.7-36.4), respectively (P=.003). Increase in distance was observed in 61% and 82% of patients at 8 and 12 mm Hg pneumoperitoneum, with a mean distance increase of 3.3% (95% CI, 1.3-5.4) and 3.6% (95% CI, 1.9-5.2), respectively (P=.840). CONCLUSIONS: Deep NMB, in comparison to moderate NMB, increased in a significant manner the abdominal space at pneumoperitoneum establishment. However, the effective increase in the abdominal cavity dimensions could be low, the increase showed a great interindividual variability, and it was not observed in every patient. Clinical significance of this increase on surgical conditions is yet to be demonstrated.

ISA virus regulates the generation of reactive oxygen species and p47phox expression in a p38 MAPK-dependent manner in Salmo salar.

Several viruses, including Orthomyxovirus, utilize cellular reactive oxygen species (ROS) for viral genomic replication and survival within host cells. However, the role of ROS in early events of viral entry and signal induction has not been elucidated. Here, we show that ISA virus (ISAV) induces ROS production very early during infection of CHSE-214 and SHK-1Ycells, and that production is sustained over the observed 24h post-infection. The mitogen-activated protein kinase (MAPK) family is responsible for important signaling pathways. In this study, we report that ISAV activates ERK and p38 in Salmo salar. In salmonid macrophages, while ERK was required for SOD, GLURED, p47phox expression, p38 regulated the ROS production by the NADPH oxidase complex activation. These results, together with the presence of several consensus target motifs for p38 MAPK in the promoter of the S. salar p47phox gene, suggest that p38 MAPK regulates p47phox gene expression in fish through the activation of this key transcription factor.