Ultrasound increases the success rate of spinal needle placement through the epidural needle during combined spinal-epidural anaesthesia: A randomised controlled study.

BACKGROUND: Combined spinal-epidural anaesthesia (CSEA) using a needle-through-needle technique is currently widely used. However, successful epidural needle placement does not mean a successful spinal needle placement during CSEA. Whether ultrasound assistance could increase the first-pass success rate of spinal needle placement for CSEA remains unknown. OBJECTIVE: The aim of this study was to investigate if ultrasound assistance could increase the first-pass success rate of spinal needle placement through the epidural needle during CSEA performed by experienced anaesthesiologists in patients undergoing caesarean section. DESIGN: A prospective, randomised, double-blind study. SETTING: Single centre, Department of Anaesthesiology, Shengjing Hospital, China Medical University, China, from June 2019 to September 2019. PATIENTS: A total of 185 patients (aged 24 years to 52 years, American Society of Anesthesiologists grade (ASA) II-III, 38 to 40 weeks gestation) scheduled to undergo elective caesarean section under CSEA were enrolled. INTERVENTION: The patients were randomised to either an ultrasound group (patients received a preprocedural ultrasound scan, and the puncture site was identified by ultrasound imaging) and a palpation group (patients received a sham procedural ultrasound scan, and the puncture site was identified by conventional palpation). MAIN OUTCOME MEASURES: The primary outcome measure was the first-pass success rate for spinal needle placement through the epidural needle. Secondary outcome measures were total duration of CSEA, time required for successful epidural needle and spinal needle placement, number of epidural needle redirections and complications. RESULTS: Preprocedural ultrasound imaging significantly increased the first-pass success rate of spinal needle placement through the epidural needle compared with conventional palpation (93.8 vs. 68.8%, P < 0.001). Preprocedural ultrasound imaging also decreased the total duration of CSEA (186.9 ±â€Š37.1 vs. 213 ±â€Š60.4 s, P = 0.0015) and the time required for successful spinal needle placement (78.3 ±â€Š22.9 vs. 100.1 ±â€Š53.7 s, P < 0.01) compared with conventional palpation. Fewer patients in the ultrasound group needed epidural needle redirections during the spinal needle placement procedure than in the palpation group (four patients vs. 20 patients, P < 0.01). CONCLUSION: For experienced anaesthesiologists, preprocedural ultrasound imaging significantly increased the first-pass success rate of spinal needle placement through the epidural needle for obstetric patients undergoing caesarean section under CSEA. TRIAL REGISTRATION: chictr.org.cn, identifier: ChiCTR1900024132.

Comparison of GlideScope Video Laryngoscopy and Direct Laryngoscopy for Tracheal Intubation in Neonates.

BACKGROUND: GlideScope video laryngoscope (GS) has been widely used to facilitate tracheal intubation in adults and pediatric patients because it can improve glottic view. Several investigations performed in pediatric patients have shown that GS provides a better view of the glottis than direct laryngoscope (DL). However, to date, there are no studies assessing the use of GS in neonates. Therefore, we conducted a prospective study to compare time to intubate (TTI) when either GS or DL was used for endotracheal intubation in neonates. METHODS: Seventy neonates (American Society of Anesthesiologists physical status I and II, scheduled to undergo elective surgery under general anesthesia) were randomized to GS group (n = 35) and DL group (n = 35). The primary outcome variable of the study was TTI. As secondary outcomes, success rate of first intubation attempt of all neonates, intubation attempts, and adverse events were also evaluated. The glottic views (depicted by Cormack and Lehane [C&L] grades) obtained with GS and DL were compared. RESULTS: There were no significant differences in TTIs of neonates with all C&L grades (95% CI, -7.36 to 4.44). There was also no difference in the subgroups of neonates with C&L grades I and II (n = 30 each; 95% CI, -0.51 to 5.04). However, GS significantly shortened the TTIs of neonates with C&L grades III and IV compared to DL (n = 5 each group; 95% CI, 4.94-46.67). GS improved the glottic view as compared to DL. Although the total tracheal intubation attempts in the GS group was fewer than that in the DL group (36 vs 41), there was no significant difference (P = .19). CONCLUSIONS: GS use did not decrease the TTI of all neonates and neonates with C&L grades I and II as compared to DL use; however, GS significantly decreased the TTI of neonates with C&L grades III and IV. Additionally, GS use provided improved glottic views.

Perioperative effects of caudal block on pediatric patients in laparoscopic upper urinary tract surgery: a randomized controlled trial.

BACKGROUND: While caudal block has been widely used during pediatric lower limbs and lower abdominal surgeries, few studies to date have evaluated the perioperative effects of caudal block on pediatric patients in laparoscopic upper urinary tract surgery. METHODS: Ninety-six pediatric patients, aged 6 months to 7 years, ASA grade I-II, scheduled to undergo laparoscopic upper urinary tract surgery, were randomized to a non-block group (no caudal block performed), an ROP1.0 group (patients received 1.0 mL/kg of 0.15% ropivacaine) and an ROP1.3 group (patients received 1.3 mL/kg of 0.15% ropivacaine). The primary outcome variable was perioperative fentanyl use. The secondary outcome variables were pain score, hemodynamic fluctuation, the number of patients needing rescue fentanyl and side effects. RESULTS: Caudal block with 1.3 mL/kg of 0.15% ropivacaine significantly decreased perioperative fentanyl usage (ROP 1.3 vs. non-caudal block, P < 0.01; ROP 1.3 vs. ROP 1.0, P < 0.05). Moreover, patients in the ROP1.3 group, compared to those without, displayed more stable hemodynamics, lower pain score in the PACU and 8 h after operation, less demand for rescue fentanyl, shorter time of PACU stay. CONCLUSIONS: Caudal block with 1.3 mL/kg of 0.15% ropivacaine reduced perioperative fentanyl use during laparoscopic upper urinary tract surgery on pediatric patients and produced good postoperative analgesia when compared with no caudal block and caudal block with 1.0 mL/kg of 0.15% ropivacaine. TRIAL REGISTRATION: Clinical trial number: ChiCTR1800015549, chictr.org.cn.

Effects of hydrogen-rich saline on aquaporin 1, 5 in septic rat lungs.

Aquaporin 1(AQP1) and AQP5 have an important role in eliminating extravascular lung water, an increase of which contributes to lung injury in patients with sepsis and its consequent mortality. It has been reported that hydrogen-rich saline (HRS) has protective effects against sepsis-related lung injury. In this study, we hypothesized that the protective effect occurred by preserving the expression of AQP1 and AQP5. To test this hypothesis, male Sprague-Dawley rats received intratracheal administration of lipopolysaccharide (LPS) followed by intraperitoneal injection of HRS. Lung function, wet-to-dry weight ratio, and histopathology scores were determined. The expression of AQP1 and AQP5 at the messenger RNA and protein levels, as well as the involved pathways, was explored by quantitative polymerase chain reaction and Western blot. LPS significantly impaired lung function and downregulated the expression of AQP1 and AQP5 in the rat lung, all of which were attenuated by HRS treatment. Moreover, HRS treatment inhibited LPS-induced activation of p38 mitogen-activated protein kinase and jun N-terminal kinase, which is associated with LPS-induced downregulation of AQP1 and AQP5.

Median effective dose of ropivacaine for prophylactic cervical cerclage in Chinese women: a dose-finding study.

BACKGROUND: Although intrathecal ropivacaine has been widely used for caesarean delivery, there are limited data for the use of ropivacaine for prophylactic cervical cerclage. We sought to determine the median effective dose of intrathecal ropivacaine for prophylactic cervical cerclage in 50% of patients (ED50) and the calculated dose required for successful block in 95% of patients (ED95). METHODS: We included Chinese women scheduled for prophylactic cervical cerclage under combined spinal-epidural (CSE) anaesthesia in the first or second trimester. A predetermined dose of intrathecal isobaric ropivacaine was administered. If this determined dose achieved an effective block at a level not lower than T12, the next dose was decreased by 0.5 mg. Otherwise, the next dose was increased by 0.5 mg. The primary outcome was the ED50 of intrathecal ropivacaine. Secondary outcomes included the calculated ED95, time from CSE to the start of surgery and so on. RESULTS: Forty patients were included in the study, 23 (57.5%) of 40 received an effective block only with intrathecal ropivacaine, while 17 (42.5%) patients needed extra epidural lidocaine to achieve a successful block. The ED50 of intrathecal ropivacaine confirmed by isotonic regression was 6.9 mg (95% CI, 6.68 to 7.12 mg), and the calculated ED95 was 7.8 mg (95% CI, 7.69 to 10.05 mg). When an effective block was achieved with intrathecal ropivacaine alone, the time to resolution of the sensory and motor blocks was 90 (75-100) min and 90 (60-100) min, respectively. CONCLUSIONS: The ED50 of intrathecal ropivacaine for prophylactic cervical cerclage was 6.9 mg. Intrathecal ropivacaine (7.8 mg) is likely to produce successful anaesthesia in 95% of patients undergoing prophylactic cervical cerclage. TRIAL REGISTRATION NUMBER: ChiCTR2100051418.

Resistin-Like Molecule α Dysregulates Cardiac Bioenergetics in Neonatal Rat Cardiomyocytes.

Heart (right) failure is the most frequent cause of death in patients with pulmonary arterial hypertension. Although historically, increased right ventricular afterload has been considered the main contributor to right heart failure in such patients, recent evidence has suggested a potential role of load-independent factors. Here, we tested the hypothesis that resistin-like molecule α (RELMα), which has been implicated in the pathogenesis of vascular remodeling in pulmonary artery hypertension, also contributes to cardiac metabolic remodeling, leading to heart failure. Recombinant RELMα (rRELMα) was generated via a Tet-On expression system in the T-REx 293 cell line. Cultured neonatal rat cardiomyocytes were treated with purified rRELMα for 24 h at a dose of 50 nM. Treated cardiomyocytes exhibited decreased mRNA and protein expression of peroxisome proliferator-activated receptor gamma coactivator 1α (PGC-1α) and transcription factors PPARα and ERRα, which regulate mitochondrial fatty acid metabolism, whereas genes that encode for glycolysis-related proteins were significantly upregulated. Cardiomyocytes treated with rRELMα also exhibited a decreased basal respiration, maximal respiration, spare respiratory capacity, ATP-linked OCR, and increased glycolysis, as assessed with a microplate-based cellular respirometry apparatus. Transmission electron microscopy revealed abnormal mitochondrial ultrastructure in cardiomyocytes treated with rRELMα. Our data indicate that RELMα affects cardiac energy metabolism and mitochondrial structure, biogenesis, and function by downregulating the expression of the PGC-1α/PPARα/ERRα axis.

[The comparison of the vasoactive effects of dopamine on isolated rabbit pulmonary and systemic arteries after incubation with lipopolysaccharide].

OBJECTIVE: To compare the vasoactive effects of dopamine (DOPA) of different concentrations on isolated rabbit pulmonary and systemic arteries after incubation with lipopolysaccharide (LPS). METHODS: Six white male rabbits were used. Thirty-six pulmonary arterial rings and 36 systemic arterial rings were prepared. The 36 pulmonary arterial rings were divided into six groups to determine the effect of different concentrations of DOPA (4x10(-5) , 8x10(-5), 16x10(-5) micromol/L) on the tension of the normal pulmonary artery (PN-DOPA4, PN-DOPA8, PN-DOPA16 groups, respectively), and the tension of the pulmonary artery rings after being incubated with LPS (PL-DOPA4, PL-DOPA8, PL-DOPA16 groups, respectively). The 36 systemic arterial rings were also divided into six groups as the pulmonary arterial rings, including normal groups (SN-DOPA4, SN-DOPA8 , SN-DOPA16) and LPS groups (SL-DOPA4, SL-DOPA8 , SL-DOPA16). RESULTS: (1) DOPA relaxed the arterial rings in PN-DOPA4 and SN-DOPA4 groups, while it produced contraction in PN-DOPA8, PN-DOPA16, SN-DOPA8 and SN-DOPA16 groups, and the contraction was more marked with the increase in concentration of DOPA. (2) After preincubation with LPS, the relaxation property of DOPA in PL-DOPA4 and SL-DOPA4 groups was observed to be reversed to contraction [(22.60+/-6.68)% vs. -(2.25+/-0.58)%, (3.80+/-0.52)% vs. -(3.65+/-0.75)%, P<0.05 and P<0.01]; the contraction response of DOPA in PL-DOPA8 group decreased compared with PN-DOPA8 group by (14.52+/-0.59)% (P<0.05), while increased by (25.90+/-1.75)% in SL-DOPA8 group compared with SN-DOPA8 group (P<0.05), and no response was observed in PL-DOPA16 and SL-DOPA16 groups. (3)After preincubation with LPS, changes in pulmonary arterial tension (PL/PN) in DOPA4 group were more obvious than those in systemic arterial tension (SL/SN, -10.90+/-5.06 vs. -1.00+/-0.24, P<0.05), while the SL/SN in DOPA8 group were more obvious (1.80+/-0.35 vs. 0.48+/-0.17, P<0.01). CONCLUSION: DOPA in low concentrations had the function of relaxation on the pulmonary arterial and systemic arterial rings. After the arterial rings are preincubated with LPS, the relaxation response of DOPA of low concentrations is changed to be vaso-contraction, and the changes in pulmonary arterial rings are most marked. DOPA of different concentrations all produce contraction effect on LPS-preincubated arterial rings.

[The effects of dopamine on pulmonary artery pressure in dogs with endotoxic shock].

OBJECTIVE: To evaluate the values of dopamine in treating endotoxic shock by observing the changes in the pulmonary artery pressure (PAP) during the treatment. METHODS: Twenty healthy dogs were randomly divided into four groups with 5 in each group. Endotoxic model was reproduced by injecting lipopolysaccharides (LPS) 1 mg/kg intravenously. Two hours later, normal saline (NS) 5 ml/h was intravenously given in model group, or dopamine 5, 10, 20 microg*kg(-1)*min(-1) was given in D5 group, D10 group, D20 group intravenously. Femoral artery pressure, femoral vein pressure and PAP were measured, and mean arterial pressure (MAP) and mean pulmonary artery pressure (MPAP) were recorded at 0, 5, 10, 30, 60, 120 minutes after infusion of NS or dopamine. RESULTS: Compared with the model group, all different concentrations of dopamine could elevate MAP, MPAP (P<0.05 or P<0.01). Compared with D5 group, the percentage of elevation of MAP of D10 group and D20 group was greater, and the percentage of elevation of MPAP of D20 group was greater than that in D5 group and D10 group (P<0.05 or P<0.01). The ratio of MAP/MPAP in each dopamine group was higher than that of model group, and the increase was more marked in the groups of higher concentrations (all P<0.05). CONCLUSION: MAP of endotoxic dog lowered obviously, while there was little change in PAP. After infusion of dopamine intravenously, both MAP and PAP are elevated. The increase in resistance of pulmonary microcirculation is the main reason for the elevation of PAP.

Effect of Intravenous Oxycodone Versus Sufentanil on the Incidence of Postoperative Nausea and Vomiting in Patients Undergoing Gynecological Laparoscopic Surgery.

More than 30% of patients who undergo surgery will experience postoperative nausea and vomiting (PONV) if no prophylactic treatments are used. Although numerous studies have been performed to investigate the factors related to PONV, the effect of perioperative intravenous oxycodone on the incidence of PONV has not been well investigated. In this study, gynecological patients (grade I-II, aged 18-65 years, scheduled to undergo elective gynecological laparoscopic surgery under general anesthesia) were randomized to the oxycodone group or the sufentanil group. In the oxycodone group, patients received intravenous oxycodone for the induction and maintenance of anesthesia, as well as postoperative analgesia, while sufentanil was used in the sufentanil group. The primary outcome variable was the incidence of PONV. As secondary outcomes, time to first PONV, the rating of the most severe PONV, postoperative pain scores at different time points, hemodynamics, and side effects were evaluated. We found that, compared with sufentanil, oxycodone decreased the incidence of PONV by 13.5% (P = .041). The time to first vomiting was longer in the oxycodone group than in the sufentanil group. Postoperative pain scores at different time points and hemodynamics were comparable between the oxycodone and sufentanil groups. We concluded that the incidence of PONV in gynecological patients who underwent laparoscopic surgery was lower when using intravenous oxycodone for anesthesia induction, anesthesia maintenance, and postoperative analgesia than when using intravenous sufentanil. However, oxycodone and sufentanil provided the same stable hemodynamics during surgery and satisfactory postoperative analgesia.

Hydrogen-Rich Saline Attenuates Lipopolysaccharide-Induced Heart Dysfunction by Restoring Fatty Acid Oxidation in Rats by Mitigating C-Jun N-Terminal Kinase Activation.

Sepsis is common in intensive care units (ICU) and is associated with high mortality. Cardiac dysfunction complicating sepsis is one of the most important causes of this mortality. This dysfunction is due to myocardial inflammation and reduced production of energy by the heart. A number of studies have shown that hydrogen-rich saline (HRS) has a beneficial effect on sepsis. Therefore, we tested whether HRS prevents cardiac dysfunction by increasing cardiac energy. Four groups of rats received intraperitoneal injections of one of the following solutions: normal saline (NS), HRS, lipopolysaccharide (LPS), and LPS plus HRS. Cardiac function was measured by echocardiography 8 h after the injections. Gene and protein expression related to fatty acid oxidation (FAO) were measured by quantitative polymerase chain reaction (PCR) and Western blot analysis. The injection of LPS compromised heart function through decreased fractional shortening (FS) and increased left ventricular diameter (LVD). The addition of HRS increased FS, palmitate triphosphate, and the ratio of phosphocreatinine (PCr) to adenosine triphosphate (ATP) as well as decreasing LVD. The LPS challenge reduced the expression of genes related to FAO, including perioxisome proliferator-activated receptor gamma coactivator 1-alpha (PGC-1α), perioxisome proliferator-activated receptor alpha (PPARα), Estrogen-related receptor alpha (ERRα), and their downstream targets, in mRNA and protein level, which were attenuated by HRS. However, HRS had little effect on glucose metabolism. Furthermore, HRS inhibited c-Jun N-terminal kinase (JNK) activation in the rat heart. Inhibition of JNK by HRS showed beneficial effects on LPS-challenged rats, at least in part, by restoring cardiac FAO.