Effect of Different Administration Routes of Dexmedetomidine on Postoperative Delirium in Elderly Patients Undergoing Elective Spinal Surgery: A Prospective Randomized Double-Blinded Controlled Trial.

BACKGROUND: Intravenous dexmedetomidine has been reported to decrease the occurrence of postoperative delirium (POD) in elderly patients. Nevertheless, some previous studies have indicated that intratracheal dexmedetomidine and intranasal dexmedetomidine are also effective and convenient. The current study aimed to compare the effect of different administration routes of dexmedetomidine on POD in elderly patients. METHODS: We randomly allocated 150 patients (aged 60 years or more) scheduled for spinal surgery to receive intravenous dexmedetomidine (0.6 µg/kg), intranasal dexmedetomidine (1 µg/kg) before anesthesia induction, or intratracheal dexmedetomidine (0.6 µg/kg) after anesthesia induction. The primary outcome was the frequency of delirium during the first 3 postoperative days. The secondary outcomes were the incidence of postoperative sore throat (POST) and sleep quality. Adverse events were recorded, and routine treatment was performed. RESULTS: Compared with the intranasal group, the intravenous group had a significantly lower occurrence of POD within 3 days (3 of 49 [6.1%] vs 14 of 50 [28.0%]; odds ratio [OR], 0.17; 95% confidence intervals [CIs], 0.05-0.63; P < .017). Meanwhile, patients in the intratracheal group had a lower incidence of POD than those in the intranasal group (5 of 49 [10.2%] vs 14 of 50 [28.0%]; OR, 0.29; 95% CI, 0.10-0.89; P < .017). Whereas, there was no difference between the intratracheal and intravenous groups (5 of 49 [10.2%] vs 3 of 49 [6.1%]; OR, 1.74; 95% CI, 0.40-7.73; P > .017). The rate of POST was lower in the intratracheal group than that in the other 2 groups at 2 hours after surgery (7 of 49 [14.3%] vs 12 of 49 [24.5%] vs 18 of 50 [36.0%], P < .017, respectively). Intravenous dexmedetomidine had the lowest Pittsburgh Sleep Quality Index score on the second morning after surgery (median [interquartile range {IQR}]: 4 [3-5] vs 6 [4-7] vs 6 [4-7], P < .017, respectively). Compared with the intranasal group, the intravenous group had a higher rate of bradycardia and a lower incidence of postoperative nausea and vomiting ( P < .017). The intranasal group was associated with the highest incidence of hypertension ( P < .017). CONCLUSIONS: For patients aged ≥60 years undergoing spinal surgery, compared with the intranasal route of dexmedetomidine, intravenous and intratracheal dexmedetomidine reduced the incidence of early POD. Meanwhile, intravenous dexmedetomidine was associated with better sleep quality after surgery, and intratracheal dexmedetomidine resulted in a lower incidence of POST. Adverse events were mild in all 3 administration routes of dexmedetomidine.

Ischemic-Preconditioning Induced Serum Exosomal miR-133a-3p Improved Post-Myocardial Infarction Repair via Targeting LTBP1 and PPP2CA.

Background: Ischemic preconditioning-induced serum exosomes (IPC-exo) protected rat heart against myocardial ischemia/reperfusion injury. However, whether IPC-exo regulate replacement fibrosis after myocardial infarction (MI) and the underlying mechanisms remain unclear. MicroRNAs (miRs) are important cargos of exosomes and play an essential role in cardioprotection. We aim to investigate whether IPC-exo regulate post-MI replacement fibrosis by transferring cardioprotective miRs and its action mechanism. Methods: Exosomes obtained from serum of adult rats in control (Con-exo) and IPC groups were identified and analyzed, subsequently intracardially injected into MI rats following ligation. Their miRs profiles were identified using high-throughput miR sequencing to identify target miRs for bioinformatics analysis. Luciferase reporter assays confirmed target genes of selected miRs. IPC-exo transfected with selected miRs antagomir or NC were intracardially administered to MI rats post-ligation. Cardiac function and degree of replacement fibrosis were detected 4 weeks post-MI. Results: IPC-exo exerted cardioprotective effects against excessive replacement fibrosis. MiR sequencing and RT-qPCR identified miR-133a-3p as most significantly different between IPC-exo and Con-exo. MiR-133a-3p directly targeted latent transforming growth factor beta binding protein 1 (LTBP1) and protein phosphatase 2, catalytic subunit, alpha isozyme (PPP2CA). KEGG analysis showed that transforming growth factor-ß (TGF-ß) was one of the most enriched signaling pathways with miR-133a-3p. Comparing to injection of IPC-exo transfected with miR-133a-3p antagomir NC, injecting IPC-exo transfected with miR-133a-3p antagomir abolished protective effects of IPC-exo on declining excessive replacement fibrosis and cardiac function enhancement, while increasing the messenger RNA and protein expression of LTBP1, PPP2CA, and TGF-ß1in MI rats. Conclusion: IPC-exo inhibit excessive replacement fibrosis and improve cardiac function post-MI by transferring miR-133a-3p, the mechanism is associated with directly targeting LTBP1 and PPP2CA, and indirectly regulating TGF-ß pathway in rats. Our finding provides potential therapeutic effect of IPC-induced exosomal miR-133a-3p for cardiac repair.

Effect of a Local Anesthetic Injection Kit on Pain Relief and Postoperative Recovery After Transumbilical Single-Incision Laparoscopic Cholecystectomy.

Purpose: This study was conducted to explore whether incisional infiltration using a local anesthetic injection kit could better relieve postoperative pain and enhance the quality of recovery compared with ultrasound-guided rectus sheath block (RSB) or conventional local anesthetic infiltration in patients undergoing transumbilical single-incision laparoscopic cholecystectomy (SILC). Patients and Methods: A total of 60 patients undergoing SILC with American Society of Anesthesiology functional status scores of I-II were randomized into the rectus sheath block group (RSB group), conventional local wound infiltration group (LAI-I group) and incisional infiltration using a local anesthetic injection kit group (LAI-II group). The primary outcomes were the patient-controlled intravenous analgesia (PCIA) demand frequency within 48 hours after the operation and postoperative pain measured by a visual analog scale (VAS) at 2 h, 4 h, 8 h, 24 h, and 48 h after surgery. Secondary outcomes were the total procedure times, cumulative consumption of anesthetic drugs, duration of surgery, duration and awaking time of anesthesia, early recovery indicator and side effects. Results: The PCIA demand frequency in LAI-II group was significantly lower compared with patients in the RSB and LAI-I group (both P < 0.001). Moreover, the total procedure times in LAI-I and LAI-II group was significantly shorter than that in the RSB group (P < 0.001, respectively), but it was comparable between LAI-I and LAI-II group (P = 0.471). Though lower at 2h and 4h postoperative in LAI-II group, pain scores at each time point had no statistical differences among three groups. There were no significant differences among three groups for other outcomes as well. Conclusion: The effect of ultrasound-guided RSB and conventional local anesthetic infiltration in SILC patients were found to be similar in terms of relieving postoperative pain and promoting recovery. Incisional infiltration using a local anesthetic injection kit can significantly reduce the demand frequency of PCIA, which serves as a rescue analgesic.