[TAVI simplification: A focus]. / Simplification des procédures TAVI : mise au point.

After a first procedure carried out in 2002 by Pr Cribier's, Transcatheter Aortic Valve Replacement or TAVR revolutionized the management of aortic stenosis with a constant increase in the number of procedures performed worldwide. Experience of operators and teams and evolution of the technique has been accompanied by a drastic reduction in complications in patients at lower surgical risk. In parallel, the procedure was considerably simplified, carried out more and more under local anesthesia, with percutaneous femoral approach, secondary radial approach, prosthesis implantation without predilatation, rapid pacing on left ventricle wire and early discharge. Thus, the "simplified" TAVR adopted in most centers nowadays is a real revolution of the technique. However, simplified TAVR must be accompanied upstream by a rigorous selection of patients who can benefit from a minimalist procedure in order to guarantee its safety.

Comparative Induction of Controlled Hypotension by Electroacupuncture at DU20 Acupoint and Remifentanil in Lumbar Laminectomy.

Hypotensive anesthesia is utilized to reduce bleeding during orthopedic surgery. One of the various drugs that have been used to reduce blood pressure is remifentanil. This study was an attempt to compare the effect of remifentanil with that of electroacupuncture (EA) at DU20 on reducing blood pressure. In this randomized controlled clinical trial, 54 patients undergoing lumbar laminectomy were allocated to two groups. Hypotensive anesthesia was performed through infusion of remifentanil 100 µg/kg/min for the control group, and EA at DU20 acupoint with a frequency of 2-10 Hz and intensity of 1-5 mA for the intervention group. Blood pressure, pulse rate, volume of blood lost and the quality of surgical field were evaluated every 10 min. There were no statistically significant differences between the two groups in terms of the changes in mean arterial pressure (MAP), pulse rate, and the quality of surgical field (P > 0.05). Therefore, EA can be as effective as remifentanil to reduce blood pressure in the patients undergoing lumbar laminectomy.

[Gastric dynamics analysis of TEAS combined SNP induced general anesthesia when controlled hypotension dropped to 60% of the MAP baseline].

OBJECTIVE: To observe the effect of gastric dynamics by transcutaneous electrical acupoint stimulation (TEAS) combined general anesthesia when controlled hypotension dropped to 60% of the mean arterial prenssure (MAP) baseline, and to provide experimental evidence for organ protection in clinical controlled hypotension. METHODS: Eighteen male beagles were randomly divided into three groups, the general anesthesia group (blank), the general anesthesia induced controlled hypotension group (control), and the general anesthesia combined TEAS induced controlled hypotension group (experiment), 6 in each group. Controlled hypotension was performed in the latter two groups with isoflurane inhalation and intravenous injection of sodium nitroprusside (SNP). The mean arterial pressure (MAP) was lowered to 60% of the MAP baseline and kept for 60 min. Controlled hypotension was not performed in Beagles of the control group. For Beagles in the experiment group, TEAS [2/100 Hz, (4 ± 1) mA] was applied to bilateral Hegu (LI4), Quchi (LI11), Zusanli (ST36), and Sanyinjiao (SP6) from stable physiological conditions to the end of maintaining stages. Changes of EGG frequencies and EGG amplitudes were monitored. Serum levels of gastrin (GAS) and motilin (MTL) were also detected at corresponding time points during and after experiment. RESULTS: As for the pressure control effect of TEAS combined general anesthesia in the controlled hypotension, during the process of controlled hypotension (T1-T4), MAP levels of two controlled pressure groups remained relatively stable, and were kept at 60% of the MAP baseline. When the blood pressure dropped to the target low MAP and maintained at 60 min (T1-T4), EGG amplitudes of Beagles in all the three groups showed decreasing tendency. But it was more obviously lower than its basic level in the control group (P <0.05), while it was not obviously decreased in the experiment group (P < 0.05). EGG frequencies of Beagles in all the three groups showed no obvious change during this stage. By the end of the MAP rising stage (T8), the EGG amplitude of the experimental group was significantly higher than that of the control group and the blank group (P < 0.05), while it didn' t show any obvious increase in the control group. During this period, EGG frequencies of the two controlled hypotension groups decreased more than those of the blank group. Two h after rising blood pressure (at T9), EGG amplitudes and frequencies in the two controlled hypotension groups basically restored to their respective baselines and levels of the blank group at T9. At 2 h (T9) after controlled hypotension, serum levels of GAS and MTL were lower than those of basic levels in the two controlled hypotension groups (P <0.05). However, serum levels of GAS and MTL had an increasing trend in the two controlled hypotension groups at 24-72 h (T10-T12). Besides, the increasing speed and amplitude was better in experiment group than in the control group at T10-T12. However, there was no statistical difference between the two groups (P > 0.05). At 72 h (T12) serum levels of GAS and MTL had basically restored to their basic levels in the two controlled hypotension groups and that of the blank control group. CONCLUSION: EGG amplitudes could be effectively improved in TEAS combined general anesthesia for controlled hypotension at 60% of the MAP baseline, the recovery of the serum GAS level accelerated, gastric power improved and stomach protected.

[Protection of Electro-acupuncture for Gastric Mucosa of Patients Undergoing Endoscopic Sinus Surgery].

OBJECTIVE: To evaluate the effect of electro-acupuncture (EA) on gastric mucosal oxygenation and systemic inflammatory response in patients undergoing endoscopic sinus surgery with controlled hypotension (CH), and to explore its protective effect on gastric mucosa. METHODS: Fifty-four patients, 18-65 years old, grade I-II of American Society of Anesthesiology (ASA), who were scheduled for endoscopic sinus surgery were randomly assigned to two groups, group A (general anesthesia group) and group B (general anesthesia combined EA anesthesia group), 27 in each group. Conrolled hypotension was executed during operation, and mean arterial pressure (MAP) was maintained at 55-65 mmHg. After tracheal intubation gastric tesiometer catheter was indwelled through nasal cavity or oral cavity. After successful indwelling, it was connected with gastric mucosa monitoring mode of multifunctional parameters monitor. Patients' MAP and heart rate (HR), pHi, partial pressure of carbon dioxide (PgCO2), arterial partial pressure of carbon dioxide (Pg-aCO2) and endtidal pressure of carbon dioxide (Pg-etCO2) were measured and recorded at T, (immediately before induced hypotension), T, (20 min following induced hypotension to target MAP), T2 (40 min following induced hypotension to target MAP), T3 (20 min after ending induced hypotension), and T4(40 min after ending induced hypotension). Blood samples were intravenously collected, TNF-alpha, IL-1, and IL-6 were detected by ELISA 24 h before operation, during operation (T3), and 24 h after operation. RESULTS: After hypotension was induced, Pg-CO2, Pg-aCO2 and Pg-etCO2 increased significantly (P < 0.01, P < 0.05), while pHi decreased significantly (P < 0.01) in both groups at T1-T4 than those at T0. During T1-T4, PgCO2, Pg-aCO2, and Pg-etCO2 were higher (P < 0.01, P < 0.05), while pHi was lower in group A than in group B (P < 0.01). Furthermore, TNF-alpha, IL-1, and IL-6 increased significantly in both groups during operation and 24 h after operation, when compared with those 24 h before operation (P < 0.01, P < 0.05). TNF-alpha and IL-1 in group A were higher than those in group B (P < 0.05) during operation and 24 h after operation, but with no significant difference in the plasma concentration of IL-6 (P > 0.05). CONCLUSION: EA exerted obvious protective effect of gastric mucosal injury in endoscopic sinus surgery with controlled hypotension, which might be achieved by increasing gastric mucosal blood flow, maintaining oxygen supply and demand, inhibiting inflammatory response, and alleviating injury of gastric mucosal barrier.

Gastric dynamics analysis of TEAS combined SNP induced general anesthesia when controlled hypotension dropped to 60% of the MAP baseline / 中国中西医结合杂志

<p><b>OBJECTIVE</b>To observe the effect of gastric dynamics by transcutaneous electrical acupoint stimulation (TEAS) combined general anesthesia when controlled hypotension dropped to 60% of the mean arterial prenssure (MAP) baseline, and to provide experimental evidence for organ protection in clinical controlled hypotension.</p><p><b>METHODS</b>Eighteen male beagles were randomly divided into three groups, the general anesthesia group (blank), the general anesthesia induced controlled hypotension group (control), and the general anesthesia combined TEAS induced controlled hypotension group (experiment), 6 in each group. Controlled hypotension was performed in the latter two groups with isoflurane inhalation and intravenous injection of sodium nitroprusside (SNP). The mean arterial pressure (MAP) was lowered to 60% of the MAP baseline and kept for 60 min. Controlled hypotension was not performed in Beagles of the control group. For Beagles in the experiment group, TEAS [2/100 Hz, (4 ± 1) mA] was applied to bilateral Hegu (LI4), Quchi (LI11), Zusanli (ST36), and Sanyinjiao (SP6) from stable physiological conditions to the end of maintaining stages. Changes of EGG frequencies and EGG amplitudes were monitored. Serum levels of gastrin (GAS) and motilin (MTL) were also detected at corresponding time points during and after experiment.</p><p><b>RESULTS</b>As for the pressure control effect of TEAS combined general anesthesia in the controlled hypotension, during the process of controlled hypotension (T1-T4), MAP levels of two controlled pressure groups remained relatively stable, and were kept at 60% of the MAP baseline. When the blood pressure dropped to the target low MAP and maintained at 60 min (T1-T4), EGG amplitudes of Beagles in all the three groups showed decreasing tendency. But it was more obviously lower than its basic level in the control group (P <0.05), while it was not obviously decreased in the experiment group (P < 0.05). EGG frequencies of Beagles in all the three groups showed no obvious change during this stage. By the end of the MAP rising stage (T8), the EGG amplitude of the experimental group was significantly higher than that of the control group and the blank group (P < 0.05), while it didn' t show any obvious increase in the control group. During this period, EGG frequencies of the two controlled hypotension groups decreased more than those of the blank group. Two h after rising blood pressure (at T9), EGG amplitudes and frequencies in the two controlled hypotension groups basically restored to their respective baselines and levels of the blank group at T9. At 2 h (T9) after controlled hypotension, serum levels of GAS and MTL were lower than those of basic levels in the two controlled hypotension groups (P <0.05). However, serum levels of GAS and MTL had an increasing trend in the two controlled hypotension groups at 24-72 h (T10-T12). Besides, the increasing speed and amplitude was better in experiment group than in the control group at T10-T12. However, there was no statistical difference between the two groups (P > 0.05). At 72 h (T12) serum levels of GAS and MTL had basically restored to their basic levels in the two controlled hypotension groups and that of the blank control group.</p><p><b>CONCLUSION</b>EGG amplitudes could be effectively improved in TEAS combined general anesthesia for controlled hypotension at 60% of the MAP baseline, the recovery of the serum GAS level accelerated, gastric power improved and stomach protected.</p>

Protection of Electro-acupuncture for Gastric Mucosa of Patients Undergoing Endoscopic Sinus Surgery / 中国中西医结合杂志

<p><b>OBJECTIVE</b>To evaluate the effect of electro-acupuncture (EA) on gastric mucosal oxygenation and systemic inflammatory response in patients undergoing endoscopic sinus surgery with controlled hypotension (CH), and to explore its protective effect on gastric mucosa.</p><p><b>METHODS</b>Fifty-four patients, 18-65 years old, grade I-II of American Society of Anesthesiology (ASA), who were scheduled for endoscopic sinus surgery were randomly assigned to two groups, group A (general anesthesia group) and group B (general anesthesia combined EA anesthesia group), 27 in each group. Conrolled hypotension was executed during operation, and mean arterial pressure (MAP) was maintained at 55-65 mmHg. After tracheal intubation gastric tesiometer catheter was indwelled through nasal cavity or oral cavity. After successful indwelling, it was connected with gastric mucosa monitoring mode of multifunctional parameters monitor. Patients' MAP and heart rate (HR), pHi, partial pressure of carbon dioxide (PgCO2), arterial partial pressure of carbon dioxide (Pg-aCO2) and endtidal pressure of carbon dioxide (Pg-etCO2) were measured and recorded at T, (immediately before induced hypotension), T, (20 min following induced hypotension to target MAP), T2 (40 min following induced hypotension to target MAP), T3 (20 min after ending induced hypotension), and T4(40 min after ending induced hypotension). Blood samples were intravenously collected, TNF-alpha, IL-1, and IL-6 were detected by ELISA 24 h before operation, during operation (T3), and 24 h after operation.</p><p><b>RESULTS</b>After hypotension was induced, Pg-CO2, Pg-aCO2 and Pg-etCO2 increased significantly (P < 0.01, P < 0.05), while pHi decreased significantly (P < 0.01) in both groups at T1-T4 than those at T0. During T1-T4, PgCO2, Pg-aCO2, and Pg-etCO2 were higher (P < 0.01, P < 0.05), while pHi was lower in group A than in group B (P < 0.01). Furthermore, TNF-alpha, IL-1, and IL-6 increased significantly in both groups during operation and 24 h after operation, when compared with those 24 h before operation (P < 0.01, P < 0.05). TNF-alpha and IL-1 in group A were higher than those in group B (P < 0.05) during operation and 24 h after operation, but with no significant difference in the plasma concentration of IL-6 (P > 0.05).</p><p><b>CONCLUSION</b>EA exerted obvious protective effect of gastric mucosal injury in endoscopic sinus surgery with controlled hypotension, which might be achieved by increasing gastric mucosal blood flow, maintaining oxygen supply and demand, inhibiting inflammatory response, and alleviating injury of gastric mucosal barrier.</p>

Transcutaneous electrical nerve stimulation regulates organ blood flow and apoptosis during controlled hypotension in dogs.

Transcutaneous electrical nerve stimulation (TENS) is commonly used in clinical practice for alleviating pains and physiological disorders. It has been reported that TENS could counteract the ischemic injury happened in some vital organs. To determine the protective effect of TENS on internal organs during CH in dogs, target hypotension was maintained for 60 min at 50% of the baseline mean arterial pressure (MAP). The perfusion to the brain, liver, stomach, and kidney was recorded and apoptosis within these organs was observed. Results showed that when arriving at the target MAP, and during the maintaining stage for 10 min, perfusion to the stomach and liver in the CH+TENS group was much higher than in the CH group (P<0.05). Perfusion to the cerebral cortex greatly declined in both the controlled pressure groups when compared with the general anesthesia (GA) group (P<0.05). After withdrawing CH, the hepatic blood flow in both the CH and CH+TENS groups, and the gastric and cerebral cortical blood flow in the CH+TENS group, were rapidly increased. By the end of MAP restoration, gastric blood flow in the CH group was still low. At 72 h after applying CH, terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling (TUNEL)-positive cells in stomach and kidney tissue from the CH group were significantly increased compared with those in the GA group (P<0.05). There was no significant difference in TUNEL-positive cells in the liver and hippocampus among the three groups. Our results demonstrated that CH with a 50% MAP level could cause lower perfusion to the liver, stomach, cerebral cortex, and kidney, with apoptosis subsequently occurring in the stomach and kidney. TENS combined GA is able to improve the blood flow to the liver, stomach, and reduce the apoptosis in the stomach and kidney.

[Effects of transcutaneous electrical acupoint stimulation combined with general anesthesia on cerebral oxygen metabolism in elderly hip replacement patients during controlled hypotension].

OBJECTIVE: To observe the protective effect of transcutaneous electrical acupoint stimulation (TEAS) on cerebral tissue in elderly hip replacement operation patients during general anesthesia under controlled hypotension. METHODS: Forty hip replacement operation patients were randomly divided into general anesthesia (GA) control group and TEAS + GA group (n = 20 in each group). Patients of the two groups during operation were treated with controlled hypotension for reducing blood loss. TEAS (2 Hz/100 Hz, 8-12 mA) was applied to bilateral Yuyao (EX-HN 4) and Fengchi (GB 20) and began 30 min before GA. General anesthesia was performed by intravenous injection of Midazolam, Diprivan, Fentanyl and Cis-atracurium, sevoflurane-inhaling, Remifentanil, etc., and the patient's mean arterial pressure was maintained to be about 70% of the normal level (controlled hypotension) by using venous administration of Remifentanil about 10 min after the operation. GEM Premier 3000 blood gas analyzer was used to analyze levels of the arterial oxygen (CaO2), internal jugular venous oxygen (CjvO2), arterio-venous oxygen content difference (Da-jvO2) and cerebral oxygen (CERO2) uptake rates of blood samples before controlled hypotension (T0), 20 min after controlled hypotension (T ). 40 min after controlled hypotension (T2) and 20 min after the end of controlled hypotension (T3). RESULTS: Self-comparison of each group showed that in comparison with pre-controlled hypotension, CjvO2 levels at the time-points of T, T2 and T3 were significantly increased in both GA control and TEAS+GA groups (P < 0.05), while Da-jvO2 and CERO2 uptake rate levels at the time-points of T,. T2 and T3 in these two groups were significantly decreased (P < 0.05). Comparison between two groups showed that CivO2 levels at the time-points of T2 and T3 were significantly higher in the TEAS + GA group than in the GA control group (P<0. 05). while Da-jvO2 and CERO2 uptake rate levels at the time-point of T2 were obviously lower in the TEAS + GA group than in the GA control group(P<0. 05), suggesting a reduction of cerebral oxygen consumption after TEAS. No significant differences were found between these two groups in blood CjvO2, Da-jvO2 and CERO2 uptake rate levels at the time-points of T0 and T1 (P > 0.05). CONCLUSION: TEAS can reduce cerebral oxygen uptake rate in elderly patients undergoing hip replacement during controlled hypotension, suggesting a protective effect of TEAS on patient's cerebral tissue.

[Inflammatory-modulating mechanism of transcutaneous electrical acupoint stimulation combined with general anesthesia or controlled hypotension on postoperative hippocampal neuroprotection].

OBJECTIVE: To observe the effects of transcutaneous electrical acupoint stimulation (TEAS) combined with general anesthesia or controlled hypotension on hippocampal neuronal damage and the inflammatory response in peripheral circulation and central nervous system (CNS) after surgery, and to investigate its brain protection mechanism. METHODS: Eighteen healthy male beagles aged 6 - 8 months were randomly divided into a general anesthesia group (group G), a controlled hypotension group (group C) and a compound anesthesia acupuncture group (group A), 6 cases in each group. Dogs in group G was anesthetized by isoflurane inhalation, and group C was combined with intravenous infusion of sodium nitroprusside based on isoflurane inhalation to induce hypotension, and followed surgery after achieving the target blood pressure, and group A was combined with TEAS at "Quchi" (LI 11), "Hegu" (LI 4) "Zu sanli" (ST 36) and "Sanyinjiao" (SP 6) based on controlled hypotension, and then brain tissue was taken out on the 72 h after mean arterial pressure (MAP) was returned to baseline levels. The concentration of IL-1beta,TNF-alpha in serum at different time points were detected by ELISA. The expression of IL-1beta, TNF-alpha, Bcl-2, Bax and cleaved caspase-3 were measured by immunohistochemistry, and the apoptosis of hippocampus were detected by TUNEL. RESULTS: (1) At different time points, the concentration of TNFalpha showed the trend of increase first and then decrease, while IL-1beta concentration represented a trend of decrease first and then increase in both group C and group A, but there were no significant differences in cytokine expression between the two groups (all P > 0.05). (2) The ratio of positive cells of IL-1beta, TNF-alpha and caspase-3 in CA1 and CA3 of hippocampus in both group C and A were higher than those in group G (all P < 0.01), and cytokines expression in group A were lower than those in group C (all P < 0.01), and caspase-3 in CA1 in group A was lower than that in group C (P < 0.01). The ratio of Bcl-2/Bax in both group C and A were lower than that in group G (all P < 0.01), and that in group A was higher than that in group C (P < 0.01 in CA1, P < 0.05 in CA3). (3) The apoptosis index (AI) of hippocampal neurons in both group C and A was significantly higher than that in group G (P < 0.01), while AI in CA1 in group A was lower than that in group C (P < 0.01). CONCLUSION: The TEAS can regulate the expression of inflammatory factor in hippocampus in animals undergoing general anesthesia or con trolled hypotension surgery, further improving Bcl-2/Bax ratio, inhibiting the expression of caspase-3 and reducing neuron apoptosis in hippocampus so as to play a neuroprotection.

Inflammatory-modulating mechanism of transcutaneous electrical acupoint stimulation combined with general anesthesia or controlled hypotension on postoperative hippocampal neuroprotection / 中国针灸

<p><b>OBJECTIVE</b>To observe the effects of transcutaneous electrical acupoint stimulation (TEAS) combined with general anesthesia or controlled hypotension on hippocampal neuronal damage and the inflammatory response in peripheral circulation and central nervous system (CNS) after surgery, and to investigate its brain protection mechanism.</p><p><b>METHODS</b>Eighteen healthy male beagles aged 6 - 8 months were randomly divided into a general anesthesia group (group G), a controlled hypotension group (group C) and a compound anesthesia acupuncture group (group A), 6 cases in each group. Dogs in group G was anesthetized by isoflurane inhalation, and group C was combined with intravenous infusion of sodium nitroprusside based on isoflurane inhalation to induce hypotension, and followed surgery after achieving the target blood pressure, and group A was combined with TEAS at "Quchi" (LI 11), "Hegu" (LI 4) "Zu sanli" (ST 36) and "Sanyinjiao" (SP 6) based on controlled hypotension, and then brain tissue was taken out on the 72 h after mean arterial pressure (MAP) was returned to baseline levels. The concentration of IL-1beta,TNF-alpha in serum at different time points were detected by ELISA. The expression of IL-1beta, TNF-alpha, Bcl-2, Bax and cleaved caspase-3 were measured by immunohistochemistry, and the apoptosis of hippocampus were detected by TUNEL.</p><p><b>RESULTS</b>(1) At different time points, the concentration of TNFalpha showed the trend of increase first and then decrease, while IL-1beta concentration represented a trend of decrease first and then increase in both group C and group A, but there were no significant differences in cytokine expression between the two groups (all P > 0.05). (2) The ratio of positive cells of IL-1beta, TNF-alpha and caspase-3 in CA1 and CA3 of hippocampus in both group C and A were higher than those in group G (all P < 0.01), and cytokines expression in group A were lower than those in group C (all P < 0.01), and caspase-3 in CA1 in group A was lower than that in group C (P < 0.01). The ratio of Bcl-2/Bax in both group C and A were lower than that in group G (all P < 0.01), and that in group A was higher than that in group C (P < 0.01 in CA1, P < 0.05 in CA3). (3) The apoptosis index (AI) of hippocampal neurons in both group C and A was significantly higher than that in group G (P < 0.01), while AI in CA1 in group A was lower than that in group C (P < 0.01).</p><p><b>CONCLUSION</b>The TEAS can regulate the expression of inflammatory factor in hippocampus in animals undergoing general anesthesia or con trolled hypotension surgery, further improving Bcl-2/Bax ratio, inhibiting the expression of caspase-3 and reducing neuron apoptosis in hippocampus so as to play a neuroprotection.</p>

[Effects of transcutaneous electrical acupoint stimulation combined with general anesthesia for controlled hypotension on heart function and oxidation resistance of myocardium].

OBJECTIVE: To investigate the intervention effect of transcutaneous electrical acupoint sitmulation (TEAS) on heart under limiting level of controlled hypotension. METHODS: Eighteen male Beagles were randomly divided into a general anesthesia group, a control group and an experimental group, 6 dogs in each group. All animals were applied with general anesthesia, and the animals of the control group and the experimental group were administered with combination of isoflurane and sodium nitroprusside (SNP) for controlled hypotension to 30% mean arterial pressure (30% MAP) of base line for 60 min. In the experimental group, TEAS (2 Hz/100 Hz, 6-8 mA) was applied to "Hegu" (LI4), "Zusanli" (ST 36), "Sanyinjiao" (SP 6) and "Quchi" (LI 11) from the beginning of physiological conditions stability to the end of maintained low MAP for 60 min. Creatine kinase isoenzymes MB (CK-MB) and lactate dehydrogenase (LDH) activity were detected at the base line and 2 h, 24 h, 48 h, 72 h after operation. Total superoxide dismutase (T-SOD) and malondialdehyde (MDA) in myocardium were observed at 72 h after operation. RESULTS: The peak of LDH arrived at 24 h after operation and then restored in 3 groups. Compared with basal level, the activity of LDH in controlled group at 72 h after operation was significantly increased (P < 0.05), and in the other two groups no obvious change (P > 0.05). The activity of CK-MB arrived to peak from 2 h to 24 h after operation, and then came back gradually in 3 groups. Compared with postoperative 72 h of the same group, the control group at 48 h significantly increased (P < 0.05), while the other two groups had no statistically significant difference (P > 0.05). The content of MDA at 72 h after operation in controlled group was higher significantly than that in the general anesthesia group and the experimental group (both P < 0.05). CONCLUSION: TEAS combined with anesthesia for controlled hypotension can elevate myocardial effect of anti-oxide free radical, reduce the postoperative release of LDH and CK-MB, so as to produce myocardial protection.

[Effects of transcutaneous electrical acupoint stimulation combined general anesthesia in controlled hypotension at different levels on the liver blood flow ].

UNLABELLED: OBJECTIVE To observe the changes of the liver blood flow in controlled hypotension by transcutaneous electrical acupoint stimulation (TEAS) combined general anesthesia, thus clarifying the mechanism of liver protection effect in acupuncture anesthesia combined with drugs. METHODS: Forty-two male beagles were randomly divided into seven groups, i.e. , the general anesthesia group, the 50% control group, the 50% experiment group, the 40% control group, the 40% experiment group, the 30% control group, and the 30% experiment group, 6 in each group. Beagles in the latter six groups were administered with isoflurane inhalation and intravenous dripping of sodium nitroprusside (SNP) for controlled hypotension. The mean arterial pressure (MAP) was lowered to 50%, 40%, and 30% basic MAP and lasted for 60 min. Beagles in the general anesthesia group was not treated with controlled hypotension. In the experiment groups, TEAS was applied to bilateral Hegu (LI4), Zusanli (ST36), Sanyinjiao (SP6), and Quchi (LI11) at 2/100 Hz with the stimulation strength of 4 +/- 1 mA. The TEAS started from the stability of physiological conditions to 60 min after maintaining the target MAP. The changes of blood flow of the liver tissue surface at corresponding time points were monitored by laser Doppler blood flow meter. RESULTS: Between the beginning of hypotension and the maintaining stage of target low blood pressure, the liver blood flow of the 50% control group was significantly lower than the level of the general anesthesia group and the basic level at corresponding time points (P < 0.05). It was significantly reduced in the 50% experiment group only at 30-60 min of maintenance. Besides, in the early period of maintenance (10-30 min), it was significantly higher in the 50% experiment group than in the 50% control group at the same time points (P < 0.05). In this stage, there was no obvious increase in the liver blood flow in the 40% and 30% experiment groups. In the recovery phase of blood pressure (20-30 min), the liver blood flow of the 40% experiment group had been restored to the level of the 40% control group and the basic level, while it had not been restored in the general anesthesia group. In this stage, the similar changing tendency of the liver blood flow occurred in the 50% and 30% experiment groups and the 50% and 30% control groups. CONCLUSIONS: Line to a high level of controlled hypotension (50%), TEAS liver protective effect was obviously embodied in the early step-down phase and the maintenance phase. Line-induced hypotension to a lower level (40%), TEAS liver protective effect was obviously embodied in the recovery phase.

Cardiopulmonary interventions to decrease blood loss and blood transfusion requirements for liver resection.

BACKGROUND: Blood loss during liver resection is considered one of the most important factors affecting the peri-operative outcomes of patients undergoing liver resection. OBJECTIVES: To determine the benefits and harms of cardiopulmonary interventions to decrease blood loss and to decrease allogeneic blood transfusion requirements in patients undergoing liver resections. SEARCH METHODS: We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until January 2012 to identify randomised trials. SELECTION CRITERIA: We included all randomised clinical trials comparing various cardiopulmonary interventions aimed at decreasing blood loss and allogeneic blood transfusion requirements in patients undergoing liver resection. Trials were included irrespective of whether they included major or minor liver resections of normal or cirrhotic livers, vascular occlusion was used or not, and irrespective of the reason for liver resection. DATA COLLECTION AND ANALYSIS: Two authors independently identified trials for inclusion and independently extracted data. We analysed the data with both the fixed-effect and the random-effects models using RevMan Analysis. For each outcome we calculated the risk ratio (RR), mean difference (MD), or standardised mean difference (SMD) with 95% confidence intervals (CI) based on intention-to-treat analysis or available case analysis. For dichotomous outcomes with only one trial included under the outcome, we performed the Fisher's exact test. MAIN RESULTS: Ten trials involving 617 patients satisfied the inclusion criteria. The interventions included low central venous pressure (CVP), autologous blood donation, haemodilution, haemodilution with controlled hypotension, and hypoventilation. Only one or two trials were included under most comparisons. All trials had a high risk of bias. There was no significant difference in the peri-operative mortality in any of the comparisons: low CVP versus no intervention (3 trials, 0/88 (0%) patients in the low CVP group versus 1/89 (1.1%) patients in the no intervention group); autologous blood donation versus no intervention (1 trial, 0/40 (0%) versus 0/39 (0%)); haemodilution versus no intervention (2 trials, 1/73 (1.4%) versus 3/77 (3.9%) in one of these trials); haemodilution with controlled hypotension versus no intervention (1 trial, 0/10 (0%) versus 0/10 (0%)); haemodilution with bovine haemoglobin (HBOC-201) versus haemodilution with hydroxy ethyl starch (HES) (1 trial, 1/6 (16.7%) versus 0/6 (0%)); hypoventilation versus no intervention (1 trial, 0/40 (0%) versus 0/39 (0%)). None of the trials reported long-term survival or quality of life. The risk ratio of requiring allogeneic blood transfusion was significantly lower in the haemodilution versus no intervention groups (3 trials, 16/115 (weighted proportion = 14.2%) versus 41/118 (34.7%), RR 0.41 (95% CI 0.25 to 0.66), P = 0.0003); and for haemodilution with controlled hypotension versus no intervention (1 trial, 0/10 (0%) versus 10/10 (100%), P < 0.0001). There were no significant differences in the allogeneic transfusion requirements in the other comparisons which reported this outcome, such as low CVP versus no intervention, autologous blood donation versus control, and hypoventilation versus no intervention. AUTHORS' CONCLUSIONS: None of the interventions seemed to decrease peri-operative morbidity or offer any long-term survival benefit. Haemodilution shows promise in the reduction of blood transfusion requirements in liver resection surgery. However, there is a high risk of type I (erroneously concluding that an intervention is beneficial when it is actually not beneficial) and type II errors (erroneously concluding that an intervention is not beneficial when it is actually beneficial) because of the few trials included, the small sample size in each trial, and the high risk of bias in the trials. Further randomised clinical trials with low risk of bias and random errors that assess clinically important outcomes such as peri-operative mortality are necessary to assess any cardiopulmonary interventions aimed at decreasing blood loss and blood transfusion requirements in patients undergoing liver resections. Trials need to be designed to assess the effect of a combination of different interventions in liver resections.

[Effects of the renal blood flow at different levels by transcutaneous electrical acupoint stimulation combined general anesthesia induced controlled hypotension].

OBJECTIVE: To observe the intervention of transcutaneous electrical acupoint stimulation (TEAS) on the renal blood flow at different levels of mean arterial pressure (MAP) in controlled hypotension. METHODS: Forty-two male beagle dogs were randomly divided into seven groups, i. e., the general anesthesia group, the 50% controlled group, the 40% controlled group, the 30% controlled group, the 50% experimental group, the 40% experimental group, and the 30% experimental group, 6 in each group. Beagles in the general anesthesia group were not treated with controlled hypotension, and the target MAP was achieved in those of the rest groups and maintained for 60 min. In the experimental groups, TEAS was applied to bilateral Hegu (LI4), Zusanli (ST36), Sanyinjiao (SP6), and Quchi (LI11) at 2/100 Hz with the stimulation strength of (4 +/- 1) mA starting from the stability of their physiological conditions to 60 min of maintaining the target MAP level. The changes of the renal blood flow were monitored at different time points using laser Doppler. RESULTS: From starting pressure control to the target MAP level, the renal blood flow was significantly lower in the 30% controlled group than in the general anesthesia group and the basic level of the same group (P < 0.05), while there was no obvious change in the 30% experimental group. In maintaining the blood pressure, the renal blood flow was significantly lower in the 50% controlled group, the 40% controlled group, the 30% controlled group, and the 30% experimental group than in the general anesthesia group (P < 0.05), while there was no obvious change in the 50% experimental group or the 40% experimental group. By the end of blood pressure recovery, the renal blood flow restored to the basic level in the 50% controlled group, the 50% experimental group, and the 40% experimental group (P > 0.05), while it was not restored to the basic level in the 40% controlled group, the 30% controlled group, and the 30% experimental group (P < 0.05). CONCLUSION: TEAS combined general anesthesia in controlled hypotension could effectively improve the renal blood flow, thus protecting the kidney.

Effects of transcutaneous electrical acupoint stimulation combined general anesthesia in controlled hypotension at different levels on the liver blood flow / 中国中西医结合杂志

<p><b>UNLABELLED</b>OBJECTIVE To observe the changes of the liver blood flow in controlled hypotension by transcutaneous electrical acupoint stimulation (TEAS) combined general anesthesia, thus clarifying the mechanism of liver protection effect in acupuncture anesthesia combined with drugs.</p><p><b>METHODS</b>Forty-two male beagles were randomly divided into seven groups, i.e. , the general anesthesia group, the 50% control group, the 50% experiment group, the 40% control group, the 40% experiment group, the 30% control group, and the 30% experiment group, 6 in each group. Beagles in the latter six groups were administered with isoflurane inhalation and intravenous dripping of sodium nitroprusside (SNP) for controlled hypotension. The mean arterial pressure (MAP) was lowered to 50%, 40%, and 30% basic MAP and lasted for 60 min. Beagles in the general anesthesia group was not treated with controlled hypotension. In the experiment groups, TEAS was applied to bilateral Hegu (LI4), Zusanli (ST36), Sanyinjiao (SP6), and Quchi (LI11) at 2/100 Hz with the stimulation strength of 4 +/- 1 mA. The TEAS started from the stability of physiological conditions to 60 min after maintaining the target MAP. The changes of blood flow of the liver tissue surface at corresponding time points were monitored by laser Doppler blood flow meter.</p><p><b>RESULTS</b>Between the beginning of hypotension and the maintaining stage of target low blood pressure, the liver blood flow of the 50% control group was significantly lower than the level of the general anesthesia group and the basic level at corresponding time points (P < 0.05). It was significantly reduced in the 50% experiment group only at 30-60 min of maintenance. Besides, in the early period of maintenance (10-30 min), it was significantly higher in the 50% experiment group than in the 50% control group at the same time points (P < 0.05). In this stage, there was no obvious increase in the liver blood flow in the 40% and 30% experiment groups. In the recovery phase of blood pressure (20-30 min), the liver blood flow of the 40% experiment group had been restored to the level of the 40% control group and the basic level, while it had not been restored in the general anesthesia group. In this stage, the similar changing tendency of the liver blood flow occurred in the 50% and 30% experiment groups and the 50% and 30% control groups.</p><p><b>CONCLUSIONS</b>Line to a high level of controlled hypotension (50%), TEAS liver protective effect was obviously embodied in the early step-down phase and the maintenance phase. Line-induced hypotension to a lower level (40%), TEAS liver protective effect was obviously embodied in the recovery phase.</p>

Effects of the renal blood flow at different levels by transcutaneous electrical acupoint stimulation combined general anesthesia induced controlled hypotension / 中国中西医结合杂志

<p><b>OBJECTIVE</b>To observe the intervention of transcutaneous electrical acupoint stimulation (TEAS) on the renal blood flow at different levels of mean arterial pressure (MAP) in controlled hypotension.</p><p><b>METHODS</b>Forty-two male beagle dogs were randomly divided into seven groups, i. e., the general anesthesia group, the 50% controlled group, the 40% controlled group, the 30% controlled group, the 50% experimental group, the 40% experimental group, and the 30% experimental group, 6 in each group. Beagles in the general anesthesia group were not treated with controlled hypotension, and the target MAP was achieved in those of the rest groups and maintained for 60 min. In the experimental groups, TEAS was applied to bilateral Hegu (LI4), Zusanli (ST36), Sanyinjiao (SP6), and Quchi (LI11) at 2/100 Hz with the stimulation strength of (4 +/- 1) mA starting from the stability of their physiological conditions to 60 min of maintaining the target MAP level. The changes of the renal blood flow were monitored at different time points using laser Doppler.</p><p><b>RESULTS</b>From starting pressure control to the target MAP level, the renal blood flow was significantly lower in the 30% controlled group than in the general anesthesia group and the basic level of the same group (P < 0.05), while there was no obvious change in the 30% experimental group. In maintaining the blood pressure, the renal blood flow was significantly lower in the 50% controlled group, the 40% controlled group, the 30% controlled group, and the 30% experimental group than in the general anesthesia group (P < 0.05), while there was no obvious change in the 50% experimental group or the 40% experimental group. By the end of blood pressure recovery, the renal blood flow restored to the basic level in the 50% controlled group, the 50% experimental group, and the 40% experimental group (P > 0.05), while it was not restored to the basic level in the 40% controlled group, the 30% controlled group, and the 30% experimental group (P < 0.05).</p><p><b>CONCLUSION</b>TEAS combined general anesthesia in controlled hypotension could effectively improve the renal blood flow, thus protecting the kidney.</p>

Effects of transcutaneous electrical acupoint stimulation combined with general anesthesia for controlled hypotension on heart function and oxidation resistance of myocardium / 中国针灸

<p><b>OBJECTIVE</b>To investigate the intervention effect of transcutaneous electrical acupoint sitmulation (TEAS) on heart under limiting level of controlled hypotension.</p><p><b>METHODS</b>Eighteen male Beagles were randomly divided into a general anesthesia group, a control group and an experimental group, 6 dogs in each group. All animals were applied with general anesthesia, and the animals of the control group and the experimental group were administered with combination of isoflurane and sodium nitroprusside (SNP) for controlled hypotension to 30% mean arterial pressure (30% MAP) of base line for 60 min. In the experimental group, TEAS (2 Hz/100 Hz, 6-8 mA) was applied to "Hegu" (LI4), "Zusanli" (ST 36), "Sanyinjiao" (SP 6) and "Quchi" (LI 11) from the beginning of physiological conditions stability to the end of maintained low MAP for 60 min. Creatine kinase isoenzymes MB (CK-MB) and lactate dehydrogenase (LDH) activity were detected at the base line and 2 h, 24 h, 48 h, 72 h after operation. Total superoxide dismutase (T-SOD) and malondialdehyde (MDA) in myocardium were observed at 72 h after operation.</p><p><b>RESULTS</b>The peak of LDH arrived at 24 h after operation and then restored in 3 groups. Compared with basal level, the activity of LDH in controlled group at 72 h after operation was significantly increased (P < 0.05), and in the other two groups no obvious change (P > 0.05). The activity of CK-MB arrived to peak from 2 h to 24 h after operation, and then came back gradually in 3 groups. Compared with postoperative 72 h of the same group, the control group at 48 h significantly increased (P < 0.05), while the other two groups had no statistically significant difference (P > 0.05). The content of MDA at 72 h after operation in controlled group was higher significantly than that in the general anesthesia group and the experimental group (both P < 0.05).</p><p><b>CONCLUSION</b>TEAS combined with anesthesia for controlled hypotension can elevate myocardial effect of anti-oxide free radical, reduce the postoperative release of LDH and CK-MB, so as to produce myocardial protection.</p>

Remifentanil Use in Pediatric Scoliosis Surgery-An Effective Alternative to Morphine (A Retrospective Study)

PURPOSE: The unique properties of remifentanil make it ideal for pediatric use despite a lack of wide randomized clinical trials and fear of adverse events due to its high potency. We aimed to consolidate preliminary conclusions regarding the efficacy of remifentanil use in pediatric scoliosis surgery. MATERIALS AND METHODS: The medical charts of children with idiopathic scoliosis who underwent primary spinal fusion between 1998 and 2007 at a large tertiary university-affiliated hospital were retrospectively reviewed and divided into two groups according to anesthetic regime (remifentanil vs. morphine). Demographic, surgery-related details and immediate postoperative course were recorded and compared. RESULTS: All 36 remifentanil children were extubated shortly after termination of surgery, compared to 2 of the 84 patients in the morphine group. The remaining patients in the morphine group were extubated hours after surgery [5.4 hours; standard deviation (SD) 1.7 hours]. Six remifentanil children were spared routine intensive care hospitalization (vs. 2 morphine children-significant difference). Shorter surgeries [5.6 hours (SD 1.82 hours) vs. 7.14 hours (SD 2.15 hours); p=0.0004] were logged for the remifentanil group. To achieve controlled hypotension during surgery, vasodilator agents were used in the morphine group only. A comparison of early postoperative major or minor complication rates (including neurological and pulmonary complications) between the two groups yielded no significant differences. CONCLUSION: Remifentanil use can shorten operating time and facilitate earlier spontaneous ventilation and extubation, with less of a need for intensive care hospitalization and no increase in significant complications.

[Cardiac protective effects of transcutaneous electrical acupoint stimulation combined with general anesthesia for controlled hypotension].

OBJECTIVE: To explore the protective effect and the mechanism of controlled hypotension induced by transcutaneous electrical acupoint stimulation (TEAS) combined with general anesthesia. METHODS: Sixteen male Beagles were randomly divided into a group of controlled hypotension induced by simple general anesthesia (control group) and a group of controlled hypotension induced by TEAS combined with general anesthesia (observation group). All the animals were administered with combination of Isoflurane and Sodium Nitroprusside (SNP) for controlled hypotension without TEAS until the arterial pressure was lowered to 30% basic mean arterial pressure (MAP) for 60 min. In the observation group, TEAS (2 Hz/100 Hz, 3-5 mA) was applied to "Hegu" (LI 4) "Zusanli" (ST 36), "Sanyinjiao" (SP 6) and "Quchi" (LI 11) from the beginning of physiological conditions stability to the end of maintained low MAP for 60 min, but there was no TEAS in control group. The changes of MAP, the left intraventricular pressure (LIVP), T wave and ST-T segment of II lead electrocardiogram (ECG) were monitored with the physiological signal acquisition system, and myocardial apoptosis was detected by TUNEL method. RESULTS: All the animals could maintain stable required low blood pressure. At one hour after cease of controlled hypotension, MAP of (109.56 +/- 6.14) mmHg returned to the basic level in the observation group, while MAP of (84.91 +/- 6.36) mmHg was still lower than its basic MAP of (111.02 +/- 4.15) mmHg in the control group (P < 0.05), showing significant difference in MAP between the two groups (P < 0.05). -dp/dtmax of (3156.32 +/- 332.82) mmHg/s showed significant lower than its basic value of (4585.33 +/- 638.55) mmHg/s when blood pressure increased for 1 h in the control group (P < 0.05), but there was no difference in the observation group. When the objective low MAP maintaining for 60 min the ST segment was decreased significantly in the control group (P < 0.05), but there was no difference in the observation group. The numbers of positive apoptosis cardiocytes in the observation group were (24.67 +/- 2.45) cells/mm2, which were significantly fewer than (37.89 +/- 1.90) cells/mm2 in the control group (P < 0. 05). CONCLUSIONS: TEAS combined with general anesthesia for controlled hypotension can significantly shorten restoration time of MAP, help to improve myocardial ischemia and the cardiac functional recovery and reduce myocardial apoptosis so as to produce myocardial protection.

[Effects of transcutaneous electrical acupoint stimulation combined with general anesthesia on changes of gastric dynamics in controlled hypotension dogs].

OBJECTIVE: To observe the effect of transcutaneous electrical acupoint stimulation (TEAS) combined with general anesthesia on gastric dynamics in controlled hypotension dogs, so as to provide experimental evidence for compound acupuncture anesthesia. METHODS: Eighteen male beagle dogs were randomly divided into general anesthesia group (GA group, n = 6), general anesthesia + controlled hypotension group (GA + OHT group, n = 6) and general anesthesia combined with TEAS + controlled hypotension group (TEAS group, n = 6). The latter two groups were administered with the same anesthetics [isofluane inhalation and intravenous sodium nitroprusside (SNP)] for inducing controlled hypotension (being the 40% of the baseline level). Beagles of the GA group were not treated with controlled hypotension (the initial concentration of SNP = 1 microg/kg x min(-1), and with an increase rate of 1 microg/kg x min(-1) until the controlled hypotension phase). In the TEAS group, TEAS [2 Hz/100 Hz, (4 +/- 1) mA]was applied to "Quchi" (LI 11) , "Zusanli" (ST 36), "Hegu" (LI 4), and "Sanyinjiao" (SP 6) from the beginning of the stable physiological condition phase to the end of the controlled-low mean arterial pressure (MAP) phase. Electrogastrogram (EGG) was recorded, and serum gastrin (GAS) and motilin (MTL) contents were detected by enzyme-linked immunosorbent assay. RESULTS: Compared with the basic level, the amplitude value of EGG at 60 mm after controlled hypotension in the GA + CHT group was significantly lower (P < 0.05), while the amplitude level of EGG of the TEAS group at the time-point of MAP recovery was significantly higher than those of the GA and GA + CHT groups (P < 0.05). No significant changes were found among the 3 groups in the frequency levels of EGG. At the time-points of MAP recovery and 2 h after MAP recovery, serum MTL and GAS levels in the TEAS group were close to their basic level (P > 0.05), and serum GAS level at the time-point of 2 h after MAP recovery in the TEAS group was considerably higher than those in the GA and GA + CHT groups (P < 0.05). Twenty-four, 48 and 72 h after MAP recovery, serum GAS levels in the TEAS group were moderately (24 h and 48 h ) and significantly (72 h) higher than that of the basic level. No significant differences were found between the GA and GA + CHT groups in serum MTL and GAS levels at the time-points of 2, 24, 48 and 72 h after MAP recovery (P > 0.05). CONCLUSION: TEAS combining with general anesthesia for controlled hypotension can improve the amplitude of EGG, and serum MTL and GAS contents, favoring the recovery of gastric dynamics and the functional protection of stomach.