Perioperative management of a patient with a giant ovarian tumor: A case report.

RATIONALE: Giant ovarian tumors are very rare. Patients with large ovarian tumors appear similar to pregnant women and morbidly obese patients. The management of such patients is associated with significant mortality. Therefore, additional clinical research is essential to understanding the perioperative complications of this disease. PATIENT CONCERNS: We report the perioperative management of a patient with a giant ovarian tumor that contained 23 L of fluid who underwent tumor resection. Given the infrequency of these giant ovarian tumors, a detailed anesthetic plan and postoperative respiratory support strategy were tailored to address the patient's hemodynamic and respiratory risks, as well as to minimize potential complications, including supine hypotensive syndrome, re-expansion pulmonary edema, and postoperative intestinal ileus. To prevent supine hypotensive syndrome, the patient used a mild left-sided position (10∼20°) after admission until the tumor was removed. In order to prevent re-expansion pulmonary edema (RPE), the intraoperative ventilator mode was set to pressure-controlled ventilation (PCV), with the addition of 8 cmH2O positive end-expiratory pressure (PEEP). The airway pressure was lower while maintaining a certain tidal volume. In the ICU, in the ventilator mode, we use pressure support ventilation as well as PEEP and adjust it according to the patient's spontaneous breathing situation and blood gas analysis to prepare for further detach from the respirator and extubation. And we prevent the occurrence of postoperative intestinal ileus by placing the abdominal binder after the operation. DIAGNOSIS: Mucinous cystadenoma of the left ovary. INTERVENTIONS: The patient underwent exploratory laparotomy with debulking of the left ovarian mass, transabdominal hysterectomy with bilateral salpingo-oophorectomy, complete omentectomy with appendectomy, and pelvic lymphadenectomy. OUTCOMES: After surgery, the patient experienced intestinal distention. Up to now, the patient has recovered well. LESSONS: A multidisciplinary approach is essential. Knowing the possibility of complications and choices for management can lead to favorable outcomes in such rare cases. This case reminds us that postoperative complications such as postoperative intestinal ileus may be fatal.

Ameliorative effect of sevoflurane on endoplasmic reticulum stress mediates cardioprotection against ischemia-reperfusion injury 1.

We aimed to investigate whether the cardioprotection of sevoflurane against ischemia-reperfusion (IR) injury is via inhibiting endoplasmic reticulum stress. The rat in vivo model of myocardial IR injury was induced by ligation of the left anterior descending coronary artery. Sevoflurane significantly ameliorated the reduced cardiac function, increased infarct size, and elevated troponin I level and lactate dehydrogenase activity in plasma induced by IR injury. Sevoflurane suppressed the IR-induced myocardial apoptosis. The increased protein levels of glucose-regulated protein 78 and C/EBP homologous protein (CHOP) after myocardial IR were significantly reduced by sevoflurane. The protein levels of phosphorylated protein kinase RNA-like endoplasmic reticulum kinase (PERK), phosphorylated eukaryotic initiation factor 2 (eIF2α), and activating transcription factor 4 (ATF4) were significantly increased in rats with IR and attenuated by sevoflurane treatment. The phosphorylation of Akt was further activated by sevoflurane. The cardioprotection of sevoflurane could be blocked by wortmannin, a PI3K/Akt inhibitor. Our results suggest that the cardioprotection of sevoflurane against IR injury might be mediated by suppressing PERK/eIF2a/ATF4/CHOP signaling via activating the Akt pathway, which helps in understanding the novel mechanism of the cardioprotection of sevoflurane.

Dexmedetomidine Added to Sufentanil Patient-Controlled Intravenous Analgesia Relieves the Postoperative Pain after Cesarean Delivery: A Prospective Randomized Controlled Multicenter Study.

This study evaluated the efficacy and safety of dexmedetomidine in intravenous patient-controlled analgesia (PCA) after cesarean delivery. This multicenter study enrolled 208 subjects who were scheduled for selective cesarean delivery from 9 research centers. Patients received 0.5 ug/kg dexmedetomidine (study group) or normal saline (control group) after delivery and an intravenous PCA pump after surgery (100 µg sufentanil +300 µg dexmedetomidine for the study group, 100 µg sufentanil for the control group, background infusion: 1 ml/h, bolus dose: 2 ml and lock time: 8 min). The sufentanil consumption, pain scores, rescue analgesia, sedation scores, analgesic satisfaction, the incidence of postoperative nausea and vomiting (PONV) and the first passage of flatus were recorded within 24 h after surgery. The sufentanil consumption in the study group was significantly lower than that in the control group (p = 0.004). Compared with the control group, the study group had lower pain scores (p < 0.01), higher analgesic satisfaction degree [p < 0.001, odd ratio 4.28 and 95% CI (2.46, 7.46)], less requirement of rescue analgesia (p = 0.003), lower incidence of PONV (p = 0.005 and p < 0.001, respectively), and shorter time to first passage of flatus (p = 0.007). Dexmedetomidine added to sufentanil intravenous PCA significantly enhanced the analgesic effects, improved analgesic satisfaction, and had the potential benefits of reducing PONV and the recovery of intestinal functions after cesarean section.

Perioperative dexmedetomidine reduces delirium after cardiac surgery: A meta-analysis of randomized controlled trials.

STUDY OBJECTIVE: To evaluate the efficiency of dexmedetomidine on the incidence of delirium in patients after cardiac surgery. DESIGN: Meta-analysis of randomized controlled trials. SETTING: Operating room and Intensive Care Unit (ICU). PATIENTS: Ten trials with a total of 1387 patients undergoing cardiac surgery met the inclusion criteria. INTERVENTION: Randomized controlled trials (RCTs) comparing the effect of dexmedetomidine versus non-treatment of dexmedetomidine (normal saline (NS), propofol and other anesthetic drugs) on delirium in patients undergoing cardiac surgery were retrieved from PubMed/Medline, Embase, the Cochrane Library and Web of science. The primary outcome was the incidence of delirium. The secondary outcomes were the rate of bradycardia and hypotension, the duration of mechanical ventilation and the length of ICU and hospital stay. MAIN RESULTS: Compared with the control group, Dexmedetomidine significantly decreased the incidence of postoperative delirium, (risk ratio 0.46; 95% confidence intervals, 0.34 to 0.62; P < 0.00001), while the incidence of bradycardia was increased in dexmedetomidine group (risk ratio 1.86; 95% confidence intervals, 1.16 to 2.99; P = 0.01). There was no significant difference between groups with regarding to the occurrence of hypotension (risk ratio 0.90; 95% confidence intervals, 0.59 to 1.38; P = 0.63), the duration of mechanical ventilation (Mean Difference 0.21; 95% confidence intervals, -0.70 to 1.12; P = 0.65), and the length of ICU (Standard Mean Difference - 0.07; 95% confidence intervals, -0.19 to 0.06; P = 0.3) and hospital stay (Mean Difference - 0.13; 95% confidence intervals, -0.56 to 0.30; P = 0.56). CONCLUSION: Perioperative dexmedetomidine administration decreased the incidence of delirium in patients after cardiac surgery, but might increase the rate of bradycardia. Furthermore, we did not observe significant differences in the incidence of hypotension, the duration of mechanical ventilation and length of ICU and hospital stay between groups. Future studies are needed to ascertain the effect of dexmedetomidine on the incidence of delirium after coronary artery bypass grafting (CABG) and in patient with cognitive disorder at baseline, whether intraoperative dexmedetomidine infusion could reduce postoperative delirium and the optimal dose of dexmedetomidine.

Ulk1/FUNDC1 Prevents Nerve Cells from Hypoxia-Induced Apoptosis by Promoting Cell Autophagy.

Cell autophagy and cell apoptosis are both observed in the process of hypoxia-induced ischemic cerebral infarction (ICI). Unc-51 like autophagy activating kinase 1 (Ulk1) and FUN14 Domain-containing Protein 1 (FUNDC1) are both involved in the regulation of cell autophagy. This study aimed to investigate the regulatory effects of Ulk1 and FUNDC1 on hypoxia-induced nerve cell autophagy and apoptosis. Cell viability was measured using cell counting kit-8 (CCK-8) assay. Cell apoptosis was detected using Annexin V-PE/7-ADD staining assay. qRT-PCR was used to quantify the mRNA levels of Ulk1 and FUNDC1 in PC-12 cells. Cell transfection was performed to up-regulate the expression of Ulk1. 3-Methyladenine (3-MA) was used as autophagy inhibitor and rapamycin was used as autophagy activator in our experiments. SP600125 was used as c-Jun N-terminal kinase (JNK) inhibitor. Western blotting was performed to analyze the expression levels of key factors that are related to cell autophagy, apoptosis and JNK pathway. We found that hypoxia simultaneously induced apoptosis and autophagy of PC-12 cells. The activation of Ulk1 and FUNDC1 were also found in PC-12 cells after hypoxia induction. Overexpression of Ulk1 promoted the activation of FUNDC1 and prevented PC-12 cells from hypoxia-induced apoptosis. Suppression of Ulk1 had opposite effects. Furthermore, we also found that JNK pathway participated in the effects of Ulk1 overexpression on PC-12 cell apoptosis reduction. To conclude, Ulk1/FUNDC1 played critical regulatory roles in hypoxia-induced nerve cell autophagy and apoptosis. Overexpression of Ulk1 prevented nerve cells from hypoxia-induced apoptosis by promoting cell autophagy.

The effect of tranexamic acid to reduce blood loss and transfusion on off-pump coronary artery bypass surgery: A systematic review and cumulative meta-analysis.

STUDY OBJECTIVE: To assess the safety and efficacy of tranexamic acid (TA) on off-pump coronary artery bypass (OPCAB) surgery. DESIGN: Meta-analysis. SETTING: Operating room, OPCAB surgery, all surgeries were elective measurements. Searching the following data sources respectively: PubMed/MEDLINE, the Cochrane Library, EMBASE and reference lists of identified articles, we performed a meta-analysis of postoperative 24h blood loss, postoperative allogeneic transfusion, re-operation for massive bleeding, postoperative mortality, and postoperative thrombotic complications. MAIN RESULTS: Using electronic databases, we selected 15 randomized control trials (RCTs), carried out between 2003 and 2016, with a total of 1250 patients for our review. TA significantly reduced the postoperative 24h blood loss (mean difference -213.32ml, 95% confidence intervals, -247.20ml to -179.43ml; P<0.0001). And, TA also significantly reduced the risk of packed red blood cell (PRBCs) transfusion (risk ratio 0.62; 95% confidence intervals 0.51 to 0.76; P<0.0001) and fresh frozen plasma (FFP) transfusion (0.65; 0.52 to 0.81; P<0.001). There were no statistical significance on platelet transfusion (risk difference -0.00, 95% confidence interval -0.02 to 0.02; P=0.73) and re-operation (0.00, -0.02 to 0.02; P=1.00). No association was found between TA and morbility (risk difference -0.00, 95% confidence interval -0.02 to 0.02; P=0.99) and thrombotic complications (-0.01, -0.01 to 0.02; P=0.70). CONCLUSIONS: TA reduced the probability of receiving a PRBCs and FFP transfusion during OPCAB surgery. And no association with postoperative death and thrombotic events was found. However, further trials with an appropriate sample size are required to confirm TA safety in OPCAB surgery.

One-Lung Ventilation with Additional Ipsilateral Ventilation of Low Tidal Volume and High Frequency in Lung Lobectomy.

BACKGROUND To investigate the protective effects of additional ipsilateral ventilation of low tidal volume and high frequency on lung functions in the patients receiving lobectomy. MATERIAL AND METHODS Sixty patients receiving lung lobectomy were randomized into the conventional one-lung ventilation (CV) group (n=30) and the ipsilateral low tidal volume high frequency ventilation (LV) group (n=30). In the CV group, patients received only contralateral OLV. In the LV group, patients received contralateral ventilation and additional ipsilateral ventilation of low tidal volume of 1-2 ml/kg and high frequency of 40 times/min. Normal lung tissues were biopsied for the analysis of lung injury. Lung injury was scored by evaluating interstitial edema, alveolar edema, neutrophil infiltration, and alveolar congestion. RESULTS At 30 min and 60 min after the initiation of one-lung ventilation and after surgery, patients in the LV group showed significantly higher ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen than those in the CV group (P<0.001). Lung injury was significantly less severe (2.7±0.7) in the LV group than in the CV group (3.1±0.7) (P=0.006). CONCLUSIONS Additional ipsilateral ventilation of low tidal volume and high frequency can decrease the risk of hypoxemia and alleviate lung injury in patients receiving lobectomy.

PU-H71 effectively induces degradation of IκB kinase ß in the presence of TNF-α.

This study is to determine if PU-H71, a heat shock protein inhibitor, induces killing of malignant breast cells together with treatment of tumor necrosis factor-α (TNF-α). The related molecular mechanisms were also studied. A primary mammary epithelial cell line HMEC2595 cells and the highly metastatic breast cell line MDA-MB-231, the HER2-positive BT-474 cells, and the ER-positive MCF7 cells were treated with PU-H71 in the presence or absence of TNF-α. The effects of PU-H71 and TNF-α treatments on cells viabilities and on intracellular signaling pathway proteins were determined using the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay, apoptosis assays, immunoblot assays, and luciferase assays. It was found that TNF-α enhances the toxic effects of PU-H71 on tumor cells but not normal cells. PU-H71 treatments lead to degradation of IKKß. Moreover, PU-H71 down-regulates the NF-κB transcriptional activity induced by TNF-α treatment. The experimental results indicated PU-H71 effectively induces cell killing of malignant breast cells in the presence of TNF-α, possibly through a mechanism related to degradation of IKKß. It is suggested that combination of PU-H71 and TNF-α treatments might be an effective therapeutic strategy of breast malignancies.

A prospective randomized study of intraoperative thoracic epidural analgesia in off-pump coronary artery bypass surgery.

OBJECTIVE: The purpose of this study was to test the hypothesis that general anesthesia (GA) plus thoracic epidural anesthesia (TEA) has no impact on the outcomes of off-pump coronary artery bypass surgery (OPCABs) compared to GA followed by patient-controlled TEA (PCTEA), while GA plus TEA leads to a higher requirement for vasoactive drug use. METHODS: Sixty-four patients, American Society of Anesthesiologists physical status II and III, who were scheduled for elective OPCABs, were offered an epidural catheter inserted at the T2-3 interspace and then randomized into 1 of 2 groups according to whether TEA was applied intraoperatively. The TEA(perio) group received GA plus TEA, while the TEA(post) group received GA alone. All groups had postoperative PCTEA. The number of requirements for vasoactive drugs and the extubation times were recorded. The analgesic effect was monitored by visual analog scale (VAS) pain scores. Heart rate, blood pressure, and blood gases were also monitored. The data are presented as mean values ± standard deviation, or medians with quartiles. RESULTS: The proportion of vasoactive drug use was significantly higher in the TEA(perio) group intraoperatively (before or during completion of anastomoses: 59.4 vs. 20.7%, p = 0.004; after completion of anastomoses: 53.1 vs. 17.2%, p = 0.007). There was no statistically significant difference in extubation times or VAS scores between the 2 groups. CONCLUSIONS: We conclude that GA plus TEA has no impact on the outcomes of OPCABs, while its use leads to a higher requirement for vasoactive drug use. GA followed by PCTEA facilitates the anesthesia administration, while it does not affect the extubation time and the postoperative analgesic effect.

[Effects of astragalus injection on renal function in patients after cardiac valve replacement with cardiopulmonary bypass].

OBJECTIVE: To observe the effects of Astragalus Injection (AI) on renal function in patients after cardiac valve replacement with cardiopulmonary bypass (CPB). METHODS: Forty patients scheduled to receive cardiac valve replacement with CPB were randomly assigned to 2 groups equally, the control group and the AI group. Patients in the AI group were administered with AI 40 mL before anesthesia by diluting it in 250 mL 5% glucose solution via intravenous dripping, 20 mL by adding it into the priming solution before CPB and 40 mL once a day diluted as before via intravenous dripping at the foremost 5 successive days after operation. For patients in the control group, equal volume of Ringer's Liquid was given instead of AI. Peripheral blood sample and urine were collected at various time points: before anesthesia (T0), the 1st (T1), 3rd (T3), 5th (T5) and 7th day (T7) after operation, for determining blood levels of urea nitrogen (BUN), creatinine (Cr) and beta2-microglobulin (beta2-MG), as well as urinary levels of beta2-MG, microalbumin (m-Alb) and N-acetyl-D-glucosaminidase (NAG). RESULTS: As compared with those at T0, in the control group, BUN, Cr at T1 and T3, serum beta2-MG at T3, urinary beta2-MG m-Alb and NAG at T1-T7 were significantly higher, while in the AI group, urinary m-Alb, NAG at T1-5 n and urinary beta2-MG at T1-7 were higher (P < 0.05). As compared with those in the control group, serum BUN at T1-3., Cr and blood beta2-MG at T3, urinary beta2-MG, m-Alb and NAG at T1-7 were lower (P < 0.05) in the AI group. CONCLUSION: CPB could induce renal failure, and applying AI at the perioperative stage can protect renal function to some certain extent.