Calpain as a Therapeutic Target for Hypoxic-Ischemic Encephalopathy.

Hypoxic-ischemic encephalopathy (HIE) is a complex pathophysiological process with multiple links and factors. It involves the interaction of inflammation, oxidative stress, and glucose metabolism, and results in acute and even long-term brain damage and impairment of brain function. Calpain is a family of Ca2+-dependent cysteine proteases that regulate cellular function. Calpain activation is involved in cerebral ischemic injury, and this involvement is achieved by the interaction among Ca2+, substrates, organelles, and multiple proteases in the neuronal necrosis and apoptosis pathways after cerebral ischemia. Many calpain inhibitors have been developed and tested in the biochemical and biomedical fields. This study reviewed the potential role of calpain in the treatment of HIE and related mechanism, providing new insights for future research on HIE.

Application of transcranial Doppler in cerebrovascular diseases.

Transcranial Doppler (TCD) is a rapid and non-invasive diagnostic technique that can provide real-time measurements of the relative changes in cerebral blood velocity (CBV). Therefore, TCD is a useful tool in the diagnosis and treatment of clinical cerebrovascular diseases (CVDs). In this review, the basic principles of TCD and its application in CVD were outlined. Specifically, TCD could be applied to evaluate occlusive CVD, assess collateral circulation in patients with ischemic stroke, and monitor cerebral vascular occlusion before and after thrombolysis as well as cerebral vasospasm (VSP) and microembolization signals after aneurysmal subarachnoid hemorrhage (SAH). Moreover, TCD could predict short-term stroke and transient cerebral ischemia in patients with anterior circulation occlusion treated with endovascular therapy and in patients with anterior circulation vascular occlusion. Additionally, TCD not only could monitor blood velocity signals during carotid endarterectomy (CEA) or carotid artery stenting (CAS) but also allowed earlier intervention through early recognition of sickle cell disease (SCD). Presently, TCD is a useful prognostic tool to guide the treatment of CVD. On the one hand, TCD is more commonly applied in clinical research, and on the other hand, TCD has an increasing role in the management of patients. Collectively, we review the principles and clinical application of TCD and propose some new research applications for TCD.

Low Dose of Methylprednisolone for Pain and Immune Function After Thoracic Surgery.

BACKGROUND: This study evaluated the effects of single low-dose preoperative methylprednisolone (MP) on the immunologic function and postoperative pain of patients undergoing elective video-assisted thoracoscopic surgery under general anesthesia. METHODS: The study randomly assigned 81 patients who underwent elective video-assisted thoracoscopic surgery to the MP group or the control group. The T-lymphocyte subsets of CD3+, CD4+, and CD8+, and the CD4+/CD8+ ratio at T0 (before anesthesia), T1 (after operation), and T2 (24 hours after operation) were recorded. Also recorded were postoperative rest and cough pain scores and postoperative adverse effects and surgery complications. RESULTS: Compared with T0, the levels of CD3+ and CD4+ subsets and CD4+/CD8+ were significantly decreased, and the level of CD8+ was increased after surgery in both groups. There was no significant difference in the variation of CD3+, CD4+, CD8+, and CD4+/CD8+ between the MP group and the control group. The rest and cough pain of patients in the MP group was significantly lower compared with the control group at 2, 4, 6, and 24 hours after surgery. The incidences of nausea and vomiting and dizziness were also significantly higher in the control group than those in the MP group. CONCLUSIONS: A preoperative single low dose of MP (1 mg/kg) had no effect on immune function but had effective analgesic effects and could reduce the incidence of dizziness and postoperative nausea and vomiting.

Sufentanil blunts the myocardial stress induced by tracheal intubation in older adult patients with coronary heart disease better than equipotent fentanyl.

BACKGROUND: To evaluate the role of sufentanil and fentanyl in the prevention of cardiovascular responses to endotracheal intubation in elderly patients with coronary heart disease (CHD). METHODS: Seventy-one CHD patients scheduled for surgery under general anesthesia were randomly divided into two groups to receive either 0.4 µg/kg of sufentanil (n=35) or 4 µg/kg of fentanyl (n=36) in a double-blind manner. Under local anesthesia, an invasive arterial catheter is used to monitor systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial blood pressure (MAP). Laryngoscopy and tracheal intubation were successfully performed within 30 seconds. MAP and heart rate (HR) were recorded before anesthesia induction, immediately before intubation, at intubation, and 1, 3, 5 min after tracheal intubation. Rate pressure product (RPP) is calculated by SBP multiple HR. RESULTS: Patients in the fentanyl group showed a significant increase in MAP, HR, and RPP associated with tracheal intubation. However, the cardiovascular stimulation induced by tracheal intubation was attenuated in the sufentanil group. CONCLUSIONS: Laryngoscope and endotracheal intubation may cause adverse increases in blood pressure (BP) and HR in elderly patients with CHD, resulting in an imbalance of myocardial oxygen consumption and supply and myocardial ischemia. Anesthesia induction with sufentanil 0.4 µg/kg is more potential than fentanyl 4 µg/kg to attenuate the cardiovascular intubation response.

Comparison of Morning and Evening Operation Under General Anesthesia on Intraoperative Anesthetic Requirement, Postoperative Sleep Quality, and Pain: A Randomized Controlled Trial.

OBJECTIVE: Postoperative sleep disorders can cause serious adverse effects on postoperative outcomes. The purpose of our study was to compare the effects of the timing of surgery under general anesthesia on intraoperative anesthetic drug requirements, postoperative sleep quality and pain in patients. MATERIALS AND METHODS: Eighty-four patients who underwent selective laparoscopic abdominal surgeries under general anesthesia were randomly assigned to the Day Group (8:00-12:00) or the Night Group (18:00-22:00). The portable sleep monitor (PSM) was used to determine sleep quality on the night before surgery (Sleep-preop), the first night after surgery (Sleep POD 1), and the third night after surgery (Sleep POD 3). The visual analog scale (VAS) was used to evaluate postoperative pain scores and the Athens Insomnia Scale (AIS) was used for assessing insomnia symptoms. The total dose of general anesthetics required and adverse effects after surgery were also assessed. RESULTS: Compared to Sleep-preop, patients presented with a lower sleep efficiency and a higher AIS score during Sleep POD 1 and Sleep POD 3. Furthermore, the Night Group had a significantly lower proportion of rapid eye movement sleep, stable sleep, and unstable sleep than did the Day Group at Sleep POD 1 and Sleep POD 3. The dosage of propofol and remifentanil required in the Day Group was significantly higher than that in the Night Group. Furthermore, patients in the Day Group had better pain relief, with a lower VAS score at 1, 6, 12, and 24 hours after surgery. The incidences of postoperative nausea and vomiting and dizziness were significantly higher in the Night Group than those in the Day Group. CONCLUSION: Morning operations required a higher dose of anesthetic drugs than did evening operations, which may be related to the circadian rhythm. The degree of postoperative sleep disorders was greater when the operation was performed in the evening than in the morning, which was also associated with increased pain perception and increased incidence of postoperative adverse effects. Thus, our results suggest that patients with hyperalgesia and sleep disorders may benefit from operations performed in the morning.

Analgesic Impact of Single-Shot Versus Continuous Femoral Nerve Block After Total Knee Arthroplasty: A Systematic Review and Meta-Analysis.

INTRODUCTION: Efficient pain management after total knee arthroplasty will accelerate functional recovery and reduce the length of hospital stay. The femoral nerve block is increasingly used in clinical practice owing to its favorable analgesic efficacy. However, the effect of continuous femoral nerve block compared to single-shot femoral nerve block remains controversial. METHODS: Three databases (Pubmed, Embase and Cochrane Library) were searched for randomized controlled trials up to April 2019. Seven studies with 525 patients were included in this analysis. RESULTS: The pooled estimates showed that the continuous femoral nerve block could relieve the pain at rest [standardized mean differences with 95% confidence intervals 1.12 (0.63-1.60), I2 = 57%, p < 0.00001] and physical therapy [standardized mean differences with 95% confidence intervals 1.05 (0.47-1.63), I2 = 71%, p = 0.0004] on postoperative day 1 and reduce total morphine consumption on postoperative day 1 [mean differences with 95% confidence intervals 16.15 (13.75-18.54), I2 = 46%, p < 0.00001] and 2 [mean differences with 95% confidence intervals 7.02 (4.82-9.22), I2 = 35%, p < 0.00001]. There is no significant difference in pain scores at rest and physical therapy on postoperative day 2 and 3, in Western Ontario and McMaster University Arthritis Index scores (p = 0.12), the length of hospital stay (p = 0.94) and the incidence of nausea and vomiting (p = 0.09). CONCLUSION: We conclude that the continuous femoral nerve block is more effective than single-shot femoral nerve block after total knee arthroplasty, which provides objective evidence of pain management for anesthetists.

Pulmonary protection of transcutaneous electrical acupoint stimulation in gynecological laparoscopic surgery: A randomized controlled trial.

Laparoscopy is performed worldwide due to its limited side effects and optimal treatment efficacy. However, it also has adverse effects, including atelectasis and ischemia-reperfusion injury, due to CO2 accumulation during ventilation in a head-down position, which may result in severe disorders and adversely affecting postoperative recovery, prolonging hospitalization. The present study was performed to assess whether transcutaneous electrical acupoint stimulation (TEAS) protects against lung injury occurring during gynecological laparoscopic surgery. Patients were randomly allocated to two groups: Control group (received no stimulation) and TEAS group (patients treated with TEAS on BL13, LI4 and LU5). The mean arterial pressure, heart rate and oxygen saturation were recorded at the time-points of arriving in the operating room (T0), immediately prior to induction of the pneumoperitoneum (T1), immediately after the end of pneumoperitoneum (T2) and on leaving the operating room (T3). Arterial blood gas analysis was performed to record the pH, determine the partial pressure of carbon dioxide and calculate the oxygenation index (OI) at T0-3. Blood samples were taken from the peripheral vein for determination of the serum concentrations of tumor necrosis factor (TNF)-α and interleukin (IL)-1ß at T0 and T3. Post-operative pulmonary complications occurring during the first five days after surgery were also recorded. A total of 100 patients were initially enrolled and 80 patients were analysed. The results indicated that the OI in the control group was significantly lower than that in the TEAS group at the T2 and T3 time-points. The serum concentrations of TNF-α and IL-1ß were significantly increased following surgery, while the extent of these increases was lower in the TEAS group compared with that in the control group. The incidence of post-operative pulmonary complications was significantly lower in the TEAS group. It was therefore indicated that TEAS protect against lung injury as a complication of gynecological laparoscopic surgery. The present study was registered at http://www.clinicaltrials.gov prior to enrollment of the patients (no. NCT02850471).

The Effect Of Intraoperative Use Of Dexmedetomidine During The Daytime Operation Vs The Nighttime Operation On Postoperative Sleep Quality And Pain Under General Anesthesia.

OBJECTIVES: The aim of our study was to compare the effect of using dexmedetomidine (DEX) during the daytime operation or the nighttime operation under general anesthesia on postoperative sleep quality and pain of patients. METHODS: Seventy-five patients scheduled for elective laparoscopic abdominal surgeries under general anesthesia were randomly assigned to receive operation in the Day Group (8:00-12:00) and the Night Group (18:00-22:00). The Portable Sleep Monitor (PSM) was performed on the following 3 nights: the night before surgery (Sleep 1), the first night after surgery (Sleep 2), and the third night after surgery (Sleep 3). Postoperative pain scores using visual analogue scoring scale, subjective sleep quality using the Athens Insomnia Scale, total dose of general anesthetics and PCA pump press numbers were also recorded. RESULTS: Intraoperative administration of DEX for patients in the Day Group could improve sleep quality with a higher sleep efficiency and a lower AIS subjective sleep quality than patients in the Night Group at Sleep 2 (P < 0.001 and P = 0.001, respectively) and Sleep 3 (P < 0.001, respectively). There were marked lower rapid eye movement (REM) sleep and Stable sleep in the Night Group than that in the Day Group at Sleep 2 (P < 0.001 and P = 0.032, respectively) and Sleep 3 (P < 0.001, respectively). Patients in the Day Group have better pain relief and less PCA pump press numbers than patients in the Night Group. CONCLUSION: Using dexmedetomidine during the daytime operation can better improve postoperative sleep quality and pain than nighttime operation in patients undergoing laparoscopic abdominal surgeries.

Use of pre-operative anxiety score to determine the precise dose of butorphanol for intra-operative sedation under regional anesthesia: A double-blinded randomized trial.

A randomized double-blinded controlled trial was performed to explore the association between pre-operative anxiety and intra-operative butorphanol requirement to evaluate the precise sedative requirement and to confirm the sedative effect of butorphanol in patients receiving lower-limb orthopedic surgery. The Amsterdam pre-operative anxiety and information scale and the Ramsay sedation score (RSS) were used to assess the patients' pre-operative anxiety score and sedation state during surgery. Patients were divided into two groups according to their pre-operative anxiety score prior to administration of pre-medication. Patients in each group were randomly divided into a butorphanol group and a 0.9% saline group. A total of 142 patients were enrolled and 131 patients were analyzed. The sedation scores of patients with high pre-operative anxiety in the 0.9% saline group were lower than those in the butorphanol group at each time-point after infusion. An increased pre-operative anxiety score predicted an increased duration to reach an RSS of 4 for an acceptable level of sedation (r2=0.887, P<0.0001). In conclusion, butorphanol had a good sedative effect on patients with pre-operative anxiety. The following formula was proposed: Precise dose of butorphanol (µg/kg)=15.26 + (0.14× pre-operative anxiety score), which may provide an improvement for patients exhibiting a high level of pre-operative anxiety. The trial was registered prior to patient enrollment at clinicaltrials.gov on 20.01.2018 (trial registration no. NCT03429179).

Effect of physical exercise on young anesthesiologists with on-call-related fatigue.

To explore whether exercise can effectively relieve the fatigue state of overnight shift anesthesiologists with chronic fatigue. 78 anesthesiologists between 30 and 40 years of age at four hospitals in China were analyzed in the investigation. The Profile of Mood States (POMS) and Chalder Fatigue Scale (CFS) were used to assess psychological symptoms and fatigue respectively, and data regarding demographics, health, exercise and work-related variables were also collected. The total and physical fatigue score were highest among those who seldom do exercise compared to those who always do exercise (p < .05, respectively). Moreover, anesthesiologists who exercised 30-60 min everyday had the lowest total and physical fatigue score. When exercise for more than 60 min, the total and physical fatigue scores then increased. After completing a night shift, the post-on-call total Profile of Mood States scores of those who seldom do exercise was significantly increased (t = -4.9, p < .001). These study findings suggested that regular exercise 30-60 min everyday could effectively reduce anesthesiologists' physical fatigue and decrease their negative psychological state, and anesthesiologists should positively adjust working and exercise time.

Effects of Transcutaneous Electrical Acupoint Stimulation on the Stress Response During Extubation After General Anesthesia in Elderly Patients Undergoing Elective Supratentorial Craniotomy: A Prospective Randomized Controlled Trial.

BACKGROUND: Elderly patients have an increased risk of a stress response during extubation after general anesthesia. In this study, we aimed to investigate whether transcutaneous electrical acupoint stimulation (TEAS) might decrease the stress response and improve the quality of recovery in elderly patients after elective supratentorial craniotomy. MATERIALS AND METHODS: In this prospective randomized controlled study, patients were randomly assigned to either a TEAS group (n=37) or a control group (n=38). The primary outcomes were the hemodynamic parameters and plasma concentrations of epinephrine, norepinephrine, and cortisol. The secondary outcome included the consumption of remifentanil and propofol, time to extubation and reorientation, extubation quality score, postoperative quality of recovery, and postoperative complications. RESULTS: Compared with the control group, hemodynamic parameters and plasma concentrations of epinephrine, norepinephrine, and cortisol during extubation were decreased in the TEAS group. TEAS reduced the consumption of remifentanil (P<0.01), as well as incidence of postoperative complications. The extubation quality score was lower (P<0.01) and the quality of recovery score was higher (P<0.01) in the TEAS group than in the control group. However, the time to extubation and reorientation, and the consumption of propofol were not significantly different between the 2 groups. CONCLUSIONS: TEAS may decrease the stress response during extubation, improve quality of postoperative recovery, and decrease incidence of postoperative complications in elderly patients undergoing elective supratentorial craniotomy.

[Effect of Transcutaneous Acupoint Electrical Stimulation on Propofol Usage in Closed-loop Anes- thesia Delivery System in Pediatric Cardiac Surgery].

Objective To evaluate the effect of transcutaneous acupoint electrical stimulation (TEAS) on propofol usage in closed-loop anesthesia delivery system and pediatric hemodynamics. Methods Sixty children patients undergoing selective tonsillectomy and adenoidectomy surgeries were randomly allocated to the TEAS group (T) and the control group (C) , 30 in each group. Anesthesia maintenance in both groups was performed by propofol closed-loop anesthesia infusion system after induction of anesthesia. Patients in group T were treated with continuous TEAS (2/100 Hz sparsedense wave, 8 - 12 mA) at unilateral Hegu (L14) and Shenmen till the end of surgery. No TEAS was performed to patients in group C. Mean arterial pressure (MAP) and heart rate (HR) were recorded before anesthesia (TO), immediately after intubation ( T1) , 5 min after intubation (T2) , 10 min after intubation (T3) , 15 min after intubation (T4) , the time for intubation (T5) , respectively. The total dose of propofol, times for propofol dose adjustment, average target concentration, cases of patients with extra Fentanyl were recorded during anesthesia maintenance. Bispectral index (BIS) was recorded. Pediatric Anesthesia Emergence Delirium (PAED) scale and Modified Children's Hospital of Eastern Ontario Pain Scale (MCHEOPS) were assessed at T5, 5 min after extubation (T6) , 10 min after extubation (T7) , 15 min after extubation (T8), 30 min after extubation (T9) , respectively. Epinephrine (NE) was measured at TO, T1, T5, and T9, concentrations of IL-1 and IL-6 were measured at TO, T5, 24 h after surgery ( T10) , 48 h after surgery (T11), respectively. Results Compared with group C, MAP at T4 and T5 and HR at T1-T5 all de- creased, PAED scale and MCHEOPS decreased at T5-T9, NE concentrations were significantly reduced at T5 and T9, concentrations of IL-1 and IL-6 decreased at T5, T10, T1 1 in group T (P <0. 05, P <0. 01). Compared with group C, the total dose of propofol, times for propofol dose adjustment, average target concentration were reduced in group T during surgery (P <0. 05, P <0. 01). Twenty cases (67%) used propofol in group C and 9 cases (30% ) used propofol in group T during surgery, with statistical difference (P <0. 01). Changes of BIS was not statistically different between the two groups (P >0. 05). Conclusion TEAS could inhibit stress response and inflammatory response of children patients, stabilize their hemo- dynamics during surgery, thereby reducing propofol dose in closed-loop anesthesia delivery system.