ABSTRACT
Neuroinflammation plays an important pathological role in experimental surgical brain injury (SBI). Apoptotic associated with phosphatidylserine (PS) externalization promotes anti-inflammatory mediator TGF-ß1 release. In the present study, we investigated the anti-neuroinflammation effect of PS liposome or isoflurane pretreatment via PS/CD36/TGF-ß1 signaling in a rat model of SBI. A total of 120 male Sprague-Dawley rats (weighing 280-330 gms) were used. SBI was induced by partial right frontal lobe corticotomy. Intranasal PS liposome or isoflurane inhalation was administered prior to SBI induction. CD36 small interfering RNA (siRNA) was administered intracerebroventricularly. Recombinant Annexin V protein (rAnnexin V) was delivered intranasally. Post-SBI assessments included neurological tests, brain water content, Western blot, and immunohistochemistry. Endogenous CD36 protein levels but not TGF-ß1 was significantly increased within peri-resection brain tissues over 72 h after SBI. SBI rats were associated with increased brain water content surrounding corticotomy and neurological deficits. PS liposome pretreatment significantly reduced brain water content and improved some neurological deficits at 24 hours and 72 hours after SBI. PS liposome increased CD36 and TGF-ß1 protein levels, but decreased IL-1ß and TNFα protein levels in peri-resection brain tissues at 24 hours after SBI. CD36 siRNA or rAnnexin V partially countered the protective effect of PS liposome. Isoflurane pretreatment produced similar antineuroinflammation and neurological benefits in SBI rats partially by upregulating CD36/Lyn/TGF-ß1 signaling. Collectively, our findings suggest that the activation of PS/CD36/TGF-ß1 pathway by PS liposome or isoflurane prior to SBI could attenuate neuroinflammation and improve neurological outcomes in rats. PS liposome or isoflurane pretreatment may serve as an effective preventive strategy to minimize the brain injury caused by neurosurgical procedures in patients.
Subject(s)
Brain Injuries/metabolism , Brain/pathology , CD36 Antigens/metabolism , Inflammation/pathology , Intraoperative Complications/metabolism , Phosphatidylserines/metabolism , Transforming Growth Factor beta1/metabolism , Animals , Brain Edema/complications , Brain Edema/drug therapy , Brain Edema/pathology , Brain Injuries/complications , Brain Injuries/drug therapy , Inflammation/drug therapy , Intraoperative Complications/drug therapy , Isoflurane , Liposomes , Male , Neuroprotective Agents/pharmacology , Neuroprotective Agents/therapeutic use , RNA, Small Interfering/metabolism , Rats, Sprague-Dawley , Signal Transduction/drug effects , Treatment Outcome , Up-Regulation/drug effectsABSTRACT
Previous studies have shown that RouxenY gastric bypass (RYGB), one of the most effective weight loss treatments for obesity, results in neurodegenerative responses in vagal afferent gutbrain connection reflected by microglia activation and reduced sensory input to the nucleus tractus solitarius (NTS). However, it is not known whether RYGBinduced microglia activation is the cause or an effect of the reported neuronal damage. Therefore, the aim of this study was to establish the order of neurodegenerative responses in vagal afferents after RYGB in the nodose ganglia (NG) and NTS in male and female rats. SpragueDawley rats were fed regular chow or an energydense diet for two weeks followed by RYGB or sham surgery. Twentyfour hours later, animals were sacrificed and NG and NTS were collected. Neuronal cell damage was determined by TUNEL assay. Microglia activation was determined by quantifying the fluorescent staining against the ionizing calcium adapterbinding molecule 1. Reorganization of vagal afferents was evaluated by fluorescent staining against isolectin 4. Results of the study revealed significantly increased DNA fragmentation in vagal neurons in the NG when observed at 24 h after RYGB. The surgery did not produce rapid changes in the density of vagal afferents and microglia activation in the NTS. These data indicate that decreased density of vagal afferents and increased microglia activation in the NTS likely ensue as a res ult of RYGBinduced neuronal damage.
Subject(s)
DNA Fragmentation , Energy Intake , Feeding Behavior , Gastric Bypass/adverse effects , Intraoperative Complications/metabolism , Microglia/metabolism , Neurons, Afferent/metabolism , Nodose Ganglion/metabolism , Solitary Nucleus/metabolism , Vagus Nerve Injuries/metabolism , Vagus Nerve/metabolism , Afferent Pathways/physiopathology , Animals , Body Composition , Body Weight , Diet, High-Fat/adverse effects , Female , Intraoperative Complications/etiology , Male , Rats , Rats, Sprague-Dawley , Vagus Nerve Injuries/etiologyABSTRACT
PURPOSE: Hydroxocobalamin, or vitamin B12 (V-B12), is frequently used to treat smoke inhalation and cyanide poisoning. Recent reports have also described its use to treat vasoplegia in cardiac surgery and liver transplantation. This narrative review discusses this "off-label" indication for V-B12, focusing on the potential biochemical mechanisms of its actions. SOURCE: PubMed, Cochrane, and Web of Science databases were searched for clinical reports on the use of V-B12 for vasoplegia in cardiac surgery and liver transplantation, with the biochemical mechanisms discussed being based on a survey of the related biochemistry literature. PRINCIPAL FINDINGS: Forty-four patients have been treated with V-B12 for vasoplegia in various isolated case reports and one series. Although 75% of patients have increased blood pressure in response to V-B12, there were some "non-responders". The true efficacy remains unknown because clinical trials have not been performed, and significant reporting bias likely exists. Plausible biochemical explanations exist for the potential beneficial effects of V-B12 in treating vasoplegia, including binding nitric oxide and other gasotransmitters. Additional research is required to clarify if and how these mechanisms are causally involved in effective clinical responders and non-responders. CONCLUSIONS: Although anecdotal reports utilizing V-B12 for vasoplegia are available, no higher-level evidence exists. Future work is necessary to further understand the dosing, timing, adverse events, and biochemical mechanisms of V-B12 compared with other therapies such as methylene blue.
Subject(s)
Cardiac Surgical Procedures/adverse effects , Intraoperative Complications/drug therapy , Intraoperative Complications/metabolism , Liver Transplantation/adverse effects , Vasoplegia/drug therapy , Vasoplegia/metabolism , Vitamin B 12/therapeutic use , Vitamins/therapeutic use , Humans , Nitric Oxide/metabolismABSTRACT
BACKGROUND AND AIMS: Biliary anastomosis is a frequent area of complications after liver transplantation (LT) and a potential area of "microangiopathy". The concept of a "marginal bile duct" is unexplored. The main aim was to make a preliminary evaluation of the utility of an innovative real-time oxygen microtension (pO2mt) testing device for the assessment of bile duct viability during LT and to correlate these pO2mt values with microvascular tissue quality by histopathology and outcomes. PATIENTS AND METHODS: Observational prospective cohort study with 23 patients. Oxygen microtension measurements were made placing a micropO2 probe in different areas of recipient and donor's bile duct intraoperative. RESULTS: Mean pO2mt in the graft bile duct at the level of the anastomosis 103.82 (31-157) mm Hg, being 121.52 (55-174) mm Hg 1.5 cm proximal to the hilar plate (P < 0.001). Mean pO2mt in the recipient's bile duct was 117.87 (62-185) mm Hg, while a value of 137.30 (81-198) mm Hg was observed 1.5 cm distal to the anastomosis (P < 0.001). Cystic duct resection (12 cases) was also related with higher pO2mt values at anastomosis [117.8 (93-157) vs 88.54 (31-124) mm Hg] and distal to anastomosis [135.6 (111-174) vs 106.2 (55-133) mm Hg; P < 0.001]. Patients with 1-, 3-, and 12-month biliary complications had significantly lower pO2mt in the intraoperative measurements. CONCLUSION: Our preliminary results show that distal borders of donor and recipient bile ducts may be low-vascularized areas. Tissue pO2mt is significantly higher in areas close to the hilar plate and to the duodenum in donor and recipient's sides, respectively. Bile duct injury and biliary complications are associated with worse tissue pO2mt.
Subject(s)
Anastomosis, Surgical/adverse effects , Biliary Tract Diseases/diagnosis , Biliary Tract/metabolism , Intraoperative Complications/diagnosis , Liver Transplantation/adverse effects , Living Donors/supply & distribution , Oxygen/metabolism , Biliary Tract/pathology , Biliary Tract Diseases/etiology , Biliary Tract Diseases/metabolism , Female , Follow-Up Studies , Humans , Intraoperative Complications/etiology , Intraoperative Complications/metabolism , Male , Middle Aged , Oxygen/adverse effects , Oxygen/analysis , Prognosis , Prospective Studies , Risk FactorsABSTRACT
Perioperative organ injury has a significant impact on surgical outcomes and presents a leading cause of death in the United States. Recent research has pointed out an important role of hypoxia signaling in the protection from organ injury, including for example myocardial infarction, acute respiratory distress syndrome, acute kidney, or gut injury. Hypoxia induces the stabilization of hypoxia-inducible factors (HIFs), thereby leading to the induction of HIF target genes, which facilitates adaptive responses to low oxygen. In this review, we focus on current therapeutic strategies targeting hypoxia signaling in various organ injury models and emphasize potential clinical approaches to integrate these findings into the care of surgical patients. Conceptually, there are 2 options to target the HIF pathway for organ protection. First, drugs became recently available that promote the stabilization of HIFs, most prominently via inhibition of prolyl hydroxylase. These compounds are currently trialed in patients, for example, for anemia treatment or prevention of ischemia and reperfusion injury. Second, HIF target genes (such as adenosine receptors) could be activated directly. We hope that some of these approaches may lead to novel pharmacologic strategies to prevent or treat organ injury in surgical patients.
Subject(s)
Gene Targeting/methods , Hypoxia/metabolism , Intraoperative Complications/metabolism , Multiple Organ Failure/metabolism , Signal Transduction/physiology , Animals , Humans , Hypoxia-Inducible Factor 1/genetics , Hypoxia-Inducible Factor 1/metabolism , Intraoperative Complications/prevention & control , Multiple Organ Failure/genetics , Multiple Organ Failure/prevention & controlABSTRACT
The bladder urothelium functions as a urine-blood barrier and consists of basal, intermediate, and superficial cell populations. Reconstructive procedures such as augmentation cystoplasty and focal mucosal resection involve localized surgical damage to the bladder wall whereby focal segments of the urothelium and underlying submucosa are respectively removed or replaced and regeneration ensues. We demonstrate using lineage-tracing systems that urothelial regeneration following augmentation cystoplasty with acellular grafts exclusively depends on host keratin 5-expressing basal cells to repopulate all lineages of the de novo urothelium at implant sites. Conversely, repair of focal mucosal defects not only employs this mechanism, but in parallel host intermediate cell daughters expressing uroplakin 2 give rise to themselves and are also contributors to superficial cells in neotissues. These results highlight the diversity of urothelial regenerative responses to surgical injury and may lead to advancements in bladder tissue engineering approaches.
Subject(s)
Keratin-5/genetics , Regeneration/genetics , Urinary Bladder/growth & development , Uroplakin II/genetics , Urothelium/growth & development , Animals , Cell Differentiation/genetics , Cell Lineage/genetics , Cell Tracking/methods , Gene Expression Regulation, Developmental/genetics , Humans , Intraoperative Complications/metabolism , Intraoperative Complications/pathology , Mice , Tissue Engineering , Urinary Bladder/injuries , Urinary Bladder/metabolism , Urine/physiology , Urothelium/injuries , Urothelium/metabolismABSTRACT
BACKGROUND: Prompt diagnosis of intra-anaesthetic acute hypersensitivity reactions (AHR) is challenging because of the possible absence and/or difficulty in detecting the usual clinical signs and because of the higher prevalence of alternative diagnoses. Delayed epinephrine administration during AHR, because of incorrect/delayed diagnosis, can be associated with poor prognosis. Low end-tidal CO2 (etCO2) is known to be linked to low cardiac output. Yet, its clinical utility during suspected intra-anaesthetic AHR is not well documented. METHODS: Clinical data from the 86 patients of the Neutrophil Activation in Systemic Anaphylaxis (NASA) multicentre study were analysed. Consenting patients with clinical signs consistent with intra-anaesthetic AHR to a neuromuscular blocking agent were included. Severe AHR was defined as a Grade 3-4 of the Ring and Messmer classification. Causes of AHR were explored following recommended guidelines. RESULTS: Among the 86 patients, 50% had severe AHR and 69% had a confirmed/suspected IgE-mediated event. Occurrence and minimum values of arterial hypotension, hypocapnia and hypoxaemia increased significantly with the severity of AHR. Low etCO2 was the only factor able to distinguish mild [median 3.5 (3.2;3.9) kPa] from severe AHR [median 2.4 (1.6;3.0) kPa], without overlap in inter-quartile range values, with an area under the receiver operator characteristic curve of 0.92 [95% confidence interval: 0.79-1.00]. Among the 41% of patients who received epinephrine, only half received it as first-line therapy despite international guidelines. CONCLUSIONS: An etCO2 value below 2.6 kPa (20 mm Hg) could be useful for prompt diagnosis of severe intra-anaesthetic AHR, and could facilitate early treatment with titrated doses of epinephrine. CLINICAL TRIAL REGISTRATION: NCT01637220.
Subject(s)
Anesthesia/adverse effects , Carbon Dioxide/metabolism , Drug Hypersensitivity/diagnosis , Intraoperative Complications/diagnosis , Acute Disease , Adolescent , Adult , Aged , Aged, 80 and over , Biomarkers/metabolism , Drug Hypersensitivity/metabolism , Female , Humans , Intraoperative Complications/metabolism , Male , Middle Aged , Reproducibility of Results , Severity of Illness Index , Young AdultABSTRACT
Brain tissue surrounding surgical resection site can be injured inadvertently due to procedures such as incision, retractor stretch, and electrocauterization when performing neurosurgical procedures, which is termed as surgical brain injury (SBI). Blood brain barrier (BBB) disruption due to SBI can exacerbate brain edema in the post-operative period. Previous studies showed that Slit2 exhibited vascular anti-permeability effects outside the brain. However, BBB protective effects of Slit2 following SBI has not been evaluated. The objective of this study was to evaluate whether recombinant Slit2 via its receptor roundabout4 (Robo4) and the adaptor protein, Paxillin were involved in reducing BBB permeability in SBI rat model. Our results showed that endogenous Slit2 increased in the surrounding peri-resection brain tissue post-SBI, Robo4 remained unchanged and Paxillin showed a decreasing trend. Recombinant Slit2 administered 1 h before injury increased BBB junction proteins, reduced BBB permeability, and decreased neurodeficits 24 h post-SBI. Furthermore, recombinant Slit2 administration increased Rac1 activity which was reversed by Robo4 and Paxillin siRNA. Our findings suggest that recombinant Slit2 reduced SBI-induced BBB permeability, possibly by stabilizing BBB tight junction via Robo4 mediated Rac1 activation. Slit2 may be beneficial for BBB protection during elective neurosurgeries.
Subject(s)
Blood-Brain Barrier/drug effects , Blood-Brain Barrier/metabolism , Brain Injuries/etiology , Brain Injuries/metabolism , Intercellular Signaling Peptides and Proteins/pharmacology , Intraoperative Complications/metabolism , Nerve Tissue Proteins/pharmacology , Receptors, Cell Surface/metabolism , rac1 GTP-Binding Protein/metabolism , Animals , Blood-Brain Barrier/pathology , Brain Injuries/drug therapy , Brain Injuries/pathology , Disease Models, Animal , Gene Expression , Intercellular Signaling Peptides and Proteins/genetics , Intercellular Signaling Peptides and Proteins/metabolism , Intraoperative Complications/drug therapy , Intraoperative Complications/pathology , Male , Nerve Tissue Proteins/genetics , Nerve Tissue Proteins/metabolism , Organ Specificity/genetics , Paxillin/genetics , Paxillin/metabolism , Permeability , Rats , Receptors, Cell Surface/genetics , Recombinant Proteins/pharmacology , Signal Transduction/drug effectsABSTRACT
INTRODUCTION: Postoperative cerebral edema is a devastating complication in neurosurgical patients. Loss of blood-brain barrier integrity has been shown to lead to the development of brain edema following neurosurgical procedures. The aim of this study was to evaluate preconditioning with Crotalus helleri venom (Cv-PC) as a potential preventive therapy for reducing postoperative brain edema in the rodent SBI model. C. helleri venom is known to contain phospholipase A2 (PLA2), an enzyme upstream to cyclooxygenase-2 (COX-2) in the inflammatory cascade, acts to increase the production of inflammatory mediators, such as prostaglandins. We hypothesize that Cv-PC will downregulate the response of the COX-2 pathway to injury, thereby reducing the inflammatory response and the development of brain edema after SBI. MATERIALS AND METHODS: 75 male Sprague Dawley rats (280-330g) were divided to the following groups-naïve+vehicle, naïve+Cv-PC, sham, vehicle, Cv-PC, Cv-PC+NS398 (COX-2 inhibitor). Vehicle preconditioned and Cv-PC animals received either three daily subcutaneous doses of saline or C. helleri venom at 72h, 48h, and 24h prior to surgery. In Cv-PC+NS398 animals, NS398 was administered intraperitoneally 1h prior to each Cv-PC injection. Sham-operated animals received craniotomy only, whereas SBI animals received a partial right frontal lobectomy. Neurological testing and brain water content were assessed at 24h and 72h after SBI; COX-2 and PGE2 expression was assessed at 24h postoperatively by Western blot and immunohistochemistry, respectively. RESULTS: At 24h after SBI, the vehicle-treated animals were observed to have increased brain water content (83.1±0.2%) compared to that of sham animals (80.2±0.1%). The brain water content of vehicle-treated animals at 72h post-SBI was elevated at 83.3±0.2%. Cv-PC-treated animals with doses of 10% LD50 had significantly reduced brain water content of 81.92±0.7% and 81.82±0.3% at 24h and 72h, respectively, after SBI compared to that of vehicle-treated animals, while Cv-PC with 5% LD50 doses showed brain water content that trended lower but did not reach statistical significance. At 24h and 72h post-SBI, Cv-PC-treated animals had significantly higher neurological score than vehicle-treated animals. The COX-2 over-expression characterized in SBI was attenuated in Cv-PC-treated animals; NS398 reversed the protective effect of Cv-PC on COX-2 expression. Cv-PC tempered the over-expression of the inflammatory marker PGE2. CONCLUSION: Our findings indicate that Cv-PC may provide a promising therapy for reducing postoperative edema and improving neurological function after neurosurgical procedures.
Subject(s)
Brain Edema/prevention & control , Brain/surgery , Frontal Lobe/injuries , Intraoperative Complications/drug therapy , Neuroprotective Agents/administration & dosage , Postoperative Complications/drug therapy , Snake Venoms/administration & dosage , Animals , Body Water/drug effects , Brain Edema/etiology , Brain Edema/metabolism , Brain Edema/pathology , Crotalus , Cyclooxygenase 2/metabolism , Cyclooxygenase 2 Inhibitors/pharmacology , Dinoprostone/metabolism , Disease Models, Animal , Epidermis/drug effects , Epidermis/immunology , Epidermis/pathology , Frontal Lobe/drug effects , Frontal Lobe/pathology , Frontal Lobe/surgery , Inflammation/drug therapy , Inflammation/metabolism , Inflammation/pathology , Intraoperative Complications/metabolism , Intraoperative Complications/pathology , Male , Neurosurgical Procedures , Nitrobenzenes/pharmacology , Postoperative Complications/metabolism , Postoperative Complications/pathology , Rats, Sprague-Dawley , Sulfonamides/pharmacologyABSTRACT
BACKGROUND: Complications after a thulium laser resection of the prostate (TmLRP) are related to re-epithelialization of the prostatic urethra. Since prostate growth and development are induced by androgen, the aim of this study was to determine the role and explore the mechanism of androgen in wound healing of the prostatic urethra. METHODS: Beagles that received TmLRPs were randomly distributed into a castration group, a testosterone undecanoate (TU) group, and a control group. The prostate wound was assessed once a week using a cystoscope. Histological analysis was then carried out to study the re-epithelialization of the prostatic urethra in each group. The inflammatory response in the wound tissue and urine was also investigated. RESULTS: The healing of the prostatic urethra after a TmLRP was more rapid in the castration group and slower in the TU group than that in the control group. Castration accelerated re-epithelialization by promoting basal cell proliferation in the wound surface and beneath the wound and by accelerating the differentiation of basal cells into urothelial cells. Castration reduced the duration of the inflammatory phase and induced the conversion of M1 macrophages to M2 macrophages, thus accelerating the maturation of the wound. By contrast, androgen supplementation enhanced the inflammatory response and prolonged the inflammatory phase. Moreover, the anti-inflammatory phase was delayed and weakened. CONCLUSION: Androgen deprivation promotes re-epithelialization of the wound, regulates the inflammatory response, and accelerates wound healing of the prostatic urethra after a TmLRP. Prostate 77:708-717, 2017. © 2017 Wiley Periodicals, Inc.
Subject(s)
Androgens , Intraoperative Complications , Prostate , Testosterone/analogs & derivatives , Transurethral Resection of Prostate/adverse effects , Urethra , Androgens/administration & dosage , Androgens/adverse effects , Androgens/metabolism , Animals , Disease Models, Animal , Dogs , Intraoperative Complications/metabolism , Intraoperative Complications/physiopathology , Intraoperative Complications/therapy , Macrophages/pathology , Macrophages/physiology , Male , Prostate/pathology , Prostate/surgery , Re-Epithelialization/drug effects , Re-Epithelialization/physiology , Statistics as Topic , Testosterone/administration & dosage , Testosterone/adverse effects , Testosterone/metabolism , Thulium/pharmacology , Transurethral Resection of Prostate/methods , Urethra/injuries , Urethra/pathology , Wound Healing/drug effects , Wound Healing/physiologyABSTRACT
OBJECTIVE: To determine whether preoperative regional cerebral oxygen saturation (rSO2) and the decrease in rSO2 during carotid clamping were predictive of the risk for neurologic complications in carotid endarterectomy and to determine the cutoff values of the studied parameters. DESIGN: Cohort, prospective, nonrandomized trial. SETTING: Research Institute of Circulation Pathology, Novosibirsk, Russia. PARTICIPANTS: The study comprised 466 adults who underwent carotid endarterectomy since 2012. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patient characteristics, postoperative complications, and brain oxygen supply during carotid endarterectomy were analyzed. The primary endpoints were the perioperative and early postoperative neurologic complications. Ischemic stroke was diagnosed in 1.5% of patients, and cognitive disorders were reported in 2.6% of patients. Preoperative rSO2 of 50% was the cutoff value for the prediction of stroke outcome after carotid endarterectomy, with a sensitivity of 90.7% and specificity of 66.7%. A 20% decrease in rSO2 during temporary carotid clamping was the cutoff value for the prediction of stroke, with a sensitivity of 86.0% and specificity of 57.1%, and for the prediction of cognitive disorders, with a sensitivity of 88.1% and specificity of 58.3%. Preoperative rSO2 less than 50% and a decrease in rSO2 of at least 20% during temporary carotid artery clamping caused a significant increase in the hospitalization period. CONCLUSIONS: A 20% or more decrease in rSO2 during temporary internal carotid artery clamping during carotid endarterectomy caused a 10-fold increased risk of ischemic stroke and an 8-fold increased risk of cognitive disorders, whereas preoperative rSO2 less than 50% resulted in a 6-fold increased risk of ischemic stroke in the perioperative and early postoperative periods of carotid endarterectomy.
Subject(s)
Brain/metabolism , Cerebrovascular Circulation/physiology , Endarterectomy, Carotid/adverse effects , Endarterectomy, Carotid/trends , Intraoperative Neurophysiological Monitoring/trends , Oxygen Consumption/physiology , Aged , Brain Ischemia/diagnosis , Brain Ischemia/etiology , Brain Ischemia/metabolism , Cognitive Dysfunction/diagnosis , Cognitive Dysfunction/etiology , Cognitive Dysfunction/metabolism , Cohort Studies , Female , Humans , Intraoperative Complications/diagnosis , Intraoperative Complications/etiology , Intraoperative Complications/metabolism , Intraoperative Neurophysiological Monitoring/methods , Male , Middle Aged , Oximetry/methods , Oximetry/trends , Prospective Studies , Risk Assessment , Spectroscopy, Near-Infrared/methodsABSTRACT
Inborn errors of metabolism (IEM) are characterized by the body's inability to convert food into energy. The pathogenetic mechanism is based on defects in a variety of cellular enzymes. In addition to impairment of energy generation, accumulation of substrates may occur, which can deposit in tissue and lead to organ dysfunction. IEM can have profound implications for perioperative management, including difficult airway management, cardiac dysfunction, aspiration risk, seizures, and metabolic dysregulation. For the anesthesiologist, comprehensive knowledge is difficult to attain because of the heterogeneity of this group and the low prevalence of specific diseases. The first part of this article reviews intermediary metabolism, whereas the second part aims to highlight important aspects in perioperative management of patients with IEM. Instead of reviewing each single disorder within the vast group of IEM, we provide a conceptual framework that will facilitate the understanding of main problems encountered in each of the disease subgroups.
Subject(s)
Anesthesia/methods , Anesthetics/administration & dosage , Intraoperative Complications/prevention & control , Metabolism, Inborn Errors/surgery , Pain Management/methods , Anesthesia/adverse effects , Anesthetics/adverse effects , Humans , Intraoperative Complications/etiology , Intraoperative Complications/metabolism , Metabolism, Inborn Errors/diagnosis , Metabolism, Inborn Errors/metabolism , Pain Management/adverse effectsABSTRACT
BACKGROUND: Better knowledge of albumin kinetics is needed to define the indications for albumin use in clinical practice. This study involved two approaches: the synthesis rate and transcapillary escape rate of albumin were measured simultaneously at different levels of plasma albumin concentration in relation to acute inflammation and surgery; and two different tracers were compared to determine plasma volume and the transcapillary escape rate. METHODS: Healthy volunteers (n = 10), patients with acute inflammatory abdominal disease (n = 10), and patients undergoing elective pancreatic resection (n = 10) were studied. The albumin synthesis rate was measured by the incorporation of deuterium-labeled phenylalanine. Plasma volume and the transcapillary escape rate were assessed using 123I-labeled and 125I-labeled albumin. RESULTS: A 50 % elevated de-novo albumin synthesis rate was seen in patients with acute inflammation and marked hypoalbuminemia, while patients with marginal hypoalbuminemia before the start of surgery had a normal albumin synthesis rate. The transcapillary escape rate was elevated intraoperatively during the reconstructive phase of pancreatic surgery, when plasma albumin was decreased but stable. In acute inflammation with marked hypoalbuminemia, the transcapillary escape rate was no different from normal. 123I-labeled and 125I-labeled albumin were found exchangeable for plasma volume determinations, but could be used only in groups of patients for the transcapillary escape rate. CONCLUSIONS: This observational study illustrates the limited information contained in albumin plasma concentrations to reflect albumin kinetics. On the contrary, single measurements of the synthesis rate and/or transcapillary escape rate of albumin obviously cannot explain the plasma level of albumin or the changes seen in plasma albumin concentration. TRIAL REGISTRATION: www.clinicaltrials.gov , study number NCT01686776 . Registered 13 September 2012.
Subject(s)
Capillary Permeability/physiology , Hypoalbuminemia/metabolism , Intraoperative Complications/metabolism , Plasma Volume/physiology , Serum Albumin/biosynthesis , Adult , Aged , Female , Humans , Hypoalbuminemia/diagnosis , Hypoalbuminemia/etiology , Inflammation/diagnosis , Inflammation/metabolism , Intraoperative Complications/diagnosis , Intraoperative Complications/etiology , Male , Middle Aged , Oximetry/methods , Serum Albumin/metabolismABSTRACT
PURPOSE: The aim of this study is to show whether peripheral perfusion monitoring methods reflect central perfusion during shoulder arthroscopy at beach chair position. We hypothesized that mean arterial pressure (MAP), central heart rate (CHR) and peripheral oxygenation (SaO2) measurements individually will not parallel cerebral oximetry measurements by near-infrared spectroscopy (NIRS). METHODS: Between 2011 and 2012, 53 patients who had arthroscopic rotator cuff repair surgery in the beach chair position were enrolled prospectively. Median ages of the patients were 58 (range 42-68) years. The regional cerebral oxygen saturation value of each hemisphere was continuously monitored by the use of NIRS. MAP, CHR, SaO2 and both hemispheric cerebral oxygen saturation values were recorded at six time periods peri-operatively. Correlation and differences between parameters were evaluated. RESULTS: Cerebral oxygen saturation of right hemisphere was dropped >20 % in 28.3 and 45.3 % of the patients. At left hemisphere, cerebral oxygen saturation was dropped >20 % in 20.8 and 43.4 % of the patients. Peripheral saturation values were statistically different from cerebral saturation values (p < 0.001). On the other hand, there was a correlation between cerebral saturation and MAP values (p < 0.05). CONCLUSION: Cerebral oximetry by NIRS may prove useful as a monitor for cerebral ischaemia. In the absence of NIRS, CHR can partially detect abnormalities but not trustable, and MAP is the most reliable method for monitoring.
Subject(s)
Arthroscopy , Brain Ischemia/diagnosis , Brain/metabolism , Intraoperative Complications/diagnosis , Oxygen/metabolism , Patient Positioning/adverse effects , Spectroscopy, Near-Infrared , Adult , Aged , Biomarkers/metabolism , Blood Pressure Determination , Brain Ischemia/etiology , Brain Ischemia/metabolism , Female , Heart Rate , Humans , Intraoperative Complications/etiology , Intraoperative Complications/metabolism , Male , Middle Aged , Oximetry , Patient Positioning/methods , Prospective Studies , Rotator Cuff/surgery , Rotator Cuff Injuries , Tendon Injuries/surgeryABSTRACT
BACKGROUND: Elevated periprocedural high sensitive C-reactive protein (hs-CRP) was shown to be associated with an increased risk for acute kidney injury (AKI) in non-myocardial infarction (MI) patients undergoing percutaneous coronary intervention (PCI), however, no information to date is present regarding its predicting role for AKI in MI patients. We evaluated whether admission serum hs-CRP levels may predict risk of AKI among ST elevation MI (STEMI) patients undergoing primary PCI. METHODS: Five hundred and sixty-two patients that were admitted with STEMI and treated with primary PCI were included in the study. Serum hs-CRP levels were determined from blood samples taken prior to PCI. Patients' medical records were reviewed for occurrence of AKI, in-hospital complications and 30 days mortality. RESULTS: Mean age was 62 ± 16 and 455 (80 %) were males. Patients were divided into two groups, according to their admission hs-CRP values: group 1: hs-CRP ≤9 mg/l (n = 394) and group 2: hs-CRP >9 mg/l (n = 168). Patients with hs-CRP >9 mg/l had significantly higher rate of AKI following PCI (17 vs. 6 %; p < 0.001), more in-hospital complications and higher30 -day mortality rate (11 vs. 1 %; p = 0.02). In a multivariable logistic regression model admission hs-CRP level >9 mg/l was an independent predictor for AKI (OR 2.7, 95 % CI: 1.39-5.29; p = 0.001) and a strong trend for 30 day mortality (OR 4.27, 95 % CI: 0.875-21.10; p = 0.07). CONCLUSION: Admission serum hs-CRP level >9 mg/l is an independent predictor for AKI following primary PCI in STEMI patients.
Subject(s)
Acute Kidney Injury/etiology , Biomarkers/analysis , C-Reactive Protein/analysis , Intraoperative Complications/metabolism , Myocardial Infarction/etiology , Percutaneous Coronary Intervention/adverse effects , Postoperative Complications/metabolism , Acute Kidney Injury/mortality , Aged , Electrocardiography , Female , Hospital Mortality , Humans , Intraoperative Complications/mortality , Male , Middle Aged , Myocardial Infarction/mortality , Percutaneous Coronary Intervention/mortality , Postoperative Complications/mortality , Predictive Value of Tests , Prognosis , Risk Factors , Treatment OutcomeABSTRACT
Aside from its actions on glycaemic control, insulin has been demonstrated to have a wide range of effects on the cardiovascular system. During the peri-operative period, the stress response to surgery leads to hyperglycaemia. There is continuing debate with regard to the level of glycaemic control and the potential benefits of insulin therapy in both diabetic and non-diabetic patients undergoing cardiac surgery. This review article sets out to discuss the evidence for glycaemic control, as well as the potential benefits of insulin therapy in the form of glucose-insulin-potassium therapy in cardiac surgery.
Subject(s)
Cardiac Surgical Procedures/adverse effects , Cardiovascular Diseases/surgery , Hyperglycemia/prevention & control , Hypoglycemic Agents/therapeutic use , Insulin/therapeutic use , Intraoperative Complications/prevention & control , Postoperative Complications/prevention & control , Blood Glucose/metabolism , Cardiovascular Diseases/metabolism , Cardiovascular Diseases/physiopathology , Critical Illness , Evidence-Based Medicine , Humans , Hyperglycemia/blood , Hyperglycemia/etiology , Intraoperative Complications/metabolism , Myocardium/metabolism , Perioperative Care , Postoperative Complications/metabolism , Randomized Controlled Trials as Topic , Treatment OutcomeABSTRACT
Cerebral ischemic events remain a major problem in patients undergoing cardiac and thoracic aortic surgery. Efforts to improve outcomes have been made in many aspects which include cerebral monitoring. New technology is making it possible to shed a light to the brain, which historically used to be a black box during general anesthesia in the operating room. Cerebral brain monitoring methods include cerebral oxymetry using near infrared spectroscopy, trans cranial Doppler, Jugular venous oxygen saturation, bispectral index, temporal artery pressure monitoring. Cerebral oxymetry probably is the most commonly used method among these based on its simplicity and reproducibility. Though it is easy to obtain numbers from cerebral oxymetry, it is important to understand the principle and the limitations to interpret the results, properly.
Subject(s)
Brain Ischemia/diagnosis , Brain Ischemia/prevention & control , Cerebrovascular Circulation , Intraoperative Complications/diagnosis , Intraoperative Complications/prevention & control , Intraoperative Neurophysiological Monitoring/methods , Oximetry/methods , Postoperative Complications/diagnosis , Postoperative Complications/prevention & control , Anesthesia, General , Arterial Pressure , Brain/metabolism , Brain Ischemia/metabolism , Brain Ischemia/physiopathology , Cardiovascular Surgical Procedures , Consciousness Monitors , Humans , Intraoperative Complications/metabolism , Intraoperative Complications/physiopathology , Jugular Veins , Oxygen/metabolism , Postoperative Complications/metabolism , Postoperative Complications/physiopathology , Spectroscopy, Near-Infrared , Temporal Arteries/physiology , Ultrasonography, Doppler, TranscranialABSTRACT
INTRODUCTION: Significant exposure to elemental mercury can occur if a mercury-weighted medical device is damaged during use. We report a case of an elemental mercury spill into the peritoneum of a patient undergoing laparoscopic gastric bypass surgery. CASE REPORT: A 64-year-old man with multiple comorbidities underwent an elective Roux-en-Y gastric bypass procedure for the treatment of morbid obesity. A mercury-weighted esophageal bougie was inadvertently used during construction of the anastomosis. A suture placed through the distal tip of the device caused elemental mercury to leak into the peritoneum. Two days later, the patient underwent another surgical procedure for removal of the mercury. Intermittent air measurements taken from the laparoscope exhaust showed a peak intraperitoneal mercury concentration of 98,169 ng/m³. Blood mercury levels peaked at 146 µg/L on day 22 after the exposure, and urine mercury concentrations peaked on day 43 at 227 µg/L. The patient had no evidence of acute toxicity, but he was found to have proteinuria on follow-up evaluation. DISCUSSION: Patients can be exposed inadvertently to toxic amounts of elemental mercury when the integrity of medical devices is compromised. We encourage hospitals to discontinue the use of devices that contain mercury. Effective alternatives that do not pose exposure risks to patients or health care workers are readily available.