Effect of thermal softening of double-lumen endobronchial tubes on postoperative sore throat in patients with prior SARS-CoV-2 infection: a randomized controlled trial.

BACKGROUND: The incidence of postoperative sore throat (POST) after tracheal intubation using double-lumen endobronchial tubes (DLTs) is higher in patients with prior severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection than in the general population. This prospective trial was conducted to determine whether thermal softening of DLTs could decrease the incidence of POST or other airway injuries in patients with prior SARS-CoV-2 infection. METHODS: A total of 120 patients with prior SARS-CoV-2 infection undergoing thoracoscopic surgery were randomly assigned to two groups (n = 60 each). In the thermal softening group, the distal portion of the DLT was placed in thermostatic saline (50 °C) for 10 min before endotracheal intubation. In the control group, the distal portion of the DLT was placed in room temperature saline for 10 min before endotracheal intubation. The incidence and severity of POST and hoarseness were assessed at 1, 6 and 24 h postoperatively. The primary outcomes were the incidence and severity of POST at 6 h postoperatively. The secondary outcomes were the incidence and severity of hoarseness, vocal cord and tracheal injuries, and hemodynamic changes in patients at intubation. RESULTS: The incidence of POST at 6 h postoperatively was greater in the control group than in the thermal softening group [41 (68%) vs. 22 (37%), P = 0.001]. The overall incidence of POST at 24 h postoperatively was greater in the control group than in the thermal softening group [46 (76%) vs. 24 (40%), P < 0.001]. The overall incidence of tracheal injuries was also greater in the control group than in the thermal softening group (P = 0.016). Vocal cord injuries occurred more frequently in the control group than in the thermal softening group (P = 0.006). CONCLUSION: Thermal softening of DLTs before intubation can reduce the incidence of POST and airway injuries in patients with prior SARS-CoV-2 infection undergoing DLT insertion. TRIAL REGISTRATION: This trial has been registered at www.chictr.org.cn (registration number: ChiCTR2200066821; registration date: December 19, 2022).

Effects of Different 0.2% Ropivacaine Infusion Regimens for Continuous Interscalene Brachial Plexus Block on Postoperative Analgesia and Respiratory Function After Shoulder Arthroscopic Surgery: A Randomized Clinical Trial.

Objective: Continuous interscalene brachial plexus block (cIBPB) is an effective perioperative analgesic therapy for shoulder arthroscopic surgery (SAS) patients. This trial aimed to compare the effect of different cIBPB infusion methods on postoperative analgesia and respiratory function in patients undergoing SAS. Methods: After SAS, 88 patients were randomly assigned to four groups. Through interscalene catheter, all the patients received an initial dose of 10 mL 0.2% ropivacaine. The CI group received 0.2% ropivacaine 4 mL/h, and the PIBI1, PIBI2, and PIBI3 groups received intermittent 0.2% ropivacaine boluses at 4 mL/h, 8 mL/2 h, and 12 mL/3 h, respectively. The patients could also use a patient-controlled analgesia (PCA) pump to self-inject a tramadol bolus each time he/she felt pain. The primary outcome was the cumulative tramadol consumption over the 48 h after surgery. Secondary outcome measures included PCA frequency, pain (visual analogue scale, VAS) score, patient satisfaction, diaphragmatic excursion, pulmonary function, and adverse events. Results: The cumulative tramadol consumption and PCA frequency over the 48 h after surgery in groups PIBI2 and PIBI3 were lower than in both the CI and PIBI1 groups (p<0.001). The VAS scores (at rest and on movement) in groups PIBI2 and PIBI3 were lower than those in the CI and PIBI1 groups at 8 and 12 h after surgery (all p<0.001). Patient satisfaction scores were significantly higher in the PIBI2 group than in the other three groups (all p<0.001). Diaphragmatic excursion was significantly decreased in the PIBI3 group compared to the other three groups (p<0.05). The incidence of adverse events over the 48 h after surgery was significantly higher in the PIBI3 group compared to the other three groups (p<0.001). Conclusion: Programmed intermittent bolus infusion with 0.2% ropivacaine 8 mL/2 h for cIBPB can achieve lower tramadol consumption, along with better analgesia after surgery, lower reduction in diaphragmatic excursion, lower incidence of adverse events, and higher patient satisfaction.

The efficiency of ultrasound-guided erector spinae plane block in early cervical cancer patients undergoing laparotomic radical hysterectomy: A double-blind randomized controlled trial.

Aims: We aim to compare the efficiency of erector spinae plane block (ESPB) with transversus abdominis plane block (TAPB) in patients undergoing laparotomic radical hysterectomy because only a few studies are reported exploring this matter. Methods: In this randomized controlled trail, 154 eligible patients were randomly allocated into ESPB group [ESPB + patient-controlled intravenous analgesia (PCIA)] and TAPB group (TAPB + PCIA) at 1:1 ratio. The primary outcome was visual analog scale (VAS) score at rest state at 12 h. Results: We found that ESPB group was associated with the lower VAS scores at rest and cough state than TAPB group at 2, 4, 6, 12, and 24 h postoperatively (P < 0.05). Less analgesic consumption and sufentanil consumption in PCIA pump were found in the ESPB group (P < 0.05). Moreover, ESPB group was followed by fewer rescue analgesia requirements, less rescue analgesic consumption, less adverse reactions, and higher analgesia satisfaction (P < 0.05). Conclusions: Our study found that ESPB had advantages on analgesic effect and opioids consumption. In the future, more studies were needed to confirm our findings. Systematic Review Registration: https://www.chictr.org.cn/index.aspx, identifier: ChiCTR2100044240.

Effect of perioperative flurbiprofen axetil on long-term survival of patients with esophageal carcinoma who underwent thoracoscopic esophagectomy: A retrospective study.

BACKGROUND AND OBJECTIVES: Nonsteroidal anti-inflammatory drugs (NSAIDs) have an anti-inflammatory response, but it remains unclear whether the perioperative use of flurbiprofen axetil can influence postoperative tumor recurrence and survival in esophageal carcinoma. We aimed to explore the effect of perioperative intravenous flurbiprofen axetil on recurrence-free survival (RFS) and overall survival (OS) in patients with esophageal carcinoma who underwent thoracoscopic esophagectomy. METHODS: This retrospective study included patients who underwent surgery for esophageal carcinoma between December 2009 and May 2015 at the Department of Thoracic Surgery, Anhui Provincial Hospital. Patients were categorized into a non-NSAIDs group (did not receive flurbiprofen axetil), single-dose NSAIDs group (received a single dose of flurbiprofen axetil intravenously), and multiple-dose NSAIDs group (received multiple doses of flurbiprofen). RESULTS: A total of 847 eligible patients were enrolled. Univariable and multivariable analyses revealed that the intraoperative use of flurbiprofen was associated with long-term RFS (hazard ratio [HR]: 0.56, 95% confidence interval [CI]: 0.42-0.76, p = .001) and prolonged OS (HR: 0.49, 95% CI: 0.38-0.63, p = .001). CONCLUSIONS: Perioperative flurbiprofen axetil therapy may be associated with prolonged RFS and OS in patients with esophageal carcinoma undergoing thoracoscopic esophagectomy.

Sufentanil Protects the Liver from Ischemia/Reperfusion-Induced Inflammation and Apoptosis by Inhibiting ATF4-Induced TP53BP2 Expression.

Liver ischemia-reperfusion (I/R) injury is a pathological process that often occurs during liver and trauma surgery. This study aimed to investigate the protective effect and potential mechanisms of sufentanil on hepatic I/R injury. I/R rat model and hypoxic/reoxygenation (H/R)-induced buffalo rat liver (BRL)-3A cell model were established. Following pretreatment with sufentanil, the enzymatic activities of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) in rat serum and the changes of hepatic histopathology were evaluated to track the extent of liver injury. The levels of inflammatory factors were determined with ELISA kits and RT-qPCR. The infiltration of macrophages was assessed after detecting monocyte chemoattractant protein 1 (MCP-1) and F4/80 expression. Additionally, apoptosis was measured by means of TUNEL staining, and gene expression related to apoptosis was examined using RT-qPCR and western blotting. Then, TP53BP2 was overexpressed in BRL-3A cells exposed to H/R condition to evaluate whether sufentanil defended the liver against injury by regulating TP53BP2 expression. Moreover, the potential binding site of ATF4 on the TP53BP2 promoter was analyzed using JASPAR databases and verified by chromosomal immunoprecipitation (ChIP) assay. Furthermore, TP53BP2 expression and endoplasmic reticulum stress (ERS)-related protein levels were determined after ATF4 was overexpressed in sufentanil-treated BRL-3A cells. Results revealed that sufentanil significantly improved hepatic I/R injury, decreased the levels of inflammatory factors, and alleviated hepatocyte apoptosis. Notably, upregulated TP53BP2 expression was observed in hepatic tissues, and TP53BP2 overexpression markedly reversed the protective effects of sufentanil on the inflammation and apoptosis in H/R-stimulated BRL-3A cells. Additionally, ATF4 was confirmed to combine with the TP53BP2 promoter. ATF4 upregulation attenuated the inhibitory effects of sufentanil on the expression of TP53BP2 and ERS-associated proteins. These findings demonstrated that sufentanil protects the liver from inflammation and apoptosis injury induced by I/R by inhibiting ATF4 expression and further suppressing TP53BP2 expression, suggesting a promising therapeutic candidate for the treatment of liver I/R injury.

Preoperative anxiety predicted the incidence of postoperative delirium in patients undergoing total hip arthroplasty: a prospective cohort study.

BACKGROUND: Delirium was characterized with a series of symptoms of a sudden onset of disturbances in attention, a loss in memory loss and defects in other cognitive abilities that were also appeared in the syndrome of anxiety. Even though there are overlapped clinical symptoms existed in anxiety and delirium, the relationship between anxiety and delirium was still unclear. The propose of this study was to investigated the effect of preoperative anxiety on postoperative delirium. METHODS: Three hundred and seventy-two adults undergoing total hip arthroplasty were enrolled from October 2019 to May 2020 in the study. The preoperative anxiety was measured with the Hospital Anxiety and Depression Scale-Anxiety (HADS-A). The participants were allocated into anxiety group (HADS-A≧7) and non-anxiety group (HADS-A < 7). The primary outcome was the incidence of the postoperative delirium assessed with the Confusion Assessment Method (CAM). The secondary outcomes were the duration and the severity of delirium evaluated with the Memorial Delirium assessment Scale (MDAS). The risks of delirium were also evaluated with logistic regression analysis. RESULTS: There were 325 patients enrolled in the end, 95 of whom met the criteria for anxiety. The incidence of delirium was 17.8% in all participants. The patients with anxiety had a higher incidence of delirium than the non-anxiety patients (25.3% vs. 14.8%, odds ratio (OR) = 0.51, 95% confidence interval (CI) = 0.92-0.29, p = 0.025). However, no significant differences were found in the duration and the severity of the delirium between the above two groups. The age, alcohol abuse, history of stroke, scores of the HADS-A, and education level were considered to be predictors of delirium. CONCLUSIONS: The preoperative anxiety predicted the incidence of the postoperative delirium in total hip arthroplasty patients. The related intervention may be a good point for delirium prophylaxis. TRIAL REGISTRATION: It was registered at Chinese Clinical Trial Registry ( www.chictr.org.cn ) with the name of "the effect of preoperative anxiety on the postoperative cognitive function" ( ChiCTR1900026054 ) at September 19, 2019.

Paracoxib Alleviates Ventilator-Induced Lung Injury Through Functional Modulation of Lung-Recruited CD11bloLy6Chi Monocytes.

OBJECTIVE: Lung-recruited Ly6Chi monocytes had been shown to be involved in ventilator-induced lung injury (VILI). Our present study aimed to investigate whether the cyclooxygenase-2 (COX-2) inhibition modulates the function of lung-recruited Ly6Chi monocytes in a mouse model of VILI. METHODS: Mice were exposed to lipopolysaccharide (LPS; 20 ng) intraperitoneally prior to injurious mechanical ventilation (Vt = 30 mL/kg, PEEP = 0 cmH2O). A subgroup of mice was treated with intravenous parecoxib (30 mg/kg), a COX-2 inhibitor, 1 h prior to ventilation. Control mice received saline and were not ventilated. At the end of the experiment, blood gas analysis was performed and lung tissue was collected for histological assessment. Flow cytometry was employed to quantify the different populations of lung monocytes/macrophages and their function. Isolated Ly6Chi cells were used to measure the intracellular concentrations of reactive oxygen species (ROS) and nitric oxide (NO) by fluorescent probes, and cytokine production by cytometric bead array. RESULTS: Exposure to LPS and injurious ventilation was associated with severe lung histological damage, oxygenation impairment, and pulmonary edema; all of which were largely attenuated following the treatment of parecoxib. Furthermore, flow cytometry analysis revealed that parecoxib caused a reduction in the number of the lung-recruited CD11bloLy6Chi monocytes while there was no effect on tissue-resident CD64+ alveolar macrophages. In addition, the production of oxidative stress products (ROS, NO), MHC-II expression, and inflammatory cytokines in response to LPS and VILI in CD11bloLy6Chi monocytes was ameliorated by parecoxib. CONCLUSION: Parecoxib-induced alleviation of oxidative stress and inflammation in lung-recruited Ly6Chi monocytes may partly explain the beneficial action of COX-2 inhibition in VILI.

Operation, Effectiveness, and Limitations of Continuous Serratus Anterior Plane Blocks for Thoracoscopic Surgery in Adults.

PURPOSE: This randomized, double-blind study evaluated the effectiveness and limitations of continuous serratus anterior plane block (cSAPB) by comparing the effect of cSAPB to patient-controlled intravenous analgesia (PCIA) on postoperative acute pain after thoracoscopic surgery in adults. PATIENTS AND METHODS: Sixty-six patients who underwent elective video-assisted thoracoscopic surgery (VATS) were randomly allocated to cSAPB or PCIA groups (n=33 per group) after surgery. For the cSAPB group, patients were treated by an initial does of 20 mL ropivacaine (0.375%), followed by continuous infusion at a rate of 5 mL/h of ropivacaine (0.2%) and a patient-controlled bolus of 5 mL ropivacaine (0.2%). PCIA started with an initial does of 0.03 µg/kg sufentanil, followed by a basal infusion of 0.03 µg/kg/h sufentanil and a patient-controlled bolus of 0.03 µg/kg sufentanil. Visual analog scale (VAS) and other items were examined postoperatively. The area under the curve of VAS-time (AUCVAS-time) at rest and on coughing in the first 24 hours postoperatively were primary outcomes. RESULTS: At the first 24 hours postoperatively, patients in the cSAPB group exhibited a smaller AUCVAS-time at rest (44.0±17.1 vs 68.9±11.8 cm·h, P<0.001) and AUCVAS-time on coughing (67.1±8.8 vs 78.0±12.5 cm·h, P<0.001) compared with those in the PCIA group. The differences in means of VAS score at rest were more than 1.0 cm between the two groups, however, on coughing they were less than 1.0 cm at each observation point. Additionally, patients in the cSAPB group had a longer time to first patient-controlled bolus (15.8±7.6 vs 10.6±8.6 hours, P=0.011). Furthermore, a higher rank of satisfaction was recorded with patients in the cSAPB group. CONCLUSION: cSAPB using PCA devices might be superior to traditional intravenous continuous analgesia, particularly with an advantage of pain relief at rest following VATS operation. Meanwhile, cSAPB lacks a satisfactory analgesic effect on cough.

Intraoperative Flurbiprofen Treatment Alters Immune Checkpoint Expression in Patients Undergoing Elective Thoracoscopic Resection of Lung Cancer.

OBJECTIVES: This study aimed to determine the effect of intraoperative administration of flurbiprofen on postoperative levels of programmed death 1 (PD-1) in patients undergoing thoracoscopic surgery. MATERIALS AND METHODS: In this prospective double-blind trial, patients were randomized to receive intralipid (control group, n = 34, 0.1 mL/kg, i.v.) or flurbiprofen axetil (flurbiprofen group, n = 34, 50 mg, i.v.) before induction of anesthesia. PD-1 levels on T cell subsets, inflammation, and immune markers in peripheral blood were examined before the induction of anesthesia (T0) and 24 h (T1), 72 h (T2), and 1 week (T3) after surgery. A linear mixed model was used to determine whether the changes from baseline values (T0) between groups were significantly different. RESULTS: The increases in the percentage of PD-1(+)CD8(+) T cells observed at T1 and T2 in the control group were higher than those in the flurbiprofen group (T1: 12.91 ± 1.65 vs. 7.86 ± 5.71%, p = 0.031; T2: 11.54 ± 1.54 vs. 8.75 ± 1.73%, p = 0.004), whereas no differences were observed in the changes in the percentage of PD-1(+)CD4(+) T cells at T1 and T2 between the groups. Moreover, extensive changes in the percentage of lymphocyte subsets and inflammatory marker concentrations were observed at T1 and T2 after surgery and flurbiprofen attenuated most of these changes. CONCLUSIONS: Perioperative administration of flurbiprofen attenuated the postoperative increase in PD-1 levels on CD8(+) T cells up to 72 h after surgery, but not after this duration. The clinical relevance of changes in PD-1 levels to long-term surgical outcome remains unknown.

Acid-sensing ion channel 3 expression is increased in dorsal root ganglion, hippocampus and hypothalamus in remifentanil-induced hyperalgesia in rats.

BACKGROUND: Remifentanil induces hyperalgesia, but the underlying mechanisms are not fully understood. Acid-sensing ion channel 3 (ASIC3) plays a regulatory role in the pain pathway. This study aimed to explore the effect of remifentanil administration on postoperative pain and on ASIC3 expression at the prespinal and supraspinal levels in a rat model. METHODS: Rats were randomly allocated to the control, incision, remifentanil, and remifentanil + incision groups. Remifentanil was given by a 1-h intravenous infusion prior to plantar incision. Paw withdrawal mechanical threshold (PWMT) and paw withdrawal thermal latency (PWTL) were measured at different time points before and after incision to evaluate mechanical and thermal hyperalgesia, respectively. The dorsal root ganglion (DRG), hippocampus, and hypothalamus were obtained after sacrifice at 48 h post-incision for determination of the protein expression of ASIC3 using western blot. RESULTS: Remifentanil administration significantly induced mechanical and thermal hyperalgesia from 2 to 48 h after incision. In addition, remifentanil exposure remarkably stimulated ASIC3 protein expression in DRG, hippocampus, and hypothalamus of rats at 48 h after incision. CONCLUSION: Remifentanil-induced hyperalgesia is accompanied by increased ASIC3 expression at the DRG and supraspinal levels, implying a possible involvement of ASIC3 in remifentanil-induced hyperalgesia.

Renin-angiotensin-system, a potential pharmacological candidate, in acute respiratory distress syndrome during mechanical ventilation.

While effective treatments for acute respiratory distress syndrome (ARDS) are lacking, mechanical lung ventilation can sustain adequate gas exchange in critically ill patients with respiratory failure due to ARDS. However, as a result of the phenomenon of ventilator-induced lung injury (VILI), there is an increasing need to seek beneficial pharmacological therapies for ARDS. Recent studies have suggested the renin-angiotensin system (RAS), which consists of the ACE/Ang-II/AT1R axis and ACE2/Ang-(1-7)/MasR axis, plays a dual role in the pathogenesis of ARDS and VILI. This review highlights the deleterious action of ACE/Ang-II/AT1R axis and the beneficial role of ACE2/Ang-(1-7)/MasR axis, as well as AT2R, in VILI and ARDS, and also discusses the possibility of targeting RAS components with pharmacological interventions to improve outcomes in ARDS.

Goal-directed fluid restriction using stroke volume variation and cardiac index during one-lung ventilation: a randomized controlled trial.

BACKGROUND: Goal-directed therapy confers a strong prognosis in patients undergoing major cardiac or noncardiac surgery. The present study investigated whether intraoperative goal-directed fluid restriction (GDFR) using stroke volume variation (SVV) and cardiac index could improve oxygenation and postoperative outcome in patients undergoing one-lung ventilation (OLV). METHODS: A Total of 168 patients scheduled for elective thoracoscopic lobectomy under OLV were randomized into the GDFR protocol (group G) or conventional fluid therapy groups (group C). Patients in group C underwent conventional fluid therapy based on mean arterial pressure (MAP), central venous pressure (CVP), and urine volume, whereas those in group G received GDFR protocol associated with the SVV from 10-13% and the cardiac index was controlled at a minimum of 2.5 L/min/m2. The primary outcome variable was PaO2/FiO2. The secondary outcomes were other pulmonary variables and lung mechanics, inflammatory response, the incidence of postoperative pulmonary complications, and the length of hospital stay. RESULTS: During surgery, the PaO2/FiO2 ratio in group G was more than that of group C at 30 and 60 min after OLV, 10 min after re-expansion, and the end of the operation (259±29 vs. 314±34; 253±30 vs. 308±35; 341±34 vs. 394±39; 349±35 vs. 401±39, respectively, all P<0.001). Compared to conventional fluid therapy, GDFR protocol also significantly improved the hemodynamic and lung mechanics with the initiation of OLV. The incidence of postoperative pulmonary complications such as acute lung injury and pneumonia, and the length of hospital stay were decreased by GDFR protocol as compared to conventional fluid therapy (all P<0.05). However, there were no significant differences between groups with respect to the concentration of serum tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), and interleukin-10 (IL-10). CONCLUSIONS: The GDFR protocol based on SVV and cardiac index applied in patients undergoing OLV improves intraoperative pulmonary oxygenation. It can also reduce the postoperative complications and length of hospital stay. However, the GDFR strategy cannot reduce the local or systemic inflammation. TRIAL REGISTRATION: Chinese Clinical Trials Register ChiCTR-INR-16008288, Registered 20 April, 2016.

Propofol in combination with remifentanil for cesarean section: Placental transfer and effect on mothers and newborns at different induction to delivery intervals.

OBJECTIVE: This study aims to describe the administration of propofol in combination with remifentanil for the induction of general anesthesia during cesarean section (CS). Our aim was to evaluate its impact on the drug concentrations of the maternal and neonatal blood at different induction of anesthesia to delivery (I-D) intervals as well as its effect on newborns. MATERIALS AND METHODS: In this double-blind randomized controlled study, patients undergoing elective CS were administered anesthesia at short (n = 20) or long (n = 20) I-D intervals. Anesthesia was induced with 1 mg/kg propofol and 1 µg/kg remifentanil and maintained by continuous infusion of 3 mg/kg/h propofol and 7 µg/kg/h remifentanil. RESULTS: The mean plasma propofol concentrations at delivery in the maternal arterial (MA) blood and the fetal umbilical arterial (UA) and venous (UV) blood in the short I-D interval group were 1.91, 1.17, and 0.51 µg/mL, respectively, while those in the long I-D interval group were 1.57, 1.07, and 0.61 µg/mL, respectively. The mean plasma remifentanil concentrations at delivery in the MA, UA, and UV in the short I-D interval group were 2.25, 1.43, and 0.65 ng/mL, respectively, and those in the long I-D interval group were 1.96, 1.25, and 0.75 ng/mL, respectively. There were no statistically significant differences in the neonatal Apgar scores and neurological adaptive capacity scores between the two groups. CONCLUSIONS: It is safe to administer propofol in combination with remifentanil by continuous infusion after the bolus dose for the induction of anesthesia during cesarean section. Prolonging the I-D interval within a certain limit will not have any significant influence on the fetus.

A short-term increase of the postoperative naturally circulating dendritic cells subsets in flurbiprofen-treated patients with esophageal carcinoma undergoing thoracic surgery.

The present study evaluated whether flurbiprofen increased the naturally circulating dendritic cells (DCs) subsets in patients with esophageal squamous cell carcinoma (ESCC) undergoing esophageal resection. Compared to healthy donors (n=20), the significantly depressed percentages of plasmacytoid DCs (pDCs), CD1c+ myeloid DCs (mDCs), and CD141+ mDCs among ESCC patients (n=60) were confirmed. Flurbiprofen was administered before skin incision and at the end of operation in group F (n=30), as well as placebo in group C (n=30). The postoperative suppressed percentages of pDCs, CD1c+ mDCs, and CD141+ mDCs increased significantly following the perioperative treatment with flurbiprofen. Flurbiprofen also significantly stimulated the postoperative IFN-f and IL-17 production, but inhibited the immunosuppressive IL-10 and TGF-ß levels. Furthermore, flurbiprofen exerted a similar analgesic effect and brought a significantly less sufentanil consumption compared to group C. Taken together, flurbiprofen provided a short-term increase of postoperative naturally circulating DCs in ESCC patients.