MitoQ protects against liver injury induced by severe burn plus delayed resuscitation by suppressing the mtDNA-NLRP3 axis.

INTRODUCTION: Liver injury induced by burn plus delayed resuscitation (B + DR) is life threatening in clinical settings. Mitochondrial damage and oxidative stress may account for the liver injury. MitoQ is a mitochondria-targeted antioxidant. We aimed to evaluate whether MitoQ protects against B + DR-induced liver injury. METHODS: Rats were randomly divided into three groups: (1) the sham group; (2) the B + DR group, which was characterized by third-degree burn of 30% of the total body surface area plus delayed resuscitation, and (3) the treatment group, in which rats from the B + DR model received the target treatment. MitoQ was injected intraperitoneally (i.p) at 15 min before resuscitation and shortly after resuscitation. In the vitro experiments, Kupffer cells (KCs) were subjected to hypoxia/reoxygenation (H/R) injury to simulate the B + DR model. Mitochondrial characteristics, oxidative stress, liver function, KCs apoptosis and activation of the NLRP3 inflammasome in KCs were measured. RESULTS: B + DR caused liver injury and oxidative stress. Excessive ROS lead to liver injury by damaging mitochondrial integrity and activating the mitochondrial DNA (mtDNA)-NLRP3 axis in KCs. The oxidized mtDNA, which was released into the cytosol during KCs apoptosis, directly bound and activated the NLRP3 inflammasome. MitoQ protected against liver injury by scavenging intracellular and mitochondrial ROS, preserving mitochondrial integrity and function, reducing KCs apoptosis, inhibiting the release of mtDNA, and suppressing the mtDNA-NLRP3 axis in KCs. CONCLUSION: MitoQ protected against B + DR-induced liver injury by suppressing the mtDNA-NLRP3 axis.

Postoperative Recurarization in a Pediatric Patient After Sugammadex Reversal of Rocuronium-Induced Neuromuscular Blockade: A Case Report.

We present a case of a pediatric patient who developed recurarization after a cardiac catheterization procedure. Intraoperative neuromuscular blockade was achieved with 2 doses of rocuronium, and the blockade was reversed with a bolus dose of sugammadex at the end of the procedure. While recovering in the pediatric cardiac intensive care unit, the patient developed respiratory failure and a decline in the train-of-four response. The patient fully recovered after receiving a second dose of sugammadex.

Incidence, risk factors, and consequences of residual neuromuscular block in the United States: The prospective, observational, multicenter RECITE-US study.

STUDY OBJECTIVE: To determine the incidence burden and associated risk factors of residual neuromuscular block (rNMB) during routine U.S. hospital care. DESIGN: Blinded multicenter cohort study. SETTING: Operating and recovery rooms of ten community and academic U.S. hospitals. PATIENTS: Two-hundred fifty-five adults, ASA PS 1-3, underwent elective abdominal surgery with general anesthesia and ≥1 dose of non-depolarizing neuromuscular blocking agent (NMBA) for endotracheal intubation and/or maintenance of NMB between August 2012 and April 2013. INTERVENTIONS: TOF measurements using acceleromyography were performed on patients already receiving routine anesthetic care for elective open or laparoscopic abdominal surgery. Measurements allowed assessment of the presence of residual neuromuscular block (rNMB), defined as a train-of-four (TOF) ratio <0.9 at tracheal extubation. We recorded patient and procedural characteristics and assessed TOF ratios (T4/T1) at various times throughout the procedure and at tracheal extubation. Differences in patient and clinical characteristics were compared using Fisher's exact test for categorical variables and t-test for continuous variables. Multivariate logistic regression assessed risk factors associated with rNMB at extubation. MAIN RESULTS: Most of the study population, 64.7% (n = 165) had rNMB (TOF ratio < 0.9), among them, 31.0% with TOF ratio <0.6. Among those receiving neostigmine and/or qualitative peripheral nerve stimulation per clinical decision, 65.0% had rNMB. After controlling for confounders, we observed male gender (odds ratio: 2.60, P = 0.008), higher BMI (odds ratio: 1.04/unit, P = 0.043), and surgery at a community hospital (odds ratio: 3.15, P = 0.006) to be independently associated with increased odds of rNMB. CONCLUSIONS: Assessing TOF ratios blinded to the care team, we found that the majority of patients (64.7%) in this study had rNMB at tracheal extubation, despite neostigmine administration and qualitative peripheral nerve stimulation used for routine clinical care. Qualitative neuromuscular monitoring and clinical judgement often fails to detect rNMB after neostigmine reversal with potential severe consequences to the patient. Our data suggests that clinical care could be improved by considering quantitative neuromuscular monitoring for routine care.

Residual neuromuscular blockade: management and impact on postoperative pulmonary outcome.

PURPOSE OF REVIEW: To revise the current literature on concepts for neuromuscular block management. Moreover, consequences of incomplete neuromuscular recovery on patients' postoperative pulmonary outcome are evaluated as well. RECENT FINDINGS: The incidence of residual paralysis may be as high as 70% and even small degrees of residual paralysis may have clinical consequences. Neostigmine should not be given before return of the fourth response of the train-of-four-stimulation and no more than 40-50 µg/kg should be given. Sugammadex acts more rapidly and more predictably than neostigmine. Finally, there is convincing evidence in the literature that incomplete neuromuscular recovery may lead to a poor postoperative pulmonary outcome. SUMMARY: New evidence has emerged about the pathophysiological implications of incomplete neuromuscular recovery. Not only are the pulmonary muscles functionally impaired, but respiratory control is also affected. Residual paralysis endangers the coordination of the pharyngeal muscles and the integrity of the upper airway. However, neuromuscular monitoring and whenever needed pharmacological reversal prevent residual paralysis.

Retraso en el despertar por accidente cerebrovascular / Delayed awakening due to stroke

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[NON-CONVULSIVE EPILEPTIC SEIZURE IN PATIENT WITH DELAYED AWAKENING AFTER SUPRATENTORIAL TUMOR REMOVAL].

In some cases after elective neurosurgical procedures we use technique of delayed awakening of patients. Prolonged sedation however can hide the development of epileptic seizures and lead to the status epilepticus formation. This article is a demonstration and discussion of a clinical case of nonconvulsive status epilepticus during delayed awakening of the patient due to prolonged sedation after elective neurosurgical interventionsforsupratentorial brain tumor Presented case suggests the presence of significant risk of nonconvulsive status epilepticus during prolonged sedation. For early detection we advise to use continuous EEG monitoring during the entire period of sedation.

Longer Immediate Recovery Time After Anesthesia Increases Risk of Respiratory Complications After Laparotomy for Bariatric Surgery: a Randomized Clinical Trial and a Cohort Study.

BACKGROUND: We compared the effects of two anesthesia protocols in both immediate recovery time (IRT) and postoperative respiratory complications (PRCs) after laparotomy for bariatric surgery, and we determined the association between the longer IRT and the increase of PRC incidence. METHODS: We conducted the study in two stages: (i) in a randomized controlled trial (RCT), patients received either intervention (sevoflurane-remifentanil-rocuronium-ropivacaine) or control protocol (isoflurane-sufentanil-atracurium-levobupivacaine). All patients received general anesthesia plus continuous epidural anesthesia and analgesia. Treatment was masked for all, except the provider anesthesiologist. We defined IRT as time since anesthetics discontinuation until tracheal extubation. Primary outcomes were IRT and PRCs incidence within 15 days after surgery. We also analyzed post-anesthesia care unit (PACU) and hospital length of stays; (ii) after the end of the RCT, we used the available data in an extension cohort study to investigate IRT > 20 min as exposure factor for PRCs. RESULTS: Control protocol (n = 152) resulted in longer IRT (30.4 ± 7.9 vs 18.2 ± 9.6 min; p < 0.0001), higher incidence of PRCs (6.58 vs 2.5 %; p = 0.048), and longer PACU and hospital stays than intervention protocol (n = 200); PRC relative risk (RR) = 2.6. Patients with IRT > 20 min (n = 190) presented higher incidence of PRCs (7.37 vs 0.62 %; p < 0.0001); RR = 12.06. CONCLUSIONS: Intervention protocol, with short-acting anesthetics, was more beneficial and safe compared to control protocol, with long-acting drugs, regarding the reduction of IRT, PRCs, and PACU and hospital stays for laparotomy in bariatric patients. We identified a 4.5-fold increase in the relative risk of PRCs when morbid obese patients are exposed to an IRT > 20 min.

Síndrome confusional agudo postanestesia en el paciente geriátrico de urgencia / Acute confusional postanesthesia in geriatric patient emergency

Introducción: el Síndrome Confusional Agudo o delirio es una enfermedad frecuente, se encuentra entre el 10-15 por ciento de los pacientes médico-quirúrgicos y esta proporción se eleva al 30 por ciento en los pacientes geriátricos. Objetivo: valorar la presencia de Síndrome Confusional Agudo postanestésico o delirio en el geriátrico de urgencia. Métodos: se realizó un estudio descriptivo, prospectivo en 100 pacientes ancianos atendidos en el servicio de anestesiología del Hospital Dr. Gustavo Aldereguía Lima de Cienfuegos, durante el período enero del 2012 a Junio del 2013. Se identificaron las complicaciones perioperatorias y se aplicó el test de Pfeiffer a los pacientes antes y 1 horas de aplicado el proceder anestésico. Resultados: al aplicar el test de Pfeiffer en los pacientes que recibieron anestesia general se encontró que el mayor número de enfermos presentó deterioro leve en un 42 por ciento, seguido por el deterioro moderado para un 33 por ciento. La anestesia regional mostró mayor número de enfermo sin grado de deterioro. En la distribución de las complicaciones postoperatorias se evidenció que predominó la confusión mental en 30 por ciento de los casos, seguidas de hipotensión, hipertensión y taquicardia en un mayor número de pacientes. Conclusiones: el estado confusional agudo en el paciente atendido por los servicios de urgencia obedece a varios factores en los que el estado previo del enfermo y las diferentes modificaciones a que es sometido el mismo a punto de partida de las exigencias de la intervención quirúrgica son elementos favorecedores de su aparición(AU)

Introduction: The Syndrome Sharp Confusional (SCA) or delirium is a frequent illness, it is among 10-15 percent of the medical patients - surgical, and this proportion rises to 30 percent in the patient geriatrics.Objective: To value the presence of Syndrome Confusional Sharp postanestésico or delirium in the geriatric of urgency. Method: He/she was carried out a descriptive study, prospective in 100 old patients assisted in the service of anesthesiology of the Hospital Dr. Gustavo Aldereguía Lima of Cienfuegos, during the period January of the 2012 to June of the 2013. The complications perioperatorias were identified and the test was applied before from Pfeiffer to the patients and 1 hours of having applied proceeding anesthetic. Results: When applying the test of Pfeiffer in the patients that received general anesthesia it was found that the biggest number of sick persons presented light deterioration in 42 percent, continued by the moderate deterioration for 33 percent. The regional anesthesia howed bigger number of sick without grade of deterioration. In the distribution of the postoperative complications it was evidenced that the mental confusion prevailed in 30 percent of the cases, followed by hypotension, hypertension and taquicardia in a bigger number of patient. Conclusions: The state sharp confusional in the patient assisted by the services of urgency obeys several factors in those that the sick person's previous state and the different modifications to that it is subjected the same one about to departure of the demands of the surgical intervention is elements favorecedores of its appearance(AU)

Takotsubo cardiomyopathy and anaesthesia: case report and review of the literature.

Takotsubo cardiomyopathy is an acute syndrome characterized by cardiac failure from disturbances in the contractility of the left ventricle. It is presumably caused by sympathetic over stimulation. We describe a case of postoperatively developed Takotsubo cardiomyopathy in a 69-year-old female. The syndrome developed in connection with awareness during complete residual paralysis. The literature on this syndrome is reviewed and implications for anaesthesia described.