Conservative management of a rare case of post thyroidectomy tracheal injury with coagulation abnormalities.

Background: Tracheal injury is a rare but potentially serious acute complication of endotracheal intubation. Very few cases of tracheal injury associated with coagulation abnormalities have been reported in the literature. We present a rare case of a patient presenting with tracheal injury in combination with coagulation abnormalities following thyroidectomy. Case presentation: A 58-year-old woman with a history of postoperative chemotherapy for breast cancer, gastric polyps, multiple colonic polyps, esophageal papillary adenomas, and thyroid adenomas presented with dyspnea following 10 ml hemoptysis on the third day after thyroidectomy; she was admitted to the intensive care unit and underwent tracheal intubation for maintaining the airway. Subsequent bronchoscopy revealed a nodular red neoplasm 5-cm from the carina in the trachea obstructing part of the lumen, with a small amount of fresh hemorrhage on the surface. Tracheal injury was considered the preliminary diagnosis. Fiberoptic bronchoscope guided tracheal intubation helped prevent rupture of the tumor, and the cannula was properly inflated to arrest the bleeding while blocking the lower part of the trachea. An emergency surgical evacuation of the cervical hematoma was performed for managing postoperative bleeding. The patient demonstrated persistent pancytopenia despite frequent transfusions. Laboratory examination results revealed abnormal coagulation parameters, anemia, and hepatic dysfunction. Following a multidisciplinary team discussion, pituitrin for hemostasis, tranexamic acid for strengthening hemostasis treatment, and nutritional support and anti-infection treatment were initiated. Endotracheal tube cuff inflation was performed to compress the bleeding site. Complete resolution of the subcutaneous hematoma was observed nine days after the tracheal injury; bronchoscopy revealed residual ecchymosis in the airway hematoma with no evidence of obstruction. Conclusion: Conservative management of tracheal injury limited to the mucosa or submucosa without significant amount of active bleeding using endotracheal intubation is considered a practical and effective approach. Successful management was ensured by appropriate clinical suspicion, early multidisciplinary team discussion, and prompt diagnosis and interventions.

Down-regulating lncRNA KCNQ1OT1 relieves type II alveolar epithelial cell apoptosis during one-lung ventilation via modulating miR-129-5p/HMGB1 axis induced pulmonary endothelial glycocalyx.

OBJECTIVE: Endothelial glycocalyx (EG) maintains vascular homeostasis and is destroyed after one-lung ventilation (OLV)-induced lung injury. Long noncoding RNAs (lncRNAs) are critically involved in various lung injuries. This study aimed to investigate the role and regulatory mechanism of KCNQ1 overlapping transcript 1 (KCNQ1OT1) in OLV-induced lung injury and LPS-induced type II alveolar epithelial cell (AECII) apoptosis. METHODS: The rat OLV model was established, and the effects of KCNQ1OT1 on OLV-induced ALI in vivo were explored. Bax and Caspase-3 expression in rat lung tissues was measured by immunochemistry (IHC). AECIIs were isolated from rat lungs and treated with LPS or normal saline (control) for in vitro analysis. The expression of KCNQ1OT1, miR-129-5p, and HMGB1 was measured by quantitative real-time PCR (qRT-PCR) or Western blot (WB). Cell proliferation and apoptosis were examined by 3-(4,5)-dimethylthiahiazo (-z-y1)-3,5-di- phenytetrazoliumromide (MTT) and flow cytometry. The downstream targets of KCNQ1OT1 were predicted by bioinformatics, and the binding relationship between KCNQ1OT1 and miR-129-3p was verified by dual-luciferase reporter assays. The potential target of miR-129-5p was further explored on the Targetscan website and revealed to target HMGB1. Enzyme-linked immunosorbent assay (ELISA) or WB was adopted to determine the levels of IL-1ß, TNF-α, MDA, SOD, heparanase (HPA), matrix metalloproteinase 9 (MMP9), heparan sulfate (HS) and syndecan-1 (SDC-1). RESULTS: KCNQ1OT1 and HMGB1 were up-regulated during OLV-induced lung injury, and their expression was positively correlated. KCNQ1OT1 knockdown reduced OLV-induced pulmonary edema and lung epithelial cell apoptosis, increased vascular permeability, reduced IL-1ß, TNF-α, MDA, and SOD levels and glycocalyx markers by targeting miR-129-5p or upregulating HMGB1. Overexpressing KCNQ1OT1 promoted cell apoptosis, reduced cell proliferation, aggravated inflammation and oxidative stress, and up-regulated HMGB1, HPA and MMP9 in LPS-treated AECIIs, while the HMGB1 silencing showed the opposite effects. MiR-129-5p mimics partially eliminated the KCNQ1OT1-induced effects, while recombinant HMGB1 restored the effects of miR-129-5p overexpression on AECIIs. Additionally, KCNQ1OT1 was demonstrated to promote the activation of the p38 MAPK/Akt/ERK signaling pathways in AECIIs via HMGB1. CONCLUSION: KCNQ1OT1 knockdown alleviated AECII apoptosis and EG damage during OLV by targeting miR-129-5p/HMGB1 to inactivate the p38 MAPK/Akt/ERK signaling. The findings of our study might deepen our understanding of the molecular basis in OLV-induced lung injury and provide clues for the targeted disease management.

Effects of Press Needling combined with general anesthesia on postoperative analgesia in thoracoscopic pulmonary resection for lung cancer: A randomized, single-blind, controlled trial.

OBJECTIVES: To investigate the effects of press needle therapy on postoperative analgesia and other relevant complications in patients undergoing thoracoscopic pulmonary resection. DESIGN: randomized, single-blind, controlled trial SETTING: Teaching hospitals affiliated with universities. INTERVENTIONS: Eighty-six patients were randomized into: the Acu group (press-needle group) and the control group MAIN OUTCOME MEASURES: Pain levels 24, 48, and three months after surgery were measured using the numeric rating scale (NRS). Perioperative hemodynamics, total and effective pressing numbers of patient-controlled intravenous analgesia (PCIA), and incidence of postoperative pulmonary complications were recorded. Peripheral blood samples were collected to measure the levels of inflammatory mediators RESULTS: Acu group had significantly lower NRS scores at 24 and 48 h after operation (NRS scores on movement at 24 h after surgery: Acu vs. Control, 3 (2,3) vs. 3 (3,5), Z = -3.393, P < 0.01 and NRS scores on movement at 48 h after surgery: 2 (1,3) vs. 3 (2,5), Z = -3.641, P < 0.01), lower number of PCIA attempts and effective rates (mean total pressing numbers: 4(2,8) vs. 6(3,19), Z = -1.994, P = 0.046 and mean effective pressing numbers: 3(2,8) vs. 6(3,16), Z = -2.116, P = 0.034). The Acu group had significantly reduced IL-1 (14.52 ± 3.84 vs. 16.36 ± 3.30, mean difference (MD): - 1.85, 95% confidence interval (CI): - 3.46, - 0.23, P = 0.026), HIF-1α (10.15 ± 1.71 vs. 10.96 ± 1.73, MD: -0.81, 95% CI: -1.59, -0.04, P = 0.040) and the incidence of pulmonary complications after surgery. CONCLUSION: Press needles are a non-invasive and feasible adjunctive intervention for postoperative analgesic management in patients undergoing thoracoscopic pulmonary resection.

Optimization of a tri-drug treatment against lung cancer using orthogonal design in preclinical studies.

A growing body of evidence suggests that anesthetics impact the outcome of patients with cancer after surgical intervention. However, the optimal dose and underlying mechanisms of co-administered anesthetics in lung tumor therapy have been poorly studied. Here, we aimed to investigate the role of combined anesthetics propofol, sufentanil, and rocuronium in treating lung cancer using an orthogonal experimental design and to explore the optimal combination of anesthetics. First, we evaluated the effects of the three anesthetics on the proliferation and invasion of A-549 cells using Cell Counting Kit 8 and Transwell migration and invasion assays. Subsequently, we applied the orthogonal experimental design (OED) method to screen the appropriate concentrations of the combined anesthetics with the most effective antitumor activity. We found that all three agents inhibited the proliferation of A-549 cells in a dose- and time-dependent manner when applied individually or in combination, with the highest differences in the magnitude of inhibition occurring 24 h after combined drug exposure. The optimal combination of the three anesthetics that achieved the strongest reduction in cell viability was 1.4 µmol/L propofol, 2 nmol/L sufentanil, and 7.83 µmol/L rocuronium. This optimal 3-drug combination produced a more beneficial result at 24 h than either single drug. Our results provide a theoretical basis for improving the efficacy of lung tumor treatment and optimizing anesthetic strategies.

Analysis of the association of sugammadex with the length of hospital stay in patients undergoing abdominal surgery: a retrospective study.

BACKGROUND: Sugammadex is a newer medication used for rapid and reliable reversal of neuromuscular blockade. This study evaluated whether sugammadex could reduce the length of postoperative hospital stay in patients undergoing abdominal surgery. METHODS: This single center retrospective cohort study included patients who underwent major abdominal surgery between January 2015 and October 2019. Patients were randomized according to reversal with sugammadex or spontaneous recovery. The primary outcome was length of postoperative hospital stay. The secondary outcomes were length of post-anesthetic care unit (PACU) stay, postoperative ambulation time, time-to-first-defecation, and incidence of pulmonary complications. After 1:1 propensity score matching, univariate and multiple linear regression analyses estimated the differences in outcomes. RESULTS: Of the 1614 patients, 517 received sugammadex and 645 spontaneously recovered. After adjusting for potential confounders, non-linear relationship was detected between administration of sugammadex and the length of postoperative hospital stay (ß = 0.29 95% confidence interval {CI}: [- 1.13, - 0.54], P = 0.4912). However, it was associated with shorter PACU stay (ß = - 20.30 95% CI: [- 24.48, - 17.11], P < 0.0001), shorter time to postoperative ambulation movement (ß = - 0.43 95% CI: [- 0.62, - 0.23], P < 0.0001), and reduced time-to-first-defecation (ß = - 2.25 95% CI: [- 0.45, - 0.05], P = 0.0129), when compared to the spontaneously recovered group. The incidence of pneumonia in the sugammadex group was significantly lower than that in the spontaneously recovered group (18.6% [44/237] vs. 39.2% [93/237] P < 0.05). CONCLUSIONS: Neuromuscular blockade reversal with sugammadex after abdominal surgery demonstrated an excellent recovery profile and was associated with decreased risk of pneumonia, although it did not affect the length of postoperative hospital stay.

A randomised controlled trial on roles of prostaglandin E1 nebulization among patients undergoing one lung ventilation.

BACKGROUND: Prostaglandin E1 (PGE1) has been reported to maintain adequate oxygenation among patients under 60% FiO2 one-lung ventilation (OLV). This research aimed to explore whether PGE1 is safe in pulmonary shunt and oxygenation under 40% FiO2 OLV and provide a reference concentration of PGE1. METHODS: Totally 90 esophageal cancer patients treated with thoracotomy were enrolled in this study, randomly divided into three groups (n = 30/group): Group A (60% FiO2 and 0.1 µg/kg PGE1), Group B (40% FiO2 and 0.1 µg/kg PGE1), and Group C (40% FiO2, 0.2 µg/kg PGE1). Primary outcomes were oxygenation and pulmonary shunt during OLV. Secondary outcomes included oxidative stress after OLV. RESULTS: During OLV, patients in Group C and B had lower levels of PaO2, SaO2, SpO2, MAP, and Qs/Qt than those in Group A (P < 0.05). At T2 (OLV 10 min), patients in Group C and B exhibited a lower level of PaO2/FiO2 than those in Group A, without any statistical difference at other time points. The IL-6 levels of patients in different groups were different at T8 (F = 3.431, P = 0.038), with IL-6 in Group C being lower than that in Group B and A. MDA levels among the three groups differed at T5 (F = 4.692, P = 0.012) and T7 (F = 5.906, P = 0.004), with the MDA level of Group C being lower than that of Group B and A at T5, and the MDA level of Group C and B being lower than that of Group A at T7. In terms of TNF-α level, patients in Group C had a lower level than those in Group B and A at T8 (F = 3.598, P = 0.033). Compared with patients who did not use PGE1, patients in Group C had comparable complications and lung infection scores. CONCLUSION: The concentration of FiO2 could be reduced from 60 to 40% to maintain oxygenation. 40% FiO2 + 0.2 µg/kg PGE1 is recommended as a better combination on account of its effects on the inflammatory factors. TRIAL REGISTRATION: Chictr.org.cn identifier: ChiCTR1800018288, 09/09/2018.

Effects of Anesthesia and Anesthetic Techniques on Metastasis of Lung Cancers: A Narrative Review.

PURPOSE: Tumor recurrence and metastasis are essential for the mortality and morbidity of cancer. Surgical resection of solid tumors is the conventional treatment approach for malignant tumors. However, even after undergoing radical surgery, certain patients develop local or distant metastasis, which may contribute to treatment failure. Anesthesia and anesthetic techniques are widely used in the perioperative period. Emerging evidence indicates that anesthetics influence tumor recurrence and metastasis. Therefore, the current review summarizes the effects of anesthesia and anesthetic techniques on tumor recurrence and lung metastasis. METHODS: Relevant literature was retrieved from the following databases: Medline/PubMed, CNKI and Wanfang. A total of 109 articles were selected and analyzed in this research. RESULTS: (1) A variety of intravenous anesthetics may affect metastasis or tumor growth, though the evidence is contradictory and inconsistent, and the clinical data are still inconclusive. (2) Volatile anesthetics have proinflammatory effects and may have direct and indirect effects on the survival of cancer cells. (3) Although the relevant clinical data are limited, there is strong evidence in vitro that local anesthetics have a protective effect on cancer recurrence. (4) No mode of anesthesia has been determined to be beneficial to patients with cancer, but clinical studies are currently recommended for anesthesia modality and composite use. CONCLUSION: Available data suggest that anesthesia and anesthetic techniques might play an important role in tumor progression and lung metastasis, the understanding of which will help in designing more effective management of the tumor and attaining fewer side effects.

Comparison of laryngeal mask airway and endotracheal intubation in gynecological cancer operation.

Endotracheal intubation (ETI) and laryngeal mask airway (LMA) in terms of hemodynamics and reaction were compared. A total of 54 general anesthesia patients were randomized into two groups with 27 cases in each group. Acceleration index (ACI), cardiac index (CI), cardiac output (CO), left cardiac work (LCW), systemic circulation resistance (SVR), mean arterial pressure (MAP), heart rate (HR), systolic blood pressure (SBP) and diastolic blood pressure (DBP) were recorded at 12 time-points: before surgery (T0), start effect (T1), lost consciousness (T2), before ETI or LMA (T3), 1 min (T4), 3 min (T5), 5 min (T6) after ETI or LMA, the beginning of surgery (T7), 30 min (T8), 1 hour (T9) after surgery, the end of surgery (T10) and extubation (T11). In each group these indexes went down and rose up gently during surgery except for T4 (intubation) and T11 (extubation) in ETI. These indexes reached the highest at T11 (extubation). This is due to the stimulus on mucosa and muscle of root of tongue, throat and epiglottis from the windpipe. The stimulus excites sympathetic nerve and increases the release of catecholamine. As a result, the heart beats faster and blood pressure rises. However, the range in the LMA group is smaller especially at T4 and T11. This is most likely due to LMA not stimulating the trachea. SVR, MAP, HR, SBP and DBP were lower in LMA with statistical significance in some time-points. The other indexes such as ACI, CI, CO and LCW were significantly higher in LMA (P<0.05). These results indicated that LMA can be suitable for use in general anesthesia for less stimulation. The airway with LMA in patients undergoing gynecological cancer operation is better than ETI in keeping stable hemodynamics and producing less anesthetic complications with smooth recovery from general anesthesia.

Effects of volume-controlled ventilation vs. pressure-controlled ventilation on respiratory function and inflammatory factors in patients undergoing video-assisted thoracoscopic radical resection of pulmonary carcinoma.

BACKGROUND: The best ventilation approach for patients undergoing video-assisted thoracic surgery (ATS) for pulmonary carcinoma remains undefined. This study aimed to assess hemodynamics, airway pressure, arterial blood gas, and inflammatory factors in patients undergoing VATS for pulmonary carcinoma under volume-controlled ventilation (VCV) or pressure-controlled ventilation (PCV). METHODS: This was a prospective study of 60 patients with pulmonary carcinoma treated at a tertiary center in 2015-2016. The subjects were randomized to the VCV or PCV group after anesthesia and total lung ventilation (TLV). Hemodynamics and blood gas parameters were compared between the two groups pre-OLV (one-lung ventilation) (T1) and after 30 (T2), 60 (T3), and 120 (T4) minutes of OLV. Radial artery blood was collected to measure interleukin (IL)-6, IL-10, and tumor necrosis factor (TNF)-α levels. RESULTS: Hemodynamic and blood gas parameters were similar between the two groups (all P>0.05). During OLV, airway resistance (RAW) was significantly lower in the PCV group compared with the VCV group at T2 (26.0±3.8 vs. 29.9±7.3 cmH2O/L/s), T3 (26.0±3.7 vs. 30.2±7.7 cmH2O/L/s), and T4 (25.8±4.1 vs. 29.6±6.7 cmH2O/L/s). Similar trends were found for peak pressure (Ppeak) and plateau pressure (Pplat). Mean pressure (Pmean) was similar between the two groups. Compared with the PCV group, TNF-α and IL-6 levels in the VCV group were significantly increased (all P<0.05). The levels of the anti-inflammatory mediator IL-10 were higher in the PCV group compared with the VCV group. CONCLUSIONS: PCV for OLV during radical resection of pulmonary carcinoma by VATS could reduce Ppeak and downregulate pro-inflammatory factors, likely decreasing airway injury.