The effects of dexmedetomidine on human internal mammary artery and saphenous vein grafts under hypothermia and normothermia

OBJECTIVES

The purpose of this study was to determine the effects of hypothermia and normothermia on the isolated human saphenous vein (SV) and internal mammary artery (IMA) responses to dexmedetomidine.

METHODS

The response of human IMA and SV strips with (E+) and without (E-) endothelium subjected to cumulative concentrations of (10-9, 0-6 M) dexmedetomidine were recorded at 37 °C and at 28 °C. OnE-way ANOVA was used for analysis. A p < 0.05 was considered significant.

RESULTS

At 37˚C dexmedetomidine resulted in similar significant concentration-dependent contractions in both E+ and E- SV strips (p < 0.05). At 37 °C dexmedetomidine resulted in significant concentration-dependent contractions in E+ IMA strips, these contractions were significantly lower at all concentrations of dexmedetomidine in E- compared to E+ IMA strips (p < 0.05). When results between similar groups of SV and IMA strips were compared, the contractions were significantly higher in the IMA strips in E+ and E- at 37 °C and also E- 28 °C groups compared to SV (p < 0.05).

CONCLUSION

In conclusion, dexmedetomidine causes in vitro vasoconstriction in human IMA and SV grafts. These contractions are greater in IMA compared to SV grafts. Endothelium-derived pathways are possibly involved in the contractile responses of IMA. Moderate hypothermia augments vasoconstriction in SV grafts (Fig. 3, Ref. 27).

Association of preoperative smoking with the occurrence of postoperative pulmonary complications: A post hoc analysis of an observational study in 29 countries

INTRODUCTION

While smoking has been consistently identified as a significant contributor to postoperative complications, the existing literature on its association with postoperative pulmonary complications remains conflicting.

AIM

We examined the association of preoperative smoking with the occurrence of postoperative pulmonary complications (PPCs).

METHODS

Post hoc analysis of an observational study in 146 hospitals across 29 countries. We included patients at increased risk of PPCs, according to the Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) score (≥ 26 points). The primary endpoint was the occurrence of one or more predefined PPCs in the first five postoperative days, including unplanned postoperative need for supplementary oxygen, respiratory failure, unplanned need for invasive ventilation, ARDS, pneumonia and pneumothorax. Secondary endpoints included length of hospital stay and in-hospital mortality. We performed propensity score matching to correct for factors with a known association with postoperative outcomes.

RESULTS

Out of 2632 patients, 531 (20.2 %) patients were smokers and 2102 (79.8 %) non-smokers. At five days after surgery, 101 (19.0 %) smokers versus 404 (19.2) non-smokers had developed one or more PPCs (P = 0.95). Respiratory failure was more common in smokers (5.1 %) than non-smokers (3.0 %) (P = 0.02), while rates of other PPCs like need for supplementary oxygen, invasive ventilation, ARDS, pneumonia, or pneumothorax did not differ between the groups. Length of hospital stay and mortality was not different between groups. Propensity score matching did not change the findings.

CONCLUSION

The occurrence of PPCs in smokers is not different from non-smokers.

FUNDING

This analysis was performed without additional funding. LAS VEGAS was partially funded and endorsed by the European Society of Anaesthesiology through their Clinical Trial Network and the Amsterdam University Medical Centers, Amsterdam, The Netherlands.

REGISTRATION

LAS VEGAS was registered at Clinicaltrials.gov (NCT01601223).

PRIOR PRESENTATION

Preliminary study results have been presented at the Euroanaesthesia 2024 International Congress, in Munich, Germany.

Postoperative delirium: A tragedy for elderly cancer patients

In this editorial, we comment on the article by Hu et al entitled "Predictive modeling for postoperative delirium in elderly patients with abdominal malignancies using synthetic minority oversampling technique". We wanted to draw attention to the general features of postoperative delirium (POD) as well as the areas where there are uncertainties and contradictions. POD can be defined as acute neurocognitive dysfunction that occurs in the first week after surgery. It is a severe postoperative complication, especially for elderly oncology patients. Although the underlying pathophysiological mechanism is not fully understood, various neuroinflammatory mechanisms and neurotransmitters are thought to be involved. Various assessment scales and diagnostic methods have been proposed for the early diagnosis of POD. As delirium is considered a preventable clinical entity in about half of the cases, various early prediction models developed with the support of machine learning have recently become a hot scientific topic. Unfortunately, a model with high sensitivity and specificity for the prediction of POD has not yet been reported. This situation reveals that all health personnel who provide health care services to elderly patients should approach patients with a high level of awareness in the perioperative period regarding POD.

Associations of intraoperative end-tidal CO2 levels with postoperative outcome-secondary analysis of a worldwide observational study

BACKGROUND

Patients receiving intraoperative ventilation during general anesthesia often have low end-tidal CO2 (etCO2). We examined the association of intraoperative etCO2 levels with the occurrence of postoperative pulmonary complications (PPCs) in a conveniently-sized international, prospective study named 'Local ASsessment of Ventilatory management during General Anesthesia for Surgery' (LAS VEGAS).

METHODS

Patients at high risk of PPCs were categorized as 'low etCO2' or 'normal to high etCO2' patients, using a cut-off of 35 mmHg. The primary endpoint was a composite of previously defined PPCs; the individual PPCs served as secondary endpoints. The need for unplanned oxygen was defined as mild PPCs and severe PPCs included pneumonia, respiratory failure, acute respiratory distress syndrome, barotrauma, and new invasive ventilation. We performed propensity score matching and LOESS regression to evaluate the relationship between the lowest etCO2 and PPCs.

RESULTS

The analysis included 1843 (74 %) 'low etCO2' patients and 648 (26 %) 'normal to high etCO2' patients. There was no difference in the occurrence of PPCs between 'low etCO2' and 'normal to high etCO2' patients (20 % vs. 19 %; RR 1.00 [95 %-confidence interval 0.94 to 1.06]; P = 0.84). The proportion of severe PPCs among total occurring PPCs, were higher in 'low etCO2' patients compared to 'normal to high etCO2' patients (35 % vs. 18 %; RR 1.16 [1.08 to 1.25]; P < 0.001). Propensity score matching did not change these findings. LOESS plot showed an inverse relationship of intraoperative etCO2 levels with the occurrence of PPCs.

CONCLUSIONS

In this cohort of patients at high risk of PPCs, the overall occurrence of PPCs was not different between 'low etCO2' patients and 'normal to high etCO2' patients, but severe PPCs occurred more often in 'low etCO2', with an inverse dose-dependent relationship between intraoperative etCO2 levels and PPCs.

FUNDING

This analysis was performed without additional funding. LAS VEGAS was partially funded and endorsed by the European Society of Anesthesiology and Intensive Care (ESAIC) and the Amsterdam University Medical Centers, location 'AMC'.

REGISTRATION

LAS VEGAS was registered at Clinicaltrials.gov (NCT01601223), first posted on May 17, 2012.

Anesthetic management of a child with Cornelia de Lange Syndrome undergoing open heart surgery: A case report

BACKGROUND

Cornelia de Lange syndrome (CdLS) is a congenital multisystemic genetic disorder. The expected lifespan of children with this disorder has been prolonged in parallel with the advances in medicine in recent years. However, they still more frequently undergo cardiac surgery. There are some challenges for clinicians when faced with CdLS patients. We present the perioperative management of a child with CdLS undergoing open-heart surgery.

CASE SUMMARY

Severe pulmonic and subpulmonic valvular stenosis, enlargement of the right side of the heart, mild tricuspid regurgitation, atrial septal defect, and patent ductus arteriosus were diagnosed in a 14-month-old boy with manifested cyanosis, developmental delay, and malnutrition. Attempted balloon valvuloplasty was unsuccessful due to a severe stenotic pulmonary valve, therefore it was decided to perform an open surgical repair. Following a successful and uncomplicated intraoperative course, the patient was extubated on postoperative day 5, and adrenalin and dopamine infusions were gradually decreased and stopped on postoperative days 6 and 10, respectively. Moderate laryngomalacia and suboptimal vocal cord movements were diagnosed, and tracheotomy and percutaneous endoscopic gastrostomy were performed under general anesthesia in the same session at postoperative day 32. The patient was discharged on postoperative day 85 after a challenging postoperative period with additional airway and nutritional problems.

CONCLUSION

This is the first report of the perioperative anesthetic and clinical management of a CdLS patient undergoing open-heart surgery.

Neurocritical Care Organization in the Low-Income and Middle-Income Countries

BACKGROUND

This study aimed to assess the organization, infrastructure, workforce, and adherence to protocols in neurocritical care across low- and middle-income countries (LMICs), with the goal of identifying key gaps and opportunities for improvement.

METHODS

We conducted a cross-sectional survey of 408 health care providers from 42 LMICs. The survey collected data on the presence of dedicated neurointensive care units, workforce composition, access to critical care technologies, and adherence to evidence-based protocols. Data were analyzed using descriptive statistics, and comparisons were made across different geographical regions (East Asia and the Pacific, Europe and Central Asia, Latin America and the Caribbean, the Middle East and North Africa, and South Asia and sub-Saharan Africa) and economic strata [low-income countries (LICs), lower middle-income countries (LoMICs), and upper middle-income countries (UMICs)].

RESULTS

Only 36.8% of respondents reported access to dedicated neurointensive care units: highest in the Middle East (100%), lowest in sub-Saharan Africa (11.5%), highest in LoMICs (42%), and lowest in LICs (13%). Access to critical care technologies, such as portable computed tomography scanners (9.3%; UMICs 11%, LICs 0%) and tele-intensive care unit services (14.9%; UMICs 19%, LICs 10%), was limited. Workforce shortages were evident, with many institutions relying on anesthesia residents for 24-h care. Adherence to protocols, including those for acute ischemic stroke (61.7%) and traumatic brain injury (55.6%), was highest in Latin America and the Caribbean (72% and 73%, respectively) and higher in UMICs (66% and 60%, respectively) but remained low in LICs (22% and 32%, respectively).

CONCLUSIONS

The study highlights critical gaps in infrastructure, workforce, and technology across LMICs, yet it also underscores the potential for improvement. Strategic investments in neurointensive care unit capacity, workforce development, and affordable technologies are an unmet need in resource-limited settings. These findings offer a road map for policymakers and global health stakeholders to prioritize neurocritical care and reduce the disparities in patient outcomes globally.

Sex dependence of postoperative pulmonary complications - A post hoc unmatched and matched analysis of LAS VEGAS

STUDY OBJECTIVE

Male sex has inconsistently been associated with the development of postoperative pulmonary complications (PPCs). These studies were different in size, design, population and preoperative risk. We reanalysed the database of 'Local ASsessment of Ventilatory management during General Anaesthesia for Surgery study' (LAS VEGAS) to evaluate differences between females and males with respect to PPCs.

DESIGN, SETTING AND PATIENTS

Post hoc unmatched and matched analysis of LAS VEGAS, an international observational study in patients undergoing intraoperative ventilation under general anaesthesia for surgery in 146 hospitals across 29 countries. The primary endpoint was a composite of PPCs in the first 5 postoperative days. Individual PPCs, hospital length of stay and mortality were secondary endpoints. Propensity score matching was used to create a similar cohort regarding type of surgery and epidemiological factors with a known association with development of PPCs.

MAIN RESULTS

The unmatched cohort consisted of 9697 patients; 5342 (55.1%) females and 4355 (44.9%) males. The matched cohort consisted of 6154 patients; 3077 (50.0%) females and 3077 (50.0%) males. The incidence in PPCs was neither significant between females and males in the unmatched cohort (10.0 vs 10.7%; odds ratio (OR) 0.93 [0.81-1.06]; P = 0.255), nor in the matched cohort (10.5 vs 10.0%; OR 1.05 [0.89-1.25]; P = 0.556). New invasive ventilation occurred less often in females in the unmatched cohort. Hospital length of stay and mortality were similar between females and males in both cohorts.

CONCLUSIONS

In this conveniently-sized worldwide cohort of patients receiving intraoperative ventilation under general anaesthesia for surgery, the PPC incidence was not significantly different between sexes.

REGISTRATION

LAS VEGAS was registered at clinicaltrial.gov (study identifier NCT01601223).