Propofol Protects Rats and Human Alveolar Epithelial Cells Against Lipopolysaccharide-Induced Acute Lung Injury via Inhibiting HMGB1 Expression

Artesunate reduces sepsis-mediated acute lung injury in a SIRT1-dependent manner

Introduction

Sepsis-mediated acute lung injury (ALI) is a critical clinical condition. Artesunate (AS) is a sesquiterpene lactone endoperoxide that was discovered in Artemisia annua, which is a traditional Chinese herb. AS has a broad set of biological and pharmacological actions; however, its protective effect on lipopolysaccharide (LPS)-induced ALI remains unclear.

Methods

LPS-mediated ALI was induced in rats through bronchial LPS inhalation. Then NR8383 cells were treated with LPS to establish an in vitro model. Further, we administered different AS doses in vivo and in vitro.

Results

AS administration significantly decreased LPS-mediated pulmonary cell death and inhibited pulmonary neutrophil infiltration. Additionally, AS administration increased SIRT1 expression in pulmonary sections. Administration of a biological antagonist or shRNA-induced reduction of SIRT1 expression significantly inhibited the protective effect of AS against LPS-induced cellular injury, pulmonary dysfunction, neutrophil infiltration, and apoptosis. This demonstrates that enhanced SIRT1 expression is crucially involved in the observed protective effects.

Conclusion

Our findings could suggest the use of AS for treating lung disorders through a mechanism involving SIRT1 expression.

Effect of Total Intravenous Anesthesia on Postoperative Pulmonary Complications in Patients Undergoing Microvascular Reconstruction for Head and Neck Cancer: A Randomized Clinical Trial

Importance

Free flap surgery is a lengthy procedure with massive tissue destruction and reconstruction, which makes postoperative pulmonary complications (PPCs) a noticeable issue among patients with head and neck cancer. Propofol-based total intravenous anesthesia (TIVA) has better survival outcomes than inhalational anesthesia (INH) in several types of cancer surgery. A previous retrospective study found that patients in the TIVA group had a lower PPC rate, which may be correlated with a lower intraoperative fluid requirement. We hypothesize that the protective effect remains among patients undergoing free flap surgery for head and neck cancer in a prospective and goal-directed fluid therapy setting.

Objective

To assess the effect of TIVA vs INH on PPCs in patients undergoing microvascular reconstruction for head and neck cancer.

Design, Setting, and Participants

This prospective, 2-arm, randomized clinical trial was conducted at a tertiary hospital in Taiwan; a total of 78 patients 18 years and older with American Society of Anesthesiologists physical status classification 1 to 3 who were scheduled for elective free flap surgery under general anesthesia were included. The trial started in October 2017, completed in October 2019, and finished analysis in January 2022.

Interventions

Patients were enrolled and randomized to the TIVA or INH group. All patients received goal-directed fluid therapy and hemodynamic management if they had a mean arterial pressure (MAP) below 75 mm Hg or a reduction of 10% from baseline MAP.

Main Outcomes and Measures

The primary outcome was a composite of PPCs. The secondary outcomes were the differences in intraoperative hemodynamic values (mean arterial pressure, MAP; cardiac index, CI; systemic vascular resistance index, SVRI; and stroke volume variation, SVV).

Results

A total of 70 patients (65 men [93%]; 5 women [7%]) completed the trial; median (IQR) age was 52.0 (48-59) years in the TIVA group and 57.0 (46-64) years in the INH group. The demographic characteristics were similar between the 2 groups, except that patients in the TIVA group had a slightly lower body mass index. Patients in the TIVA group had a lower risk of developing PPCs (unadjusted odds ratio, 0.25; 95% CI, 0.08-0.80). The TIVA group had significantly higher MAP, lower CI, and higher SVRI than the INH group after the third hour of monitoring. The TIVA group showed a relatively stable hourly MAP, CI, SVRI, and SVV across time points, while the INH group showed a more varying pattern. The generalized estimating equation showed no clinical differences in the trend of hemodynamic parameters across time between groups.

Conclusions and Relevance

In this randomized clinical trial, using propofol-based TIVA reduced the incidence of PPCs in free flap surgery. This finding may be related to more stable hemodynamic manifestations and a lower total balance of fluid throughout the surgery.

Trial Registration

ClinicalTrials.gov Identifier: NCT03263078.

Propofol ameliorates ischemic brain injury by blocking TLR4 pathway in mice

Ischemic brain injury is one of the most serious perioperative complications. However, effective preventative methods have not yet been established. This study aimed to investigate whether propofol has neuroprotective effects against ischemic brain injury, with a specific focus on Toll-like receptor 4 (TLR4). Focal brain ischemia was induced via a combination of left common carotid artery occlusion and distal left middle cerebral artery coagulation in mice. Either propofol (10 mg/kg) or vehicle was intravenously injected 10 min prior to the induction of brain ischemia in wild-type and TLR4 knockout mice. Infarct volume, pro-inflammatory cytokine expression, inflammatory cell infiltration, and neurobehavioral function were assessed. Propofol administration significantly reduced infarct volume in wild-type mice (26.9 ± 2.7 vs 15.7 ± 2.0 mm³ at day 7), but not in TLR4 knockout mice. Compared with the control mice, the propofol-treated wild-type mice exhibited lower levels of IL-6 (0.57 ± 0.23 vs 1.00 ± 0.39 at 24 h), and smaller numbers of TLR4-expressing microglia in the penumbra (11.7 ± 3.1 vs 25.1 ± 4.7 cells/0.1 mm²). In conclusion, propofol administration prior to ischemic brain insult attenuated brain injury by blocking the TLR4-dependent pathway and suppressing pro-inflammatory cytokine production.

Propofol reduces renal ischemia/reperfusion-induced acute lung injury by stimulating sirtuin 1 and inhibiting pyroptosis

The activation of pyroptosis is an important feature of renal ischemia/reperfusion (rI/R)-induced acute lung injury (ALI). Propofol, a general anesthetic, is known to inhibit inflammation in I/R-induced ALI. We investigated whether propofol could suppress pyroptosis during rI/R-induced ALI by upregulating sirtuin 1 (SIRT1). We generated an in vivo model of rI/R-induced ALI by applying microvascular clamps to the renal pedicles of rats for 45 min. Pathological studies revealed that rI/R provoked substantial lung injury and inflammatory cell infiltration. The rI/R stimulus markedly activated pyroptotic proteins such as NLRP3, ASC, caspase 1, interleukin-1β and interleukin-18 in the lungs, but reduced the mRNA and protein levels of SIRT1. Propofol treatment greatly inhibited rI/R-induced lung injury and pyroptosis, whereas it elevated SIRT1 expression. Treatment with the selective SIRT1 inhibitor nicotinamide reversed the protective effects of propofol during rI/R-induced ALI. Analogous defensive properties of propofol were detected in vitro in rat alveolar macrophages incubated with serum from the rI/R rat model. These findings indicate that propofol attenuates rI/R-induced ALI by suppressing pyroptosis, possibly by upregulating SIRT1 in the lungs.

Propofol Protects Lung Endothelial Barrier Function by Suppression of High-Mobility Group Box 1 (HMGB1) Release and Mitochondrial Oxidative Damage Catalyzed by HMGB1

Background

The processes of mechanical ventilation-induced lung injury (VILI) triggers the release of high-mobility group box 1 (HMGB1), a prominent damage-associated molecular pattern (DAMP) family member, which can cause damage to pulmonary vascular endothelial cells. We aimed to determine whether propofol protected against endothelial cell injury induced by HMGB1 in vitro and in vivo.

Material/Methods

ICR mice (male) were mechanically ventilated for 4 h after anesthetization at both low tidal volume (LVT, 6 ml/kg) and high tidal volume (HVT, 30 ml/kg). A propofol bolus (10 mg/kg) was administered to the animals prior to the onset of ventilation, followed by infusion at 5 mg/(kg·h). We obtained confluent cultures of mouse lung vascular endothelial cells (MLVECs) and then performed cyclic stretching at 20% stretch for 4 h with or without propofol.

Results

HMGB1 reduced the expression of tight junctions between endothelial cells, including VE-cadherin and ZO-1, and increased endothelial permeability, and both were blocked by propofol. We found that MLVECs exhibited mitochondrial oxidative damage by HMGB1, which was successfully suppressed through administration of MnTBAP as well as propofol. Propofol ameliorated HVT-associated lung vascular hyperpermeability and HMGB1 production in vivo. Propofol also inhibited HMBG1 release caused by cyclic stretching in MLVECs in vitro.

Conclusions

Our results prove that the cyto-protective function of propofol protects against lung ventilation-induced dysfunction of the lung endothelial barrier. This function of propofol is mediated through inhibition of HMGB1 release caused by mechanical stretching and mitochondrial oxidative damage triggered by HMGB1.

Limiting sedation for patients with acute respiratory distress syndrome - time to wake up

PURPOSE OF REVIEW

Critically ill patients with acute respiratory distress syndrome (ARDS) may require sedation in their clinical care. The goals of sedation in ARDS patients are to improve patient comfort and tolerance of supportive and therapeutic measures without contributing to adverse outcomes. This review discusses the current evidence for sedation management in patients with ARDS.

RECENT FINDINGS

Deep sedation strategies should be avoided in the care of patients with ARDS because deep sedation has been associated with increased time on mechanical ventilation, longer ICU and hospital length of stay, and higher mortality in critically ill patients. Adoption of protocol-based, light-sedation strategies is preferred and improves patient outcomes. Although the optimal sedative agent for ARDS patients is unclear, benzodiazepines should be avoided because of associations with oversedation, delirium, prolonged ICU and hospital length of stay, and increased mortality. Minimizing sedation in patients with ARDS facilitates early mobilization and early discharge from the ICU, potentially aiding in recovery from critical illness. Strategies to optimize ventilation in ARDS patients, such as low tidal volume ventilation and high positive end-expiratory pressure can be employed without deep sedation; however, deep sedation is required if patients receive neuromuscular blockade, which may benefit some ARDS patients. Knowledge gaps persist as to whether or not prone positioning and extracorporeal membrane oxygenation can be tolerated with light sedation.

SUMMARY

Current evidence supports the use of protocol-based, light-sedation strategies in critically ill patients with ARDS. Further research into sedation management specifically in ARDS populations is needed.

Pulmonary Surfactant and Bacterial Lipopolysaccharide: The Interaction and its Functional Consequences

The respiratory system is constantly exposed to pathogens which enter the lungs by inhalation or via blood stream. Lipopolysaccharide (LPS), also named endotoxin, can reach the airspaces as the major component of the outer membrane of Gram-negative bacteria, and lead to local inflammation and systemic toxicity. LPS affects alveolar type II (ATII) cells and pulmonary surfactant and although surfactant molecule has the effective protective mechanisms, excessive amount of LPS interacts with surfactant film and leads to its inactivation. From immunological point of view, surfactant specific proteins (SPs) SP-A and SP-D are best characterized, however, there is increasing evidence on the involvement of SP-B and SP-C and certain phospholipids in immune reactions. In animal models, the instillation of LPS to the respiratory system induces acute lung injury (ALI). It is of clinical importance that endotoxin-induced lung injury can be favorably influenced by intratracheal instillation of exogenous surfactant. The beneficial effect of this treatment was confirmed for both natural porcine and synthetic surfactants. It is believed that the surfactant preparations have anti-inflammatory properties through regulating cytokine production by inflammatory cells. The mechanism by which LPS interferes with ATII cells and surfactant layer, and its consequences are discussed below.

Effects of inflammatory factors including plasma tumor necrosis factor-α in the clinical treatment of acute respiratory distress syndrome

The present study investigated the association between the levels of plasma tumor necrosis factor-α (TNF-α), interleukin (IL)-6, IL-8, high-sensitivity C-reactive protein and fibrinogen levels of patients with acute respiratory distress syndrome (ARDS) with ARDS treatment outcome and duration of mechanical ventilation, with the aim of improving the efficacy of ARDS therapy. A total of 140 patients with ARDS were randomly divided into groups A and B, with 70 patients in each group. The patients in group A received a combination of conventional treatment and comprehensive treatment (test group) and the patients in group B were treated with conventional therapy only (control group). Elbow venous blood was obtained from each patient in the morning prior to treatment, on the 3rd day of treatment and on the 5th day of treatment. The levels of inflammatory factors, the clinical effects and the duration of mechanical ventilation of the two groups were statistically analyzed. The levels of IL-6, TNF-α and IL-8 in patients from group A were significantly reduced compared with those from group B (P<0.05). Additionally, the oxygenation index and arterial partial oxygen pressure of patients in group A were significantly higher compared with group B patients (P<0.05), the duration of mechanical ventilation of group A was decreased compared with that of group B (P<0.05) and the overall response rate of group A was >90%, whereas group B had a response rate of 80.0%. These results indicate that the treatment administered to patients in group A exhibited an improved clinical efficacy. The combination of comprehensive and conventional therapy may effectively reduce the levels of inflammatory factors and the inflammatory response, and these levels may be important for the effective treatment of ARDS and in reducing treatment duration. Therefore the current study may improve upon current clinical practice.