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Taylor B, Ellis J, Ponty S, Patrick L, Scott TE, Chockalingam N. Effect of volatile anaesthetic agents on intracranial pressure, cerebrovascular flow and autoregulation: a protocol for a systematic review and meta-analysis. BMJ Open 2024; 14:e086727. [PMID: 39322591 PMCID: PMC11425943 DOI: 10.1136/bmjopen-2024-086727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 08/29/2024] [Indexed: 09/27/2024] Open
Abstract
INTRODUCTION The use of volatile anaesthetic agents for the sedation of patients requiring critical care treatment offers several theoretical advantages over intravenous sedation, which may be of benefit in neurocritical care. However, there are concerns that they may increase intracranial pressure. The objective of this systematic review is to assess whether, and if so, to what extent volatile anaesthetic agents affect intracranial pressure, cerebral blood flow (CBF), cerebral oximetry and cerebrovascular autoregulation. If sufficient data exist, subgroup analyses will be conducted in traumatic brain injury and decompressive craniectomy patients. METHODS AND ANALYSIS A database search of PubMed, Medline (including Medline plus), CINAHL (including CINAHL Plus), Embase databases and the Cochrane Central Controlled Trials Register without time limits will be conducted. The search results will be screened by title and abstract by two independent researchers on a rule-in basis against predetermined criteria-controlled studies in humans of contemporary fluorinated volatile anaesthetic agents against a control, which measures intracranial pressure, CBF, cerebral oximetry or cerebrovascular autoregulation. Articles responsive to screening will then be reviewed in full text by two independent researchers, requiring consensus or a tie-break by a third independent researcher. Reference lists and a non-generative AI tool will be examined for missed articles, with all identified articles being reviewed in full text by two independent researchers. The included articles will be assessed for risk of bias and will have data extracted by two independent researchers. If sufficient data exist, a meta-analysis will be performed; otherwise, a narrative description of outcomes will be performed. ETHICS AND DISSEMINATION No ethics approval will be sought for this systematic review. This study has no explicit funding. The results of this study will be disseminated in a peer-reviewed journal, in a conference presentation and on PROSPERO. TRIAL REGISTRATION NUMBER PROSPERO number CRD42023474587.
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Affiliation(s)
- Ben Taylor
- Staffordshire University Faculty of Health Sciences, Stoke-on-Trent, UK
- Keele University Faculty of Medicine & Health Sciences, Keele, Staffordshire, UK
- Academic Department of Military Anaesthesia and Critical Care, MOD, London, Greater London, UK
- University Hospital of North Midlands, Stoke-on-Trent, UK
| | - Jack Ellis
- University Hospital of North Midlands, Stoke-on-Trent, UK
| | - Sam Ponty
- Keele University Faculty of Medicine & Health Sciences, Keele, Staffordshire, UK
| | - Lewis Patrick
- Keele University Faculty of Medicine & Health Sciences, Keele, Staffordshire, UK
| | - Timothy E Scott
- Staffordshire University Faculty of Health Sciences, Stoke-on-Trent, UK
- Academic Department of Military Anaesthesia and Critical Care, MOD, London, Greater London, UK
- University Hospital of North Midlands, Stoke-on-Trent, UK
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Papastefan ST, Alhajjat AM, Ott KC, Liesman DR, Langereis MM, Boat AC, Pombar XF, Kominiarek MA, Bowman RM, Shaaban AF. Fetal bradycardia in open versus fetoscopic prenatal repair of spina bifida. Prenat Diagn 2024; 44:1088-1097. [PMID: 38877305 DOI: 10.1002/pd.6626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 05/27/2024] [Accepted: 06/08/2024] [Indexed: 06/16/2024]
Abstract
OBJECTIVE To compare the occurrence of fetal bradycardia in open versus fetoscopic fetal spina bifida surgery. METHODS This is a single-institution retrospective cohort study of patients undergoing open (n = 25) or fetoscopic (n = 26) spina bifida repair between 2017 and 2022. From October 2017 to June 2020, spina bifida repairs were performed via an open classical hysterotomy, and from November 2020 to June 2022 fetoscopic repairs were performed following transition to this technique. Fetal heart rate (FHR) in beats per minute (bpm) was recorded via echocardiography every 15 min during the procedure. Cohort characteristics, fetal bradycardia and maternal physiologic parameters were compared between the groups. RESULTS Fetuses undergoing an open repair more frequently developed bradycardia defined as <110 bpm (32% vs. 3.8%, p = 0.008), and a trend was observed for FHR decreases more than 25 bpm from baseline (20% vs. 3.8%, p = 0.073). Profound bradycardia less than 80 bpm was rare, occurring in only three operations (two in open, one in fetoscopic repair) with two fetuses (one in each group) requiring emergency cesarean delivery. CONCLUSION When compared to open fetal surgery, fetal bradycardia occurred less frequently in fetoscopic surgery despite a significantly greater anesthetic exposure and the use of the intraamniotic carbon dioxide insufflation.
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Affiliation(s)
- Steven T Papastefan
- Department of Surgery, The Chicago Institute for Fetal Health, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Amir M Alhajjat
- Department of Surgery, The Chicago Institute for Fetal Health, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Katherine C Ott
- Department of Surgery, The Chicago Institute for Fetal Health, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Daniel R Liesman
- Department of Surgery, The Chicago Institute for Fetal Health, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Morgan M Langereis
- Department of Surgery, The Chicago Institute for Fetal Health, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Anne C Boat
- Division of Anesthesiology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Xavier F Pombar
- Department of Surgery, The Chicago Institute for Fetal Health, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Obstetrics and Gynecology, Rush University Medical Center, Chicago, Illinois, USA
| | - Michelle A Kominiarek
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Robin M Bowman
- Division of Neurosurgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Aimen F Shaaban
- Department of Surgery, The Chicago Institute for Fetal Health, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Dexter F, Epstein RH, Ip V, Marian AA. Inhalational Agent Dosing Behaviors of Anesthesia Practitioners Cause Variability in End-Tidal Concentrations at the End of Surgery and Prolonged Times to Tracheal Extubation. Cureus 2024; 16:e65527. [PMID: 39188447 PMCID: PMC11346799 DOI: 10.7759/cureus.65527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2024] [Indexed: 08/28/2024] Open
Abstract
INTRODUCTION Prolonged times to tracheal extubation are intervals from the end of surgery to extubation ≥15 minutes. We examined why there are associations with the end-tidal inhalational agent concentration as a proportion of the age‑adjusted minimum alveolar concentration (MAC fraction) at the end of surgery. METHODS The retrospective cohort study used 11.7 years of data from one hospital. All p‑values were adjusted for multiple comparisons. RESULTS There was a greater odds of prolonged time to extubation if the anesthesia practitioner was a trainee (odds ratio 1.68) or had finished fewer than five cases with the surgeon during the preceding three years (odds ratio 1.12) (both P<0.0001). There was a greater risk of prolonged time to extubation if the MAC fraction was >0.4 at the end of surgery (odds ratio 2.66, P<0.0001). Anesthesia practitioners who were trainees and all practitioners who had finished fewer than five cases with the surgeon had greater mean MAC fractions at the end of surgery and had greater relative risks of the MAC fraction >0.4 at the end of surgery (all P<0.0001). The source for greater MAC fractions at the end of surgery was not greater MAC fractions throughout the anesthetic because the means during the case did not differ among groups. Rather, there was substantial variability of MAC fractions at the end of surgery among cases of the same anesthesia practitioner, with the mean (standard deviation) among practitioners of each practitioner's standard deviation being 0.35 (0.05) and the coefficient of variation being 71% (13%). CONCLUSION More prolonged extubations were associated with greater MAC fractions at the end of surgery. The cause of the large MAC fractions was the substantial variability of MAC fractions among cases of each practitioner at the end of surgery. That variability matches what was expected from earlier studies, both from variability among practitioners in their goals for the MAC fraction given at the start of surgical closure and from inadequate dynamic forecasting of the timing of when surgery would end. Future studies should examine how best to reduce prolonged extubations by using anesthesia machines' display of MAC fraction and feedback control of end-tidal agent concentration.
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Affiliation(s)
| | - Richard H Epstein
- Anesthesiology, Perioperative Medicine, and Pain Management, University of Miami Miller School of Medicine, Miami, USA
| | - Vivian Ip
- Anesthesiology, University of Calgary, Calgary, CAN
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Li Z, Wang P, Han L, Hao X, Mi W, Tong L, Liang Z. Age-dependent coupling characteristics of bilateral frontal EEG during desflurane anesthesia. Physiol Meas 2024; 45:055012. [PMID: 38697205 DOI: 10.1088/1361-6579/ad46e0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 05/01/2024] [Indexed: 05/04/2024]
Abstract
Objectives.The purpose of this study is to investigate the age dependence of bilateral frontal electroencephalogram (EEG) coupling characteristics, and find potential age-independent depth of anesthesia monitoring indicators for the elderlies.Approach.We recorded bilateral forehead EEG data from 41 patients (ranged in 19-82 years old), and separated into three age groups: 18-40 years (n= 12); 40-65 years (n= 14), >65 years (n= 15). All these patients underwent desflurane maintained general anesthesia (GA). We analyzed the age-related EEG spectra, phase amplitude coupling (PAC), coherence and phase lag index (PLI) of EEG data in the states of awake, GA, and recovery.Main results.The frontal alpha power shows age dependence in the state of GA maintained by desflurane. Modulation index in slow oscillation-alpha and delta-alpha bands showed age dependence and state dependence in varying degrees, the PAC pattern also became less pronounced with increasing age. In the awake state, the coherence in delta, theta and alpha frequency bands were all significantly higher in the >65 years age group than in the 18-40 years age group (p< 0.05 for three frequency bands). The coherence in alpha-band was significantly enhanced in all age groups in GA (p< 0.01) and then decreased in recovery state. Notably, the PLI in the alpha band was able to significantly distinguish the three states of awake, GA and recovery (p< 0.01) and the results of PLI in delta and theta frequency bands had similar changes to those of coherence.Significance.We found the EEG coupling and synchronization between bilateral forehead are age-dependent. The PAC, coherence and PLI portray this age-dependence. The PLI and coherence based on bilateral frontal EEG functional connectivity measures and PAC based on frontal single-channel are closely associated with anesthesia-induced unconsciousness.
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Affiliation(s)
- Ziyang Li
- Institute of Electrical Engineering, Yanshan University, Qinhuangdao 066004, People's Republic of China
- Key Laboratory of Intelligent Rehabilitation and Neuromodulation of Hebei Province, Qinhuangdao 066004, People's Republic of China
| | - Peiqi Wang
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, Beijing 100853, People's Republic of China
| | - Licheng Han
- Institute of Electrical Engineering, Yanshan University, Qinhuangdao 066004, People's Republic of China
- Key Laboratory of Intelligent Rehabilitation and Neuromodulation of Hebei Province, Qinhuangdao 066004, People's Republic of China
| | - Xinyu Hao
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, Beijing 100853, People's Republic of China
| | - Weidong Mi
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, Beijing 100853, People's Republic of China
| | - Li Tong
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, Beijing 100853, People's Republic of China
| | - Zhenhu Liang
- Institute of Electrical Engineering, Yanshan University, Qinhuangdao 066004, People's Republic of China
- Key Laboratory of Intelligent Rehabilitation and Neuromodulation of Hebei Province, Qinhuangdao 066004, People's Republic of China
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LeClair N, Ejimone M, Lynch D, Dasika J, Rao D, Hoefnagel AL, Mongan PD. T2-weighted Imaging Hyperintensity and Transcranial Motor-evoked Potentials During Cervical Spine Surgery: Effects of Sevoflurane in 150 Consecutive Cases. J Neurosurg Anesthesiol 2024; 36:150-158. [PMID: 36805419 DOI: 10.1097/ana.0000000000000909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 01/11/2023] [Indexed: 02/22/2023]
Abstract
BACKGROUND There is debate on the impact of inhalational esthetic agents on transcranial motor evoked potentials (TcMEPs) during intraoperative neuromonitoring. Current guidelines advise their avoidance, which contrasts with common clinical practice. METHODS This retrospective cohort study of 150 consecutive cervical spine surgeries at a single institution compared stimulation voltages and TcMEP amplitudes in patients who did and did not receive sevoflurane as part of a balanced anesthetic technique. Patients were divided into 3 groups stratified by the presence or absence of increased signal intensity within the cervical spinal cord on T2-weighted magnetic resonance imaging (indicative or myelopathy/spinal cord injury [SCI]) and sevoflurane use. RESULTS Patients with no magnetic resonance imaging evidence of myelopathy/SCI that received sevoflurane (n=80) had the lowest stimulation voltages and largest TcMEP amplitude responses in the lower extremities compared with those with no magnetic resonance imaging evidence of myelopathy/SCI (n=30). In patients with evidence of myelopathy/SCI who did not receive sevoflurane (n=19), lower extremity TcMEP amplitudes were similar to patients with a myelopathy/SCI that received sevoflurane. Six of these 19 patients had initial low-dose sevoflurane discontinued because of concerns of low/absent baseline TcMEP amplitudes. CONCLUSIONS Balanced anesthesia with 0.5 MAC sevoflurane in patients with and without radiological evidence of myelopathy/SCI allows reliable TcMEP monitoring. However, in communication with surgical and neuromonitoring teams, it may be advisable in a subset of patients to avoid or discontinue sevoflurane in favor of a propofol/opioid-based anesthetic to ensure adequate and reproducible TcMEPs.
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Affiliation(s)
| | | | | | | | - Dinesh Rao
- Radiology, University of Florida-Jacksonville, Jacksonville, FL
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Bratke S, Schmid S, Ulm B, Jungwirth B, Blobner M, Borgstedt L. Genotype- and sex-specific changes in vital parameters during isoflurane anesthesia in a mouse model of Alzheimer's disease. Front Med (Lausanne) 2024; 11:1342752. [PMID: 38601113 PMCID: PMC11004241 DOI: 10.3389/fmed.2024.1342752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 02/20/2024] [Indexed: 04/12/2024] Open
Abstract
Background The prevalence of neurodegenerative diseases is increasing as is life expectancy with Alzheimer's disease accounting for two-thirds of dementia cases globally. Whether general anesthesia and surgery worsen cognitive decline is still a matter of debate and most likely depending on the interplay of various influencing factors. In order to account for this complexity, Alzheimer's disease animal models have been developed. The Tg2576 model of Alzheimer's disease is a well-established mouse model exhibiting amyloidopathy and age-dependent sex-specific differences in Alzheimer's disease symptomology. Yet, data on anesthesia in this mouse model is scarce and a systematic comparison of vital parameters during anesthesia with wild-type animals is missing. In order to investigate the safety of general anesthesia and changes in vital parameters during general anesthesia in Tg2576 mice, we did a secondary analysis of vital parameters collected during general anesthesia in aged Tg2576 mice. Methods After governmental approval (General Administration of the Free State of Bavaria, file number: 55.2-1-54-2532-149-11) 60 mice at 10-12 months of age were exposed to isoflurane (1.6 Vol%) for 120 min, data of 58 mice was analyzed. During general anesthesia, heart rate, respiratory rate, temperature, isoflurane concentration and fraction of inspired oxygen were monitored and collected. Data were analyzed using univariate and multivariate linear mixed regression models. Results During general anesthesia, heart rate decreased in a sex-specific manner. Respiratory rate decreased and body temperature increased dependent on genotype. However, the changes were limited and all vital parameters stayed within physiological limits. Conclusion Isoflurane anesthesia in the Tg2576 mouse model is safe and does not seem to influence experimental results by interacting with vital parameters. The present study provides information on appropriate anesthesia in order to advance research on anesthesia and AD and could contribute to improving laboratory animal welfare.
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Affiliation(s)
- Sebastian Bratke
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, University of Ulm, Ulm, Germany
| | - Sebastian Schmid
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, University of Ulm, Ulm, Germany
| | - Bernhard Ulm
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, University of Ulm, Ulm, Germany
- Department of Anesthesiology and Intensive Care Medicine, School of Medicine, Technical University of Munich, Munich, Germany
| | - Bettina Jungwirth
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, University of Ulm, Ulm, Germany
| | - Manfred Blobner
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, University of Ulm, Ulm, Germany
- Department of Anesthesiology and Intensive Care Medicine, School of Medicine, Technical University of Munich, Munich, Germany
| | - Laura Borgstedt
- Department of Anesthesiology and Intensive Care Medicine, School of Medicine, Technical University of Munich, Munich, Germany
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Dexter F, Epstein RH, Marian AA, Guerra-Londono CE. Preventing Prolonged Times to Awakening While Mitigating the Risk of Patient Awareness: Gas Man Computer Simulations of Sevoflurane Consumption From Brief, High Fresh Gas Flow Before the End of Surgery. Cureus 2024; 16:e55626. [PMID: 38586680 PMCID: PMC10995762 DOI: 10.7759/cureus.55626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2024] [Indexed: 04/09/2024] Open
Abstract
Prolonged times to tracheal extubation are associated with adverse patient and economic outcomes. We simulated awakening patients from sevoflurane after long-duration surgery at 2% end-tidal concentration, 1.0 minimum alveolar concentration (MAC) in a 40-year-old. Our end-of-surgery target was 0.5 MAC, the Michigan Awareness Control Study's threshold for intraoperative alerts. Consider an anesthetist who uses a 1 liter/minute gas flow until surgery ends. During surgical closure, the inspired sevoflurane concentration is reduced from 2.05% to 0.62% (i.e., MAC-awake). The estimated time to reach 0.5 MAC is 28 minutes. From a previous study, 28 minutes exceeded ≥95% of surgical closure times for all 244 distinct surgical procedures (N=23,343 cases). Alternatively, the anesthetist uses 8 liters/minute gas flow with the vaporizer at MAC-awake for 1.8 minutes, which reduces the end-tidal concentration to 0.5 MAC. The anesthetist then increases the vaporizer to keep end-tidal 0.5 MAC until the surgery ends. An additional simulation shows that, compared with simulated end-tidal agent feedback control, this approach consumed 0.45 mL extra agent. Simulation results are the same for an 80-year-old patient. The extra 0.45 mL has a global warming potential comparable to driving 26 seconds at 40 kilometers (25 miles) per hour, comparable to route modification to avoid potential roadway hazards.
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Affiliation(s)
| | - Richard H Epstein
- Anesthesiology, Perioperative Medicine, and Pain Management, University of Miami Miller School of Medicine, Miami, USA
| | | | - Carlos E Guerra-Londono
- Anesthesiology, Perioperative Medicine, and Pain Management, Henry Ford Health System, Detroit, USA
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Schnetz MP, Reon BJ, Ibinson JW, Kaynar M, Mahajan A, Vogt KM. Bispectral Index Changes Following Boluses of Commonly Used Intravenous Medications During Volatile Anesthesia Identified From Retrospective Data. Anesth Analg 2024; 138:635-644. [PMID: 37582055 PMCID: PMC10867275 DOI: 10.1213/ane.0000000000006633] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2023]
Abstract
BACKGROUND Although patients are commonly monitored for depth of anesthesia, it is unclear to what extent administration of intravenous anesthetic medications may affect calculated bispectral (BIS) index values under general anesthesia. METHODS In a retrospective analysis of electronic anesthesia records from an academic medical center, we examined BIS index changes associated with 14 different intravenous medications, as administered in routine practice, during volatile-based anesthesia using a novel screening approach. Discrete-time windows were identified in which only a single drug bolus was administered, and subsequent changes in the BIS index, concentration of volatile anesthetic, and arterial pressure were analyzed. Our primary outcome was change in BIS index, following drug administration. Adjusted 95% confidence intervals were compared to predetermined thresholds for clinical significance. Secondary sensitivity analyses examined the same outcomes, with available data separated according to differences in baseline volatile anesthetic concentrations, doses of the administered medications, and length of time window. RESULTS The study cohort was comprised of data from 20,170 distinct cases, 54.7% of patients were men, with a median age of 55. In the primary analysis, ketamine at a median dose of 20 mg was associated with a median (confidence limits) increase in BIS index of 3.8 (2.5-5.0). Midazolam (median dose 2 mg) was associated with a median decrease in BIS index of 3.0 (1.5-4.5). Neither of these drug administrations occurred during time periods associated with changes in volatile anesthetic concentration. Analysis for dexmedetomidine was confounded by concomitant decreases in volatile anesthetic concentration. No other medication analyzed, including propofol and common opioids, was associated with a significant change in BIS index. Secondary analyses revealed that similar BIS index changes occurred when midazolam and ketamine were administered at different volatile anesthetic concentrations and different doses, and these changes persisted 11 to 20 minutes postadministration. CONCLUSIONS Modest, but persistent changes in BIS index occurred following doses of ketamine (increase) and midazolam (decrease) during periods of stable volatile anesthetic administration.
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Affiliation(s)
- Michael P. Schnetz
- Anesthesiology and Perioperative Medicine, School of Medicine, University of Pittsburgh; Pittsburgh, PA, USA
| | - Brian J. Reon
- Anesthesiology and Perioperative Medicine, School of Medicine, University of Pittsburgh; Pittsburgh, PA, USA
| | - James W. Ibinson
- Anesthesiology and Perioperative Medicine, School of Medicine, University of Pittsburgh; Pittsburgh, PA, USA
- Clinical and Translational Science Institute, University of Pittsburgh; Pittsburgh, PA, USA
| | - Murat Kaynar
- Anesthesiology and Perioperative Medicine, School of Medicine, University of Pittsburgh; Pittsburgh, PA, USA
- Critical Care Medicine, School of Medicine, University of Pittsburgh; Pittsburgh, PA, USA
| | - Aman Mahajan
- Anesthesiology and Perioperative Medicine, School of Medicine, University of Pittsburgh; Pittsburgh, PA, USA
- Biomedical Informatics, School of Medicine, University of Pittsburgh; Pittsburgh, PA, USA
- Bioengineering, Swanson School of Engineering, University of Pittsburgh; Pittsburgh, PA, USA
| | - Keith M. Vogt
- Anesthesiology and Perioperative Medicine, School of Medicine, University of Pittsburgh; Pittsburgh, PA, USA
- Clinical and Translational Science Institute, University of Pittsburgh; Pittsburgh, PA, USA
- Bioengineering, Swanson School of Engineering, University of Pittsburgh; Pittsburgh, PA, USA
- Center for the Neural Basis of Cognition, University of Pittsburgh; Pittsburgh, PA, USA
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Ostertag J, Engelhard A, Nuttall R, Aydin D, Schneider G, García PS, Hinzmann D, Sleigh JW, Kratzer S, Kreuzer M. Development of Postanesthesia Care Unit Delirium Is Associated with Differences in Aperiodic and Periodic Alpha Parameters of the Electroencephalogram during Emergence from General Anesthesia: Results from a Prospective Observational Cohort Study. Anesthesiology 2024; 140:73-84. [PMID: 37815856 DOI: 10.1097/aln.0000000000004797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
BACKGROUND Intraoperative alpha-band power in frontal electrodes may provide helpful information about the balance of hypnosis and analgesia and has been associated with reduced occurrence of delirium in the postanesthesia care unit. Recent studies suggest that narrow-band power computations from neural power spectra can benefit from separating periodic and aperiodic components of the electroencephalogram. This study investigates whether such techniques are more useful in separating patients with and without delirium in the postanesthesia care unit at the group level as opposed to conventional power spectra. METHODS Intraoperative electroencephalography recordings of 32 patients who developed perioperative neurocognitive disorders and 137 patients who did not were considered in this post hoc secondary analysis. The power spectra were calculated using conventional methods and the "fitting oscillations and one over f" algorithm was applied to separate aperiodic and periodic components to see whether the electroencephalography signature is different between groups. RESULTS At the group level, patients who did not develop perioperative neurocognitive disorders presented with significantly higher alpha-band power and a broadband increase in power, allowing a "fair" separation based on conventional power spectra. Within the first third of emergence, the difference in median absolute alpha-band power amounted to 8.53 decibels (area under the receiver operator characteristics curve, 0.74 [0.65; 0.82]), reaching its highest value. In relative terms, the best separation was achieved in the second third of emergence, with a difference in medians of 7.71% (area under the receiver operator characteristics curve, 0.70 [0.61; 0.79]). The area under the receiver operator characteristics curve values were generally lower toward the end of emergence with increasing arousal. CONCLUSIONS Increased alpha-band power during emergence in patients who did not develop perioperative neurocognitive disorders can be traced back to an increase in oscillatory alpha activity and an overall increase in aperiodic broadband power. Although the differences between patients with and without perioperative neurocognitive disorders can be detected relying on traditional methods, the separation of the signal allows a more detailed analysis. This may enable clinicians to detect patients at risk for developing perioperative neurocognitive disorders in the postanesthesia care unit early in the emergence phase. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Julian Ostertag
- Department of Anesthesiology and Intensive Care, Technical University of Munich - School of Medicine, Munich, Germany
| | - Antonia Engelhard
- Department of Anesthesiology and Intensive Care, Technical University of Munich - School of Medicine, Munich, Germany
| | - Rachel Nuttall
- Department of Anesthesiology and Intensive Care, Technical University of Munich - School of Medicine, Munich, Germany
| | - Duygu Aydin
- Department of Anesthesiology and Intensive Care, Technical University of Munich - School of Medicine, Munich, Germany
| | - Gerhard Schneider
- Department of Anesthesiology and Intensive Care, Technical University of Munich - School of Medicine, Munich, Germany
| | - Paul S García
- Department of Anesthesiology, Columbia University, New York, New York
| | - Dominik Hinzmann
- Department of Anesthesiology and Intensive Care, Technical University of Munich - School of Medicine, Munich, Germany
| | - Jamie W Sleigh
- Department of Anesthesiology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Stephan Kratzer
- Department of Anesthesiology and Intensive Care, Technical University of Munich - School of Medicine, Munich, Germany
| | - Matthias Kreuzer
- Department of Anesthesiology and Intensive Care, Technical University of Munich - School of Medicine, Munich, Germany
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Mitsuzawa K, Ishida T, Tanaka R, Ito M, Tanaka S, Kawamata M. Effects of anesthetics on nociceptive sensory evoked potentials by intraepidermal noxious electrical stimulation of A-δ fibers. J Anesth 2023; 37:841-852. [PMID: 37597005 DOI: 10.1007/s00540-023-03243-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 08/05/2023] [Indexed: 08/21/2023]
Abstract
PURPOSE Generation of nociceptive sensory evoked potentials (NEPs) by selective stimulation of nociceptive intraepidermal nerve fibers is a simple technique which could be used as intraoperative nociception monitor. We evaluated the effects of remifentanil, propofol and sevoflurane on NEPs by this technique. METHODS Patients undergoing general anesthesia were assigned to groups in two studies. A-δ fiber selective NEPs were recorded. Study 1: NEPs were recorded at control, under anesthetics administration: remifentanil at an effect-site concentration (Ce) of 1.0 ng/mL (n = 10), propofol at Ce of 0.5 µg/mL (n = 10), or sevoflurane at 0.2 minimum alveolar concentration (MAC) (n = 10), and recovery from the anesthetics. Study 2: NEPs were recorded at control and under administration of higher dose anesthetics: propofol at Ce of 0.5 and 1.0 µg/mL (n = 10) or sevoflurane at 0.2 and 0.5 MAC (n = 10). A P-value < 0.016 was considered statistically significant in multiple analyses. RESULTS Study 1: Remifentanil at Ce of 1.0 ng/mL significantly suppressed the amplitude of NEPs (mean amplitude (standard deviation) of control vs. remifentanil administration: 16.8 µV (3.8) vs. 10.1 µV (2.5), P < 0.001). Propofol and sevoflurane did not suppress the amplitude significantly. Study 2: Propofol at Ce of 0.5 and 1.0 µg/mL and sevoflurane at 0.2 and 0.5 MAC did not suppress the amplitude significantly. CONCLUSION The amplitude of A-δ fiber selective NEPs was suppressed by remifentanil but not propofol or sevoflurane. NEPs with intraepidermal electrical stimulation can assess the analgesic effect of anesthetics. CLINICAL TRIAL NUMBER UMIN000038214 REGISTRY URL: https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000043328.
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Affiliation(s)
- Kunihiro Mitsuzawa
- Department of Anesthesiology and Resuscitology, Shinshu University School of Medicine, 3-1-1, Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Takashi Ishida
- Department of Anesthesiology and Resuscitology, Shinshu University School of Medicine, 3-1-1, Asahi, Matsumoto, Nagano, 390-8621, Japan.
| | - Ryusuke Tanaka
- Department of Anesthesiology and Resuscitology, Shinshu University School of Medicine, 3-1-1, Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Mariko Ito
- Department of Anesthesiology and Resuscitology, Shinshu University School of Medicine, 3-1-1, Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Satoshi Tanaka
- Department of Anesthesiology and Resuscitology, Shinshu University School of Medicine, 3-1-1, Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Mikito Kawamata
- Department of Anesthesiology and Resuscitology, Shinshu University School of Medicine, 3-1-1, Asahi, Matsumoto, Nagano, 390-8621, Japan
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11
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Shorin D, Kamiya S, Nakamura R, Ishibashi A, Saeki N, Tsuji T, Tsutsumi YM. Prediction of blood pressure changes during surgical incision using the minimum evoked current of vascular stiffness value under sevoflurane anesthesia. Sci Rep 2023; 13:20486. [PMID: 37993532 PMCID: PMC10665398 DOI: 10.1038/s41598-023-46942-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 11/07/2023] [Indexed: 11/24/2023] Open
Abstract
Necessary and sufficient opioids should be administered for safe and stable anesthesia. However, opioid sensitivity varies among individuals. We previously reported that sympathetic responses to nociceptive stimuli under propofol anesthesia could be predicted by measuring the minimum evoked current of the vascular stiffness value (MECK). However, this result has only been proven under propofol anesthesia. We propose that MECK could be used under anesthesia with a volatile anesthetic. Thirty patients undergoing laparotomy with sevoflurane anesthesia received 0.7 minimum alveolar concentration (MAC) sevoflurane and intravenous remifentanil at a constant concentration of 2 ng/mL, followed by tetanic stimulation, to measure MECK. After tetanic stimulation, the same anesthetic conditions were maintained, and the rate of change in systolic blood pressure (ROCBP) during the skin incision was measured. The correlation coefficient between the MECK and ROCBP during skin incision under sevoflurane anesthesia was R = - 0.735 (P < 0.01), similar to that in a previous study with propofol (R = - 0.723). Thus, a high correlation was observed. The slope of the linear regression equation was - 0.27, similar to that obtained in the study on propofol (- 0.28). These results suggest that, as with propofol anesthesia, MECK can be used as a predictive index for ROCBP under 0.7 MAC sevoflurane anesthesia.Clinical trial registration: Registry, University hospital Medical Information Network; registration number, UMIN000047425; principal investigator's name, Noboru Saeki; date of registration, April 8, 2022.
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Affiliation(s)
- Daiki Shorin
- Department of Anesthesiology and Critical Care, Hiroshima University Hospital, 1-2-3 Kasumi, Minami, Hiroshima, 734-8551, Japan
| | - Satoshi Kamiya
- Department of Anesthesiology and Critical Care, Hiroshima University Hospital, 1-2-3 Kasumi, Minami, Hiroshima, 734-8551, Japan
| | - Ryuji Nakamura
- Department of Anesthesiology and Critical Care, Hiroshima University Hospital, 1-2-3 Kasumi, Minami, Hiroshima, 734-8551, Japan.
| | - Ayaka Ishibashi
- Department of Anesthesiology and Critical Care, Hiroshima University Hospital, 1-2-3 Kasumi, Minami, Hiroshima, 734-8551, Japan
| | - Noboru Saeki
- Department of Anesthesiology and Critical Care, Hiroshima University Hospital, 1-2-3 Kasumi, Minami, Hiroshima, 734-8551, Japan
| | - Toshio Tsuji
- Graduate School of Advanced Science and Engineering, Hiroshima University, Hiroshima, Japan
| | - Yasuo M Tsutsumi
- Department of Anesthesiology and Critical Care, Hiroshima University Hospital, 1-2-3 Kasumi, Minami, Hiroshima, 734-8551, Japan
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12
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Livingston CE, Levy DT, Saroukhani S, Fox EE, Wade CE, Holcomb JB, Gumbert SD, Galvagno SM, Kaslow OY, Pittet JF, Pivalizza EP. Volatile anesthetic and outcome in acute trauma care: planned secondary analysis of the PROPPR study. Proc AMIA Symp 2023; 36:680-685. [PMID: 37829226 PMCID: PMC10566423 DOI: 10.1080/08998280.2023.2243204] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 07/25/2023] [Indexed: 10/14/2023] Open
Abstract
Background This retrospective analysis of prospectively collected data from the PROPPR study describes volatile anesthetic use in severely injured trauma patients undergoing anesthesia. Methods After exclusions, 402 subjects were reviewed of the original 680, and 292 had complete data available for analysis. Anesthesia was not protocolized, so analysis was of contemporary practice. Results The small group who received no volatile anesthetic (n = 25) had greater injury burden (Glasgow Coma Scale P = 0.05, Injury Severity Score P = 0.001, Revised Trauma Score P = 0.03), higher 6- and 24-hour mortality (P < 0.001), and higher incidence of systemic inflammatory response syndrome (P = 0.003) and ventilator-associated pneumonia (P = 0.02) than those receiving any volatile (n = 267). There were no differences in mortality between volatile agents at 6 hours (P = 0.51) or 24 hours (P = 0.35). The desflurane group was less severely injured than the isoflurane group. Mean minimum alveolar concentration was < 0.6 and lowest in the isoflurane group compared to the sevoflurane and desflurane groups (both P < 0.01). The incidence of systemic inflammatory response syndrome was lower in the desflurane group than in the isoflurane group (P = 0.007). Conclusion In this acutely injured trauma population, choice of volatile anesthetic did not appear to influence short-term mortality and morbidity. Subjects who received no volatile were more severely injured with greater mortality, representing hemodynamic compromise where volatile agent was limited until stable. As anesthetic was not protocolized, these findings that choice of specific volatile was not associated with short-term survival require prospective, randomized evaluation.
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Affiliation(s)
- Colleen E. Livingston
- Department of Anesthesiology, McGovern Medical School at UTHealth, Houston, Texas, USA;
| | - Dominique T. Levy
- Department of Anesthesiology, McGovern Medical School at UTHealth, Houston, Texas, USA;
| | - Sepideh Saroukhani
- Department of Internal Medicine, Division of Clinical and Translational Sciences, McGovern Medical School at UTHealth, and Biostatistics/Epidemiology/Research Design Component, Center for Clinical and Translational Sciences, UTHealth, Houston, Texas, USA;
| | - Erin E. Fox
- Department of Surgery, Center for Translational Injury Research, McGovern Medical School at UTHealth, Houston, Texas, USA;
| | - Charles E. Wade
- Department of Surgery, Center for Translational Injury Research, McGovern Medical School at UTHealth, Houston, Texas, USA;
| | - John B. Holcomb
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA;
| | - Sam D. Gumbert
- Department of Anesthesiology, Cleveland Clinic, Cleveland, Ohio, USA;
| | - Samuel M. Galvagno
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland, USA;
| | - Olga Y. Kaslow
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA;
| | - Jean-Francois Pittet
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Evan P. Pivalizza
- Department of Anesthesiology, McGovern Medical School at UTHealth, Houston, Texas, USA;
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13
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Hu C, Wang B, Liu Z, Chen Q, Ishikawa M, Lin H, Lian Q, Li J, Li JV, Ma D. Sevoflurane but not propofol enhances ovarian cancer cell biology through regulating cellular metabolic and signaling mechanisms. Cell Biol Toxicol 2023; 39:1395-1411. [PMID: 36207479 PMCID: PMC10425485 DOI: 10.1007/s10565-022-09766-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 08/26/2022] [Indexed: 11/02/2022]
Abstract
Perioperative risk factors, including the choice of anesthetics, may influence ovarian cancer recurrence after surgery. Inhalational anesthetic sevoflurane and intravenous agent propofol might affect cancer cell metabolism and signaling, which, in turn, may influence the malignancy of ovarian cancer cells. The different effects between sevoflurane and propofol on ovarian cancer cell biology and underlying mechanisms were studied. Cultured ovarian cancer cells were exposed to 2.5% sevoflurane, 4 μg/mL propofol, or sham condition as the control for 2 h followed by 24-h recovery. Glucose transporter 1 (GLUT1), mitochondrial pyruvate carrier 1 (MPC1), glutamate dehydrogenase 1 (GLUD1), pigment epithelium-derived factor (PEDF), p-Erk1/2, and hypoxia-inducible factor 1-alpha (HIF-1α) expressions were determined with immunostaining and/or Western blot. Cultured media were collected for 1H-NMR spectroscopy-based metabolomics analysis. Principal component analysis (PCA) and orthogonal projections to latent structures discriminant analysis (OPLS-DA) were used to analyze metabolomics data. Sevoflurane increased the GLUT1, MPC1, GLUD1, p-Erk1/2, and HIF-1α expressions but decreased the PEDF expression relative to the controls. In contrast to sevoflurane, propofol decreased GLUT1, MPC1, GLUD1, p-Erk1/2, and HIF-1α but increased PEDF expression. Sevoflurane increased metabolite isopropanol and decreased glucose and glutamine energy substrates in the media, but the opposite changes were found after propofol treatment. Our data indicated that, unlike the pro-tumor property of sevoflurane, propofol negatively modulated PEDF/Erk/HIF-1α cellular signaling pathway and inhibited ovarian cancer metabolic efficiency and survival, and hence decreased malignancy. The translational value of this work warrants further study. • Sevoflurane promoted but propofol inhibited ovarian cancer cell biology. • Sevoflurane upregulated but propofol downregulated the GLUT1, MPC1, and GLUD1 expressions of ovarian cancer cells. • Sevoflurane enhanced but propofol inhibited ovarian cancer cellular glucose. metabolism and glutaminolysis. • Sevoflurane downregulated PEDF but upregulated the Erk pathway and HIF-1α, while propofol had the adverse effects on ovarian cancer cells.
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Affiliation(s)
- Cong Hu
- Zhejiang Province Key Lab of Anesthesiology, Department of Anesthesiology and Perioperative Medicine, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, 325027 Zhejiang China
- Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea & Westminster Hospital, London, SW10 9NH UK
| | - Bincheng Wang
- Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea & Westminster Hospital, London, SW10 9NH UK
| | - Zhigang Liu
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, SW7 2AZ UK
| | - Qiling Chen
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, SW7 2AZ UK
| | - Masashi Ishikawa
- Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea & Westminster Hospital, London, SW10 9NH UK
| | - Han Lin
- Zhejiang Province Key Lab of Anesthesiology, Department of Anesthesiology and Perioperative Medicine, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, 325027 Zhejiang China
| | - Qingquan Lian
- Zhejiang Province Key Lab of Anesthesiology, Department of Anesthesiology and Perioperative Medicine, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, 325027 Zhejiang China
| | - Jun Li
- Zhejiang Province Key Lab of Anesthesiology, Department of Anesthesiology and Perioperative Medicine, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, 325027 Zhejiang China
| | - Jia V. Li
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, SW7 2AZ UK
| | - Daqing Ma
- Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea & Westminster Hospital, London, SW10 9NH UK
| | - The ESA-IC Onco-Anaesthesiology Research Group
- Zhejiang Province Key Lab of Anesthesiology, Department of Anesthesiology and Perioperative Medicine, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, 325027 Zhejiang China
- Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea & Westminster Hospital, London, SW10 9NH UK
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, SW7 2AZ UK
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14
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Kılıç BÖ, Savran Karadeniz M, Şentürk E, Güler MM, Gürvit İH, Sungur Z, Demirel E, Tuğrul KM. The Effect of Anaesthesia Management with Different Fresh Gas Flows on Cognitive Functions of Geriatric Patients: A Randomized Double-blind Study. Turk J Anaesthesiol Reanim 2023; 51:219-226. [PMID: 37455516 DOI: 10.4274/tjar.2022.21630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023] Open
Abstract
Objective The present study aimed to compare the effects of two different fresh gas flows (FGFs) (0.5 L min-1 and 2 L min-1) applied during maintenance of anaesthesia on recovery from anaesthesia and early cognitive functions in geriatric patients. Methods In this prospective, randomised, double-blind study, sixty patients were divided into two groups according to the amount of FGF. Minimal-flow anaesthesia (0.5 L min-1 FGF) was applied to group I and medium-flow anaesthesia (2 L min-1 FGF) was applied to group II during maintenance of anaesthesia. Following the termination of inhalation anaesthesia, recovery times were recorded. The evaluation of cognitive functions was performed using the Addenbrooke's Cognitive Examination (ACE-R). Results There was no significant difference between the two groups in terms of demographic characteristics and recovery (P > 0.05). There was no significant difference between the two groups in terms of the preoperative day, the first postoperative day, and the third postoperative day; ACE-R scores (P > 0.05). In group II, on the third postoperative day ACE-R scores were found to be significantly lower than the preoperative ACE-R scores (P=0.04). In group II, third postoperative day ACE-R memory sub-scores (14.53 ± 3.34) were found to be significantly lower than preoperative ACE-R memory sub-scores (15.03 ± 3.57) (P=0.04). Conclusion In geriatric patients, minimal-flow anaesthesia was not superior to medium-flow anaesthesia in terms of recovery properties and cognitive functions. Keeping in mind that hypoxaemia and changes in anaesthesia levels may occur with the reduction of FGF, both minimal- and medium-flow anaesthesia can be applied with appropriate monitoring without adverse effects on recovery and cognitive functions.
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Affiliation(s)
- Bilge Özge Kılıç
- Department of Anaesthesiology and Reanimation, İstanbul University İstanbul Faculty of Medicine, İstanbul, Turkey
| | - Meltem Savran Karadeniz
- Department of Anaesthesiology and Reanimation, İstanbul University İstanbul Faculty of Medicine, İstanbul, Turkey
| | - Emre Şentürk
- Department of Anaesthesiology and Reanimation, İstanbul University İstanbul Faculty of Medicine, İstanbul, Turkey
| | - Meltem Merve Güler
- Department of Anaesthesiology and Reanimation, İstanbul University İstanbul Faculty of Medicine, İstanbul, Turkey
| | - İbrahim Hakan Gürvit
- Department of Neurology, İstanbul University, İstanbul Faculty of Medicine, İstanbul, Turkey
| | - Zerrin Sungur
- Department of Anaesthesiology and Reanimation, İstanbul University İstanbul Faculty of Medicine, İstanbul, Turkey
| | - Ebru Demirel
- Department of Anaesthesiology and Reanimation, İstanbul University İstanbul Faculty of Medicine, İstanbul, Turkey
| | - Kamil Mehmet Tuğrul
- Department of Anaesthesiology and Reanimation, İstanbul University İstanbul Faculty of Medicine, İstanbul, Turkey
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15
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Liang Z, Wang X, Yu Z, Tong Y, Li X, Ma Y, Guo H. Age-dependent neurovascular coupling characteristics in children and adults during general anesthesia. BIOMEDICAL OPTICS EXPRESS 2023; 14:2240-2259. [PMID: 37206124 PMCID: PMC10191645 DOI: 10.1364/boe.482127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 04/06/2023] [Accepted: 04/11/2023] [Indexed: 05/21/2023]
Abstract
General anesthesia is an indispensable procedure in clinical practice. Anesthetic drugs induce dramatic changes in neuronal activity and cerebral metabolism. However, the age-related changes in neurophysiology and hemodynamics during general anesthesia remain unclear. Therefore, the objective of this study was to explore the neurovascular coupling between neurophysiology and hemodynamics in children and adults during general anesthesia. We analyzed frontal electroencephalogram (EEG) and functional near-infrared spectroscopy (fNIRS) signals recorded from children (6-12 years old, n = 17) and adults (18-60 years old, n = 25) during propofol-induced and sevoflurane-maintained general anesthesia. The neurovascular coupling was evaluated in wakefulness, maintenance of a surgical state of anesthesia (MOSSA), and recovery by using correlation, coherence and Granger-causality (GC) between the EEG indices [EEG power in different bands and permutation entropy (PE)], and hemodynamic responses the oxyhemoglobin (Δ[HbO]) and deoxy-hemoglobin (Δ[Hb]) from fNIRS in the frequency band in 0.01-0.1 Hz. The PE and Δ[Hb] performed well in distinguishing the anesthesia state (p > 0.001). The correlation between PE and Δ[Hb] was higher than those of other indices in the two age groups. The coherence significantly increased during MOSSA (p < 0.05) compared with wakefulness, and the coherences between theta, alpha and gamma, and hemodynamic activities of children are significantly stronger than that of adults' bands. The GC from neuronal activities to hemodynamic responses decreased during MOSSA, and can better distinguish anesthesia state in adults. Propofol-induced and sevoflurane-maintained combination exhibited age-dependent neuronal activities, hemodynamics, and neurovascular coupling, which suggests the need for separate rules for children's and adults' brain states monitoring during general anesthesia.
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Affiliation(s)
- Zhenhu Liang
- School of Electrical Engineering, Yanshan University, Qinhuangdao 066004, China
- Key Laboratory of Intelligent Rehabilitation and Neuromodulation of Hebei Province, Qinhuangdao 066004, China
| | - Xin Wang
- School of Electrical Engineering, Yanshan University, Qinhuangdao 066004, China
- Key Laboratory of Intelligent Rehabilitation and Neuromodulation of Hebei Province, Qinhuangdao 066004, China
| | - Zhenyang Yu
- School of Electrical Engineering, Yanshan University, Qinhuangdao 066004, China
- Key Laboratory of Intelligent Rehabilitation and Neuromodulation of Hebei Province, Qinhuangdao 066004, China
| | - Yunjie Tong
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, USA
| | - Xiaoli Li
- Center for Cognition and Neuroergonomics, Beijing Normal University (Zhuhai), Zhuhai, Guangdong, 519087, China
| | - Yaqun Ma
- Department of Anesthesiology, the Seventh Medical Center to Chinese PLA General Hospital, Beijing, 100700, China
| | - Hang Guo
- Department of Anesthesiology, the Seventh Medical Center to Chinese PLA General Hospital, Beijing, 100700, China
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16
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Corner H, Barley M, Metodiev Y. The use of processed electroencephalography (pEEG) in obstetric anaesthesia: a narrative review. Int J Obstet Anesth 2023; 54:103650. [PMID: 36934515 DOI: 10.1016/j.ijoa.2023.103650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 02/16/2023] [Accepted: 02/28/2023] [Indexed: 03/08/2023]
Abstract
Accidental awareness under general anaesthesia (AAGA) remains a major complication of anaesthesia. The incidence of AAGA during obstetric anaesthesia is high relative to other specialities. The use of processed electroencephalography (pEEG) in the form of "depth of anaesthesia" monitoring has been shown to reduce the incidence of AAGA in the non-obstetric population. The evidence for using pEEG to prevent AAGA in the obstetric population is poor and requires further exploration. Furthermore, pregnancy and disease states affecting the central nervous system, such as pre-eclampsia, may alter the interpretation of pEEG waveforms although this has not been fully characterised. National guidelines exist for pEEG monitoring with total intravenous anaesthesia and for "high-risk" cases regardless of technique, including the obstetric population. However, none of the currently available guidelines relates specifically to obstetric anaesthesia. Using pEEG monitoring for obstetric anaesthesia may also provide additional benefits beyond a reduction in risk of AAGA. These potential benefits include reduced postoperative nausea and vomiting, reduced anaesthetic agent use, a shorter post-anaesthetic recovery stay. In addition, pEEG acts as a surrogate marker of cerebral perfusion, and thus as an additional monitor for impending cardiovascular collapse, as seen in amniotic fluid embolism. The subtle physiological and pathological changes in EEG activity that may occur during pregnancy are an unexplored research area in the context of anaesthetic pEEG monitors. We believe that the direction of clinical practice is moving towards greater use of pEEG monitoring and individualisation of anaesthesia.
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Affiliation(s)
- H Corner
- Department of Anaesthesia, Leicester Royal Infirmary, Leicester, UK.
| | - M Barley
- Department of Anaesthesia, Queens Medical Centre, Nottingham, UK
| | - Y Metodiev
- Department of Anaesthesia, University Hospital of Wales, Cardiff, UK
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17
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Kristensen L, Zardo JQ, Hansen SM, Bertelsen MF, Alstrup AKO, Wang T, Williams CJA. Effect of atropine and propofol on the minimum anaesthetic concentration of isoflurane in the freshwater turtle Trachemys scripta (yellow-bellied slider). Vet Anaesth Analg 2023; 50:180-187. [PMID: 36739261 DOI: 10.1016/j.vaa.2021.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 10/06/2021] [Accepted: 10/27/2021] [Indexed: 12/05/2022]
Abstract
OBJECTIVE To determine if the administration of atropine would reduce the measured minimum anaesthetic concentration of isoflurane (MACisoflurane) in freshwater turtles - the yellow-bellied slider (Trachemys scripta scripta). STUDY DESIGN Paired, blinded, randomized, prospective studies of 1) the effect of atropine in isoflurane anaesthetized freshwater turtles (T. scripta scripta) and 2) the effect of atropine in yellow-bellied sliders in which anaesthesia was induced with propofol and maintained with isoflurane. ANIMALS T. scripta scripta (n = 8), female, adult. METHODS Atropine (2 mg kg-1) or an isovolumetric control injection of saline was administered intraperitoneally 15 minutes prior to induction of anaesthesia with isoflurane. Individual MACisoflurane was then determined by end-tidal gas analysis in a bracketing design by an experimenter blinded to the administered drug, with a 2 week washout period. The experiment was repeated, with atropine (2 mg kg-1) or saline administered intravascularly in combination with propofol for anaesthetic induction. Linear mixed modelling was used to determine the effects of atropine and propofol on the individual MACisoflurane. Data are presented as mean ± standard deviation. RESULTS Premedication with atropine significantly reduced MACisoflurane (p = 0.0039). In isoflurane-induced T. scripta scripta, MACisoflurane decreased from 4.2 ± 0.4% to 3.3 ± 0.8% when atropine had been administered. Propofol as an induction agent had a MAC-sparing effect (p < 0.001) such that MACisoflurane following propofol and a control injection of saline was 2.3 ± 1.0%, which decreased further to 1.5 ± 0.8% when propofol was combined with atropine. CONCLUSIONS AND CLINICAL RELEVANCE Atropine, presumably by inhibiting parasympathetically mediated pulmonary artery constriction, decreases right-to-left cardiac shunting and the MACisoflurane in yellow-bellied sliders, and thereby may facilitate control of inhalant anaesthesia. Propofol can be used for induction of anaesthesia and reduces the required concentration of inhaled anaesthesia assessed 1.5 hours following induction.
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Affiliation(s)
- Line Kristensen
- Zoophysiology, Department of Biology, Aarhus University, Aarhus, Denmark
| | - Juliana Q Zardo
- School of Veterinary Medicine and Animal Science, Copenhagen University, Copenhagen, Denmark
| | - Sofie M Hansen
- School of Veterinary Medicine and Animal Science, Copenhagen University, Copenhagen, Denmark
| | - Mads F Bertelsen
- Center for Zoo and Wild Animal Health, Copenhagen Zoo, Frederiksberg, Denmark
| | - Aage K O Alstrup
- Department of Nuclear Medicine & PET, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Tobias Wang
- Zoophysiology, Department of Biology, Aarhus University, Aarhus, Denmark
| | - Catherine J A Williams
- Zoophysiology, Department of Biology, Aarhus University, Aarhus, Denmark; Department of Biomedical Sciences, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada.
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18
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Fedorov A, Lehto A, Klein J. Inhibition of mitochondrial respiration by general anesthetic drugs. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2023; 396:375-381. [PMID: 36385685 PMCID: PMC9832080 DOI: 10.1007/s00210-022-02338-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 11/10/2022] [Indexed: 11/18/2022]
Abstract
General anesthetic drugs have been associated with various unwanted effects including an interference with mitochondrial function. We had previously observed increases of lactate formation in the mouse brain during anesthesia with volatile anesthetic agents. In the present work, we used mitochondria that were freshly isolated from mouse brain to test mitochondrial respiration and ATP synthesis in the presence of six common anesthetic drugs. The volatile anesthetics isoflurane, halothane, and (to a lesser extent) sevoflurane caused an inhibition of complex I of the electron transport chain in a dose-dependent manner. Significant effects were seen at concentrations that are reached under clinical conditions (< 0.5 mM). Pentobarbital and propofol also inhibited complex I but at concentrations that were two-fold higher than clinical EC50 values. Only propofol caused an inhibition of complex II. Complex IV respiration was not affected by either agent. Ketamine did not affect mitochondrial respiration. Similarly, all anesthetic agents except ketamine suppressed ATP production at high concentrations. Only halothane increased cytochrome c release indicating damage of the mitochondrial membrane. In summary, volatile general anesthetic agents as well as pentobarbital and propofol dose-dependently inhibit mitochondrial respiration. This action may contribute to depressive actions of the drugs in the brain.
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Affiliation(s)
- Anton Fedorov
- Department of Pharmacology and Clinical Pharmacy, College of Pharmacy, Goethe University Frankfurt, Max-Von-Laue-Str. 9, 60438 Frankfurt, Germany
| | - Alina Lehto
- Department of Pharmacology and Clinical Pharmacy, College of Pharmacy, Goethe University Frankfurt, Max-Von-Laue-Str. 9, 60438 Frankfurt, Germany
| | - Jochen Klein
- Department of Pharmacology and Clinical Pharmacy, College of Pharmacy, Goethe University Frankfurt, Max-Von-Laue-Str. 9, 60438 Frankfurt, Germany
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19
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The Influence of Carbon Dioxide on Cerebral Autoregulation During Sevoflurane-based Anesthesia in Patients With Type 2 Diabetes. J Neurosurg Anesthesiol 2023; 35:65-73. [PMID: 34387283 DOI: 10.1097/ana.0000000000000794] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 07/06/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cerebral autoregulation (CA) continuously adjusts cerebrovascular resistance to maintain cerebral blood flow (CBF) constant despite changes in blood pressure. Also, CBF is proportional to changes in arterial carbon dioxide (CO 2 ) (cerebrovascular CO 2 reactivity). Hypercapnia elicits cerebral vasodilation that attenuates CA efficacy, while hypocapnia produces cerebral vasoconstriction that enhances CA efficacy. In this study, we quantified the influence of sevoflurane anesthesia on CO 2 reactivity and the CA-CO 2 relationship. METHODS We studied patients with type 2 diabetes mellitus (DM), prone to cerebrovascular disease, and compared them to control subjects. In 33 patients (19 DM, 14 control), end-tidal CO 2 , blood pressure, and CBF velocity were monitored awake and during sevoflurane-based anesthesia. CA, calculated with transfer function analysis assessing phase lead (degrees) between low-frequency oscillations in CBF velocity and mean arterial blood pressure, was quantified during hypocapnia, normocapnia, and hypercapnia. RESULTS In both control and DM patients, awake CO 2 reactivity was smaller (2.8%/mm Hg CO 2 ) than during sevoflurane anesthesia (3.9%/mm Hg; P <0.005). Hyperventilation increased CA efficacy more (3 deg./mm Hg CO 2 ) in controls than in DM patients (1.8 deg./mm Hg CO 2 ; P <0.001) in both awake and sevoflurane-anesthetized states. CONCLUSIONS The CA-CO 2 relationship is impaired in awake patients with type 2 DM. Sevoflurane-based anesthesia does not further impair this relationship. In patients with DM, hypocapnia induces cerebral vasoconstriction, but CA efficacy does not improve as observed in healthy subjects.
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20
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Zhou N, Liang X, Gong J, Li H, Liu W, Zhou S, Xiang W, Li Z, Huang Y, Mo X, Li W. S-ketamine used during anesthesia induction increases the perfusion index and mean arterial pressure after induction: A randomized, double-blind, placebo-controlled trial. Eur J Pharm Sci 2022; 179:106312. [DOI: 10.1016/j.ejps.2022.106312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 10/15/2022] [Accepted: 10/20/2022] [Indexed: 11/03/2022]
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21
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Kafashan M, Brian Hickman L, Labonte AK, Huels ER, Maybrier H, Guay CS, Subramanian S, Farber NB, Ching S, Hogan RE, Kelz MB, Avidan MS, Mashour GA, Palanca BJA. Quiescence during burst suppression and postictal generalized EEG suppression are distinct patterns of activity. Clin Neurophysiol 2022; 142:125-132. [PMID: 36030576 PMCID: PMC10287541 DOI: 10.1016/j.clinph.2022.07.493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 06/15/2022] [Accepted: 07/17/2022] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Periods of low-amplitude electroencephalographic (EEG) signal (quiescence) are present during both anesthetic-induced burst suppression (BS) and postictal generalized electroencephalographic suppression (PGES). PGES following generalized seizures induced by electroconvulsive therapy (ECT) has been previously linked to antidepressant response. The commonality of quiescence during both BS and PGES motivated trials to recapitulate the antidepressant effects of ECT using high doses of anesthetics. However, there have been no direct electrographic comparisons of these quiescent periods to address whether these are distinct entities. METHODS We compared periods of EEG quiescence recorded from two human studies: BS induced in 29 healthy adult volunteers by isoflurane general anesthesia and PGES in 11 patients undergoing right unilateral ECT for treatment-resistant depression. An automated algorithm allowed detection of EEG quiescence based on a 10-microvolt amplitude threshold. Spatial, spectral, and temporal analyses compared quiescent epochs during BS and PGES. RESULTS The median (interquartile range) voltage for quiescent periods during PGES was greater than during BS (1.81 (0.22) microvolts vs 1.22 (0.33) microvolts, p < 0.001). Relative power was greater for quiescence during PGES than BS for the 1-4 Hz delta band (p < 0.001), at the expense of power in the theta (4-8 Hz, p < 0.001), beta (13-30 Hz, p = 0.04) and gamma (30-70 Hz, p = 0.006) frequency bands. Topographic analyses revealed that amplitude across the scalp was consistently higher for quiescent periods during PGES than BS, whose voltage was within the noise floor. CONCLUSIONS Quiescent epochs during PGES and BS have distinct patterns of EEG signals across voltage, frequency, and spatial domains. SIGNIFICANCE Quiescent epochs during PGES and BS, important neurophysiological markers for clinical outcomes, are shown to have distinct voltage and frequency characteristics.
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Affiliation(s)
- MohammadMehdi Kafashan
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - L Brian Hickman
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; Department of Neurology, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA, USA
| | - Alyssa K Labonte
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; Neuroscience Graduate Program, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Emma R Huels
- Neuroscience Graduate Program, University of Michigan, Ann Arbor, MI, USA; Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Hannah Maybrier
- Psychological & Brain Sciences Department, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Christian S Guay
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Picower Institute for Learning & Memory, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Subha Subramanian
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Nuri B Farber
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - ShiNung Ching
- Department of Electrical & Systems Engineering, Washington University in St. Louis, St. Louis, MO, USA; Division of Biology and Biomedical Sciences, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - R Edward Hogan
- Department of Neurology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Max B Kelz
- Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - George A Mashour
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Ben J A Palanca
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; Department of Electrical & Systems Engineering, Washington University in St. Louis, St. Louis, MO, USA; Division of Biology and Biomedical Sciences, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, USA.
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22
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Tribuddharat S, Sathitkarnmanee T, Ngamsaengsirisup K, Sornpirom S. Efficacy of early goal-directed therapy using FloTrac/EV1000 to improve postoperative outcomes in patients undergoing off-pump coronary artery bypass surgery: a randomized controlled trial. J Cardiothorac Surg 2022; 17:196. [PMID: 35989328 PMCID: PMC9394084 DOI: 10.1186/s13019-022-01933-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 08/14/2022] [Indexed: 11/18/2022] Open
Abstract
Background Early goal-directed therapy (EGDT) using FloTrac reduced length of stay (LOS) in intensive care (ICU) and hospital among patients undergoing coronary artery bypass graft (CABG) with a cardiopulmonary bypass. However, this platform in off-pump CABG (OPCAB) has received scant attention, so we evaluated the efficacy of EGDT using FloTrac/EV1000 as a modality for improving postoperative outcomes in patients undergoing OPCAB. Methods Forty patients undergoing OPCAB were randomized to the EV1000 or Control group. The Control group received fluid, inotropic, or vasoactive drugs (at the discretion of the attending anesthesiologist) to maintain a mean arterial pressure 65–90 mmHg; central venous pressure 8–12 mmHg; urine output ≥ 0.5 mL kg−1 h−1; SpO2 > 95%; and hematocrit ≥ 30%. The EV1000 group achieved identical targets using information from the FloTrac/EV1000. The goals included stroke volume variation < 13%; cardiac index (CI) of 2.2–4.0 L min−1 m−2; and systemic vascular resistance index of 1500–2500 dynes s−1 cm−5 m−2. Results The EV1000 group had a shorter LOS in ICU (mean difference − 1.3 d, 95% CI − 1.8 to − 0.8; P < 0.001). The ventilator time for both groups was comparable (P = 0.316), but the hospital stay for the EV1000 group was shorter (mean difference − 1.4 d, 95% CI − 2.1 to − 0.6; P < 0.001). Conclusions EGDT using FloTrac/EV1000 compared to conventional protocol reduces LOS in ICU and hospital among patients undergoing OPCAB. Trial registration This study was retrospectively registered at www.ClinicalTrials.gov (NCT04292951) on 3 March 2020.
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23
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Sirmpilatze N, Mylius J, Ortiz-Rios M, Baudewig J, Paasonen J, Golkowski D, Ranft A, Ilg R, Gröhn O, Boretius S. Spatial signatures of anesthesia-induced burst-suppression differ between primates and rodents. eLife 2022; 11:e74813. [PMID: 35607889 PMCID: PMC9129882 DOI: 10.7554/elife.74813] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 05/01/2022] [Indexed: 01/19/2023] Open
Abstract
During deep anesthesia, the electroencephalographic (EEG) signal of the brain alternates between bursts of activity and periods of relative silence (suppressions). The origin of burst-suppression and its distribution across the brain remain matters of debate. In this work, we used functional magnetic resonance imaging (fMRI) to map the brain areas involved in anesthesia-induced burst-suppression across four mammalian species: humans, long-tailed macaques, common marmosets, and rats. At first, we determined the fMRI signatures of burst-suppression in human EEG-fMRI data. Applying this method to animal fMRI datasets, we found distinct burst-suppression signatures in all species. The burst-suppression maps revealed a marked inter-species difference: in rats, the entire neocortex engaged in burst-suppression, while in primates most sensory areas were excluded-predominantly the primary visual cortex. We anticipate that the identified species-specific fMRI signatures and whole-brain maps will guide future targeted studies investigating the cellular and molecular mechanisms of burst-suppression in unconscious states.
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Affiliation(s)
- Nikoloz Sirmpilatze
- Functional Imaging Laboratory, German Primate Center – Leibniz Institute for Primate ResearchGöttingenGermany
- Georg-August University of GöttingenGöttingenGermany
- International Max Planck Research School for NeurosciencesGöttingenGermany
| | - Judith Mylius
- Functional Imaging Laboratory, German Primate Center – Leibniz Institute for Primate ResearchGöttingenGermany
| | - Michael Ortiz-Rios
- Functional Imaging Laboratory, German Primate Center – Leibniz Institute for Primate ResearchGöttingenGermany
| | - Jürgen Baudewig
- Functional Imaging Laboratory, German Primate Center – Leibniz Institute for Primate ResearchGöttingenGermany
| | - Jaakko Paasonen
- A.I.V. Institute for Molecular Sciences, University of Eastern FinlandKuopioFinland
| | - Daniel Golkowski
- Department of Neurology, Klinikum Rechts der Isar der Technischen Universität MünchenMunichGermany
- Department of Neurology, Heidelberg University HospitalHeidelbergGermany
| | - Andreas Ranft
- Department of Anesthesiology and Intensive Care Medicine, Klinikum Rechts der Isar der Technischen Universität MünchenMunichGermany
| | - Rüdiger Ilg
- Department of Neurology, Klinikum Rechts der Isar der Technischen Universität MünchenMunichGermany
- Department of Neurology, Asklepios Stadtklinik Bad TölzBad TölzGermany
| | - Olli Gröhn
- A.I.V. Institute for Molecular Sciences, University of Eastern FinlandKuopioFinland
| | - Susann Boretius
- Functional Imaging Laboratory, German Primate Center – Leibniz Institute for Primate ResearchGöttingenGermany
- Georg-August University of GöttingenGöttingenGermany
- International Max Planck Research School for NeurosciencesGöttingenGermany
- Leibniz Science Campus Primate CognitionGöttingenGermany
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24
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Kim SY, Kim JY, Kim J, Yu S, Lee KH, Lee HS, Oh MS, Kim E. Comparison of Antinociceptive Properties Between Sevoflurane and Desflurane Using Pupillary Dilation Reflex Under Equivalent Minimum Alveolar Concentration: A Randomized Controlled Trial. Anesth Analg 2022; 135:798-806. [PMID: 35552287 DOI: 10.1213/ane.0000000000006079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The pupillary dilation reflex (PDR), the change in pupil size after a nociceptive stimulus, has been used to assess antinociception during anesthesia. The aim of this study was to compare the antinociceptive properties of sevoflurane and desflurane by measuring the PDR amplitude. METHODS Seventy patients between 20 and 55 years of age were randomly allocated to receive either sevoflurane or desflurane. The PDR amplitude after an electrical standardized noxious stimulation (SNT) was measured using an infrared pupillometer under 1.0 minimum alveolar concentration (MAC). The pupil diameter was measured from 5 seconds before to 5 minutes after the SNT. The mean arterial pressure (MAP), heart rate (HR), and bispectral index (BIS) were also measured immediately before and after SNT as well as 1 minute and 5 minutes after SNT. The primary outcome was the maximum percent increase from the prestimulation value of the pupil diameter, and the secondary outcomes were the maximum percent increase from the prestimulation value of the MAP, HR, and BIS after SNT. RESULTS The maximum percent increase of the pupil diameter after SNT was not different between the 2 groups (median [first quartile to third quartile], 45.1 [29.3-80.3] vs 43.4 [27.0-103.1]; median difference, -0.3 [95% confidence interval, -16.0 to 16.5]; P = .986). Before SNT, the MAP was higher under 1.0 MAC of sevoflurane than desflurane; however, the maximum percent increase of MAP, HR, and BIS was not different between the 2 groups. CONCLUSIONS The amount of change in the PDR amplitude, MAP, and HR after SNT was not different between sevoflurane and desflurane anesthesia. This result might suggest that sevoflurane and desflurane may not have different antinociceptive properties at equivalent MAC.
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Affiliation(s)
- Soo Yeon Kim
- From the Department of Anesthesiology and Pain Medicine, Hanyang University Hospital, Seoul, Republic of Korea
| | - Ji-Yoon Kim
- From the Department of Anesthesiology and Pain Medicine, Hanyang University Hospital, Seoul, Republic of Korea
| | - Jonghae Kim
- Department of Anesthesiology and Pain Medicine, Daegu Catholic University Medical Center, School of Medicine, Daegu Catholic University, Daegu, Republic of Korea; and
| | - Seungcheol Yu
- From the Department of Anesthesiology and Pain Medicine, Hanyang University Hospital, Seoul, Republic of Korea
| | - Kwang Hyun Lee
- From the Department of Anesthesiology and Pain Medicine, Hanyang University Hospital, Seoul, Republic of Korea
| | - Hyeon Seok Lee
- From the Department of Anesthesiology and Pain Medicine, Hanyang University Hospital, Seoul, Republic of Korea
| | - Min Seok Oh
- Department of Anesthesiology and Pain Medicine, Hanyang University College of Medicine, Hanyang University Hospital, Seoul, Republic of Korea
| | - Eugene Kim
- Department of Anesthesiology and Pain Medicine, Hanyang University College of Medicine, Hanyang University Hospital, Seoul, Republic of Korea
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25
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Kho E, Sperna Weiland NH, Vlaar APJ, Veelo DP, van der Ster BJP, Corsmit OT, Koolbergen DR, Dilai J, Immink RV. Cerebral hemodynamics during sustained intra-operative hypotension. J Appl Physiol (1985) 2022; 132:1560-1568. [PMID: 35511723 DOI: 10.1152/japplphysiol.00050.2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background Static cerebral autoregulation (CA) maintains cerebral blood flow (CBF) relatively constant above a mean arterial blood pressure (BPmean) of 60-65 mmHg. Below this lower limit of CA (LLCA), CBF declines along with BPmean. Data are lacking describing how CA reacts to sustained hypotension, since hypotension is usually avoided. In this study, we took advantage of a procedure requiring sustained hypotension. We assessed static CA for LLCA determination, and a more continuous CA, which counter short-term blood pressure variations. With these data, we analyzed CA during longstanding hypotension. Methods Continuous arterial blood pressure and middle cerebral artery blood flow velocity (MCAVmean) were monitored in 23 patients that required deep intra-operative hypotension. The LLCA was determined for every patient, and BPmean below this LLCA was classified as the patient specific hypotension. With the mean flow index (Mxa) continuous CA (Mxa-CA) was quantified. Mxa was calculated and averaged after induction of general anesthesia (baseline), every 15 minutes during, and 15 minutes after one-hour of hypotension. Functioning CA was defined as Mxa <0.4. Data are expressed as median (25th-75th percentile). Results The LLCA was located at 56 (47-74) mmHg. At baseline, Mxa was 0.21 (0.14-0.32) and 0.61 (0.48-0.78) during hypotension (p<0.01), with no appreciable change over time, n=12. After blood pressure restoration, Mxa improved, 0.25 (0.06-0.35, n=9). Conclusions Mxa-CA became and remained disturbed during the one-hour of hypotension, and improved after blood pressure restoration. This completely reversible situation suggests no ischemic hyperemia occurs and renders an adaptation mechanism during sustained hypotension unlikely.
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Affiliation(s)
- Eline Kho
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Alexander P J Vlaar
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Denise P Veelo
- Department of Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Björn J P van der Ster
- Department of Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Oskar T Corsmit
- Department of Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Dave R Koolbergen
- Department of Cardio-thoracic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - José Dilai
- Department of Clinical Neurophysiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Rogier V Immink
- Department of Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Hight D, Schanderhazi C, Huber M, Stüber F, Kaiser HA. Age, minimum alveolar concentration and choice of depth of sedation monitor: examining the paradox of age when using the Narcotrend monitor: A secondary analysis of an observational study. Eur J Anaesthesiol 2022; 39:305-314. [PMID: 34313611 DOI: 10.1097/eja.0000000000001576] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND With an ageing global population, it is important to individualise titration of anaesthetics according to age and by measuring their effect on the brain. A recent study reported that during general surgery, the given concentration of volatile anaesthetics, expressed as a fraction of the minimum alveolar concentration (MAC fraction), decreases by around only 3% per age-decade, which is less than the 6% expected from age-adjusted MAC. Paradoxically, despite the excessive dosing, Bispectral index (BIS) values also increased. OBJECTIVE We planned to investigate the paradox of age when using the Narcotrend depth of anaesthesia monitor. DESIGN Secondary analyses of a prospective observational study. SETTING Tertiary hospital in Switzerland, recordings took place during 2016 and 2017. PATIENTS One thousand and seventy-two patients undergoing cardiac surgery entered the study, and 909 with noise-free recordings and isoflurane anaesthesia were included in this analysis. INTERVENTION We calculated mean end-tidal MAC fraction and mean index value of the Narcotrend depth of sedation monitor used in the study during the prebypass period. Statistical associations were modelled using linear regression, local weighted regression (LOESS) and a generalised additive model (GAM). MAIN OUTCOME MEASURES Primary endpoints in this study were the change in end-tidal MAC fraction and mean Narcotrend index values, both measured per age-decade. RESULTS We observed a linear decrease in end-tidal MAC fraction of 3.2% per age-decade [95% confidence interval (CI) -3.97% to -2.38%, P < 0.001], consistent with previous findings. In contrast to the BIS, mean Narcotrend index values decreased with age at 3.0 index points per age-decade (95% CI, -3.55 points to -2.36 points, P < 0.001), a direction of change commensurate with the increasing age-adjusted MAC fraction with patient age. These relationships were consistent regardless of whether age-adjusted MAC was displayed on the anaesthetic machine. CONCLUSIONS We caution that the 'paradox of age' may in part depend on the choice of depth of sedation monitor. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02976584.
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Affiliation(s)
- Darren Hight
- From the Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern (DH, CS, MH, FS, HAK) and Department of General Internal Medicine, Canton Hospital Frauenfeld, Frauenfeld, Switzerland (CS)
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27
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Briguglio M, Crespi T, Langella F, Riso P, Porrini M, Scaramuzzo L, Bassani R, Brayda-Bruno M, Berjano P. Perioperative Anesthesia and Acute Smell Alterations in Spine Surgery: A "Sniffing Impairment" Influencing Refeeding? Front Surg 2022; 9:785676. [PMID: 35372489 PMCID: PMC8965841 DOI: 10.3389/fsurg.2022.785676] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 02/17/2022] [Indexed: 11/13/2022] Open
Abstract
Medications for general anesthesia can cause smell alterations after surgery, with inhalation anesthetics being the most acknowledged drugs. However, spine patients have been poorly studied in past investigations and whether these alterations could influence the refeeding remains unclear. This research aims to observe detectable dysosmias after spine surgery, to explore any amplified affection of halogenates (DESflurane and SEVoflurane) against total intravenous anesthesia (TIVA), and to spot potential repercussions on the refeeding. Fifty patients between 50 and 85 years old were recruited before elective spine procedure and tested for odor acuity and discrimination using the Sniffin' Sticks test. The odor abilities were re-assessed within the first 15 h after surgery together with the monitoring of food intakes. The threshold reduced from 4.92 ± 1.61 to 4.81 ± 1.64 (p = 0.237) and the discrimination ability reduced from 10.50 ± 1.83 to 9.52 ± 1.98 (p = 0.0005). Anesthetic-specific analysis showed a significant reduction of both threshold (p = 0.004) and discrimination (p = 0.004) in the SEV group, and a significant reduction of discrimination abilities (p = 0.016) in the DES group. No dysosmias were observed in TIVA patients after surgery. Food intakes were lower in the TIVA group compared to both DES (p = 0.026) and SEV (p = 0.017). The food consumed was not associated with the sniffing impairment but appeared to be inversely associated with the surgical time. These results confirmed the evidence on inhalation anesthetics to cause smell alterations in spine patients. Furthermore, the poor early oral intake after complex procedures suggests that spinal deformity surgery could be a practical challenge to early oral nutrition.
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Affiliation(s)
- Matteo Briguglio
- IRCCS Orthopedic Institute Galeazzi, Scientific Direction, Milan, Italy
| | - Tiziano Crespi
- IRCCS Orthopedic Institute Galeazzi, Intensive Care Unit, Milan, Italy
| | | | - Patrizia Riso
- University of Milan, Department of Food, Environmental and Nutritional Sciences, Division of Human Nutrition, Milan, Italy
| | - Marisa Porrini
- University of Milan, Department of Food, Environmental and Nutritional Sciences, Division of Human Nutrition, Milan, Italy
| | | | - Roberto Bassani
- IRCCS Orthopedic Institute Galeazzi, Spine Unit 2, Milan, Italy
| | | | - Pedro Berjano
- IRCCS Orthopedic Institute Galeazzi, GSpine 4, Milan, Italy
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28
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Park M, Park IH, Kim GS. The Requirement of Isoflurane and Remifentanil During Liver Transplantation Using Bispectral Index and Surgical Pleth Index: An Observational Study. Transplant Proc 2022; 54:726-730. [PMID: 35241299 DOI: 10.1016/j.transproceed.2021.12.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 12/07/2021] [Accepted: 12/27/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND During liver transplantation (LT), patients and surgical factors potentially influence the pharmacokinetics of the anesthetic agents. The aim of this study was to investigate the requirement of isoflurane and remifentanil according to severity of liver disease during LT under balanced anesthesia. METHODS We enrolled 44 patients undergoing LT. Anesthetic depth was maintained within the bispectral index score of 40 to 60 and Surgical Pleth Index of 20 to 60. Patients were divided into 2 groups according to their median Model for End-Stage Liver Disease (MELD) score: low MELD group and high MELD group. We compared end-tidal inhaled anesthetics and remifentanil consumption. RESULTS Patients were divided into 2 groups according to median value of MELD score: MELD score <16 (low MELD group; n = 20) or MELD ≥16 (high MELD group; n = 20). There was no significant difference between the 2 groups in end-tidal concentration of isoflurane during 3 phases. However, the remifentanil requirement was lower in the high MELD group during the dissection and anhepatic phases (mean (SD), 0.105 (0.067) vs 0.064 (0.055) µg/kg/min; P = .037, and 0.167 (0.096) vs 0.108 (0.079) µg/kg/min; P = .039, respectively; low MELD group vs high MELD group) with no significant difference during the neohepatic phase. CONCLUSIONS The severity of liver dysfunction based on MELD score affected the intraoperative remifentanil requirement during LT. Patients with cirrhosis are required to use analgesics appropriate to their individual patient characteristics in clinical practice.
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Affiliation(s)
- MiHye Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - I Hyun Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Gaab Soo Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
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Wada K, Sonoda M, Firestone E, Sakakura K, Kuroda N, Takayama Y, Iijima K, Iwasaki M, Mihara T, Goto T, Asano E, Miyazaki T. Sevoflurane-based enhancement of phase-amplitude coupling and localization of the epileptogenic zone. Clin Neurophysiol 2022; 134:1-8. [PMID: 34922194 PMCID: PMC8766927 DOI: 10.1016/j.clinph.2021.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 10/05/2021] [Accepted: 11/03/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Phase-amplitude coupling between high-frequency (≥150 Hz) and delta (3-4 Hz) oscillations - modulation index (MI) - is a promising, objective biomarker of epileptogenicity. We determined whether sevoflurane anesthesia preferentially enhances this metric within the epileptogenic zone. METHODS This is an observational study of intraoperative electrocorticography data from 621 electrodes chronically implanted into eight patients with drug-resistant, focal epilepsy. All patients were anesthetized with sevoflurane during resective surgery, which subsequently resulted in seizure control. We classified 'removed' and 'retained' brain sites as epileptogenic and non-epileptogenic, respectively. Mixed model analysis determined which anesthetic stage optimized MI-based classification of epileptogenic sites. RESULTS MI increased as a function of anesthetic stage, ranging from baseline (i.e., oxygen alone) to 2.0 minimum alveolar concentration (MAC) of sevoflurane, preferentially at sites showing higher initial MI values. This phenomenon was accentuated just prior to sevoflurane reaching 2.0 MAC, at which time, the odds of a site being classified as epileptogenic were enhanced by 86.6 times for every increase of 1.0 MI. CONCLUSIONS Intraoperative MI best localized the epileptogenic zone immediately before sevoflurane reaching 2.0 MAC in this small cohort of patients. SIGNIFICANCE Prospective, large cohort studies are warranted to determine whether sevoflurane anesthesia can reduce the need for extraoperative, invasive evaluation.
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Affiliation(s)
- Keiko Wada
- Department of Anesthesiology, National Center Hospital, National Center of Neurology and Psychiatry, Kodaira, Tokyo 1878551, Japan,Department of Anesthesiology and Critical Care, Yokohama City University Graduate School of Medicine, Yokohama, 2360004, Japan
| | - Masaki Sonoda
- Department of Pediatrics, Children’s Hospital of Michigan, Detroit Medical Center, Wayne State University, Detroit, MI 48201, USA,Department of Neurosurgery, Yokohama City University Graduate School of Medicine, Yokohama 2360004, Japan
| | - Ethan Firestone
- Department of Pediatrics, Children’s Hospital of Michigan, Detroit Medical Center, Wayne State University, Detroit, MI 48201, USA,Department of Physiology, Wayne State University, Detroit, MI 48201, USA
| | - Kazuki Sakakura
- Department of Pediatrics, Children’s Hospital of Michigan, Detroit Medical Center, Wayne State University, Detroit, MI 48201, USA,Department of Neurosurgery, University of Tsukuba, Tsukuba, 3058575, Japan
| | - Naoto Kuroda
- Department of Pediatrics, Children’s Hospital of Michigan, Detroit Medical Center, Wayne State University, Detroit, MI 48201, USA,Department of Epileptology, Tohoku University Graduate School of Medicine, Sendai 9808575, Japan
| | - Yutaro Takayama
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, Yokohama 2360004, Japan,Department of Neurosurgery, National Center Hospital, National Center of Neurology and Psychiatry, Kodaira, Tokyo 1878551, Japan
| | - Keiya Iijima
- Department of Neurosurgery, National Center Hospital, National Center of Neurology and Psychiatry, Kodaira, Tokyo 1878551, Japan
| | - Masaki Iwasaki
- Department of Neurosurgery, National Center Hospital, National Center of Neurology and Psychiatry, Kodaira, Tokyo 1878551, Japan
| | - Takahiro Mihara
- Department of Anesthesiology and Critical Care, Yokohama City University Graduate School of Medicine, Yokohama, 2360004, Japan,Department of Health Data Science, Yokohama City University Graduate School of Data Science, Yokohama, 2360027, Japan
| | - Takahisa Goto
- Department of Anesthesiology and Critical Care, Yokohama City University Graduate School of Medicine, Yokohama, 2360004, Japan
| | - Eishi Asano
- Department of Pediatrics, Children’s Hospital of Michigan, Detroit Medical Center, Wayne State University, Detroit, MI 48201, USA,Department of Neurology, Children’s Hospital of Michigan, Detroit Medical Center, Wayne State University, Detroit, MI 48201, USA,E.A. and T.M. share the senior authorship. Corresponding Authors: Eishi Asano, M.D., Ph.D., M.S. (C.R.D.S.A.), Address: Division of Pediatric Neurology, Children’s Hospital of Michigan, Wayne State University. 3901 Beaubien St., Detroit, MI, 48201, USA, Phone: +1-313-745-5547, FAX: +1-313-745-9435, and Tomoyuki Miyazaki, M.D., Ph.D., Address: Department of Physiology/Anesthesiology, Yokohama City University Graduate School of Medicine. 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, Japan, Phone: +81-45-787-2918, FAX: +81-45-787-2917,
| | - Tomoyuki Miyazaki
- Department of Anesthesiology and Critical Care, Yokohama City University Graduate School of Medicine, Yokohama, 2360004, Japan,Department of Physiology, Yokohama City University Graduate School of Medicine, Yokohama 2360004, Japan,E.A. and T.M. share the senior authorship. Corresponding Authors: Eishi Asano, M.D., Ph.D., M.S. (C.R.D.S.A.), Address: Division of Pediatric Neurology, Children’s Hospital of Michigan, Wayne State University. 3901 Beaubien St., Detroit, MI, 48201, USA, Phone: +1-313-745-5547, FAX: +1-313-745-9435, and Tomoyuki Miyazaki, M.D., Ph.D., Address: Department of Physiology/Anesthesiology, Yokohama City University Graduate School of Medicine. 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, Japan, Phone: +81-45-787-2918, FAX: +81-45-787-2917,
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Hofmann C, Sander A, Wang XX, Buerge M, Jungwirth B, Borgstedt L, Kreuzer M, Kopp C, Schorpp K, Hadian K, Wotjak CT, Ebert T, Ruitenberg M, Parsons CG, Rammes G. Inhalational Anesthetics Do Not Deteriorate Amyloid-β-Derived Pathophysiology in Alzheimer's Disease: Investigations on the Molecular, Neuronal, and Behavioral Level. J Alzheimers Dis 2021; 84:1193-1218. [PMID: 34657881 DOI: 10.3233/jad-201185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Studies suggest that general anesthetics like isoflurane and sevoflurane may aggravate Alzheimer's disease (AD) neuropathogenesis, e.g., increased amyloid-β (Aβ) protein aggregation resulting in synaptotoxicity and cognitive dysfunction. Other studies showed neuroprotective effects, e.g., with xenon. OBJECTIVE In the present study, we want to detail the interactions of inhalational anesthetics with Aβ-derived pathology. We hypothesize xenon-mediated beneficial mechanisms regarding Aβ oligomerization and Aβ-mediated neurotoxicity on processes related to cognition. METHODS Oligomerization of Aβ 1-42 in the presence of anesthetics has been analyzed by means of TR-FRET and silver staining. For monitoring changes in neuronal plasticity due to anesthetics and Aβ 1-42, Aβ 1-40, pyroglutamate-modified amyloid-(AβpE3), and nitrated Aβ (3NTyrAβ), we quantified long-term potentiation (LTP) and spine density. We analyzed network activity in the hippocampus via voltage-sensitive dye imaging (VSDI) and cognitive performance and Aβ plaque burden in transgenic AD mice (ArcAβ) after anesthesia. RESULTS Whereas isoflurane and sevoflurane did not affect Aβ 1-42 aggregation, xenon alleviated the propensity for aggregation and partially reversed AβpE3 induced synaptotoxic effects on LTP. Xenon and sevoflurane reversed Aβ 1-42-induced spine density attenuation. In the presence of Aβ 1-40 and AβpE3, anesthetic-induced depression of VSDI-monitored signaling recovered after xenon, but not isoflurane and sevoflurane removal. In slices pretreated with Aβ 1-42 or 3NTyrAβ, activity did not recover after washout. Cognitive performance and plaque burden were unaffected after anesthetizing WT and ArcAβ mice. CONCLUSION None of the anesthetics aggravated Aβ-derived AD pathology in vivo. However, Aβ and anesthetics affected neuronal activity in vitro, whereby xenon showed beneficial effects on Aβ 1-42 aggregation, LTP, and spine density.
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Affiliation(s)
- Carolin Hofmann
- Department of Anesthesiology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Annika Sander
- Department of Anesthesiology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Xing Xing Wang
- Department of Anesthesiology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Martina Buerge
- Department of Anesthesiology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Bettina Jungwirth
- Department of Anesthesiology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.,Department of Anesthesiology, University Hospital Ulm, Ulm, Germany
| | - Laura Borgstedt
- Department of Anesthesiology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Matthias Kreuzer
- Department of Anesthesiology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Claudia Kopp
- Department of Anesthesiology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Kenji Schorpp
- Assay Development and Screening Platform, Institute of Molecular Toxicology and Pharmacology, Helmholtz Zentrum München, Neuherberg, Germany
| | - Kamyar Hadian
- Assay Development and Screening Platform, Institute of Molecular Toxicology and Pharmacology, Helmholtz Zentrum München, Neuherberg, Germany
| | - Carsten T Wotjak
- Max Planck Institute of Psychiatry, Neuronal Plasticity, Munich, Germany.,Central Nervous System Diseases Research, Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach an der Riss, Germany
| | - Tim Ebert
- Max Planck Institute of Psychiatry, Neuronal Plasticity, Munich, Germany
| | | | | | - Gerhard Rammes
- Department of Anesthesiology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
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Poon YY, Hung KC, Chou WY, Wang CH, Hung CT, Chin JC, Wu SC. Is Prevention of Postoperative Vomiting Surgery Dependent? A Retrospective Cohort Study of Total Knee Arthroplasty. J Pers Med 2021; 11:jpm11101018. [PMID: 34683159 PMCID: PMC8540625 DOI: 10.3390/jpm11101018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 10/04/2021] [Accepted: 10/07/2021] [Indexed: 12/02/2022] Open
Abstract
The study of postoperative nausea and vomiting (PONV) has been ongoing since the early days of general anesthesia. The search for risk factors of PONV and the development of new agents to treat PONV are the two main strategies to combat the adverse side effects of general anesthesia. Female sex, non-smoking status, a history of PONV/motion sickness, and postoperative opioid use are the four independent risk factors for PONV derived after a series of prospective studies, evidence-based systematic reviews, and meta-analyses. The two frequently asked questions that arise ask whether risk factors apply to different clinical settings and whether prevention measures of PONV can be surgery dependent. We conducted a comprehensive review of 665 patients who underwent primary total knee arthroplasty (TKA) between January and December 2019. As nausea is subjective and its measurement is not standardized, postoperative vomiting (POV) was used as a study endpoint. The exclusion criteria were desflurane anesthesia, spinal anesthesia, anesthesia without bispectral index monitoring, and day surgery. Three well-recognized risk factors, consisting of body weight, sevoflurane consumption, and postoperative opioid consumption, were not considered as independent risk factors of POV, while female sex, preoperative adductor canal block (ACB), and dexamethasone were identified as being so in this study. The risk of POV in the female sex was 2.49 times that in the male sex; however, when dexamethasone was used, this risk was reduced by >40% compared with no antiemetic use, and by >50% when patients received preoperative ACB compared with those without the block. The clinical characteristics of our TKA patients—female dominance, old age, and their fairly constant body weights that were distinct from those of other surgical patients—suggested that age may play a crucial role in determining the relative contributions of the different risk factors of POV. We concluded that risk factors of POV are dependent on clinical settings. Based on these results, it is reasonable to speculate that a surgery-dependent plan for the prevention of POV is feasible for patients in similar clinical settings.
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Affiliation(s)
- Yan-Yuen Poon
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta-Pei Rd., Niao-Song Dist., Kaohsiung City 833401, Taiwan; (Y.-Y.P.); (C.-H.W.); (C.-T.H.)
| | - Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, No. 901, Zhonghua Rd., Yongkang Dist., Tainan City 710, Taiwan;
| | - Wen-Yi Chou
- Department of Orthopedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta-Pei Rd., Niao-Song Dist., Kaohsiung City 833, Taiwan;
| | - Chih-Hsien Wang
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta-Pei Rd., Niao-Song Dist., Kaohsiung City 833401, Taiwan; (Y.-Y.P.); (C.-H.W.); (C.-T.H.)
| | - Chao-Ting Hung
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta-Pei Rd., Niao-Song Dist., Kaohsiung City 833401, Taiwan; (Y.-Y.P.); (C.-H.W.); (C.-T.H.)
| | - Jo-Chi Chin
- Department of Anesthesiology, Park One International Hospital, Kaohsiung 813322, Taiwan;
| | - Shao-Chun Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta-Pei Rd., Niao-Song Dist., Kaohsiung City 833401, Taiwan; (Y.-Y.P.); (C.-H.W.); (C.-T.H.)
- Correspondence: ; Tel.: +886-7-7317123 (ext. 2788); Fax: +886-7-7351638
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Sevoflurane and Desflurane Exposures Following Aneurysmal Subarachnoid Hemorrhage Confer Multifaceted Protection against Delayed Cerebral Ischemia. Biomedicines 2021; 9:biomedicines9070820. [PMID: 34356884 PMCID: PMC8301428 DOI: 10.3390/biomedicines9070820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 07/05/2021] [Accepted: 07/12/2021] [Indexed: 11/17/2022] Open
Abstract
Numerous studies have demonstrated the ability of isoflurane conditioning to provide multifaceted protection against aneurysmal subarachnoid hemorrhage (SAH)-associated delayed cerebral ischemia (DCI); however, preclinical studies have not yet examined whether other commonly used inhalational anesthetics in neurological patients such as sevoflurane or desflurane are also protective against SAH-induced neurovascular deficits. We therefore sought to identify the potential for sevoflurane and desflurane conditioning to protect against DCI in an endovascular perforation mouse model of SAH. Neurological function was assessed daily via neuroscore. Large artery vasospasm and microvessel thrombosis were assessed three days after SAH or sham surgery. Four groups were examined: Sham, SAH + room air, SAH + 2% Sevoflurane, and SAH + 6% Desflurane. For the SAH groups, one hour after surgery, mice received 2% sevoflurane, 6% desflurane, or room air for one hour. We found that conditioning with sevoflurane or desflurane attenuated large artery vasospasm, reduced microvessel thrombosis, and improved neurologic function. Given their frequent clinical use and strong safety profile in patients (including those with SAH), these data strongly support further studies to validate these findings in preclinical and clinical studies and to elucidate the mechanisms by which these agents might be acting.
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Liang Z, Ren N, Wen X, Li H, Guo H, Ma Y, Li Z, Li X. Age-dependent cross frequency coupling features from children to adults during general anesthesia. Neuroimage 2021; 240:118372. [PMID: 34245867 DOI: 10.1016/j.neuroimage.2021.118372] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 07/03/2021] [Accepted: 07/06/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The frequency coupling characteristics in electroencephalogram (EEG) induced by anesthetics have been well studied in adults, but the investigation of the age-dependent cross frequency coupling features from children to adults is still lacking. METHODS We analyzed EEG signals recorded from pediatric to adult patients (n = 131), separated into six age groups: <1 year (n = 15), 1-3 years (n = 23), 3-6 years (n = 19), 6-12 years (n = 18), 12-18 years (n = 16), and 18-45 years (n = 40). Age related EEG power and cross frequency coupling analysis (phase amplitude coupling (PAC) and quadratic phase coupling) of data from maintenance of a surgical state of anesthesia (MOSSA) was conducted. Also, for patients of ages less than 6 years, we analyzed the performance of cross frequency coupling derived indices in distinguishing the states of wakefulness, MOSSA, and recovery of consciousness (ROC). RESULTS (1) During MOSSA, EEG power substantially increased with age from infancy to 3-6 years then decreased with age in the theta-gamma frequency bands. The infant group (<1 year) had the highest slow oscillation (SO) power among all age groups. (2) The distinct PAC pattern is absent in patients less than 1 year of age both in SO-alpha and delta-alpha frequency band coupling during propofol induced unconsciousness. The modulation index between delta and alpha oscillations in MOSSA increased with age. (3) Wavelet bicoherence derived indices reach their peaks in the 3-6 years group and then decrease with age growth. (4) The Diag_En index (normalized entropy of the diagonal bicoherence entries of the bicoherence matrix) performed the best at distinguishing different states for ages less than 6 years (p<0.05). CONCLUSIONS The combination of propofol induction and sevoflurane maintenance exhibited age-dependent EEG power spectra, PAC, and bicoherence, likely related to brain development. These observations suggest new rules for infant and child brain state monitoring during general anesthesia are needed.
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Affiliation(s)
- Zhenhu Liang
- Institute of Electrical Engineering, Yanshan University, Qinhuangdao 066004, China; Key Laboratory of Intelligent Rehabilitation and Neuromodulation of Hebei Province, Qinhuangdao 066004, China
| | - Na Ren
- Institute of Electrical Engineering, Yanshan University, Qinhuangdao 066004, China; Key Laboratory of Intelligent Rehabilitation and Neuromodulation of Hebei Province, Qinhuangdao 066004, China
| | - Xin Wen
- Institute of Electrical Engineering, Yanshan University, Qinhuangdao 066004, China; Key Laboratory of Intelligent Rehabilitation and Neuromodulation of Hebei Province, Qinhuangdao 066004, China
| | - Haiwen Li
- Department of Anesthesiology, the Seventh Medical Center to Chinese PLA General Hospital, Beijing 100700, China; College of Anesthesiology, Shanxi Medical University, Taiyuan 030001, Shanxi, China
| | - Hang Guo
- Department of Anesthesiology, the Seventh Medical Center to Chinese PLA General Hospital, Beijing 100700, China.
| | - Yaqun Ma
- Department of Anesthesiology, the Seventh Medical Center to Chinese PLA General Hospital, Beijing 100700, China
| | - Zheng Li
- Center for Cognition and Neuroergonomics, State Key Laboratory of Cognitive Neuroscience and Learning, Beijing Normal University at Zhuhai, Zhuhai, 519087, China
| | - Xiaoli Li
- State Key Laboratory of Cognitive Neuroscience and Learning, Beijing, 100875, China; Center for Cognition and Neuroergonomics, State Key Laboratory of Cognitive Neuroscience and Learning, Beijing Normal University at Zhuhai, Zhuhai, 519087, China.
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Yeung BG, Ma MW, Scolaro JA, Nelson AM. Cannabis Exposure Decreases Need for Blood Pressure Support During General Anesthesia in Orthopedic Trauma Surgery. Cannabis Cannabinoid Res 2021; 7:328-335. [PMID: 34227872 PMCID: PMC9225405 DOI: 10.1089/can.2021.0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Introduction: As cannabis use continues to increase in popularity, it is important to investigate how it impacts public health in all sectors of the population, including patients undergoing anesthetic management. This retrospective study focuses on the orthopedic trauma population presenting through an emergency department (ED) and receiving a urine drug screen (UDS) with subsequent urgent surgical intervention. We aimed to evaluate differences in response to general anesthesia in patients with exposure to THC, a major cannabinoid, compared to controls that screened negative for THC. Materials and Methods: All ED visits at UC Irvine, a level 1 trauma center between November 4, 2017 and January 7, 2020, were evaluated in this study. Only adult patients who received a UDS and underwent urgent orthopedic trauma surgery within 48 h of ED visit were included in this study. Additional inclusion criteria required an anesthesia time greater than 1 h as well as anesthesia induction and intubation while in the operating room. Overall, we analyzed a total of 221 adult patients. Discussion: When adjusting for demographic variability, there were statistically significant differences in response to general anesthesia between these two groups. The THC-positive (THC(+)) group was less likely to receive intraoperative vasopressors, had higher mean arterial blood pressure and mean diastolic blood pressure, needed less total fluid input and had a lower overall fluid balance. Chronic exposure to THC has been shown to downregulate cannabinoid 1 receptors and cause alterations in endocannabinoid tone. These are two potential mechanisms by which the THC(+) group in our study may have become more resistant to the typically observed hypotensive effects of general anesthesia. Conclusion: The present study suggests that prior use of cannabis, objectively assessed by urinalysis, results in a decreased need for blood pressure support during general anesthesia. The physiological basis for this phenomenon is unclear, but possible causes might include the downregulation of vascular cannabinoid receptor 1 and/or altered endocannabinoid levels after exposure to cannabis.
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Affiliation(s)
- Brent G Yeung
- Department of Anesthesiology and Perioperative Care and University of California-Irvine, Orange, California, USA
| | - Michael W Ma
- Department of Anesthesiology and Perioperative Care and University of California-Irvine, Orange, California, USA
| | - John A Scolaro
- Department of Orthopaedic Surgery, University of California-Irvine, Orange, California, USA
| | - Ariana M Nelson
- Department of Anesthesiology and Perioperative Care and University of California-Irvine, Orange, California, USA
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Tribuddharat S, Sathitkarnmanee T, Ngamsangsirisup K, Nongnuang K. Efficacy of Intraoperative Hemodynamic Optimization Using FloTrac/EV1000 Platform for Early Goal-Directed Therapy to Improve Postoperative Outcomes in Patients Undergoing Coronary Artery Bypass Graft with Cardiopulmonary Bypass: A Randomized Controlled Trial. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2021; 14:201-209. [PMID: 34234581 PMCID: PMC8253926 DOI: 10.2147/mder.s316033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 06/10/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose Early goal-directed therapy (EGDT) using the FloTrac system reportedly improved postoperative outcomes among high-risk patients undergoing non-cardiac surgery. This study's objective was to evaluate the FloTrac/EV1000 platform's efficacy for improving postoperative outcomes in cardiac surgery. Patients and Methods Eighty-six adults undergoing coronary artery bypass graft (CABG) with cardiopulmonary bypass (CPB) in 2 tertiary referral centers were randomized to the EGDT or Control group. The Control group was managed with standard care to achieve the following goals: mean arterial pressure 65-90 mmHg; central venous pressure 8-12 mmHg; urine output ≥0.5 mL·kg-1·h-1; oxygen saturation >95%; and hematocrit 26-30%. The EGDT group was managed to reach similar goals using information from the FloTrac/EV1000 monitor. The targets were stroke volume variation <13%; stroke volume index 33-65 mL·beat-1·m-2; cardiac index 2.2-4.0 L·min-1·m-2; and systemic vascular resistance index 1600-2500 dynes·s·cm-5·m-2. Results The intensive care unit (ICU) stay of the EGDT group was significantly shorter (mean difference -29.5 h; 95% CI -17.2 to -41.8, P < 0.001). The mechanical ventilation time was also shorter in the EGDT group (mean difference -11.3 h; 95% CI -2.7 to -19.9, P = 0.011). The hospital LOS was shorter in the EGDT group (mean difference -1.1 d; 95% CI -0.1 to -2.1, P = 0.038). Conclusion EGDT using FloTrac/EV1000 can be applied in CABG with CPB to improve postoperative outcomes.
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Affiliation(s)
- Sirirat Tribuddharat
- Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
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Kermad A, Speltz J, Danziger G, Mertke T, Bals R, Volk T, Lepper PM, Meiser A. Comparison of isoflurane and propofol sedation in critically ill COVID-19 patients-a retrospective chart review. J Anesth 2021; 35:625-632. [PMID: 34169362 PMCID: PMC8225486 DOI: 10.1007/s00540-021-02960-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 06/06/2021] [Indexed: 02/07/2023]
Abstract
Purpose In this retrospective study, we compared inhaled sedation with isoflurane to intravenous propofol in invasively ventilated COVID-19 patients with ARDS (Acute Respiratory Distress Syndrome). Methods Charts of all 20 patients with COVID-19 ARDS admitted to the ICU of a German University Hospital during the first wave of the pandemic between 22/03/2020 and 21/04/2020 were reviewed. Among screened 333 days, isoflurane was used in 97 days, while in 187 days, propofol was used for 12 h or more. The effect and dose of these two sedatives were compared. Mixed sedation days were excluded. Results Patients’ age (median [interquartile range]) was 64 (60–68) years. They were invasively ventilated for 36 [21–50] days. End-tidal isoflurane concentrations were high (0.96 ± 0.41 Vol %); multiple linear regression yielded the ratio (isoflurane infusion rate)/(minute ventilation) as the single best predictor. Infusion rates were decreased under ECMO (3.5 ± 1.4 versus 7.1 ± 3.2 ml∙h−1; p < 0.001). In five patients, the maximum recommended dose of propofol of 4 mg∙hour−1∙kg−1ABW was exceeded on several days. On isoflurane compared to propofol days, neuro-muscular blocking agents (NMBAs) were used less frequently (11% versus 21%; p < 0.05), as were co-sedatives (7% versus 31%, p < 0.001); daily opioid doses were lower (720 [720–960] versus 1080 [720–1620] mg morphine equivalents, p < 0.001); and RASS scores indicated deeper levels of sedation (− 4.0 [− 4.0 to − 3.0] versus − 3.0 [− 3.6 to − 2.5]; p < 0.01). Conclusion Isoflurane provided sufficient sedation with less NMBAs, less polypharmacy and lower opioid doses compared to propofol. High doses of both drugs were needed in severely ill COVID-19 patients.
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Affiliation(s)
- Azzeddine Kermad
- Department of Anesthesiology, Intensive Care and Pain Medicine, Saarland University Hospital Medical Center, Kirrberger Str. 100, 66421, Homburg, Saarland, Germany.
| | - Jacques Speltz
- Department of Anesthesiology, Intensive Care and Pain Medicine, Saarland University Hospital Medical Center, Kirrberger Str. 100, 66421, Homburg, Saarland, Germany
| | - Guy Danziger
- Department of Internal Medicine V-Pulmonology, Allergology and Intensive Care Medicine, Saarland University Hospital Medical Center, Homburg, Saarland, Germany
| | - Thilo Mertke
- Department of Anesthesiology, Intensive Care and Pain Medicine, Saarland University Hospital Medical Center, Kirrberger Str. 100, 66421, Homburg, Saarland, Germany
| | - Robert Bals
- Department of Internal Medicine V-Pulmonology, Allergology and Intensive Care Medicine, Saarland University Hospital Medical Center, Homburg, Saarland, Germany
| | - Thomas Volk
- Department of Anesthesiology, Intensive Care and Pain Medicine, Saarland University Hospital Medical Center, Kirrberger Str. 100, 66421, Homburg, Saarland, Germany
| | - Philipp M Lepper
- Department of Internal Medicine V-Pulmonology, Allergology and Intensive Care Medicine, Saarland University Hospital Medical Center, Homburg, Saarland, Germany
| | - Andreas Meiser
- Department of Anesthesiology, Intensive Care and Pain Medicine, Saarland University Hospital Medical Center, Kirrberger Str. 100, 66421, Homburg, Saarland, Germany
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Moody AE, Beutler BD, Moody CE. Predicting cost of inhalational anesthesia at low fresh gas flows: impact of a new generation carbon dioxide absorbent. Med Gas Res 2021; 10:64-66. [PMID: 32541130 PMCID: PMC7885709 DOI: 10.4103/2045-9912.285558] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
It is well known that low fresh gas flows result in lower cost of inhalational agents. A new generation of carbon dioxide absorbents allows low flow anesthesia with all anesthetics but these new compounds are more expensive. This study examines the cost of inhalational anesthesia at different fresh gas flows combined with the cost of absorbent. The cost of sevoflurane and desflurane is lower at low fresh gas flows. Paradoxically the cost of isoflurane is cheaper at 2 L/min than at lower fresh gas flows due to increased cost of carbon dioxide absorbent. Therefore low fresh gas flows should be used when feasible with sevoflurane and desflurane, but higher fresh gas flows up to 2 L/min may be more economical with isoflurane during maintenance phase of anesthesia.
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Affiliation(s)
- Alastair E Moody
- Department of Anesthesiology, University of Utah, Salt Lake City, UT, USA
| | - Bryce D Beutler
- Department of Internal Medicine, University of Nevada Reno, Reno, NV, USA
| | - Catriona E Moody
- Department of Anesthesiology, University of Utah, Salt Lake City, UT, USA
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Zhang JW, Lv ZG, Zhang WW, Wang Z, Wang BG. Correlation between pain rating index and end-tidal sevoflurane concentration during sevoflurane anesthesia. J Int Med Res 2021; 49:300060520987769. [PMID: 33535843 PMCID: PMC7869065 DOI: 10.1177/0300060520987769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective To investigate the correlation between the pain rating index (PRi), which is an index derived from processed electroencephalography signals, and the end-tidal sevoflurane concentration (ETsevo). Methods This study involved 50 adults with a body mass index of 18 to 25 kg/m2 who were undergoing elective surgery under general anesthesia. Thyrocricocentesis was performed with 2.5 mL of 2% tetracaine for endotracheal surface anesthesia, and intravenous injections of midazolam, etomidate, and rocuronium were then administered. The patients’ tracheas were intubated and their ventilatory rate was adjusted to maintain the partial pressure of end-tidal carbon dioxide at 30 to 35 mmHg. Anesthesia was maintained with sevoflurane. The ETsevo was adjusted to maintain anesthesia at 0.6, 0.8, 1.0, and 1.2 minimum alveolar concentration for 15 minutes each, and the PRi, mean arterial pressure (MAP), and heart rate were recorded at each concentration. Results A negative correlation was found between the PRi and ETsevo (−0.882) and between the MAP and ETsevo (−0.571). A low positive correlation was found between the PRi and MAP (0.484). Conclusions The PRi showed a high negative correlation with the ETsevo. Therefore, the PRi can be used to guide the depth regulation of sevoflurane anesthesia. Clinical trial registration number: ChiCTR-IPR-17012092
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Affiliation(s)
- Jian-Wen Zhang
- Department of Anesthesiology, Sanbo Brain Hospital, Capital Medical University, Beijing, China.,Department of Anesthesiology, Shanxi Bethune Hospital, Taiyuan, China
| | - Zhi-Gan Lv
- Department of Anesthesiology, Shanxi Bethune Hospital, Taiyuan, China
| | - Wei-Wei Zhang
- Department of Anesthesiology, Shanxi Bethune Hospital, Taiyuan, China
| | - Zhe Wang
- Department of Anesthesiology, Shanxi Bethune Hospital, Taiyuan, China
| | - Bao-Guo Wang
- Department of Anesthesiology, Sanbo Brain Hospital, Capital Medical University, Beijing, China
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40
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Mashour GA, Palanca BJA, Basner M, Li D, Wang W, Blain-Moraes S, Lin N, Maier K, Muench M, Tarnal V, Vanini G, Ochroch EA, Hogg R, Schwartz M, Maybrier H, Hardie R, Janke E, Golmirzaie G, Picton P, McKinstry-Wu AR, Avidan MS, Kelz MB. Recovery of consciousness and cognition after general anesthesia in humans. eLife 2021; 10:59525. [PMID: 33970101 PMCID: PMC8163502 DOI: 10.7554/elife.59525] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 05/06/2021] [Indexed: 12/13/2022] Open
Abstract
Understanding how the brain recovers from unconsciousness can inform neurobiological theories of consciousness and guide clinical investigation. To address this question, we conducted a multicenter study of 60 healthy humans, half of whom received general anesthesia for 3 hr and half of whom served as awake controls. We administered a battery of neurocognitive tests and recorded electroencephalography to assess cortical dynamics. We hypothesized that recovery of consciousness and cognition is an extended process, with differential recovery of cognitive functions that would commence with return of responsiveness and end with return of executive function, mediated by prefrontal cortex. We found that, just prior to the recovery of consciousness, frontal-parietal dynamics returned to baseline. Consistent with our hypothesis, cognitive reconstitution after anesthesia evolved over time. Contrary to our hypothesis, executive function returned first. Early engagement of prefrontal cortex in recovery of consciousness and cognition is consistent with global neuronal workspace theory.
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Affiliation(s)
- George A Mashour
- Center for Consciousness Science, Department of Anesthesiology, University of Michigan Medical SchoolAnn ArborUnited States
| | - Ben JA Palanca
- Department of Anesthesiology, Washington University School of MedicineSt. LouisUnited States
| | - Mathias Basner
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaUnited States
| | - Duan Li
- Center for Consciousness Science, Department of Anesthesiology, University of Michigan Medical SchoolAnn ArborUnited States
| | - Wei Wang
- Department of Mathematics and Statistics, Washington UniversitySt. LouisUnited States
| | - Stefanie Blain-Moraes
- Center for Consciousness Science, Department of Anesthesiology, University of Michigan Medical SchoolAnn ArborUnited States
| | - Nan Lin
- Department of Mathematics and Statistics, Washington UniversitySt. LouisUnited States
| | - Kaitlyn Maier
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaUnited States
| | - Maxwell Muench
- Department of Anesthesiology, Washington University School of MedicineSt. LouisUnited States
| | - Vijay Tarnal
- Center for Consciousness Science, Department of Anesthesiology, University of Michigan Medical SchoolAnn ArborUnited States
| | - Giancarlo Vanini
- Center for Consciousness Science, Department of Anesthesiology, University of Michigan Medical SchoolAnn ArborUnited States
| | - E Andrew Ochroch
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaUnited States
| | - Rosemary Hogg
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaUnited States
| | - Marlon Schwartz
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaUnited States
| | - Hannah Maybrier
- Department of Anesthesiology, Washington University School of MedicineSt. LouisUnited States
| | - Randall Hardie
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaUnited States
| | - Ellen Janke
- Center for Consciousness Science, Department of Anesthesiology, University of Michigan Medical SchoolAnn ArborUnited States
| | - Goodarz Golmirzaie
- Center for Consciousness Science, Department of Anesthesiology, University of Michigan Medical SchoolAnn ArborUnited States
| | - Paul Picton
- Center for Consciousness Science, Department of Anesthesiology, University of Michigan Medical SchoolAnn ArborUnited States
| | - Andrew R McKinstry-Wu
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaUnited States
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of MedicineSt. LouisUnited States
| | - Max B Kelz
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaUnited States
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Takeyama E, Nakajima M, Nakanishi Y, Amano E, Shibuya H. Longer time to extubation after general anesthesia with desflurane in patients with obstructive respiratory dysfunction: a retrospective study. JA Clin Rep 2021; 7:40. [PMID: 33939055 PMCID: PMC8093330 DOI: 10.1186/s40981-021-00443-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 04/04/2021] [Accepted: 04/19/2021] [Indexed: 11/10/2022] Open
Abstract
Background The prospect of patients with obstructive respiratory dysfunction undergoing surgery has increased with the growth in the elderly population; however, there have been few investigations about the recovery profile from volatile anesthesia. This study aimed to investigate the impact of obstructive respiratory dysfunction on recovery from desflurane anesthesia. Methods A retrospective cohort study included patients who underwent orthopedic lower limb surgery between September 2018 and March 2020. Patients were divided into two groups: those whose preoperative forced expiratory volume in 1 s/forced vital capacity ratio was <70% (obstructive respiratory dysfunction group, n = 180) or ≥70% (control group, n = 45). Time from discontinuation of desflurane to extubation (extubation time) was compared between the two groups. Univariate and multivariable Cox regression models were used to compare odds ratios for prolonged extubation (≥10 min). Results A total of 45 patients with obstructive respiratory dysfunction and 180 control patients were eligible for analysis. Extubation time was significantly longer in patients in the obstructive respiratory dysfunction group than those in the control group. In the multivariable Cox model, male sex (HR = 2.00, 95% CI 1.12–3.57; P = 0.020) and obstructive respiratory dysfunction (HR = 2.07, 95% CI 1.05–4.08; P = 0.036) were associated with prolonged extubation. Conclusions This retrospective study indicated that extubation time was longer in patients with obstructive respiratory function than in patients without obstructive respiratory function. Male sex and obstructive respiratory function were factors that contributed to extubation time.
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Affiliation(s)
- Eriko Takeyama
- Department of Anesthesiology, National Hospital Organization Osaka National Hospital, 2-1-14, Hoenzaka, Chuo-Ku, Osaka City, Osaka, 540-0006, Japan
| | - Mariko Nakajima
- Department of Anesthesiology, National Hospital Organization Osaka National Hospital, 2-1-14, Hoenzaka, Chuo-Ku, Osaka City, Osaka, 540-0006, Japan
| | - Yukiko Nakanishi
- Department of Anesthesiology, National Hospital Organization Osaka National Hospital, 2-1-14, Hoenzaka, Chuo-Ku, Osaka City, Osaka, 540-0006, Japan
| | - Eizo Amano
- Department of Anesthesiology, National Hospital Organization Osaka National Hospital, 2-1-14, Hoenzaka, Chuo-Ku, Osaka City, Osaka, 540-0006, Japan
| | - Hiromi Shibuya
- Department of Anesthesiology, National Hospital Organization Osaka National Hospital, 2-1-14, Hoenzaka, Chuo-Ku, Osaka City, Osaka, 540-0006, Japan.
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Intraoperative impaired cerebrovascular autoregulation and delayed neurocognitive recovery after major oncologic surgery: a secondary analysis of pooled data. J Clin Monit Comput 2021; 36:765-773. [PMID: 33860406 PMCID: PMC9162974 DOI: 10.1007/s10877-021-00706-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 04/08/2021] [Indexed: 11/22/2022]
Abstract
Cerebral blood flow is tightly regulated by cerebrovascular autoregulation (CVA), and intraoperative impairment of CVA has been linked with perioperative neurocognitive disorders. We aim to assess whether impairment of CVA during major oncologic surgery is associated with delayed neurocognitive recovery (DNCR) postoperatively. We performed a secondary analysis of prospectively collected data. Patients were included if they had undergone complete pre- and postoperative neuropsychological assessments, continuous intraoperative measurement of CVA, and major oncologic surgery for visceral, urological, or gynecological cancer. Intraoperative CVA was measured using the time-correlation method based on near-infrared-spectroscopy, and DNCR was assessed with a neuropsychological test battery. A decline in cognitive function before hospital discharge compared with a preoperative baseline assessment was defined as DNCR. One hundred ninety-five patients were included in the analysis. The median age of the study population was 65 years (IQR: 60–68); 11 patients (5.6%) were female. Forty-one patients (21.0%) fulfilled the criteria for DNCR in the early postoperative period. We found a significant association between impaired intraoperative CVA and DNCR before hospital discharge (OR = 1.042 [95% CI: 1.005; 1.080], p = 0.028). The type of surgery (radical prostatectomy vs. other major oncologic surgery; OR = 0.269 [95% CI: 0.099; 0.728], p = 0.010) and premedication with midazolam (OR = 3.360 [95% CI: 1.039; 10.870], p = 0.043) were significantly associated with the occurrence of DNCR in the early postoperative period. Intraoperative impairment of CVA is associated with postoperative neurocognitive function early after oncologic surgery. Therefore, intraoperative monitoring of CVA may be a target for neuroprotective interventions. The initial studies were retrospectively registered with primary clinical trial registries recognized by the World Health Organization (ClinicalTrials.gov Identifiers: DRKS00010014, 21.03.2016 and NCT04101006, 24.07.2019).
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Kermad A, Appenzeller M, Morinello E, Schneider SO, Kleinschmidt S, O'Gara B, Volk T, Meiser A. Reflection Versus Rebreathing for Administration of Sevoflurane During Minor Gynecological Surgery. Anesth Analg 2021; 132:1042-1050. [PMID: 32701542 DOI: 10.1213/ane.0000000000005074] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Contemporary anesthetic circle systems, when used at low fresh gas flows (FGF) to allow rebreathing of anesthetic, lack the ability for rapid dose titration. The small-scale anesthetic reflection device Anaesthetic Conserving Device (50mL Version; AnaConDa-S) permits administration of volatile anesthetics with high-flow ventilators. We compared washin, washout, and sevoflurane consumption using AnaConDa-S versus a circle system with low and minimal FGF. METHODS Forty patients undergoing breast surgery were randomized to receive 0.5 minimal alveolar concentration (MAC) sevoflurane with AnaConDa-S (21 patients, reflection group) or with a circle system (low flow: FGF = 0.2 minute ventilation [V'E], 9 patients; or minimal flow: 0.1 V'E, 10 patients). In the reflection group, syringe pump boluses were given for priming and washin; to simulate an open system, the FGF of the anesthesia ventilator was set to 18 L·min-1 with the soda lime removed. In the other groups, the FGF was increased for washin (1 V'E for 8 minutes) and washout (3 V'E). For all patients, tidal volume was 7 mL·kg-1 and the respiratory rate adjusted to ensure normoventilation. Analgesia was attained with remifentanil 0.3 µg·kg-1·min-1. Sevoflurane consumption was compared between the reflection group and the low- and minimal-flow groups, respectively, using a post hoc test (Fisher Least Significant Difference). To compare washin and washout (half-life), the low- and minimal-flow groups were combined. RESULTS Sevoflurane consumption was reduced in the reflection group (9.4 ± 2.0 vs 15.0 ± 3.5 [low flow, P < .001] vs 11.6 ± 2.3 mL·MAC h-1 [minimal flow, P = .02]); washin (33 ± 15 vs 49 ± 12 seconds, P = .001) and washout (28 ± 15 vs 55 ± 19 seconds, P < .001) times were also significantly shorter. CONCLUSIONS In this clinical setting with short procedures, low anesthetic requirements, and low tidal volumes, AnaConDa-S decreased anesthetic consumption, washin, and washout times compared to a circle system.
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Affiliation(s)
- Azzeddine Kermad
- From the Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Saarland University Hospital Medical Center, Homburg/Saar, Germany
| | - Madeleine Appenzeller
- From the Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Saarland University Hospital Medical Center, Homburg/Saar, Germany
| | - Emanuela Morinello
- From the Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Saarland University Hospital Medical Center, Homburg/Saar, Germany
| | - Sven Oliver Schneider
- From the Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Saarland University Hospital Medical Center, Homburg/Saar, Germany
| | - Stefan Kleinschmidt
- From the Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Saarland University Hospital Medical Center, Homburg/Saar, Germany
| | - Brian O'Gara
- Department of Anesthesiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Thomas Volk
- From the Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Saarland University Hospital Medical Center, Homburg/Saar, Germany
| | - Andreas Meiser
- From the Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Saarland University Hospital Medical Center, Homburg/Saar, Germany
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Raub D, Platzbecker K, Grabitz SD, Xu X, Wongtangman K, Pham SB, Murugappan KR, Hanafy KA, Nozari A, Houle TT, Kendale SM, Eikermann M. Effects of Volatile Anesthetics on Postoperative Ischemic Stroke Incidence. J Am Heart Assoc 2021; 10:e018952. [PMID: 33634705 PMCID: PMC8174248 DOI: 10.1161/jaha.120.018952] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background Preclinical studies suggest that volatile anesthetics decrease infarct volume and improve the outcome of ischemic stroke. This study aims to determine their effect during noncardiac surgery on postoperative ischemic stroke incidence. Methods and Results This was a retrospective cohort study of surgical patients undergoing general anesthesia at 2 tertiary care centers in Boston, MA, between October 2005 and September 2017. Exclusion criteria comprised brain death, age <18 years, cardiac surgery, and missing covariate data. The exposure was defined as median age‐adjusted minimum alveolar concentration of all intraoperative measurements of desflurane, sevoflurane, and isoflurane. The primary outcome was postoperative ischemic stroke within 30 days. Among 314 932 patients, 1957 (0.6%) experienced the primary outcome. Higher doses of volatile anesthetics had a protective effect on postoperative ischemic stroke incidence (adjusted odds ratio per 1 minimum alveolar concentration increase 0.49, 95% CI, 0.40–0.59, P<0.001). In Cox proportional hazards regression, the effect was observed for 17 postoperative days (postoperative day 1: hazard ratio (HR), 0.56; 95% CI, 0.48–0.65; versus day 17: HR, 0.85; 95% CI, 0.74–0.99). Volatile anesthetics were also associated with lower stroke severity: Every 1‐unit increase in minimum alveolar concentration was associated with a 0.006‐unit decrease in the National Institutes of Health Stroke Scale (95% CI, −0.01 to −0.002, P=0.002). The effects were robust throughout various sensitivity analyses including adjustment for anesthesia providers as random effect. Conclusions Among patients undergoing noncardiac surgery, volatile anesthetics showed a dose‐dependent protective effect on the incidence and severity of early postoperative ischemic stroke.
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Affiliation(s)
- Dana Raub
- Department of Anesthesia, Critical Care and Pain Medicine Beth Israel Deaconess Medical CenterHarvard Medical School Boston MA.,Department of Anesthesia, Critical Care and Pain Medicine Massachusetts General HospitalHarvard Medical School Boston MA
| | - Katharina Platzbecker
- Department of Anesthesia, Critical Care and Pain Medicine Beth Israel Deaconess Medical CenterHarvard Medical School Boston MA
| | - Stephanie D Grabitz
- Department of Anesthesia, Critical Care and Pain Medicine Beth Israel Deaconess Medical CenterHarvard Medical School Boston MA
| | - Xinling Xu
- Department of Anesthesia, Critical Care and Pain Medicine Beth Israel Deaconess Medical CenterHarvard Medical School Boston MA
| | - Karuna Wongtangman
- Department of Anesthesia, Critical Care and Pain Medicine Beth Israel Deaconess Medical CenterHarvard Medical School Boston MA.,Department of Anesthesiology Faculty of Medicine Siriraj HospitalMahidol University Bangkok Thailand
| | - Stephanie B Pham
- Department of Anesthesia, Critical Care and Pain Medicine Beth Israel Deaconess Medical CenterHarvard Medical School Boston MA
| | - Kadhiresan R Murugappan
- Department of Anesthesia, Critical Care and Pain Medicine Beth Israel Deaconess Medical CenterHarvard Medical School Boston MA
| | - Khalid A Hanafy
- Department of Neurology Beth Israel Deaconess Medical CenterHarvard Medical School Boston MA
| | - Ala Nozari
- Department of Anesthesia, Critical Care and Pain Medicine Beth Israel Deaconess Medical CenterHarvard Medical School Boston MA.,Department of Anesthesia Boston Medical CenterBoston University Boston MA
| | - Timothy T Houle
- Department of Anesthesia, Critical Care and Pain Medicine Massachusetts General HospitalHarvard Medical School Boston MA
| | - Samir M Kendale
- Department of Anesthesia, Critical Care and Pain Medicine Beth Israel Deaconess Medical CenterHarvard Medical School Boston MA
| | - Matthias Eikermann
- Department of Anesthesia, Critical Care and Pain Medicine Beth Israel Deaconess Medical CenterHarvard Medical School Boston MA.,Klinik für Anästhesiologie Universitätsklinikum Essen Essen Germany
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Brain network motifs are markers of loss and recovery of consciousness. Sci Rep 2021; 11:3892. [PMID: 33594110 PMCID: PMC7887248 DOI: 10.1038/s41598-021-83482-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 02/03/2021] [Indexed: 01/12/2023] Open
Abstract
Motifs are patterns of inter-connections between nodes of a network, and have been investigated as building blocks of directed networks. This study explored the re-organization of 3-node motifs during loss and recovery of consciousness. Nine healthy subjects underwent a 3-h anesthetic protocol while 128-channel electroencephalography (EEG) was recorded. In the alpha (8-13 Hz) band, 5-min epochs of EEG were extracted for: Baseline; Induction; Unconscious; 30-, 10- and 5-min pre-recovery of responsiveness; 30- and 180-min post-recovery of responsiveness. We constructed a functional brain network using the weighted and directed phase lag index, on which we calculated the frequency and topology of 3-node motifs. Three motifs (motifs 1, 2 and 5) were significantly present across participants and epochs, when compared to random networks (p < 0.05). The topology of motifs 1 and 5 changed significantly between responsive and unresponsive epochs (p-values < 0.01; Kendall's W = 0.664 (motif 1) and 0.529 (motif 5)). Motif 1 was constituted of long-range chain-like connections, while motif 5 was constituted of short-range, loop-like connections. Our results suggest that anesthetic-induced unconsciousness is associated with a topological re-organization of network motifs. As motif topological re-organization may precede (motif 5) or accompany (motif 1) the return of responsiveness, motifs could contribute to the understanding of the neural correlates of consciousness.
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Tribuddharat S, Sathitkarnmanee T, Sukhong P, Thananun M, Promkhote P, Nonlhaopol D. Comparative study of analgesia nociception index (ANI) vs. standard pharmacokinetic pattern for guiding intraoperative fentanyl administration among mastectomy patients. BMC Anesthesiol 2021; 21:50. [PMID: 33581721 PMCID: PMC7881489 DOI: 10.1186/s12871-021-01272-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 02/05/2021] [Indexed: 12/01/2022] Open
Abstract
Background The Analgesia Nociception Index (ANI) has been suggested as a non-invasive guide for analgesia. Our objective was to compare the efficacy of ANI vs. standard pharmacokinetic pattern for guiding intraoperative fentanyl administration. Methods This was a prospective, randomized, controlled study of adult female patients undergoing elective mastectomy under general anesthesia. The patients were randomized to the ANI-guided group receiving a loading dose of 75 μg of fentanyl followed by 25 μg when the ANI score was under 50. The Control group received the same loading dose followed by 25 μg every 30 min with additional doses when there were signs of inadequate analgesia (viz., tachycardia or hypertension). Results Sixty patients—30 in each group—were recruited. Although the actual mean ANI score was higher in the ANI-guided than in the Control group (mean difference 2.2; 95% CI: 0.3 to 4.0, P = 0.022), there was no difference in the primary outcome—i.e., intraoperative fentanyl consumption (mean difference − 4.2 μg; 95% CI: − 24.7 to 16.4, P = 0.686 and − 0.14 μg·kg− 1·h− 1; 95% CI: − 0.31 to 0.03, P = 0.105). No difference between groups was shown for either intraoperative blood pressure and heart rate, or for postoperative outcomes (i.e., pain scores, morphine consumption, or sedation scores) in the postanesthesia care unit. Conclusions Intraoperative fentanyl administration guided by ANI was equivalent to that guided by a modified pharmacologic pattern. In a surgical model of mastectomy, the ANI-guided intraoperative administration of fentanyl had no impact on clinical outcomes. Trial registration The study was registered with ClinicalTrials.gov (NCT03716453) on 21/10/2018.
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Affiliation(s)
- Sirirat Tribuddharat
- Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, 123 Mitrapap road, Ampur Muang, Khon Kaen, 40002, Thailand
| | - Thepakorn Sathitkarnmanee
- Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, 123 Mitrapap road, Ampur Muang, Khon Kaen, 40002, Thailand.
| | - Pornlada Sukhong
- Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, 123 Mitrapap road, Ampur Muang, Khon Kaen, 40002, Thailand
| | - Maneerat Thananun
- Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, 123 Mitrapap road, Ampur Muang, Khon Kaen, 40002, Thailand
| | - Parinda Promkhote
- Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, 123 Mitrapap road, Ampur Muang, Khon Kaen, 40002, Thailand
| | - Duangthida Nonlhaopol
- Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, 123 Mitrapap road, Ampur Muang, Khon Kaen, 40002, Thailand
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Weber J, Mißbach C, Schmidt J, Wenzel C, Schumann S, Philip JH, Wirth S. Prediction of expiratory desflurane and sevoflurane concentrations in lung-healthy patients utilizing cardiac output and alveolar ventilation matched pharmacokinetic models: A comparative observational study. Medicine (Baltimore) 2021; 100:e23570. [PMID: 33578509 PMCID: PMC7886476 DOI: 10.1097/md.0000000000023570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 11/04/2020] [Indexed: 01/05/2023] Open
Abstract
The Gas Man simulation software provides an opportunity to teach, understand and examine the pharmacokinetics of volatile anesthetics. The primary aim of this study was to investigate the accuracy of a cardiac output and alveolar ventilation matched Gas Man model and to compare its predictive performance with the standard pharmacokinetic model using patient data.Therefore, patient data from volatile anesthesia were successively compared to simulated administration of desflurane and sevoflurane for the standard and a parameter-matched simulation model with modified alveolar ventilation and cardiac output. We calculated the root-mean-square deviation (RMSD) between measured and calculated induction, maintenance and elimination and the expiratory decrement times during emergence and recovery for the standard and the parameter-matched model.During induction, RMSDs for the standard Gas Man simulation model were higher than for the parameter-matched Gas Man simulation model [induction (desflurane), standard: 1.8 (0.4) % Atm, parameter-matched: 0.9 (0.5) % Atm., P = .001; induction (sevoflurane), standard: 1.2 (0.9) % Atm, parameter-matched: 0.4 (0.4) % Atm, P = .029]. During elimination, RMSDs for the standard Gas Man simulation model were higher than for the parameter-matched Gas Man simulation model [elimination (desflurane), standard: 0.7 (0.6) % Atm, parameter-matched: 0.2 (0.2) % Atm, P = .001; elimination (sevoflurane), standard: 0.7 (0.5) % Atm, parameter-matched: 0.2 (0.2) % Atm, P = .008]. The RMSDs during the maintenance of anesthesia and the expiratory decrement times during emergence and recovery showed no significant differences between the patient and simulated data for both simulation models.Gas Man simulation software predicts expiratory concentrations of desflurane and sevoflurane in humans with good accuracy, especially when compared to models for intravenous anesthetics. Enhancing the standard model by ventilation and hemodynamic input variables increases the predictive performance of the simulation model. In most patients and clinical scenarios, the predictive performance of the standard Gas Man simulation model will be high enough to estimate pharmacokinetics of desflurane and sevoflurane with appropriate accuracy.
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Affiliation(s)
- Jonas Weber
- Department of Anesthesiology and Critical Care, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Claudia Mißbach
- Department of Anesthesiology and Critical Care, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Johannes Schmidt
- Department of Anesthesiology and Critical Care, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christin Wenzel
- Department of Anesthesiology and Critical Care, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Stefan Schumann
- Department of Anesthesiology and Critical Care, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - James H. Philip
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Steffen Wirth
- Department of Anesthesiology and Critical Care, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Measurement of anesthetic pollution in veterinary operating rooms for small animals: Isoflurane pollution in a university veterinary hospital. Braz J Anesthesiol 2021; 71:517-522. [PMID: 33685758 PMCID: PMC9373702 DOI: 10.1016/j.bjane.2021.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 10/25/2020] [Indexed: 11/28/2022] Open
Abstract
Introduction Inhaled anesthetics are used worldwide for anesthesia maintenance both in human and veterinary operating rooms. High concentrations of waste anesthetic gases can lead to health risks for the professionals exposed. Considering that anesthetic pollution in a veterinary surgical center in developing countries is unknown, this study aimed, for the first time, to measure the residual concentration of isoflurane in the air of operating rooms for small animals in a Brazilian university hospital. Method Residual isoflurane concentrations were measured by an infrared analyzer at the following sites: corner opposite to anesthesia machine; breathing zones of the surgeon, anesthesiologist, and patient (animal); and in front of the anesthesia machine at three time points, that is, 5, 30 and 120 minutes after anesthesia induction. Results Mean residual isoflurane concentrations gradually increased in the corner opposite to anesthesia machine and in the breathing zones of the surgeon and the anesthesiologist (p < 0.05). There was an increase at 30 minutes and 120 minutes when compared to the initial time points in the animal's breathing zone, and in the front of the anesthesia machine (p < 0.05). There was no significant difference at measurement sites regardless of the moment of assessment. Conclusion This study reported high residual isoflurane concentrations in veterinary operating rooms without an exhaust system, which exceeds the limit recommended by an international agency. Based on our findings, there is urgent need to implement exhaust systems to reduce anesthetic pollution and decrease occupational exposure.
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Ryu KH, Hwang SH, Shim JG, Ahn JH, Cho EA, Lee SH, Byun JH. Comparison of vasodilatory properties between desflurane and sevoflurane using perfusion index: a randomised controlled trial. Br J Anaesth 2020; 125:935-942. [DOI: 10.1016/j.bja.2020.07.050] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 07/03/2020] [Accepted: 07/18/2020] [Indexed: 02/09/2023] Open
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Kim H, Park SS, Shim J. Differences in midazolam premedication effects on recovery after short-duration ambulatory anesthesia with propofol or sevoflurane for gynecologic surgery in young patients: A randomized controlled trial. Medicine (Baltimore) 2020; 99:e23194. [PMID: 33217829 PMCID: PMC7676561 DOI: 10.1097/md.0000000000023194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Anxiolytic premedication requires careful consideration owing to potential side effects including delayed recovery after ambulatory anesthesia. We aimed to compare the effect of midazolam on recovery profiles postoperatively, depending on whether propofol or sevoflurane was the primary anesthetic. METHODS We enrolled 226 patients (age, 18-50 years) undergoing ambulatory gynecologic laparoscopic surgery. Patients were categorized into propofol without midazolam (P), propofol with midazolam (MP), sevoflurane without midazolam (S), and sevoflurane with midazolam (MS) groups. As premedication, placebo or 0.02 mg/kg intravenous midazolam was used. The primary outcome was the difference in the time from anesthetic discontinuation to eye opening in response to verbal command. Secondary outcomes included postoperative nausea and pain occurrence and time to reach the discharge score. RESULTS The time from anesthetic discontinuation to eye opening was longer in the MP group (n = 49) than in the P group (n = 50; P < .001) but was not significantly different between the MS (n = 50) and S groups (n = 49; P = .1). Midazolam premedication did not significantly affect postoperative nausea in the MP group compared with that in the P group (P = .3) but had a nausea prevention effect in the MS group compared with that in the S group (P < .001). The time to reach the discharge score was similar in all patients regardless of midazolam administration. CONCLUSION In the recovery from short-duration ambulatory gynecologic surgery in young patients, intravenous midazolam premedication showed positive effects on postoperative nausea without affecting the time from anesthetic discontinuation to eye opening with sevoflurane-based anesthesia but prolonged the time from anesthetic discontinuation to eye opening with propofol-based anesthesia. Because this difference between the propofol groups is not clinically significant, the results support midazolam premedication in young women. Further studies assessing larger populations are needed.
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