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Bain CR, Myles PS, Corcoran T, Dieleman JM. Postoperative systemic inflammatory dysregulation and corticosteroids: a narrative review. Anaesthesia 2023; 78:356-370. [PMID: 36308338 PMCID: PMC10092416 DOI: 10.1111/anae.15896] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2022] [Indexed: 12/15/2022]
Abstract
In some patients, the inflammatory-immune response to surgical injury progresses to a harmful, dysregulated state. We posit that postoperative systemic inflammatory dysregulation forms part of a pathophysiological response to surgical injury that places patients at increased risk of complications and subsequently prolongs hospital stay. In this narrative review, we have outlined the evolution, measurement and prediction of postoperative systemic inflammatory dysregulation, distinguishing it from a healthy and self-limiting host response. We reviewed the actions of glucocorticoids and the potential for heterogeneous responses to peri-operative corticosteroid supplementation. We have then appraised the evidence highlighting the safety of corticosteroid supplementation, and the potential benefits of high/repeated doses to reduce the risks of major complications and death. Finally, we addressed how clinical trials in the future should target patients at higher risk of peri-operative inflammatory complications, whereby corticosteroid regimes should be tailored to modify not only the a priori risk, but also further adjusted in response to markers of an evolving pathophysiological response.
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Affiliation(s)
- C R Bain
- Department of Anaesthesiology and Peri-operative Medicine, Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | - P S Myles
- Department of Anaesthesiology and Peri-operative Medicine, Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | - T Corcoran
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Perth, WA, Australia
| | - J M Dieleman
- Department of Anaesthesia and Peri-operative Medicine, Westmead Hospital, Sydney and Western Sydney University, Sydney, NSW, Australia
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Sun L, Ma W, Gao W, Xing Y, Chen L, Xia Z, Zhang Z, Dai Z. Propofol directly induces caspase-1-dependent macrophage pyroptosis through the NLRP3-ASC inflammasome. Cell Death Dis 2019; 10:542. [PMID: 31316052 PMCID: PMC6637184 DOI: 10.1038/s41419-019-1761-4] [Citation(s) in RCA: 150] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 06/21/2019] [Accepted: 06/24/2019] [Indexed: 12/13/2022]
Abstract
Propofol infusion syndrome (PRIS) is an uncommon life-threatening complication observed most often in patients receiving high-dose propofol. High-dose propofol treatment with a prolonged duration can damage the immune system. However, the associated molecular mechanisms remain unclear. An increasing number of clinical and experimental observations have demonstrated that tissue-resident macrophages play a critical role in immune regulation during anaesthesia and procedural sedation. Since the inflammatory response is essential for mediating propofol-induced cell death and proinflammatory reactions, we hypothesised that propofol overdose induces macrophage pyroptosis through inflammasomes. Using primary cultured bone marrow-derived macrophages, murine macrophage cell lines (RAW264.7, RAW-asc and J774) and a mouse model, we investigated the role of NLRP3 inflammasome activation and secondary pyroptosis in propofol-induced cell death. We found that high-dose propofol strongly cleaved caspase-1 but not caspase-11 and biosynthesis of downstream interleukin (IL)-1β and IL-18. Inhibition of caspase-1 activity blocks IL-1β production. Moreover, NLRP3 deletion moderately suppressed cleaved caspase-1 as well as the proportion of pyroptosis, while levels of AIM2 were increased, triggering a compensatory pathway to pyroptosis in NLRP3-/- macrophages. Here, we show that propofol-induced mitochondrial reactive oxygen species (ROS) can trigger NLRP3 inflammasome activation. Furthermore, apoptosis-associated speck-like protein (ASC) was found to mediate NLRP3 and AIM2 signalling and contribute to propofol-induced macrophage pyroptosis. In addition, our work shows that propofol-induced apoptotic initiator caspase (caspase-9) subsequently cleaved effector caspases (caspase-3 and 7), indicating that both apoptotic and pyroptotic cellular death pathways are activated after propofol exposure. Our studies suggest, for the first time, that propofol-induced pyroptosis might be restricted to macrophage through an NLRP3/ASC/caspase-1 pathway, which provides potential targets for limiting adverse reactions during propofol application. These findings demonstrate that propofol overdose can trigger cell death through caspase-1 activation and offer new insights into the use of anaesthetic drugs.
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Affiliation(s)
- Lingbin Sun
- The Department of Anesthesiology, The Second Clinical Medical College (Shenzhen People's Hospital), Jinan University, No. 1017 Dongmen North Road, Shenzhen, People's Republic of China.,Integrated Chinese and Western Medicine Postdoctoral Research Station, Jinan University, Shipai, Guangzhou, People's Republic of China
| | - Wei Ma
- Translational Medicine Collaorative Innovation Center, The Second Clinical Medical College (Shenzhen People's Hospital), Jinan University, No. 1017 Dongmen North Road, Shenzhen, People's Republic of China
| | - Wenli Gao
- The Department of Anesthesiology, The Second Clinical Medical College (Shenzhen People's Hospital), Jinan University, No. 1017 Dongmen North Road, Shenzhen, People's Republic of China
| | - Yanmei Xing
- The Department of Anesthesiology, The Second Clinical Medical College (Shenzhen People's Hospital), Jinan University, No. 1017 Dongmen North Road, Shenzhen, People's Republic of China
| | - Lixin Chen
- Department of Pharmacology, Medical College, Jinan University, Shipai, Guangzhou, People's Republic of China
| | - Zhengyuan Xia
- Department of Anesthesiology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong SAR, People's Republic of China
| | - Zhongjun Zhang
- The Department of Anesthesiology, The Second Clinical Medical College (Shenzhen People's Hospital), Jinan University, No. 1017 Dongmen North Road, Shenzhen, People's Republic of China
| | - Zhongliang Dai
- The Department of Anesthesiology, The Second Clinical Medical College (Shenzhen People's Hospital), Jinan University, No. 1017 Dongmen North Road, Shenzhen, People's Republic of China.
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Torrance HDT, Longbottom ER, Vivian ME, Lalabekyan B, Abbott TEF, Ackland GL, Hinds CJ, Pearse RM, O’Dwyer MJ. Post-operative immune suppression is mediated via reversible, Interleukin-10 dependent pathways in circulating monocytes following major abdominal surgery. PLoS One 2018; 13:e0203795. [PMID: 30212506 PMCID: PMC6136775 DOI: 10.1371/journal.pone.0203795] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 08/28/2018] [Indexed: 12/04/2022] Open
Abstract
Introduction Post-operative infections occur frequently following major surgery. The magnitude of the post-operative immune response is associated with an increased risk of post-operative infections, although the mechanisms driving post-operative immune-dysfunction and the potential reversibility of this response with immune stimulants are not well understood. This study aims to describe the immediate immune response to major surgery and establish links to both post-operative infection and functional aspects of immune dysregulation. We also investigate the potential of clinically available immune stimulants to reverse features of post-operative immune-dysfunction. Methods Patients over 45 years old undergoing elective gastro-intestinal surgery with planned post-operative surgical ICU admission were recruited. The expression of selected genes was determined pre-operatively and at 2, 24 and 48 hours post-operatively using qRT-PCR. Circulating levels of Interleukin-10 protein were determined by ELISA. Peri-operative cell surface monocyte HLA-DR (mHLA-DR) expression was determined using flow cytometry. Gene expression and mHLA-DR levels were determined in healthy monocytes cultured in peri-operative serum with and without neutralising antibodies and immune stimulants. Results 119 patients were recruited; 44 developed a post-operative infection. Interleukin-10 mRNA and protein increased 4-fold post-operatively (P<0.0001), peaking within 2 hours of the procedure. Higher post-operative Interleukin-10 mRNA (P = 0.007) and protein (P = 0.001) levels were associated with an increased risk of infection. Cell surface mHLA-DR expression fell post-operatively (P<0.0001). Reduced production, rather than intracellular sequestration, accounted for the post-operative decline in cell surface mHLA-DR expression. Interleukin-10 antibody prevented the decrease in mHLA-DR expression observed when post-operative serum was added to healthy monocytes. GM-CSF and IFN-γ prevented the decline in mHLA-DR production through distinct pathways. Conclusions Monocyte dysfunction and features of immune suppression occur frequently after major surgery. Greater post-operative Interleukin-10 production is associated with later infection. Interleukin-10 is an important mediator of post-operative reductions in mHLA-DR expression, while clinically available immune stimulants can restore mHLA-DR levels.
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Affiliation(s)
- Hew D. T. Torrance
- Centre for Translational Medicine and Therapeutics, William Harvey Research Institute, Barts and the London School of Medicine, Queen Mary University of London, United Kingdom
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - E. Rebecca Longbottom
- Centre for Translational Medicine and Therapeutics, William Harvey Research Institute, Barts and the London School of Medicine, Queen Mary University of London, United Kingdom
| | - Mark E. Vivian
- Cambridge University Division of Anaesthesia, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Bagrat Lalabekyan
- Centre for Translational Medicine and Therapeutics, William Harvey Research Institute, Barts and the London School of Medicine, Queen Mary University of London, United Kingdom
| | - Tom E. F. Abbott
- Centre for Translational Medicine and Therapeutics, William Harvey Research Institute, Barts and the London School of Medicine, Queen Mary University of London, United Kingdom
| | - Gareth L. Ackland
- Centre for Translational Medicine and Therapeutics, William Harvey Research Institute, Barts and the London School of Medicine, Queen Mary University of London, United Kingdom
| | - Charles J. Hinds
- Centre for Translational Medicine and Therapeutics, William Harvey Research Institute, Barts and the London School of Medicine, Queen Mary University of London, United Kingdom
| | - Rupert M. Pearse
- Centre for Translational Medicine and Therapeutics, William Harvey Research Institute, Barts and the London School of Medicine, Queen Mary University of London, United Kingdom
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Michael J. O’Dwyer
- Centre for Translational Medicine and Therapeutics, William Harvey Research Institute, Barts and the London School of Medicine, Queen Mary University of London, United Kingdom
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
- * E-mail:
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Microbiological Contamination of Drugs during Their Administration for Anesthesia in the Operating Room. Anesthesiology 2016; 124:785-94. [DOI: 10.1097/aln.0000000000001041] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Abstract
Background
The aseptic techniques of anesthesiologists in the preparation and administration of injected medications have not been extensively investigated, but emerging data demonstrate that inadvertent lapses in aseptic technique may be an important contributor to surgical site and other postoperative infections.
Methods
A prospective, open, microbiological audit of 303 cases in which anesthesiologists were asked to inject all bolus drugs, except propofol and antibiotics, through a 0.2-µm filter was performed. The authors cultured microorganisms, if present, from the 0.2-µm filter unit and from the residual contents of the syringes used for drawing up or administering drugs. Participating anesthesiologists rated ease of use of the filters after each case.
Results
Twenty-three anesthesiologists each anesthetized up to 25 adult patients. The authors isolated microorganisms from filter units in 19 (6.3%) of 300 cases (3 cases were excluded), including Staphylococcus capitis, Staphylococcus warneri, Staphylococcus epidermidis, Staphylococcus haemolyticus, Micrococcus luteus/lylae, Corynebacterium, and Bacillus species. The authors collected used syringes at the end of each case and grew microorganisms from residual drug in 55 of these 2,318 (2.4%) syringes including all the aforementioned microorganisms and also Kocuria kristinae, Staphylococcus aureus, and Staphylococcus hominus. Participants’ average rating of ease of use of the filter units was 3.5 out of 10 (0 being very easy and 10 being very difficult).
Conclusions
Microorganisms with the potential to cause infection are being injected (presumably inadvertently) into some patients during the administration of intravenous drugs by bolus during anesthesia. The relevance of this finding to postoperative infections warrants further investigation.
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