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Kumar A, Jain A. Intraoperative Vasopressors and Delirium: Comment. Anesthesiology 2024:142124. [PMID: 39392796 DOI: 10.1097/aln.0000000000005155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2024]
Affiliation(s)
- Ashish Kumar
- Mid and South Essex NHS Foundation Trust, Essex, United Kingdom (A.K.).
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Meng L, Sun Y, Zhao X, Rasmussen M, Al-Tarshan Y, Meng DM, Liu Z, Adams DC, McDonagh DL. Noradrenaline-induced changes in cerebral blood flow in health, traumatic brain injury and critical illness: a systematic review with meta-analysis. Anaesthesia 2024; 79:978-991. [PMID: 38831595 DOI: 10.1111/anae.16313] [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] [Accepted: 04/22/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND Noradrenaline is a standard treatment for hypotension in acute care. The precise effects of noradrenaline on cerebral blood flow in health and disease remain unclear. METHODS We systematically reviewed and synthesised data from studies examining changes in cerebral blood flow in healthy participants and patients with traumatic brain injury and critical illness. RESULTS Twenty-eight eligible studies were included. In healthy subjects and patients without critical illness or traumatic brain injury, noradrenaline did not significantly change cerebral blood flow velocity (-1.7%, 95%CI -4.7-1.3%) despite a 24.1% (95%CI 19.4-28.7%) increase in mean arterial pressure. In patients with traumatic brain injury, noradrenaline significantly increased cerebral blood flow velocity (21.5%, 95%CI 11.0-32.0%), along with a 33.8% (95%CI 14.7-52.9%) increase in mean arterial pressure. In patients who were critically ill, noradrenaline significantly increased cerebral blood flow velocity (20.0%, 95%CI 9.7-30.3%), along with a 32.4% (95%CI 25.0-39.9%) increase in mean arterial pressure. Our analyses suggest intact cerebral autoregulation in healthy subjects and patients without critical illness or traumatic brain injury., and impaired cerebral autoregulation in patients with traumatic brain injury and who were critically ill. The extent of mean arterial pressure changes and the pre-treatment blood pressure levels may affect the magnitude of cerebral blood flow changes. Studies assessing cerebral blood flow using non-transcranial Doppler methods were inadequate and heterogeneous in enabling meaningful meta-analysis. CONCLUSIONS Noradrenaline significantly increases cerebral blood flow in humans with impaired, not intact, cerebral autoregulation, with the extent of changes related to the severity of functional impairment, the extent of mean arterial pressure changes and pre-treatment blood pressure levels.
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Affiliation(s)
- Lingzhong Meng
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Yanhua Sun
- Department of Anesthesiology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Xu Zhao
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Mads Rasmussen
- Department of Anesthesiology, Section of Neuroanesthesia, Aarhus University Hospital, Aarhus, Denmark
| | | | - Deyi M Meng
- Choate Rosemary Hall School, Wallingford, CT, USA
| | - Ziyue Liu
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, USA
| | - David C Adams
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN, USA
| | - David L McDonagh
- Departments of Anesthesiology and Pain Management, Neurological Surgery, Neurology, UT Southwestern Medical Center, Dallas, TX, USA
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Zheng C, Wang B, Fu J, Peng H, Chen Y, Hu X. Effect of phenylephrine versus ephedrine on the incidence of postoperative delirium in olderly adults undergoing knee arthroplasty under general anesthesia: a single-center trial. Sci Rep 2024; 14:17333. [PMID: 39068245 PMCID: PMC11283455 DOI: 10.1038/s41598-024-68273-2] [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: 05/30/2024] [Accepted: 07/22/2024] [Indexed: 07/30/2024] Open
Abstract
In addition to stabilizing blood pressure (BP), ephedrine and phenylephrine have distinct effects on regional cerebral oxygen saturation (rSO2). However, whether its effect on rSO2 affects the occurrence of postoperative delirium (POD) remains unclear. Therefore, the aim of this study is to compare the effects of ephedrine and phenylephrine for BP maintenance on the incidence of POD in olderly adults who underwent knee arthroplasty under general anesthesia. One hundred twenty patients who were between 60 and 90 years old and underwent knee arthroplasty were included in this study. The patients were randomly divided into two groups: the ephedrine group and the phenylephrine group. After anesthesia induction, ephedrine and phenylephrine were continuously infused to maintain the intraoperative mean arterial pressure within the normal range (baseline mean arterial pressure ± 20%). The primary outcome measures included the incidence of POD within 1-3 days after surgery. The incidence of POD on the first day after surgery was lower in the ephedrine group than in the phenylephrine group (33% vs. 7%, P < 0.001). However, there was no significant difference in the incidence of POD between the two groups on the second and third postoperative days. Compared with the phenylephrine group, the ephedrine group experienced significantly greater cardiac output (CO) and rSO2 (P < 0.05).Clinical Trials Registry: ChiCTR2200064849, principal investigator: Changjian Zheng.
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Affiliation(s)
- Changjian Zheng
- Department of Anesthesiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, 230032, China
- Department of Anesthesiology, The First Affiliated Hospital of Wannan Medical College, Wuhu, 241000, China
| | - Bin Wang
- Department of Anesthesiology, The First Affiliated Hospital of Wannan Medical College, Wuhu, 241000, China
| | - Jiuzhou Fu
- Department of Anesthesiology, The First Affiliated Hospital of Wannan Medical College, Wuhu, 241000, China
| | - Hui Peng
- Department of Anesthesiology, The First Affiliated Hospital of Wannan Medical College, Wuhu, 241000, China
| | - Yongquan Chen
- Department of Anesthesiology, The First Affiliated Hospital of Wannan Medical College, Wuhu, 241000, China
| | - Xianwen Hu
- Department of Anesthesiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, 230032, China.
- Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei, 230032, Anhui, China.
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Katunaric B, SenthilKumar G, Stehula FJ, Werthman A, Bordas-Murphy H, Freed JK. Noninvasive assessment of human microvascular function in health and disease using incident dark-field microscopy. Am J Physiol Heart Circ Physiol 2024; 327:H261-H267. [PMID: 38787388 PMCID: PMC11380954 DOI: 10.1152/ajpheart.00292.2024] [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: 05/07/2024] [Revised: 05/22/2024] [Accepted: 05/22/2024] [Indexed: 05/25/2024]
Abstract
Reduced peripheral microvascular reactivity is associated with an increased risk for major adverse cardiac events (MACEs). Tools for noninvasive assessment of peripheral microvascular function are limited, and existing technology is poorly validated in both healthy populations and patients with cardiovascular disease (CVD). Here, we used a handheld incident dark-field imaging tool (CytoCam) to test the hypothesis that, compared with healthy individuals (no risk factors for CVD), subjects formally diagnosed with coronary artery disease (CAD) or those with ≥2 risk factors for CAD (at risk) would exhibit impaired peripheral microvascular reactivity. A total of 17 participants (11 healthy, 6 at risk) were included in this pilot study. CytoCam was used to measure sublingual microvascular total vessel density (TVD), perfused vessel density (PVD), and microvascular flow index (MFI) in response to the topical application of acetylcholine (ACh) and sublingual administration of nitroglycerin (NTG). Baseline MFI and PVD were significantly reduced in the at-risk cohort compared with healthy individuals. Surprisingly, following the application of acetylcholine and nitroglycerin, both groups showed a significant improvement in all three microvascular perfusion parameters. These results suggest that, despite baseline reductions in both microvascular density and perfusion, human in vivo peripheral microvascular reactivity to both endothelial-dependent and -independent vasoactive agents remains intact in individuals with CAD or multiple risk factors for disease.NEW & NOTEWORTHY To our knowledge, this is the first study to comprehensively characterize in vivo sublingual microvascular structure and function (endothelium-dependent and -independent) in healthy patients and those with CVD. Importantly, we used an easy-to-use handheld device that can be easily translated to clinical settings. Our results indicate that baseline microvascular impairments in structure and function can be detected using the CytoCam technology, although reactivity to acetylcholine may be maintained even during disease in the peripheral microcirculation.
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Affiliation(s)
- Boran Katunaric
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
- Cardiovascular Center, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - Gopika SenthilKumar
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
- Cardiovascular Center, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - Forrest J Stehula
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - Alec Werthman
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - Henry Bordas-Murphy
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
- Cardiovascular Center, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - Julie K Freed
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
- Cardiovascular Center, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
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Gaskell AL, Campbell D, Lam AM. Caveat Emptor: Vasopressor Choice and Postoperative Delirium-A Complex Relationship Explored. Anesthesiology 2024; 140:642-645. [PMID: 38470117 DOI: 10.1097/aln.0000000000004876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Affiliation(s)
- Amy L Gaskell
- Te Whatu Ora - Waikato, Hamilton, New Zealand; and University of Auckland, Auckland, New Zealand
| | - Douglas Campbell
- Te Whatu Ora - Auckland, Auckland, New Zealand; and University of Auckland, Auckland, New Zealand
| | - Arthur M Lam
- University of California, San Diego, San Diego, California; and Virginia Mason Medical Center. Seattle, Washington
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Ma H, Ahrens E, Wachtendorf LJ, Suleiman A, Shay D, Munoz-Acuna R, Tartler TM, Teja B, Wagner S, Subramaniam B, Rhee J, Schaefer MS. Intraoperative Use of Phenylephrine versus Ephedrine and Postoperative Delirium: A Multicenter Retrospective Cohort Study. Anesthesiology 2024; 140:657-667. [PMID: 37725759 DOI: 10.1097/aln.0000000000004774] [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: 09/21/2023]
Abstract
BACKGROUND The treatment of intraoperative hypotension with phenylephrine may impair cerebral perfusion through vasoconstriction, which has been linked to postoperative delirium. The hypothesis was that intraoperative administration of phenylephrine, compared to ephedrine, is associated with higher odds of postoperative delirium. METHODS A total of 103,094 hospitalized adults undergoing general anesthesia for noncardiac, non-neurosurgical procedures between 2008 and 2020 at two tertiary academic healthcare networks in Massachusetts were included in this multicenter hospital registry study. The primary exposure was the administration of phenylephrine versus ephedrine during surgery, and the primary outcome was postoperative delirium within 7 days. Multivariable logistic regression analyses adjusted for a priori defined confounding variables including patient demographics, comorbidities, and procedural factors including magnitude of intraoperative hypotension were applied. RESULTS Between the two healthcare networks, 78,982 (76.6%) patients received phenylephrine, and 24,112 (23.4%) patients received ephedrine during surgery; 770 patients (0.8%) developed delirium within 7 days. The median (interquartile range) total intraoperative dose of phenylephrine was 1.0 (0.2 to 3.3) mg and 10.0 (10.0 to 20.0) mg for ephedrine. In adjusted analyses, the administration of phenylephrine, compared to ephedrine, was associated with higher odds of developing postoperative delirium within 7 days (adjusted odds ratio, 1.35; 95% CI, 1.06 to 1.71; and adjusted absolute risk difference, 0.2%; 95% CI, 0.1 to 0.3%; P = 0.015). A keyword and manual chart review-based approach in a subset of 45,465 patients further validated these findings (delirium incidence, 3.2%; adjusted odds ratio, 1.88; 95% CI, 1.49 to 2.37; P < 0.001). Fractional polynomial regression analysis further indicated a dose-dependent effect of phenylephrine (adjusted coefficient, 0.08; 95% CI, 0.02 to 0.14; P = 0.013, per each μg/kg increase in the cumulative phenylephrine dose). CONCLUSIONS The administration of phenylephrine compared to ephedrine during general anesthesia was associated with higher odds of developing postoperative delirium. Based on these data, clinical trials are warranted to determine whether favoring ephedrine over phenylephrine for treatment of intraoperative hypotension can reduce delirium after surgery. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Haobo Ma
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Elena Ahrens
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Luca J Wachtendorf
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Aiman Suleiman
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Boston, Massachusetts; and Department of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, University of Jordan, Amman, Jordan
| | - Denys Shay
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Boston, Massachusetts; and Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Ricardo Munoz-Acuna
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Tim M Tartler
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Bijan Teja
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Soeren Wagner
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Balachundhar Subramaniam
- Department of Anesthesia, Critical Care and Pain Medicine and Sadhguru Center for a Conscious Planet, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - James Rhee
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Maximilian S Schaefer
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Boston, Massachusetts; and Department of Anesthesiology, University Hospital Duesseldorf, Düsseldorf, Germany
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7
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Meng L, Sun Y, Zhao X, Meng DM, Liu Z, Adams DC, McDonagh DL, Rasmussen M. Effects of phenylephrine on systemic and cerebral circulations in humans: a systematic review with mechanistic explanations. Anaesthesia 2024; 79:71-85. [PMID: 37948131 DOI: 10.1111/anae.16172] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2023] [Indexed: 11/12/2023]
Abstract
We conducted a systematic review of the literature reporting phenylephrine-induced changes in blood pressure, cardiac output, cerebral blood flow and cerebral tissue oxygen saturation as measured by near-infrared spectroscopy in humans. We used the proportion change of the group mean values reported by the original studies in our analysis. Phenylephrine elevates blood pressure whilst concurrently inducing a reduction in cardiac output. Furthermore, despite increasing cerebral blood flow, it decreases cerebral tissue oxygen saturation. The extent of phenylephrine's influence on cardiac output (r = -0.54 and p = 0.09 in awake humans; r = -0.55 and p = 0.007 in anaesthetised humans), cerebral blood flow (r = 0.65 and p = 0.002 in awake humans; r = 0.80 and p = 0.003 in anaesthetised humans) and cerebral tissue oxygen saturation (r = -0.72 and p = 0.03 in awake humans; r = -0.24 and p = 0.48 in anaesthetised humans) appears closely linked to the magnitude of phenylephrine-induced blood pressure changes. When comparing the effects of phenylephrine in awake and anaesthetised humans, we found no evidence of a significant difference in cardiac output, cerebral blood flow or cerebral tissue oxygen saturation. There was also no evidence of a significant difference in effect on systemic and cerebral circulations whether phenylephrine was given by bolus or infusion. We explore the underlying mechanisms driving the phenylephrine-induced cardiac output reduction, cerebral blood flow increase and cerebral tissue oxygen saturation decrease. Individualised treatment approaches, close monitoring and consideration of potential risks and benefits remain vital to the safe and effective use of phenylephrine in acute care.
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Affiliation(s)
- L Meng
- Department of Anesthesia, Indiana University School of Medicine, IA, Indianapolis, USA
| | - Y Sun
- Department of Anesthesiology, Nanjing Drum Tower Hospital, Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - X Zhao
- Department of Anesthesiology, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - D M Meng
- Choate Rosemary Hall School, CT, Wallingford, USA
| | - Z Liu
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, IA, Indianapolis, USA
| | - D C Adams
- Department of Anesthesia, Indiana University School of Medicine, IA, Indianapolis, USA
| | - D L McDonagh
- Departments of Anesthesiology and Pain Management, Neurological Surgery, Neurology and Neurotherapeutics, UT Southwestern Medical Center, TX, Dallas, USA
| | - M Rasmussen
- Department of Anesthesiology, Section of Neuroanesthesia, Aarhus University Hospital, Aarhus, Denmark
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Khanna AK, Saha AK, Segal S. Association of the exclusive use of intraoperative phenylephrine for treatment of hypotension with the risk of acute kidney injury after noncardiac surgery. Anaesth Crit Care Pain Med 2023; 42:101224. [PMID: 37030396 DOI: 10.1016/j.accpm.2023.101224] [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: 01/27/2023] [Revised: 03/18/2023] [Accepted: 03/22/2023] [Indexed: 04/09/2023]
Abstract
STUDY OBJECTIVE The hypothesis that the exclusive use of the commonly used vasopressor phenylephrine during the intraoperative period in noncardiac surgery is associated with postoperative acute kidney injury (AKI) was tested. DESIGN A retrospective cohort analysis of 16,306 adults undergoing major noncardiac surgery who either did or did not receive phenylephrine was conducted. The primary outcome was the association of the use of phenylephrine with the risk of postoperative AKI defined by the Kidney Disease Improving Global Outcomes (KDIGO) criteria. Logistic regression models with all independently associated potential confounders, and an exploratory model considering only patients with no untreated minutes of hypotension (post-phenylephrine in the exposed cohort, or entire case in the unexposed cohort) were used in the analysis. SETTING The study was conducted in a tertiary care university hospital where a total of 8,221 patients were exposed to phenylephrine, and 8,085 were not. RESULTS In unadjusted analysis, phenylephrine exposure was associated with an increased risk of AKI (OR 1.615, 95% CI [1.522-1.725], p < 0.001). In an adjusted model including several variables associated with AKI, phenylephrine remained associated with AKI (OR 1.325 [1.153-1.524]), as did post-phenylephrine exposure lengths of hypotension. Exclusion of patients with >1 min of post-phenylephrine exposure hypotension, also demonstrated that phenylephrine use was associated with AKI (OR 1.478, [1.245-1.753]). CONCLUSIONS The exclusive use of intraoperative phenylephrine is associated with an increased risk of postoperative renal injury. Anesthesiologists must consider a balanced approach to correct hypotension under anesthesia, including judicious choices for fluids, inotropic support when indicated, and an appropriate adjustment of the plane of anesthesia.
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Affiliation(s)
- Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, United States; Outcomes Research Consortium, Cleveland, OH, United States; Perioperative Outcomes and Informatics Collaborative, Winston-Salem, North Carolina, United States.
| | - Amit K Saha
- Perioperative Outcomes and Informatics Collaborative, Winston-Salem, North Carolina, United States; Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, United States
| | - Scott Segal
- Perioperative Outcomes and Informatics Collaborative, Winston-Salem, North Carolina, United States; Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, United States
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Kubo Y, Kubo T, Toki T, Yokota I, Morimoto Y. Effects of ephedrine and phenylephrine on cerebral oxygenation: observational prospective study using near-infrared time-resolved spectroscopy. J Clin Monit Comput 2023; 37:1171-1177. [PMID: 37243955 DOI: 10.1007/s10877-023-01036-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 05/16/2023] [Indexed: 05/29/2023]
Abstract
It has been reported that cerebral oxygenation (ScO2) measured by near infrared spectroscopy is maintained or increased by treatment with ephedrine, whereas almost all previous reports demonstrated that phenylephrine reduced ScO2. As the mechanism of the latter, the interference of the extracranial blood flow, that is extracranial contamination, has been suspected. Accordingly, in this prospective observational study, we utilized time-resolved spectroscopy (TRS), in which the effect of extracranial contamination is thought to be minimal, and evaluated whether the same result was obtained. We measured the changes in ScO2 as well as the total cerebral hemoglobin concentration (tHb) after treatment with ephedrine or phenylephrine during laparoscopic surgery by using a tNIRS-1 (Hamamatsu Photonics, Hamamatsu, Japan), which is a commercial instrument utilizing TRS. Based on a mixed-effects model with random intercepts for ScO2 or tHb including mean blood pressure, the mean difference and 95% confidence interval were evaluated as well as the predicted mean difference and its confidence interval using the interquartile range of mean blood pressure. Fifty treatments with ephedrine or phenylephrine were done. The mean differences of ScO2 were less than 0.1% and the predicted mean differences were less than 1.1% for the two drugs. The mean differences of tHb were less than 0.02 μM and the predicted mean differences were less than 0.2 μM for the drugs. The changes in ScO2 and tHb after treatments with ephedrine and phenylephrine were very small and clinically insignificant when measured by TRS. Previous reports about phenylephrine may have been affected by extracranial contamination.
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Affiliation(s)
- Yasunori Kubo
- Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N15 W7, Kita-Ku, Sapporo, 0608638, Japan.
| | - Tomonori Kubo
- Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N15 W7, Kita-Ku, Sapporo, 0608638, Japan
| | - Takayuki Toki
- Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N15 W7, Kita-Ku, Sapporo, 0608638, Japan
| | - Isao Yokota
- Department of Biostatistics, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Yuji Morimoto
- Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N15 W7, Kita-Ku, Sapporo, 0608638, Japan
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10
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Olsen MH, Capion T, Riberholt CG, Bache S, Ebdrup SR, Rasmussen R, Mathiesen T, Berg RMG, Møller K. Effect of controlled blood pressure increase on cerebral blood flow velocity and oxygenation in patients with subarachnoid haemorrhage. Acta Anaesthesiol Scand 2023; 67:1054-1060. [PMID: 37192754 DOI: 10.1111/aas.14277] [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: 12/30/2022] [Revised: 03/24/2023] [Accepted: 05/01/2023] [Indexed: 05/18/2023]
Abstract
BACKGROUND Patients with aneurysmal subarachnoid haemorrhage (SAH) might have impaired cerebral autoregulation, that is, CBF - and thereby oxygen delivery - passively increase with an increase in CPP. This physiological study aimed to investigate the cerebral haemodynamic effects of controlled blood pressure increase in the early phase after SAH before any signs of delayed cerebral ischaemia (DCI) occurred. METHODS The study was carried out within 5 days after ictus. Data were recorded at baseline and after 20 min of noradrenaline infusion to increase mean arterial blood pressure (MAP) by a maximum of 30 mmHg and to an absolute level of no more than 130 mmHg. The primary outcome was the difference in middle cerebral artery blood flow velocity (MCAv) measured by transcranial Doppler (TCD), while differences in intracranial pressure (ICP), brain tissue oxygen tension (PbtO2 ), and microdialysis markers of cerebral oxidative metabolism and cell injury were assessed as exploratory outcomes. Data were analysed using Wilcoxon signed-rank test with correction for multiplicity for the exploratory outcomes using the Benjamini-Hochberg correction. RESULTS Thirty-six participants underwent the intervention 4 (median, IQR: 3-4.75) days after ictus. MAP was increased from 82 (IQR: 76-85) to 95 (IQR: 88-98) mmHg (p-value: <.001). MCAv remained stable (baseline, median 57, IQR: 46-70 cm/s; controlled blood pressure increase, median: 55, IQR: 48-71 cm/s; p-value: .054), whereas PbtO2 increased significantly (baseline, median: 24, 95%CI: 19-31 mmHg; controlled blood pressure increase, median: 27, 95%CI: 24-33 mmHg; p-value <.001). The remaining exploratory outcomes were unchanged. CONCLUSION In this study of patients with SAH, MCAv was not significantly affected by a brief course of controlled blood pressure increase; despite this, PbtO2 increased. This suggests that autoregulation might not be impaired in these patients or other mechanisms could mediate the increase in brain oxygenation. Alternatively, a CBF increase did occur that, in turn, increased cerebral oxygenation, but was not detected by TCD. TRIAL REGISTRATION clinicaltrials.gov (NCT03987139; 14 June 2019).
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Affiliation(s)
- Markus Harboe Olsen
- Department of Neuroanaesthesiology, The Neuroscience Centre, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Tenna Capion
- Department of Neurosurgery, The Neuroscience Centre, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Christian Gunge Riberholt
- Department of Neuroanaesthesiology, The Neuroscience Centre, Copenhagen University Hospital, Rigshospitalet, Denmark
- Department of Brain and Spinal Cord Injury, The Neuroscience Centre, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Søren Bache
- Department of Neuroanaesthesiology, The Neuroscience Centre, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Søren Røddik Ebdrup
- Department of Neuroanaesthesiology, The Neuroscience Centre, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Rune Rasmussen
- Department of Neurosurgery, The Neuroscience Centre, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Tiit Mathiesen
- Department of Neurosurgery, The Neuroscience Centre, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Ronan M G Berg
- Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital, Denmark
- Centre for Physical Activity Research, Copenhagen University Hospital, Rigshospitalet, Denmark
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - Kirsten Møller
- Department of Neuroanaesthesiology, The Neuroscience Centre, Copenhagen University Hospital, Rigshospitalet, Denmark
- Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
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Karamchandani K, Dave S, Hoffmann U, Khanna AK, Saugel B. Intraoperative arterial pressure management: knowns and unknowns. Br J Anaesth 2023; 131:445-451. [PMID: 37419749 DOI: 10.1016/j.bja.2023.05.027] [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: 04/03/2023] [Revised: 05/16/2023] [Accepted: 05/29/2023] [Indexed: 07/09/2023] Open
Abstract
Preventing postoperative organ dysfunction is integral to the practice of anaesthesia. Although intraoperative hypotension is associated with postoperative end organ dysfunction, there remains ambiguity with regards to its definition, targets, thresholds for initiating treatment, and ideal treatment modalities.
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Affiliation(s)
- Kunal Karamchandani
- Department of Anesthesiology and Pain Management, Division of Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Siddharth Dave
- Department of Anesthesiology and Pain Management, Division of Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ulrike Hoffmann
- Department of Anesthesiology and Pain Management, Division of Neuroanesthesia, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Perioperative Outcomes and Informatics Collaborative (POIC), Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA; Outcomes Research Consortium, Cleveland, OH, USA
| | - Bernd Saugel
- Outcomes Research Consortium, Cleveland, OH, USA; Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Uemura Y, Kinoshita M, Sakai Y, Tanaka K. Hemodynamic impact of ephedrine on hypotension during general anesthesia: a prospective cohort study on middle-aged and older patients. BMC Anesthesiol 2023; 23:283. [PMID: 37608253 PMCID: PMC10464275 DOI: 10.1186/s12871-023-02244-4] [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: 05/24/2023] [Accepted: 08/16/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND Ephedrine is a mixed α- and β-agonist vasopressor that is frequently used for the correction of hypotension during general anesthesia. β-responsiveness has been shown to decrease with age; therefore, this study aimed to determine whether aging would reduce the pressor effect of ephedrine on hypotension during general anesthesia. METHODS Seventy-five patients aged ≥ 45 years were included in this study, with 25 patients allocated to each of the three age groups: 45-64 years, 65-74 years, and ≥ 75 years. All patients received propofol, remifentanil, and rocuronium for the induction of general anesthesia, followed by desflurane and remifentanil. Cardiac output (CO) was estimated using esCCO technology. Ephedrine (0.1 mg/kg) was administered for the correction of hypotension. The primary and secondary outcome measures were changes in the mean arterial pressure (MAP) and CO, respectively, at 5 min after the administration of ephedrine. RESULTS: The administration of ephedrine significantly increased MAP (p < 0.001, mean difference: 8.34 [95% confidence interval (CI), 5.95-10.75] mmHg) and CO (p < 0.001, mean difference: 7.43 [95% CI, 5.20-9.65] %) across all groups. However, analysis of variance revealed that the degree of elevation of MAP (F [2, 72] = 0.546, p = 0.581, η2 = 0.015 [95% CI, 0.000-0.089]) and CO (F [2, 72] = 2.023, p = 0.140, η2 = 0.053 [95% CI, 0.000-0.162]) did not differ significantly among the groups. Similarly, Spearman's rank correlation and multiple regression analysis revealed no significant relation between age and the changes in MAP or CO after the administration of ephedrine. CONCLUSION The administration of ephedrine significantly increased MAP and CO; however, no significant correlation with age was observed in patients aged > 45 years. These findings suggest that ephedrine is effective for the correction of hypotension during general anesthesia, even in elderly patients. TRIAL REGISTRATION UMIN-CTR (UMIN000045038; 02/08/2021).
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Affiliation(s)
- Yuta Uemura
- Department of Anesthesiology, Tokushima University Graduate School of Biomedical Sciences, 3-8-15 Kuramoto-cho, Tokushima-shi, Tokushima, 770-8503, Japan
- Department of Anesthesiology, Tokushima University Hospital, 2-50-1 Kuramoto-cho, Tokushima-shi, Tokushima, 770-8503, Japan
| | - Michiko Kinoshita
- Department of Anesthesiology, Tokushima University Hospital, 2-50-1 Kuramoto-cho, Tokushima-shi, Tokushima, 770-8503, Japan.
| | - Yoko Sakai
- Division of Anesthesiology, Tokushima University Hospital, 2-50-1 Kuramoto-cho, Tokushima-shi, Tokushima, 770-8503, Japan
| | - Katsuya Tanaka
- Department of Anesthesiology, Tokushima University Graduate School of Biomedical Sciences, 3-8-15 Kuramoto-cho, Tokushima-shi, Tokushima, 770-8503, Japan
- Department of Anesthesiology, Tokushima University Hospital, 2-50-1 Kuramoto-cho, Tokushima-shi, Tokushima, 770-8503, Japan
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13
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Joys S, Panda NB, Ahuja CK, Luthra A, Tripathi M, Mahajan S, Kaloria N, Jain C, Singh N, Regmi S, Jangra K, Chauhan R, Soni SL, Bhagat H. Comparison of Effects of Propofol and Sevoflurane on the Cerebral Vasculature Assessed by Digital Subtraction Angiographic Parameters in Patients Treated for Ruptured Cerebral Aneurysm: A Preliminary Study. J Neurosurg Anesthesiol 2023; 35:327-332. [PMID: 35090162 DOI: 10.1097/ana.0000000000000833] [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: 05/26/2021] [Accepted: 12/17/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Studies have evaluated the effects of volatile and intravenous anesthetic agents on the cerebral vasculature with inconsistent results. We used digital subtraction angiography to compare the effects of propofol and sevoflurane on the luminal diameter of cerebral vessels and on cerebral transit time in patients with aneurysmal subarachnoid hemorrhage (aSAH). METHODS This prospective preliminary study included adult patients with good-grade aSAH scheduled for endovascular coil embolization; patients were randomized to receive propofol or sevoflurane anesthesia during endovascular coiling. The primary outcome was the luminal diameter of 7 cerebral vessel segments measured on the diseased and nondiseased sides of the brain at 3 time points: awake, postinduction of anesthesia, and postcoiling. Cerebral transit time was also measured as a surrogate for cerebral blood flow. RESULTS Eighteen patients were included in the analysis (9 per group). Baseline and intraoperative parameters were similar between the groups. Propofol increased the diameter of 1 vessel segment at postinduction and postcoiling on the diseased side and in 1 segment at postcoiling on the nondiseased side of the brain ( P <0.05). Sevoflurane increased vessel diameter in 3 segments at postinduction and in 2 segments at postcoiling on the diseased side, and in 4 segments at postcoiling on the nondiseased side ( P <0.05). Cerebral transit time did not change compared with baseline awake state in either group and was not different between the groups. CONCLUSIONS Sevoflurane has cerebral vasodilating properties compared with propofol in patients with good-grade aSAH. However, sevoflurane affects cerebral transit time comparably to propofol.
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Affiliation(s)
- Steve Joys
- Departments of Anaesthesia and Intensive Care
| | | | | | | | - Manjul Tripathi
- Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | | | | | - Nidhi Singh
- Departments of Anaesthesia and Intensive Care
| | | | | | | | - Shiv L Soni
- Departments of Anaesthesia and Intensive Care
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Kim H. Anesthetic management of the traumatic brain injury patients undergoing non-neurosurgery. Anesth Pain Med (Seoul) 2023; 18:104-113. [PMID: 37183278 PMCID: PMC10183618 DOI: 10.17085/apm.23017] [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: 02/27/2023] [Accepted: 03/15/2023] [Indexed: 05/16/2023] Open
Abstract
This article describes the anesthetic management of patients with traumatic brain injury (TBI) undergoing non-neurosurgery, primarily targeting intraoperative management for multiple-trauma surgery. The aim of this review is to promote the best clinical practice for patients with TBI in order to prevent secondary brain injury. Based on the current clinical guidelines and evidence, anesthetic selection and administration; maintenance of optimal cerebral perfusion pressure, oxygenation and ventilation; coagulation monitoring; glucose control; and temperature management are addressed. Neurological recovery, which is critical for improving the patient's quality of life, is most important; therefore, future research needs to be focused on this aspect.
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Affiliation(s)
- Hyunjee Kim
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
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Krishnamoorthy S, Paulraj S, Selvaraj NP, Ragupathy B, Arumugam S. A novel approach for neural networks based diagnosis and grading of stroke in tumor-affected brain MRIs. NETWORK (BRISTOL, ENGLAND) 2023; 34:190-220. [PMID: 37352128 DOI: 10.1080/0954898x.2023.2225601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 04/28/2023] [Accepted: 06/11/2023] [Indexed: 06/25/2023]
Abstract
Recognition and diagnosis of stroke from magnetic resonance Image (MRIs) are significant for medical procedures in therapeutic standards. The primary goal of this scheme is the discovery of stroke in tumour locale in brain tissues influenced image. The probability of stroke is categorized on brain tumour influenced images into mild, moderate, or serious cases. The mild and moderate phases of stroke are recognized as "Ahead of schedule" findings and serious cases are distinguished as "Advance" determination. The proposed Glioblastoma brain tumour recognition strategy used the Multifaceted Brain Tumour Image Segmentation test open-access dataset for evaluating the presentation. The brain images are classified utilizing the Deep Neural Networks classification algorithm as normal and abnormal images. The tumour region is segmented from the identified set of abnormal images using the normalized graph cut algorithm. The stroke likelihood is identified using the Deep Neural Networks by analysing the proximity of tumour section in brain matters. The proposed stroke analysis framework accurately groups 10 images as "Right on time" stroke probability images and accomplishes 90% order rate. The proposed stroke prediction framework effectively characterizes images as "Advance" stroke probability images and accomplishes 90% characterization rate.
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Affiliation(s)
| | - Sivakumar Paulraj
- School of Computer Science and Engineering, Vellore Institute of Technology, Chennai, Tamil Nadu, India
| | - Nagendra Prabhu Selvaraj
- Department of Computational Intelligence, SRM Institute of Science and Technology, Chennai, Tamil Nadu, India
| | - Balakumaresan Ragupathy
- Department of Electronics and Communication Engineering, PSNA College of Engineering and Technology, Dindigul, Tamil Nadu, India
| | - Selvapandian Arumugam
- Department of Electronics and Communication Engineering, PSNA College of Engineering and Technology, Dindigul, Tamil Nadu, India
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Valorization of rice straw, sugarcane bagasse and sweet sorghum bagasse for the production of bioethanol and phenylacetylcarbinol. Sci Rep 2023; 13:727. [PMID: 36639688 PMCID: PMC9839728 DOI: 10.1038/s41598-023-27451-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 01/02/2023] [Indexed: 01/15/2023] Open
Abstract
Open burning of agricultural residues causes numerous complications including particulate matter pollution in the air, soil degradation, global warming and many more. Since they possess bio-conversion potential, agro-industrial residues including sugarcane bagasse (SCB), rice straw (RS), corncob (CC) and sweet sorghum bagasse (SSB) were chosen for the study. Yeast strains, Candida tropicalis, C. shehatae, Saccharomyces cerevisiae, and Kluyveromyces marxianus var. marxianus were compared for their production potential of bioethanol and phenylacetylcarbinol (PAC), an intermediate in the manufacture of crucial pharmaceuticals, namely, ephedrine, and pseudoephedrine. Among the substrates and yeasts evaluated, RS cultivated with C. tropicalis produced significantly (p ≤ 0.05) higher ethanol concentration at 15.3 g L-1 after 24 h cultivation. The product per substrate yield (Yeth/s) was 0.38 g g-1 with the volumetric productivity (Qp) of 0.64 g L-1 h-1 and fermentation efficiency of 73.6% based on a theoretical yield of 0.51 g ethanol/g glucose. C. tropicalis grown in RS medium produced 0.303 U mL-1 pyruvate decarboxylase (PDC), a key enzyme that catalyzes the production of PAC, with a specific activity of 0.400 U mg-1 protein after 24 h cultivation. This present study also compared the whole cells biomass of C. tropicalis with its partially purified PDC preparation for PAC biotransformation. The whole cells C. tropicalis PDC at 1.29 U mL-1 produced an overall concentration of 62.3 mM PAC, which was 68.4% higher when compared to partially purified enzyme preparation. The results suggest that the valorization of lignocellulosic residues into bioethanol and PAC will not only aid in mitigating the environmental challenge posed by their surroundings but also has the potential to improve the bioeconomy.
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Shao E, Hasanaly N, Venkatraghavan L. Year in Review: Synopsis of Selected Articles in Neuroanesthesia and Neurocritical Care from 2021. JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2022. [DOI: 10.1055/s-0042-1744045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
AbstractThis review is a synopsis of selected articles from neuroscience, neuroanesthesia, and neurocritical care from 2021 (January–December 2021). The journals reviewed include anesthesia journals, critical care medicine journals, neurology, and neurosurgical journals as well as high-impact medical journals such as the Lancet, Journal of American Medical Association, New England Journal of Medicine, and Stroke. This summary of important articles will serve to update the knowledge of anesthesiologists and other perioperative physicians who provide care to neurosurgical and neurocritical care patients. In addition, some of the important narrative reviews that are of interest to neuroanesthesiologists are also listed.
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Affiliation(s)
- Evan Shao
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Nahemah Hasanaly
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Lashmi Venkatraghavan
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada
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Vasopressor Effects on Cerebral Microcirculation: Comment. Anesthesiology 2022; 136:867-868. [PMID: 35157752 DOI: 10.1097/aln.0000000000004149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Vasopressor Effects on Cerebral Microcirculation: Reply. Anesthesiology 2022; 136:868. [PMID: 35157755 DOI: 10.1097/aln.0000000000004150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Phenylephrine or Ephedrine for Intraoperative Hypotension? Consider the Cerebral Microcirculation. Anesthesiology 2021; 135:775-777. [PMID: 34597387 DOI: 10.1097/aln.0000000000003975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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