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Ma XX, Xie HY, Hou PP, Wang XJ, Zhou W, Wang ZH. Nuclear Factor Erythroid 2-Related Factor 2 is Essential for Low-Normobaric Oxygen Treatment-Mediated Blood-Brain Barrier Protection Following Ischemic Stroke. Mol Neurobiol 2024; 61:2938-2948. [PMID: 37950788 DOI: 10.1007/s12035-023-03767-0] [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: 07/18/2023] [Accepted: 11/01/2023] [Indexed: 11/13/2023]
Abstract
Cerebral ischemia/reperfusion (I/R) injury increases blood-brain barrier (BBB) permeability, leading to hemorrhagic transformation and brain edema. Normobaric oxygen (NBO) is a routine clinical treatment strategy for this condition. However, its neuroprotective effects remain controversial. This study investigated the effect of different NBO concentrations on I/R injury and explores the involvement of the nuclear factor erythroid 2-related factor 2 (Nrf2) pathway in the underlying mechanism. A mouse middle cerebral artery occlusion (MCAO) model, and an oxygen and glucose deprivation (OGD) model featuring mouse brain microvascular endothelial cells (ECs) called bEnd.3, were used to investigate the effect of NBO on I/R injury. A reactive oxygen species (ROS) inducer and Nrf2-knockdown by RNA were used to explore whether the Nrf2 pathway mediates the effect of NBO on cerebrovascular ECs. In the early stage of MCAO, 40% O2 NBO exposure significantly improved blood perfusion in the ischemic area and effectively relieved BBB permeability, cerebral edema, cerebral injury, and neurological function after MCAO. In the OGD model, 40% O2 NBO exposure significantly reduced apoptosis, inhibited ROS generation, reduced ER stress, upregulated the expression of tight junction proteins, and stabilized the permeability of ECs. Blocking the Nrf2 pathway nullified the protective effect of 40% O2 NBO on ECs after OGD. Finally, our study confirmed that low concentrations of NBO have a neuroprotective effect on I/R by activating the Nrf2 pathway in ECs.
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Affiliation(s)
- Xiao-Xiao Ma
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hai-Yi Xie
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Pin-Pin Hou
- Central Laboratory, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xiao-Jing Wang
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wei Zhou
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Zhen-Hong Wang
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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2
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Stuby J, Kaserer A, Ott S, Ruetzler K, Rössler J. [Perioperative hyperoxia-More harmful than beneficial?]. DIE ANAESTHESIOLOGIE 2023; 72:342-347. [PMID: 37084143 DOI: 10.1007/s00101-023-01274-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/01/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND The ideal perioperative oxygen concentration is controversial and study results are inconsistent. OBJECTIVE Current knowledge on the beneficial and adverse effects of perioperative hyperoxia. MATERIAL AND METHODS Narrative review RESULTS: Perioperative hyperoxia is unlikely to increase the incidence of atelectasis, pulmonary or cardiovascular complications or mortality. Few and small potential beneficial effects, such as reduction of surgical wound infections or postoperative nausea and vomiting have been demonstrated. According to the current state of evidence, it is recommended to avoid perioperative hyperoxia and to aim for normoxia instead.
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Affiliation(s)
- Johann Stuby
- Institut für Anästhesiologie, Universitätsspital Zürich, 8091, Zürich, Schweiz.
| | - Alexander Kaserer
- Institut für Anästhesiologie, Universitätsspital Zürich, 8091, Zürich, Schweiz
| | - Sascha Ott
- Klinik für Kardioanästhesiologie und Intensivmedizin, Deutsches Herzzentrum Berlin, 13353, Berlin, Deutschland
- Klinik für Kardioanästhesiologie und Intensivmedizin, Charité Universitätsmedizin Berlin, 13353, Berlin, Deutschland
- DZHK (Deutsches Zentrum für Herz-Kreislauf-Forschung), Standort Berlin, Berlin, Deutschland
| | - Kurt Ruetzler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, USA
- Department of General Anesthesia, Anesthesiology Institute, Cleveland Clinic, Cleveland, USA
| | - Julian Rössler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, USA
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3
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Pedersen SS, Meyhoff CS, Olsen MH, Stisen ZR, Lund A, Møller K, Skjøth-Rasmussen J, Moltke FB, Sørensen MK. Impact of hyperoxia and phenylephrine on cerebral oxygenation: An experimental clinical study. Acta Anaesthesiol Scand 2023; 67:57-65. [PMID: 36112064 PMCID: PMC10092244 DOI: 10.1111/aas.14149] [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: 05/26/2022] [Revised: 07/16/2022] [Accepted: 08/21/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Oxygen supply to the brain is of special importance during intracranial surgery because it may be compromised by intracranial pathology. A high arterial blood pressure (mean arterial pressure above 80 mmHg) and a high arterial oxygen tension (PaO2 above 12 kPa) is therefore often targeted in these patients, when for example intracranial pressure is increased or when a mass effect on brain tissue from a tumour is present, and it is pursued by administering vasopressors such as phenylephrine and by increasing inspiratory oxygen fraction (FiO2 ). However, whether these interventions increase cerebral oxygenation remains uncertain. We aimed to investigate the effect of hyperoxia and phenylephrine on brain tissue oxygen tension (PbtO2 ) in patients undergoing craniotomy. METHODS In this experimental study, we included 17 adult patients scheduled for elective craniotomy. After securing a stable baseline of the oxygen probe, PbtO2 was measured in white matter peripherally in the surgical field during general anaesthesia. Primary comparisons were PbtO2 before versus after an increase in FiO2 from 0.30 to 0.80 as well as before versus after a bolus dose of phenylephrine (0.1-0.2 mg depending on patient haemodynamics). Data were analysed with the Wilcoxon signed rank test. RESULTS We obtained complete data sets in 11 patients undergoing the FiO2 increase and six patients receiving the phenylephrine bolus. PbtO2 was 22 (median; 5%-95% range, 4.6-54) mmHg during 30% oxygen, 68 (8.4-99) mmHg during 80% oxygen (p = .004 compared to 30% oxygen), 21 (4.5-81) mmHg before phenylephrine, and 19 (4.2-56) mmHg after phenylephrine (p = .56 compared to before phenylephrine). CONCLUSION In patients undergoing craniotomy under general anaesthesia, brain tissue oxygen tension increased with a high inspiratory oxygen fraction but remained unchanged after a bolus dose of phenylephrine.
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Affiliation(s)
- Sofie S Pedersen
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark.,Copenhagen Center for Translational Research, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Christian S Meyhoff
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark.,Copenhagen Center for Translational Research, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Markus Harboe Olsen
- Department of Neuroanaesthesiology, The Neuroscience Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Zara R Stisen
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark.,Copenhagen Center for Translational Research, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Anton Lund
- Department of Neuroanaesthesiology, The Neuroscience Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Kirsten Møller
- Department of Neuroanaesthesiology, The Neuroscience Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jane Skjøth-Rasmussen
- Department of Neurosurgery, The Neuroscience Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Finn B Moltke
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Martin Kryspin Sørensen
- Department of Neuroanaesthesiology, The Neuroscience Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
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Høybye M, Lind PC, Holmberg MJ, Bolther M, Jessen MK, Vallentin MF, Hansen FB, Holst JM, Magnussen A, Hansen NS, Johannsen CM, Enevoldsen J, Jensen TH, Roessler LL, Klitholm MP, Eggertsen MA, Caap P, Boye C, Dabrowski KM, Vormfenne L, Henriksen J, Karlsson CM, Balleby IR, Rasmussen MS, Paelestik K, Granfeldt A, Andersen LW. Fraction of Inspired Oxygen During General Anesthesia for Non-Cardiac Surgery: Systematic Review and Meta-Analysis. Acta Anaesthesiol Scand 2022; 66:923-933. [PMID: 35675085 PMCID: PMC9543529 DOI: 10.1111/aas.14102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 05/19/2022] [Accepted: 05/28/2022] [Indexed: 12/02/2022]
Abstract
Background Controversy exists regarding the effects of a high versus a low intraoperative fraction of inspired oxygen (FiO2) in adults undergoing general anesthesia. This systematic review and meta‐analysis investigated the effect of a high versus a low FiO2 on postoperative outcomes. Methods PubMed and Embase were searched on March 22, 2022 for randomized clinical trials investigating the effect of different FiO2 levels in adults undergoing general anesthesia for non‐cardiac surgery. Two investigators independently reviewed studies for relevance, extracted data, and assessed risk of bias. Meta‐analyses were performed for relevant outcomes, and potential effect measure modification was assessed in subgroup analyses and meta‐regression. The evidence certainty was evaluated using GRADE. Results This review included 25 original trials investigating the effect of a high (mostly 80%) versus a low (mostly 30%) FiO2. Risk of bias was intermediate for all trials. A high FiO2 did not result in a significant reduction in surgical site infections (OR: 0.91, 95% CI 0.81–1.02 [p = .10]). No effect was found for all other included outcomes, including mortality (OR = 1.27, 95% CI: 0.90–1.79 [p = .18]) and hospital length of stay (mean difference = 0.03 days, 95% CI −0.25 to 0.30 [p = .84). Results from subgroup analyses and meta‐regression did not identify any clear effect modifiers across outcomes. The certainty of evidence (GRADE) was rated as low for most outcomes. Conclusions In adults undergoing general anesthesia for non‐cardiac surgery, a high FiO2 did not improve outcomes including surgical site infections, length of stay, or mortality. However, the certainty of the evidence was assessed as low.
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Affiliation(s)
- Maria Høybye
- Research Center for Emergency Medicine, Aarhus University Hospital, Denmark.,Department of Clinical Medicine, Aarhus University, Denmark
| | - Peter Carøe Lind
- Department of Surgical Gastroenterology, Aalborg University Hospital, Denmark
| | - Mathias J Holmberg
- Research Center for Emergency Medicine, Aarhus University Hospital, Denmark.,Department of Clinical Medicine, Aarhus University, Denmark.,Department of Cardiology, Viborg Regional Hospital, Viborg, Denmark
| | - Maria Bolther
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Denmark
| | - Marie K Jessen
- Research Center for Emergency Medicine, Aarhus University Hospital, Denmark.,Department of Clinical Medicine, Aarhus University, Denmark
| | - Mikael F Vallentin
- Department of Clinical Medicine, Aarhus University, Denmark.,Prehospital Emergency Medical Services, Central Denmark Region, Aarhus, Denmark
| | | | - Johanne M Holst
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Denmark
| | | | - Niklas S Hansen
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Denmark
| | | | | | - Thomas H Jensen
- Department of Internal Medicine, University Hospital of North Norway, Narvik, Norway
| | - Lara L Roessler
- Department of Emergency Medicine, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Maibritt P Klitholm
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Denmark
| | | | - Philip Caap
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Denmark
| | - Caroline Boye
- Department of Clinical Medicine, Aarhus University, Denmark
| | - Karol M Dabrowski
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Denmark
| | | | - Jeppe Henriksen
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Denmark
| | - C M Karlsson
- Department of Anesthesiology and Intensive Care, Aalborg University Hospital, Denmark
| | - Ida R Balleby
- National Hospital of the Faroe Islands, Torshavn, Faroe Islands
| | - Marie S Rasmussen
- Department of Anesthesiology and Intensive Care, Aalborg University Hospital, Denmark
| | - Kim Paelestik
- Department of Anesthesiology and Intensive Care, Viborg Regional Hospital, Viborg, Denmark
| | - Asger Granfeldt
- Department of Clinical Medicine, Aarhus University, Denmark.,Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Denmark
| | - Lars W Andersen
- Research Center for Emergency Medicine, Aarhus University Hospital, Denmark.,Department of Clinical Medicine, Aarhus University, Denmark.,Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Denmark.,Prehospital Emergency Medical Services, Central Denmark Region, Aarhus, Denmark
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Farag E, Liang C, Mascha EJ, Toth G, Argalious M, Manlapaz M, Gomes J, Ebrahim Z, Hussain MS. Oxygen Saturation and Postoperative Mortality in Patients With Acute Ischemic Stroke Treated by Endovascular Thrombectomy. Anesth Analg 2021; 134:369-379. [PMID: 34609988 DOI: 10.1213/ane.0000000000005763] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Monitored anesthesia care (MAC) and general anesthesia (GA) with endotracheal intubation are the 2 most used techniques for patients with acute ischemic stroke (AIS) undergoing endovascular thrombectomy. We aimed to test the hypothesis that increased arterial oxygen concentration during reperfusion period is a mechanism underlying the association between use of GA (versus MAC) and increased risk of in-hospital mortality. METHODS In this retrospective cohort study, data were collected at the Cleveland Clinic between 2013 and 2018. To assess the potential mediation effect of time-weighted average oxygen saturation (Spo2) in first postoperative 48 hours between the association between GA versus MAC and in-hospital mortality, we assessed the association between anesthesia type and post-operative Spo2 tertiles (exposure-mediator relationship) through a cumulative logistic regression model and assessed the association between Spo2 and in-hospital mortality (mediator-outcome relationship) using logistic regression models. Confounding factors were adjusted for using propensity score methods. Both significant exposure-mediator and significant mediator-outcome relationships are needed to suggest potential mediation effect. RESULTS Among 358 patients included in the study, 104 (29%) patients received GA and 254 (71%) received MAC, with respective hospital mortality rate of 19% and 5% (unadjusted P value <.001). GA patients were 1.6 (1.2, 2.1) (P < .001) times more likely to have a higher Spo2 tertile as compared to MAC patients. Patients with higher Spo2 tertile had 3.8 (2.1, 6.9) times higher odds of mortality than patients with middle Spo2 tertile, while patients in the lower Spo2 tertile did not have significant higher odds compared to the middle tertile odds ratio (OR) (1.8 [0.9, 3.4]; overall P < .001). The significant exposure-mediator and mediator-outcome relationships suggest that Spo2 may be a mediator of the relationship between anesthetic method and mortality. However, the estimated direct effect of GA versus MAC on mortality (ie, after adjusting for Spo2; OR [95% confidence interval {CI}] of 2.1 [0.9-4.9]) was close to the estimated association ignoring Spo2 (OR [95% CI] of 2.2 [1.0-5.1]), neither statistically significant, suggesting that Spo2 had at most a modest mediator role. CONCLUSIONS GA was associated with a higher Spo2 compared to MAC among those treated by endovascular thrombectomy for AIS. Spo2 values that were higher than the middle tertile were associated with higher odds of mortality. However, GA was not significantly associated with higher odds of death. Spo2 at most constituted a modest mediator role in explaining the relationship between GA versus MAC and mortality.
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Affiliation(s)
- Ehab Farag
- From the Department of General Anesthesia.,Department of Outcomes Research, Anesthesiology & Pain Management Institute
| | - Chen Liang
- Department of Outcomes Research, Anesthesiology & Pain Management Institute.,Department of Quantitative Health Sciences, Lerner Research Institute
| | - Edward J Mascha
- Department of Outcomes Research, Anesthesiology & Pain Management Institute.,Department of Quantitative Health Sciences, Lerner Research Institute
| | - Gabor Toth
- Department of Neurointerventional Radiology
| | | | | | - Joao Gomes
- Department of Neurology, Neurological Institute, The Cleveland Clinic, Cleveland, Ohio
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Ristescu AI, Tiron CE, Tiron A, Grigoras I. Exploring Hyperoxia Effects in Cancer-From Perioperative Clinical Data to Potential Molecular Mechanisms. Biomedicines 2021; 9:1213. [PMID: 34572400 PMCID: PMC8470547 DOI: 10.3390/biomedicines9091213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 09/06/2021] [Accepted: 09/10/2021] [Indexed: 12/15/2022] Open
Abstract
Increased inspiratory oxygen concentration is constantly used during the perioperative period of cancer patients to prevent the potential development of hypoxemia and to provide an adequate oxygen transport to the organs, tissues and cells. Although the primary tumours are surgically removed, the effects of perioperative hyperoxia exposure on distal micro-metastases and on circulating cancer cells can potentially play a role in cancer progression or recurrence. In clinical trials, hyperoxia seems to increase the rate of postoperative complications and, by delaying postoperative recovery, it can alter the return to intended oncological treatment. The effects of supplemental oxygen on the long-term mortality of surgical cancer patients offer, at this point, conflicting results. In experimental studies, hyperoxia effects on cancer biology were explored following multiple pathways. In cancer cell cultures and animal models, hyperoxia increases the production of reactive oxygen species (ROS) and increases the oxidative stress. These can be followed by the induction of the expression of Brain-derived neurotrophic factor (BDNF) and other molecules involved in angiogenesis and by the promotion of various degrees of epithelial mesenchymal transition (EMT).
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Affiliation(s)
- Anca Irina Ristescu
- Department of Anaesthesia and Intensive Care, School of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (A.I.R.); (I.G.)
- Department of Anaesthesia and Intensive Care, Regional Institute of Oncology, 700483 Iasi, Romania
| | - Crina Elena Tiron
- TRANSCEND Research Centre, Regional Institute of Oncology, 700483 Iasi, Romania;
| | - Adrian Tiron
- TRANSCEND Research Centre, Regional Institute of Oncology, 700483 Iasi, Romania;
| | - Ioana Grigoras
- Department of Anaesthesia and Intensive Care, School of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (A.I.R.); (I.G.)
- Department of Anaesthesia and Intensive Care, Regional Institute of Oncology, 700483 Iasi, Romania
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Perioperative Hyperoxyphobia: Justified or Not? Benefits and Harms of Hyperoxia during Surgery. J Clin Med 2020; 9:jcm9030642. [PMID: 32121051 PMCID: PMC7141263 DOI: 10.3390/jcm9030642] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 02/18/2020] [Accepted: 02/26/2020] [Indexed: 12/12/2022] Open
Abstract
The use of an inspiratory oxygen fraction of 0.80 during surgery is a topic of ongoing debate. Opponents claim that increased oxidative stress, atelectasis, and impaired oxygen delivery due to hyperoxic vasoconstriction are detrimental. Proponents point to the beneficial effects on the incidence of surgical site infections and postoperative nausea and vomiting. Also, hyperoxygenation is thought to extend the safety margin in case of acute intraoperative emergencies. This review provides a comprehensive risk-benefit analysis for the use of perioperative hyperoxia in noncritically ill adults based on clinical evidence and supported by physiological deduction where needed. Data from the field of hyperbaric medicine, as a model of extreme hyperoxygenation, are extrapolated to the perioperative setting. We ultimately conclude that current evidence is in favour of hyperoxia in noncritically ill intubated adult surgical patients.
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Abstract
PURPOSE OF REVIEW The topic of perioperative hyperoxia remains controversial, with valid arguments on both the 'pro' and 'con' side. On the 'pro' side, the prevention of surgical site infections was a strong argument, leading to the recommendation of the use of hyperoxia in the guidelines of the Center for Disease Control and the WHO. On the 'con' side, the pathophysiology of hyperoxia has increasingly been acknowledged, in particular the pulmonary side effects and aggravation of ischaemia/reperfusion injuries. RECENT FINDINGS Some 'pro' articles leading to the Center for Disease Control and WHO guidelines advocating perioperative hyperoxia have been retracted, and the recommendations were downgraded from 'strong' to 'conditional'. At the same time, evidence that supports a tailored, more restrictive use of oxygen, for example, in patients with myocardial infarction or following cardiac arrest, is accumulating. SUMMARY The change in recommendation exemplifies that despite much work performed on the field of hyperoxia recently, evidence on either side of the argument remains weak. Outcome-based research is needed for reaching a definite recommendation.
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