Anaesthesia for elite athletes

BACKGROUND

Sports participation has been growing rapidly since the 1960s. Anaesthesiologists are increasingly confronted with athletes in a peri-operative setting. The right choice of type of anaesthesia technique, pain management of injuries, specific physiologic adaptations of the athlete and knowledge of prohibited substances are eminent for a correct approach of this subpopulation.

PURPOSE

This review aims to give an overview of athletes' specific anaesthetic management in peri-operative and postoperative settings and to guide the nonspecialised anaesthetist.

METHODS

We comprehensively reviewed the literature, gathered all the information available on, and synthesised it in a narrative way, regarding preoperative evaluation, intraoperative implications and postoperative pain management of the elite athlete undergoing a surgical procedure.

RESULTS

An anaesthesiologist should recognise the most common benign ECG findings in athletes like bradycardia, isolated left ventricle hypertrophy on voltage criteria and early repolarisation as normal features in the athlete's heart. Isotonic physiology typically produces four-chamber dilation. In contrast, isometric stress creates high intravascular pressure leading to left ventricular hypertrophy. Pre-operative evaluation should also identify possible consumers of performance-enhancing drugs. Intraoperative points of interest for the anaesthesiologist is mainly avoiding drugs on the prohibited list of the World Anti-Doping Agency (WADA). Postoperative and chronic pain management are still developing fields in this population. The International Olympic Committee (IOC) proposed treating acute pain with a combination of paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), topical analgesics, injectable NSAIDs and local anaesthetics. It may be suggested that chronic pain management in elite athletes could benefit from treatment in specialised multidisciplinary pain clinics.

CONCLUSION

This literature review aims to serve as a guide for the anaesthesiologist taking care of the elite athlete.

Aging exacerbates impairments of cerebral blood flow autoregulation and cognition in diabetic rats

Diabetes mellitus (DM) is a leading risk factor for aging-related dementia; however, the underlying mechanisms are not well understood. The present study, utilizing a non-obese T2DN diabetic model, demonstrates that the myogenic response of the middle cerebral artery (MCA) and parenchymal arteriole (PA) and autoregulation of cerebral blood flow (CBF) in the surface and deep cortex were impaired at both young and old ages. The impaired CBF autoregulation was more severe in old than young DM rats, and in the deep than the surface cortex. The myogenic tone of the MCA was enhanced at perfusion pressure in the range of 40-100 mmHg in young DM rats but was reduced at 140-180 mmHg in old DM rats. No change of the myogenic tone of the PA was observed in young DM rats, whereas it was significantly reduced at 30-60 mmHg in old DM rats. Old DM rats had enhanced blood-brain barrier (BBB) leakage and neurodegeneration, reduced vascular density, tight junction, and pericyte coverage on cerebral capillaries in the CA3 region in the hippocampus. Additionally, DM rats displayed impaired functional hyperemia and spatial learning and short- and long-term memory at both young and old ages. Old DM rats had impaired non-spatial short-term memory. These results revealed that impaired CBF autoregulation and enhanced BBB leakage plays an essential role in the pathogenesis of age- and diabetes-related dementia. These findings will lay the foundations for the discovery of anti-diabetic therapies targeting restoring CBF autoregulation to prevent the onset and progression of dementia in elderly DM.

Dynamic cerebral autoregulation in anterior and posterior cerebral circulation during cold pressor test

We hypothesized that cerebral blood flow (CBF) regulation in the posterior circulation differs from that of the anterior circulation during a cold pressor test (CPT) and is accompanied by elevations in arterial blood pressure (ABP) and sympathetic nervous activity (SNA). To test this, dynamic cerebral autoregulation (dCA) in the middle and posterior cerebral arteries (MCA and PCA) were measured at three different conditions: control, early phase of the CPT, and the late phase of the CPT. The dCA was examined using a thigh cuff occlusion and release technique. The MCA and PCA blood velocities were unchanged at CPT compared with the control conditions despite an elevation in the ABP. The dCA in both the MCA and PCA remained unaltered at CPT. These findings suggest that CPT-induced elevations in the ABP and SNA did not cause changes in the CBF regulation in the posterior circulation compared with the anterior circulation.

Systematic review of intra-abdominal and intrathoracic pressures initiated by the Valsalva manoeuvre during high-intensity resistance exercises

The Valsalva manoeuvre, intra-abdominal pressure (IAP) and intrathoracic pressure (ITP) play important roles in resistance training and common daily activities. The purpose of this review is to summarize the ITP and IAP responses to resistance exercises and to determine which exercises elicit the highest or lowest body pressure values under high-intensity resistance exercise. The PubMed, Scopus and Web of Science databases were searched until November 1, 2018. A combination of the following search terms was used: Valsalva manoeuvre, hold breath, controlled breathing, controlled breath, abdominal pressure, intrathoracic pressure AND weight training, resistance exercise, power lifting. The search process yielded 1125 studies, of which 16 were accepted according to the selection criteria and methodological quality. The highest IAP was recorded during squats (over 200 mmHg) followed by deadlift, slide row and leg press (161–176 mmHg), and the lowest IAP was found during bench press (79±44 mmHg). The highest ITP was elicited by the leg press, deadlift and box lift (105–130 mmHg), which were higher than during the bench press (95±37 mmHg) and slide row (88±32 mmHg). We recommend the bench press and slide row as exercises useful for beginners and individuals with hypertension. Untrained individuals should not use heavy squats, deadlift, box lift and clean exercises until they have undergone progressive adaptation for lifting high loads resulting in high IAP and ITP. The values of IAP and ITP during high-intensity exercise seem to be determined mutually by the position of the human body and the external load.

Astrocytes and radial glia-like cells, but not neurons, display a nonapoptotic increase in caspase-3 expression following exercise

BACKGROUND

Exercise induces plasticity in the hippocampus, which includes increases in neurogenesis, the proliferation of new neurons, and angiogenesis, the sprouting of new capillaries from preexisting blood vessels. Following exercise, astrocytes also undergo morphological changes that parallel the events occurring in the neurovascular system. Interestingly, there have also been reports of apoptosis in the hippocampus following aerobic exercise. This experiment aimed to identify which population of hippocampal cells undergoes apoptosis after an acute bout of exercise.

METHODS

Cleaved caspase-3, a terminal protein in the apoptotic cascade, was initially used to identify apoptotic cells in the hippocampus after rats completed an acute bout of exercise. Next, the proportion of immature neurons, adult neurons, astrocytes, or radial glia-like cells expressing cleaved caspase-3 was quantified. TUNEL staining was completed as a second measure of apoptosis.

RESULTS

Following exercise, cleaved caspase-3 expression was increased in the CA1 and DG regions of the hippocampus. Cleaved caspase-3 was not highly expressed in neuronal populations, and expression was not increased in these cells postexercise. Instead, cleaved caspase-3 was predominantly expressed in astrocytes. Following exercise, there was an increased number of cleaved caspase-3 positive astrocytes in DG and CA1, and cleaved caspase-3 positive radial glia-like cells located in the subgranular zone. To determine whether cleaved caspase-3 expression in these glial cells was associated with apoptosis, a TUNEL assay was completed. TUNEL staining was negligible in all groups and did not mirror the pattern of caspase-3 labeling.

CONCLUSIONS

Cleaved caspase-3 expression was detected largely in non-neuronal cell populations, and the pattern of cleaved caspase-3 expression did not match that of TUNEL. This suggests that after exercise, cleaved caspase-3 expression may serve a nonapoptotic role in these hippocampal astrocytes and radial glia-like cells. It will be important to identify the function of exercise-induced cleaved caspase-3 expression in the future experiments.

An acute bout of localized resistance exercise can rapidly improve inhibitory control

The positive effect of acute resistance exercise on executive function, such as inhibitory control (IC), is poorly understood. Several previous studies have demonstrated this effect using whole-body resistance exercise. However, it remains unclear whether localized resistance exercise performed using only limited muscle groups could also acutely improve IC. Thus, the present study examined the effect of an acute bout of localized resistance exercise on IC. Twelve healthy men performed a color-word Stroop task (CWST) before and immediately after the experimental conditions, which consisted of 2 resistance exercises and a resting control (CON). Bilateral knee extension was used to create 2 resistance exercise conditions: light-intensity resistance exercise (LRE) and high-intensity resistance exercise (HRE) conditions, which were 40% and 80% of one-repetition maximum, respectively. The resistance exercise session was programmed for 6 sets with 10 repetitions per set. The CWST-measured IC was significantly improved immediately after both LRE and HRE, but it did not improve immediately after CON. However, the improved IC was significantly greater in HRE than in LRE. The present findings showed that IC could be rapidly improved by an acute bout of localized resistance exercise, especially with high-intensity. Therefore, we suggest that in addition to whole-body resistance exercise, localized resistance exercise performed using limited muscle groups may be sufficient for improving IC.

Argon does not affect cerebral circulation or metabolism in male humans

OBJECTIVE

Accumulating data have recently underlined argon´s neuroprotective potential. However, to the best of our knowledge, no data are available on the cerebrovascular effects of argon (Ar) in humans. We hypothesized that argon inhalation does not affect mean blood flow velocity of the middle cerebral artery (Vmca), cerebral flow index (FI), zero flow pressure (ZFP), effective cerebral perfusion pressure (CPPe), resistance area product (RAP) and the arterio-jugular venous content differences of oxygen (AJVDO2), glucose (AJVDG), and lactate (AJVDL) in anesthetized patients.

MATERIALS AND METHODS

In a secondary analysis of an earlier controlled cross-over trial we compared parameters of the cerebral circulation under 15 minutes exposure to 70%Ar/30%O2 versus 70%N2/30%O2 in 29 male patients under fentanyl-midazolam anaesthesia before coronary surgery. Vmca was measured by transcranial Doppler sonography. ZFP and RAP were estimated by linear regression analysis of pressure-flow velocity relationships of the middle cerebral artery. CPPe was calculated as the difference between mean arterial pressure and ZFP. AJVDO2, AJVDG and AJVDL were calculated as the differences in contents between arterial and jugular-venous blood of oxygen, glucose, and lactate. Statistical analysis was done by t-tests and ANOVA.

RESULTS

Mechanical ventilation with 70% Ar did not cause any significant changes in mean arterial pressure, Vmca, FI, ZFP, CPPe, RAP, AJVDO2, AJVDG, and AJVDL.

DISCUSSION

Short-term inhalation of 70% Ar does not affect global cerebral circulation or metabolism in male humans under general anaesthesia.

Carbon dioxide induced changes in cerebral blood flow and flow velocity: role of cerebrovascular resistance and effective cerebral perfusion pressure

In addition to cerebrovascular resistance (CVR) zero flow pressure (ZFP), effective cerebral perfusion pressure (CPPe) and the resistance area product (RAP) are supplemental determinants of cerebral blood flow (CBF). Until now, the interrelationship of PaCO2-induced changes in CBF, CVR, CPPe, ZFP, and RAP is not fully understood. In a controlled crossover trial, we investigated 10 anesthetized patients aiming at PaCO2 levels of 30, 37, 43, and 50 mm Hg. Cerebral blood flow was measured with a modified Kety-Schmidt-technique. Zero flow pressure and RAP was estimated by linear regression analysis of pressure-flow velocity relationships of the middle cerebral artery. Effective cerebral perfusion pressure was calculated as the difference between mean arterial pressure and ZFP, CVR as the ratio CPPe/CBF. Statistical analysis was performed by one-way RM-ANOVA. When comparing hypocapnia with hypercapnia, CBF showed a significant exponential reduction by 55% and mean VMCA by 41%. Effective cerebral perfusion pressure linearly decreased by 17% while ZFP increased from 14 to 29 mm Hg. Cerebrovascular resistance increased by 96% and RAP by 39%; despite these concordant changes in mean CVR and Doppler-derived RAP correlation between these variables was weak (r=0.43). In conclusion, under general anesthesia hypocapnia-induced reduction in CBF is caused by both an increase in CVR and a decrease in CPPe, as a consequence of an increase in ZFP.

Peripheral circulation

Blood flow (BF) increases with increasing exercise intensity in skeletal, respiratory, and cardiac muscle. In humans during maximal exercise intensities, 85% to 90% of total cardiac output is distributed to skeletal and cardiac muscle. During exercise BF increases modestly and heterogeneously to brain and decreases in gastrointestinal, reproductive, and renal tissues and shows little to no change in skin. If the duration of exercise is sufficient to increase body/core temperature, skin BF is also increased in humans. Because blood pressure changes little during exercise, changes in distribution of BF with incremental exercise result from changes in vascular conductance. These changes in distribution of BF throughout the body contribute to decreases in mixed venous oxygen content, serve to supply adequate oxygen to the active skeletal muscles, and support metabolism of other tissues while maintaining homeostasis. This review discusses the response of the peripheral circulation of humans to acute and chronic dynamic exercise and mechanisms responsible for these responses. This is accomplished in the context of leading the reader on a tour through the peripheral circulation during dynamic exercise. During this tour, we consider what is known about how each vascular bed controls BF during exercise and how these control mechanisms are modified by chronic physical activity/exercise training. The tour ends by comparing responses of the systemic circulation to those of the pulmonary circulation relative to the effects of exercise on the regional distribution of BF and mechanisms responsible for control of resistance/conductance in the systemic and pulmonary circulations.

Dynamic cerebral autoregulation changes during sub-maximal handgrip maneuver

Purpose

We investigated the effect of handgrip (HG) maneuver on time-varying estimates of dynamic cerebral autoregulation (CA) using the autoregressive moving average technique.

Methods

Twelve healthy subjects were recruited to perform HG maneuver during 3 minutes with 30% of maximum contraction force. Cerebral blood flow velocity, end-tidal CO₂ pressure (PETCO₂), and noninvasive arterial blood pressure (ABP) were continuously recorded during baseline, HG and recovery. Critical closing pressure (CrCP), resistance area-product (RAP), and time-varying autoregulation index (ARI) were obtained.

Results

PETCO₂ did not show significant changes during HG maneuver. Whilst ABP increased continuously during the maneuver, to 27% above its baseline value, CBFV raised to a plateau approximately 15% above baseline. This was sustained by a parallel increase in RAP, suggestive of myogenic vasoconstriction, and a reduction in CrCP that could be associated with metabolic vasodilation. The time-varying ARI index dropped at the beginning and end of the maneuver (p<0.005), which could be related to corresponding alert reactions or to different time constants of the myogenic, metabolic and/or neurogenic mechanisms.

Conclusion

Changes in dynamic CA during HG suggest a complex interplay of regulatory mechanisms during static exercise that should be considered when assessing the determinants of cerebral blood flow and metabolism.

Cerebral critical closing pressure and CO2 responses during the progression toward syncope

Syncope from sustained orthostasis results from cerebral hypoperfusion associated with reductions in arterial pressure at the level of the brain (BPMCA) and reductions in arterial CO2 as reflected by end-tidal values (PetCO2). It was hypothesized that reductions in PetCO2 increase cerebrovascular tone before a drop in BPMCA that ultimately leads to syncope. Twelve men (21–42 yr of age) completed an orthostatic tolerance test consisting of head-up tilt and progressive lower body negative pressure to presyncope, before and after completing 5 days of continuous head-down bed rest (HDBR). Cerebral blood velocity (CBFV), BPMCA, and PetCO2 were continuously recorded throughout the test. Cerebrovascular indicators, cerebrovascular resistance, critical closing pressure (CrCP), and resistance area product (RAP), were calculated. Comparing from supine baseline to 6–10 min after the start of tilt, there were reductions in CBFV, PetCO2, BPMCA, and CrCP, an increase in RAP, and no change in cerebrovascular resistance index. Over the final 15 min before syncope in the pre-HDBR tests, CBFV and CrCP were significantly related to changes in PetCO2 ( r = 0.69 ± 0.17 and r = 0.63 ± 0.20, respectively), and BPMCA, which was not reduced until the last minute of the test, was correlated with a reduction in RAP ( r = 0.91 ± 0.09). Post-HDBR, tilt tolerance was markedly reduced, and changes in CBFV were dominated by a greater reduction in BPMCA with no relationships to PetCO2. Therefore, pre-HDBR, changes in PetCO2 with orthostasis contributed to increases in cerebrovascular tone and reductions in CBFV during the progression toward syncope, whereas, after 5 days of HDBR, orthostatic responses were dominated by changes in BPMCA.

The functional role of the alpha-1 adrenergic receptors in cerebral blood flow regulation

Cerebral vasculature is richly innervated by the α-1 adrenergic receptors similar to that of the peripheral vasculature. However, the functional role of the α-1adrenergic receptors in cerebral blood flow (CBF) regulation is yet to be established. The traditional thinking being that during normotension and normocapnia sympathetic neural activity does not play a significant role in CBF regulation. Reports in the past have stated that catecholamines do not penetrate the blood brain barrier (BBB) and therefore only influence cerebral vessels from outside the BBB and hence, have a limited role in CBF regulation. However, with the advent of dynamic measurement techniques, beat-to-beat CBF assessment can be done during dynamic changes in arterial blood pressure. Several studies in the recent years have reported a functional role of the α-1adrenergic receptors in CBF regulation. This review focuses on the recent developments on the role of the sympathetic nervous system, specifically that of the α-1 adrenergic receptors in CBF regulation.

Sympathetic influence on cerebral blood flow and metabolism during exercise in humans

This review focuses on the possibility that autonomic activity influences cerebral blood flow (CBF) and metabolism during exercise in humans. Apart from cerebral autoregulation, the arterial carbon dioxide tension, and neuronal activation, it may be that the autonomic nervous system influences CBF as evidenced by pharmacological manipulation of adrenergic and cholinergic receptors. Cholinergic blockade by glycopyrrolate blocks the exercise-induced increase in the transcranial Doppler determined mean flow velocity (MCA Vmean). Conversely, alpha-adrenergic activation increases that expression of cerebral perfusion and reduces the near-infrared determined cerebral oxygenation at rest, but not during exercise associated with an increased cerebral metabolic rate for oxygen (CMRO(2)), suggesting competition between CMRO(2) and sympathetic control of CBF. CMRO(2) does not change during even intense handgrip, but increases during cycling exercise. The increase in CMRO(2) is unaffected by beta-adrenergic blockade even though CBF is reduced suggesting that cerebral oxygenation becomes critical and a limited cerebral mitochondrial oxygen tension may induce fatigue. Also, sympathetic activity may drive cerebral non-oxidative carbohydrate uptake during exercise. Adrenaline appears to accelerate cerebral glycolysis through a beta2-adrenergic receptor mechanism since noradrenaline is without such an effect. In addition, the exercise-induced cerebral non-oxidative carbohydrate uptake is blocked by combined beta 1/2-adrenergic blockade, but not by beta1-adrenergic blockade. Furthermore, endurance training appears to lower the cerebral non-oxidative carbohydrate uptake and preserve cerebral oxygenation during submaximal exercise. This is possibly related to an attenuated catecholamine response. Finally, exercise promotes brain health as evidenced by increased release of brain-derived neurotrophic factor (BDNF) from the brain.

Cerebral autoregulation dynamics in endurance-trained individuals

Aerobic fitness may be associated with reduced orthostatic tolerance. To investigate whether trained individuals have less effective regulation of cerebral vascular resistance, we studied the middle cerebral artery (MCA) mean blood velocity ( Vmean) response to a sudden drop in mean arterial pressure (MAP) after 2.5 min of leg ischemia in endurance athletes and untrained subjects (maximal O2 uptake: 69 ± 7 vs. 42 ± 5 ml O2·min−1·kg−1; n = 9 for both, means ± SE). After cuff release when seated, endurance athletes had larger drops in MAP (94 ± 6 to 62 ± 5 mmHg, −39%, vs. 99 ± 5 to 73 ± 4 mmHg, −26%) and MCA Vmean (53 ± 3 to 37 ± 2 cm/s, −30%, vs. 58 ± 3 to 43 ± 2 cm/s, −25%). The athletes also had a slower recovery to baseline of both MAP (25 ± 2 vs. 16 ± 1 s, P < 0.01) and MCA Vmean (15 ± 1 vs. 11 ± 1 s, P < 0.05). The onset of autoregulation, determined by the time point of increase in the cerebrovascular conductance index (CVCi = MCA Vmean/MAP) appeared later in the athletes (3.9 ± 0.4 vs. 2.7 ± 0.4s, P = 0.01). Spectral analysis revealed a normal MAP-to-MCA Vmean phase in both groups but ∼40% higher normalized MAP to MCA Vmean low-frequency transfer function gain in the trained subjects. No significant differences were detected in the rates of recovery of MAP and MCA Vmean and the rate of CVCi regulation (18 ± 4 vs. 24 ± 7%/s, P = 0.2). In highly trained endurance athletes, a drop in blood pressure after the release of resting leg ischemia was more pronounced than in untrained subjects and was associated with parallel changes in indexes of cerebral blood flow. Once initiated, the autoregulatory response was similar between the groups. A delayed onset of autoregulation with a larger normalized transfer gain conforms with a less effective dampening of MAP oscillations, indicating that athletes may be more prone to instances of symptomatic cerebral hypoperfusion when MAP declines.

The influence of calculation method on estimates of cerebral critical closing pressure

The critical closing pressure (CrCP) of cerebral circulation is normally estimated by extrapolation of instantaneous velocity-pressure curves. Different methods of estimation were analysed to assess their robustness and reproducibility in both static and dynamic applications. In ten healthy subjects (mean ± SD age 37.5 ± 9.2 years) continuous recordings of arterial blood pressure (BP, Finapres) and bilateral cerebral blood flow velocity (transcranial Doppler ultrasound, middle cerebral arteries) were obtained at rest. Each session consisted of three separate 5 min recordings. A total of four recording sessions for each subject took place over a 2 week period. A total of 117 recordings contained 34 014 cardiac cycles. For each cardiac cycle, CrCP and resistance-area product (RAP) were estimated using linear regression (LR), principal component analysis (PCA), first harmonic fitting (H1), 2-point systolic/diastolic values (2Ps) and 2-point mean/diastolic values (2Pm). LR and PCA were also applied using only the diastolic phase (LRd, PCAd). The mean values of CrCP and RAP for the entire 5 min recording ('static' condition) were not significantly different for LRd, PCAd, H1 and 2Pm, as opposed to the other methods. The same four methods provided the best results regarding the absence of negative values of CrCP and the coefficient of variation (CV) of the intra-subject standard error of the mean (SEM). On the other hand, 'dynamic' applications, such as the transfer function between mean BP and RAP (coherence and RAP step response) led to a different ranking of methods, but without significant differences in CV SEM coherence. For the CV of the RAP step response though, LRd and PCAd performed badly. These results suggest that H1 or 2Pm perform better than LR analysis and should be used for the estimation of CrCP and RAP for both static and dynamic applications.

Utility of transcranial Doppler ultrasound for the integrative assessment of cerebrovascular function

There is considerable utility in the use of transcranial Doppler ultrasound (TCD) to assess cerebrovascular function. The brain is unique in its high energy and oxygen demand but limited capacity for energy storage that necessitates an effective means of regional blood delivery. The relative low cost, ease-of-use, non-invasiveness, and excellent temporal resolution of TCD make it an ideal tool for the examination of cerebrovascular function in both research and clinical settings. TCD is an efficient tool to access blood velocities within the cerebral vessels, cerebral autoregulation, cerebrovascular reactivity to CO(2), and neurovascular coupling, in both physiological states and in pathological conditions such as stroke and head trauma. In this review, we provide: (1) an overview of TCD methodology with respect to other techniques; (2) a methodological synopsis of the cerebrovascular exam using TCD; (3) an overview of the physiological mechanisms involved in regulation of the cerebral blood flow; (4) the utility of TCD for assessment of cerebrovascular pathology; and (5) recommendations for the assessment of four critical and complimentary aspects of cerebrovascular function: intra-cranial blood flow velocity, cerebral autoregulation, cerebral reactivity, and neurovascular coupling. The integration of these regulatory mechanisms from an integrated systems perspective is discussed, and future research directions are explored.