Salivary cortisol levels and anxiety in melanoma patients undergoing sentinel lymph node excision under local anesthesia versus general anesthesia: a prospective study

Influence of nerve block combined with general anesthesia on cognitive function and postoperative pain in patients undergoing knee joint replacement

OBJECTIVE

To investigate the influence of nerve block combined with general anesthesia on the cognitive function and postoperative pain of patients undergoing knee joint replacement and analyze the risk factors of postoperative cognitive dysfunction.

METHODS

A retrospective analysis was conducted on 104 elderly patients undergoing knee joint replacement in our hospital between January 2018 and January 2021. The control group (n=50) received laryngeal mask anesthesia, while the observation group (n=54) received ultrasound-guided nerve block combined with laryngeal mask anesthesia. The visual analogue scale (VAS) was adopted for scoring the pain intensity of both groups, and the Mini-Mental State Examination (MMSE) was used for evaluating changes in cognitive function before and after operation. The self-rating anxiety scale (SAS) and self-rating depression scale (SDS) were adopted for scoring patientsbefore and after operation. Additionally, the time to spontaneous breathing recovery, time to wake up, time to open eyes when ordered, and extubation time of the two groups were recorded. The changes in serum IL-6, cortisol (Cor), and IL-10 before and after operation were compared. The two groups were compared in the dosage of used analgesic drugs, the first getting out-of-bed time, treatment expense, and hospitalization time. The correlation between VAS score and IL-6, Cor and IL-10 before and after treatment was analyzed. The adverse reactions of the two groups were also compared. Logistic regression was used to analyze risk factors for cognitive dysfunction.

RESULTS

After operation, the observation group experienced shorter spontaneous breathing recovery time, time to wake up, time to open eyes when ordered, and extubation time, than the control group (P<0.05). The observation group also consumed less sufentanil than the control group (P<0.05). Additionally, the observation group had lower VAS and MMSE scores than the control group at 6 and 12 h after operation (P>0.05) and lower SAS and SDS scores than the control group (P<0.05). Moreover, at 6 h after operation, the control group showed higher levels of IL-6, Cor and IL-10 than the observation group (P<0.05), and the control group experienced later first getting out-of-bed time and a longer hospitalization time than the observation group (P<0.05). There was a positive correlation between VAS score and IL-6 as well as Cor before and after treatment (P<0.05). The two groups were similar in treatment expense (P>0.05) and the incidence of adverse reactions (P>0.05). Age and anesthesia scheme were risk factors for postoperative cognitive dysfunction.

CONCLUSION

Nerve block combined with general anesthesia can effectively improve the cognitive function and analgesic effect of elderly patients undergoing knee joint replacement, and accelerate recovery time, without increasing f adverse reactions, and can also accelerate recovery of their cognitive function.

Pain during cardiac implantable electronic device implantation

In order to evaluate the extent and causes of pain during cardiac implantable electronic device (CIED) implantation in our hospital, a prospective audit over a 23-month period using a patient selfreporting questionnaire was undertaken. In total, 599 procedures were reported, 52.9% for de novo pacemaker implantation and 23.4% for high-energy devices (cardiac resynchronisation therapy defibrillator [CRT-D], implantable cardiac defibrillator [ICD], subcutaneous ICD). Overall, the median pain score was 2/10 (interquartile range 2-4). In total, 61.6% (367/599) reported no pain or mild pain (pain scores 0-3/10), 27.7% (165/599) reported moderate pain (pain score of 4-6/10) and 10.7% (64/599) reported severe pain (pain score of 7-10/10) during the procedure. Significant preimplant worry (odds ratio [OR] 2.13, 95% confidence interval [CI] 1.22 to 3.73) and higher lidocaine doses (OR 1.06, 95%CI 1.00 to 1.11) were associated with severe patient-reported pain. In conclusion, most patients underwent CIED implantation with minimum stress and maximum comfort. An important minority reported severe pain during the procedure. Optimising surgical technique and interventions targeted at reducing pre- and peri-implant worry, particularly in women, and especially in those receiving ICDs, warrants further investigation to reduce patient-reported pain during CIED implantation.

Effects of general versus subarachnoid anaesthesia on circadian melatonin rhythm and postoperative delirium in elderly patients undergoing hip fracture surgery: A prospective cohort clinical trial

BACKGROUND

Circadian rhythm disturbance is common postoperatively in older patients with hip fractures, which may contribute to the development of postoperative delirium (POD). As a reliable biomarker of endogenous circadian rhythms, melatonin regulates the sleep-wake cycle and environmental adaptation, and its secretory rhythm may be modified by anaesthesia and surgery. This study compared the impact of subarachnoid anaesthesia (SA) and general anaesthesia (GA), on the peak of melatonin secretion (primary outcome), the circadian rhythm of melatonin, cortisol and sleep, and the POD incidence (secondary outcome).

METHODS

In this prospective cohort observational study, hip fracture surgery patients were enrolled and assigned to receive either SA or GA. Postoperative plasma melatonin and cortisol levels were dynamically measured every six hours on seven time-points, and the circadian rhythm parameters including mesor, amplitude, and acrophase were calculated. Subjective and objective sleep assessments were performed by sleep diaries and sleep trackers, respectively. The Confusion Assessment Method was used twice daily by a specific geriatrician to screen for POD occurrence.

FINDINGS

In a cohort of 138 patients who underwent hip fracture surgery, the circadian rhythm disruption of the patients in the GA group (n=69) was greater than the SA group (n=69). Compared with SA, GA provided the lower peak concentration, mesor, and amplitude of melatonin secretion on postoperative day 1 (p < 0.05). Patients in the GA group experienced higher awakenings, more sleep deprivation, and poor sleep quality on surgery day (p < 0.05). A proportion of 12 patients in the SA group (17.4%) and 24 patients in the GA group (34.8%) experienced POD (p = 0.020).

INTERPRETATION

These results suggest that SA may be superior to GA in elderly patients undergoing hip fracture surgery as SA is associated with less impairment of the melatonin rhythm and sleep patterns, and fewer POD occurrences.

FUNDING

The study was supported by the National Natural Science Foundation of China (81971012, 81873726, 81901095, 81701052, and 81801070), Key Clinical Projects of Peking University Third Hospital (BYSYZD2019027), and Peking University "Clinical Medicine plus X" Youth Project (PKU2020LCXQ016).