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Wang W, Xiao J, Shen S, Wang S, Chen M, Hu Y. Emerging effect of anesthesia on post-operative tumor recurrence and metastasis. J Int Med Res 2019; 47:3550-3558. [PMID: 31296069 PMCID: PMC6726782 DOI: 10.1177/0300060519861455] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Post-operative recurrence and metastasis of malignant tumors are difficult to control, which probably results from multiple factors that affect the prognosis and the undefined mechanism. Anesthesia may be an influential factor. Researchers have performed many meaningful studies on the relationship between anesthetic drugs/methods and tumor growth/immune function, which provide important references for the anesthetic selection and peri-operative management of tumor patients. Anesthetics, analgesics, and sedatives should be used with caution because their effects in post-operative patients remain controversial. This review summarizes the emerging progress on the effect of anesthesia on post-operative tumor recurrence and metastasis, particularly focusing on the effects of anesthetic drugs, anesthetic methods, and post-operative analgesia on tumor growth and metastasis. Future studies should provide strict criteria for the proper use of anesthetics in patients with malignant tumors and provide experimental evidence for the improvement and development of novel anesthetics and anesthetic methods that have the important clinical significance.
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Affiliation(s)
- Weilian Wang
- 1 Department of Anesthesia, Jingzhou Central Hospital, The Second Clinical Medical College, Yangtze University, Jingzhou, Hubei, P.R. China
| | - Jinliang Xiao
- 1 Department of Anesthesia, Jingzhou Central Hospital, The Second Clinical Medical College, Yangtze University, Jingzhou, Hubei, P.R. China
| | - Shuwei Shen
- 1 Department of Anesthesia, Jingzhou Central Hospital, The Second Clinical Medical College, Yangtze University, Jingzhou, Hubei, P.R. China
| | - Shu Wang
- 2 Department of Anesthesia, Benxi Central Hospital, Benxi, Liaoning, P.R. China
| | - Minghao Chen
- 3 Department of Anesthesia, Weihai Municipal Hospital, Weihai, Shandong, P.R. China
| | - Ya Hu
- 4 Department of Pharmacology, Health Science Center, Yangtze University, Jingzhou, Hubei, P.R. China
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Loftus RW, Dexter F, Robinson AD. High-risk Staphylococcus aureus transmission in the operating room: A call for widespread improvements in perioperative hand hygiene and patient decolonization practices. Am J Infect Control 2018; 46:1134-1141. [PMID: 29907449 DOI: 10.1016/j.ajic.2018.04.211] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 04/02/2018] [Accepted: 04/02/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Increased awareness of the epidemiology of transmission of pathogenic bacterial strain characteristics may help to improve compliance with intraoperative infection control measures. Our aim was to characterize the epidemiology of intraoperative transmission of high-risk Staphylococcus aureus sequence types (STs). METHODS S aureus isolates collected from 3 academic medical centers underwent whole cell genome analysis, analytical profile indexing, and biofilm absorbance. Transmission dynamics for hypertransmissible, strong biofilm-forming, antibiotic-resistant, and virulent STs were assessed. RESULTS S aureus ST 5 was associated with increased risk of transmission (adjusted incidence risk ratio, 6.67; 95% confidence interval [CI], 1.82-24.41; P = .0008), greater biofilm absorbance (ST 5 median absorbance ± SD, 3.08 ± 0.642 vs other ST median absorbance ± SD, 2.38 ± 1.01; corrected P = .021), multidrug resistance (odds ratio, 7.82; 95% CI, 2.19-27.95; P = .002), and infection (6/38 ST 5 vs 6/140 STs; relative risk, 3.68; 95% CI, 1.26-10.78; P = .022). Provider hands (n = 3) and patients (n = 4) were confirmed sources of ST 5 transmission. Transmission locations included provider hands (n = 3), patient skin sites (n = 4), and environmental surfaces (n = 2). All observed transmission stories involved the within-case mode of transmission. Two of the ST 5 transmission events were directly linked to infection. CONCLUSIONS Intraoperative S aureus ST 5 isolates are hypertransmissible and pathogenic. Improved compliance with hand hygiene and patient decolonization may help to control the spread of these dangerous pathogens.
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Zhou Y, Huang J, Bai Y, Li C, Lu X. Effects of preemptive analgesia with flurbiprofen ester on lymphocytes and natural killer cells in patients undergoing esophagectomy: A randomized controlled pilot study. Thorac Cancer 2017; 8:649-654. [PMID: 28892265 PMCID: PMC5668486 DOI: 10.1111/1759-7714.12502] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 08/03/2017] [Accepted: 08/03/2017] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Tumors may induce systemic immune dysfunction, which can be aggravated by surgery and anesthesia/analgesia. Data on the effect of flurbiprofen preemptive analgesia on immune dysfunction is limited. The aim of this study was to investigate the effect of flurbiprofen preemptive analgesia on lymphocytes and natural killer (NK) cells in patients undergoing thoracotomy and thoracoscopy radical esophagectomy, and to explore the analgesic methods suitable for tumor patients. METHODS This was a randomized controlled pilot study of 89 patients with esophageal cancer treated with surgery at the Henan Cancer Hospital between January 1, 2015 and December 31, 2016. The patients were divided into three groups: group 1, thoracotomy; group 2, thoracoscopy and laparoscopic surgery; and group 3, flurbiprofen, thoracoscopy, and laparoscopic surgery. CD3+, CD19+, NK, CD4+, and CD8+ cells in whole blood were measured by flow cytometry 30 minutes before surgery (T0), at the end of the thoracic section of the procedure (T1), and at the end of the operation (T2). RESULTS There were no significant differences in CD3+, CD19+, CD8+, NK, and CD4+ cells between the three groups or regarding the time points during the procedure (all P > 0.05). Thoracotomy and thoracoscopy surgery resulted in similar immunological outcomes. CONCLUSION Flurbiprofen ester preemptive analgesia did not suppress the immune function in patients and could be a safe analgesic method for patients with esophageal cancer undergoing surgery.
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Affiliation(s)
- Yi Zhou
- Department of AnesthesiologyThe Affiliated Cancer Hospital of Zhengzhou UniversityZhengzhouChina
| | - Jinxi Huang
- Department of General SurgeryThe Affiliated Cancer Hospital of Zhengzhou UniversityZhengzhouChina
| | - Yu Bai
- Department of AnesthesiologyThe Affiliated Cancer Hospital of Zhengzhou UniversityZhengzhouChina
| | - Changsheng Li
- Department of AnesthesiologyThe Affiliated Cancer Hospital of Zhengzhou UniversityZhengzhouChina
| | - Xihua Lu
- Department of AnesthesiologyThe Affiliated Cancer Hospital of Zhengzhou UniversityZhengzhouChina
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Planinsic RM, Raval JS, Gorantla VS. Anesthesia and Perioperative Care in Reconstructive Transplantation. Anesthesiol Clin 2017; 35:523-538. [PMID: 28784224 DOI: 10.1016/j.anclin.2017.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Reconstructive transplantation of vascularized composite allografts (VCAs), such as upper extremity, craniofacial, abdominal, lower extremity, or genitourinary transplants, has emerged as a cutting-edge specialty, with more than 50 programs in the United States and 30 programs across the world performing these procedures. Most VCAs involve complicated technical planning and preparation, protracted surgery, and complex immunosuppressive or immunomodulatory protocols, each associated with unique anesthesiology challenges. This article outlines key procedural, patient, and protocol-related aspects of VCA relevant to anesthesiology management with the goal of ensuring patient safety and optimizing surgical, immunologic, and functional outcomes.
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Affiliation(s)
- Raymond M Planinsic
- Department of Anesthesiology, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite C-200, Pittsburgh, PA 15213, USA.
| | - Jay S Raval
- Division of Transfusion Medicine, Department of Pathology and Laboratory Medicine, Transfusion Medicine Service, Hematopoietic Progenitor Cell Laboratory, University of North Carolina at Chapel Hill, 101 Manning Drive, Suite C3162, Chapel Hill, NC 27514, USA
| | - Vijay S Gorantla
- Departments of Surgery, Ophthalmology and Bioengineering, US Air Force, Wake Forest Institute for Regenerative Medicine, Wake Forest Baptist Medical Center, Richard H. Dean Biomedical Building, 391 Technology Way, Winston Salem, NC 27101, USA.
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The effect of different anesthetics on tumor cytotoxicity by natural killer cells. Toxicol Lett 2016; 266:23-31. [PMID: 27940100 DOI: 10.1016/j.toxlet.2016.12.007] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 12/05/2016] [Accepted: 12/08/2016] [Indexed: 02/06/2023]
Abstract
A number of retrospective studies have suggested that choice of anesthetic drugs during surgical tumor resection might affect tumor recurrence/metastasis, or outcome of patients. The recent study showed that volatile anesthetics-based general anesthesia was associated with the worse outcomes than intravenous anesthetics-based general anesthesia. However, the underlying mechanism is yet to be determined. Because natural killer (NK) cells are implicated as important immune cells for tumor recurrence/metastasis in the perioperative period, we examined the effect of different anesthetics on NK cell-mediated tumor cytotoxicity. Because adhesion molecule leukocyte function-associated antigen-1 (LFA-1) is functionally important in NK cells and is inhibited by commonly used volatile anesthetics isoflurane and sevoflurane, we hypothesized that these anesthetics would attenuate NK cell-mediated cytotoxicity. Using human NK cell line NK92-MI cells and tumor cell line K562 cells as a model system, we performed cytotoxicity, proliferation, conjugation and degranulation assays. Lytic granule polarization was also assessed. We showed that isoflurane, sevoflurane and LFA-1 inhibitor BIRT377 attenuated cytotoxicity, and reduced conjugation and polarization, but not degranulation of NK cells. Our data suggest that isoflurane and sevoflurane attenuated NK cell-mediated cytotoxicity at least partly by their LFA-1 inhibition in vitro. Whether or not isoflurane and sevoflurane attenuate NK cell-mediated tumor cytotoxicity in patients needs to be determined in the future.
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Cata JP, Conrad C, Rezvani K. Potential Use of Natural Killer Cell Transfer Therapy in the Perioperative Period to Improve Oncologic Outcomes. SCIENTIFICA 2015; 2015:732438. [PMID: 26576322 PMCID: PMC4632007 DOI: 10.1155/2015/732438] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 10/05/2015] [Indexed: 06/05/2023]
Abstract
Immune suppression after oncologic surgery is a common phenomenon. Several studies have demonstrated that it is associated with poor survival owing to cancer progression. Immunotherapy, especially NK cell transfer therapy, is an attractive alternative because current methodologies to isolate, generate, and expand NK cells have shown good safety profiles in current active investigations. We believe that the use of NK cell transfer therapy in the context of postoperative minimal residual disease deserves significant investigation.
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Affiliation(s)
- Juan P. Cata
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA
| | - Claudius Conrad
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Katy Rezvani
- Department of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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Wu J, Buggy D, Fleischmann E, Parra-Sanchez I, Treschan T, Kurz A, Mascha EJ, Sessler DI. Thoracic paravertebral regional anesthesia improves analgesia after breast cancer surgery: a randomized controlled multicentre clinical trial. Can J Anaesth 2014; 62:241-51. [DOI: 10.1007/s12630-014-0285-8] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Accepted: 11/24/2014] [Indexed: 12/21/2022] Open
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Rewari V, Garg R, Trikha A. Rabies vaccine and neuraxial anaesthesia. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2014. [DOI: 10.1080/22201173.2010.10872707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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VOTTA-VELIS EG, PIEGELER T, MINSHALL RD, AGUIRRE J, BECK-SCHIMMER B, SCHWARTZ DE, BORGEAT A. Regional anaesthesia and cancer metastases: the implication of local anaesthetics. Acta Anaesthesiol Scand 2013; 57:1211-29. [PMID: 24134442 DOI: 10.1111/aas.12210] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2013] [Indexed: 12/21/2022]
Abstract
Clinical and basic science studies have demonstrated the anti-inflammatory properties of local anaesthetics. Recent studies have begun to unravel molecular pathways linking inflammation and cancer. Regional anaesthesia is associated in some retrospective clinical studies with reduced risk of metastasis and increased long-term survival. The potential beneficial effects of regional anaesthesia have been attributed mainly to the inhibition of the neuroendocrine stress response to surgery and to the reduction in the requirements of volatile anaesthetics and opioids. Because cancer is linked to inflammation and local anaesthetics have anti-inflammatory effects, these agents may participate in reducing the risk of metastasis, but their mechanism of action is unknown. We demonstrated in vitro that amide local anaesthetics attenuate tumour cell migration as well as signalling pathways enhancing tumour growth and metastasis. This has provided the first evidence of a molecular mechanism by which regional anaesthesia might inhibit or reduce cancer metastases.
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Affiliation(s)
- E. G. VOTTA-VELIS
- Department of Anaesthesiology; University of Illinois at Chicago; Chicago IL USA
- Jesse Brown VA Medical Center; University of Illinois at Chicago; Chicago IL USA
| | - T. PIEGELER
- Department of Anaesthesiology; University of Illinois at Chicago; Chicago IL USA
- Institute of Anaesthesiology; University Hospital Zurich; Zurich Switzerland
| | - R. D. MINSHALL
- Department of Anaesthesiology; University of Illinois at Chicago; Chicago IL USA
- Department of Pharmacology; University of Illinois at Chicago; Chicago IL USA
- Center for Lung and Vascular Biology; University of Illinois at Chicago; Chicago IL USA
| | - J. AGUIRRE
- Department of Anaesthesiology; Balgrist University Hospital Zurich; Zurich Switzerland
| | - B. BECK-SCHIMMER
- Institute of Anaesthesiology; University Hospital Zurich; Zurich Switzerland
| | - D. E. SCHWARTZ
- Department of Anaesthesiology; University of Illinois at Chicago; Chicago IL USA
| | - A. BORGEAT
- Department of Anaesthesiology; Balgrist University Hospital Zurich; Zurich Switzerland
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Dong YJ, Gao LL. Effect of epidural block on 24-hour urine protein in pregnant rat models with preeclampsia. Arch Gynecol Obstet 2012; 286:609-11. [PMID: 22552377 DOI: 10.1007/s00404-012-2354-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2011] [Accepted: 04/19/2012] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate the effects of epidural block on 24-hour urine protein in rat with preeclampsia (PE). METHODS Thirty healthy pregnant Wistar rats were randomly divided into three groups (each group with 10 rats). From the 14th day of pregnancy, the rats in Group A were given subcutaneous normal saline (0.5 ml) every day in a total of 7 days; the rats in Group B were given subcutaneous L: -nitroarginomethyl ester (L: -NAME) (50 mg) every day in a total of 7 days; and the rats in Group C both were given subcutaneous L: -NAME (50 mg) every day and underwent epidural block with 25 μl of 0.125 % bupivacaine twice every day all in a total of 7 days. The 24-hour urine protein and systolic blood pressure on the 13th and 20th day of pregnancy were measured. RESULTS On the 13th day of pregnancy, there was no statistical significant difference in 24-hour urine protein and systolic blood pressure between the three groups (P > 0.05). On the 20th day of pregnancy, 24-hour urine protein and systolic blood pressure all were higher in Group B and C than in Group A (P < 0.01 and P < 0.05)) and all were lower in Group C than in Group B (P < 0.01 and P < 0.05). CONCLUSION Epidural block can decrease 24-hour urine protein and systolic blood pressure in pregnant rat models with PE. This study provides a potential strategy for treatment of PE.
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Affiliation(s)
- You-Jing Dong
- Department of Anesthesia, Shengjing Hospital of China Medical University, No 36, Sanhao Street, Herping District, Shenyang, 110004, China.
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Cata JP, Gottumukkala V, Sessler DI. How regional analgesia might reduce postoperative cancer recurrence. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/j.eujps.2011.08.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Moselli NM, Baricocchi E, Ribero D, Sottile A, Suita L, Debernardi F. Intraoperative Epidural Analgesia Prevents the Early Proinflammatory Response to Surgical Trauma. Results from a Prospective Randomized Clinical Trial of Intraoperative Epidural Versus General Analgesia. Ann Surg Oncol 2011; 18:2722-31. [DOI: 10.1245/s10434-011-1700-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2010] [Indexed: 12/15/2022]
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Forget P, De Kock M. [Could anaesthesia, analgesia and sympathetic modulation affect neoplasic recurrence after surgery? A systematic review centred over the modulation of natural killer cells activity]. ACTA ACUST UNITED AC 2009; 28:751-68. [PMID: 19717275 DOI: 10.1016/j.annfar.2009.07.078] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2008] [Accepted: 07/02/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The Natural Killer cells (NK) are an important part of non-specific cellular-mediated and antitumoral immunity. The goal of this review is to recapitulate data published over NK activity during the perioperative period and the influence of anaesthesia, analgesia and modulation of sympathetic system. DATA SOURCES Pubmed/Medline database. STUDY SELECTION AND DATA EXTRACTION Keywords-based selection, without limit of date: fundamental studies, randomized controlled trials and non-randomized comparative studies. DATA SYNTHESIS In human as in animal studies, an important correlation exists between NK activity and prognosis linked to the development of metastasis. The great depression of this cytotoxicity during the perioperative period could be able to compromise host defenses. The influence of anaesthetics and analgesics is important. The effects of the opioids, the agonists and the antagonists of the sympathetic nervous system, the prostaglandins, the NSAIDs, the ketamine, the hypnotics and the locoregional anaesthesia are systematically reviewed. The limits of experimental model presented are covered. CONCLUSION The effects of anaesthetic/analgesic drugs and techniques, the consequences of sympathomodulation on NK activity are numerous and sometimes opposite. It is important for the anaesthesiologist to keep in mind that the long term consequences of his techniques on the patients' outcome must be clarified.
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Affiliation(s)
- P Forget
- Service d'anesthésiologie, université catholique de Louvain, cliniques universitaires Saint-Luc, 10, avenue Hippocrates, 1200 Bruxelles, Belgium.
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Routh JC, Bacon DR, Leibovich BC, Zincke H, Blute ML, Frank I. How long is too long? The effect of the duration of anaesthesia on the incidence of non-urological complications after surgery. BJU Int 2008; 102:301-4. [DOI: 10.1111/j.1464-410x.2008.07663.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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The role of fracture-associated soft tissue injury in the induction of systemic inflammation and remote organ dysfunction after bilateral femur fracture. J Orthop Trauma 2008; 22:385-90. [PMID: 18594302 DOI: 10.1097/bot.0b013e318175dd88] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The storage of preformed cytokines in soft tissue as well as the immunocompetence of adipocytes has been reported. We hypothesized that fracture-associated soft tissue injury plays a pivotal role in the induction of systemic inflammation and remote organ dysfunction after fracture. MATERIALS AND METHODS Male C57/BL6 mice sustained either severe soft tissue injury to both thighs (STI), bilateral femur fracture with minimal soft tissue injury (Fx), or the combination of both (Fx+STI) and were euthanized 6 hours after injury. Serum cytokine concentrations were measured using the Luminex multiplexing platform, and serum ALT levels were measured with the Vitros 950 Chemistry System. Hepatic myeloperoxidase activity, a marker for polymorphonuclear cell infiltration, and hepatic IL-6 levels were determined using ELISA kits. Hepatic permeability changes were assessed via measurement of edema formation. RESULTS STI as well as Fx both induced significantly elevated serum IL-6 and L-10 levels as compared with Sham animals (P < 0.05). Further, serum IL-6 and IL-10 levels were significantly higher after STI as compared with Fx (P < 0.05). Serum KC and MCP-1 levels were significantly elevated after STI but not after Fx (P < 0.05). STI as well as Fx resulted in significantly increased serum ALT levels and hepatic polymorphonuclear cell infiltration. The combination of both injuries resulted in further increased systemic inflammatory mediators as well as marked liver inflammation and dysfunction represented by significantly elevated serum ALT levels, hepatic polymorphonuclear cell infiltration, hepatic IL-6 concentrations, and hepatic edema formation as compared with Sham animals (P < 0.05). CONCLUSIONS Although STI and Fx both induced a systemic inflammatory response, this was more pronounced after STI. However, the combination of both injuries (Fx+STI) was required to induce marked liver dysfunction. Our data indicate that fracture-associated soft tissue injury is a major contributor to the systemic inflammatory response after bilateral femur fracture. This should be recognized especially in multiply injured patients, who are susceptible to systemic inflammation with remote organ dysfunction.
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Yeager MP, Procopio MA, DeLeo JA, Arruda JL, Hildebrandt L, Howell AL. Intravenous Fentanyl Increases Natural Killer Cell Cytotoxicity and Circulating CD16+ Lymphocytes in Humans. Anesth Analg 2002. [DOI: 10.1213/00000539-200201000-00018] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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