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Maisat W, Yuki K. Narrative review of systemic inflammatory response mechanisms in cardiac surgery and immunomodulatory role of anesthetic agents. Ann Card Anaesth 2023; 26:133-142. [PMID: 37706376 PMCID: PMC10284469 DOI: 10.4103/aca.aca_147_22] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 12/05/2022] [Accepted: 12/18/2022] [Indexed: 09/15/2023] Open
Abstract
Although surgical techniques and perioperative care have made significant advances, perioperative mortality in cardiac surgery remains relatively high. Single- or multiple-organ failure remains the leading cause of postoperative mortality. Systemic inflammatory response syndrome (SIRS) is a common trigger for organ injury or dysfunction in surgical patients. Cardiac surgery involves major surgical dissection, the use of cardiopulmonary bypass (CPB), and frequent blood transfusions. Ischemia-reperfusion injury and contact activation from CPB are among the major triggers for SIRS. Blood transfusion can also induce proinflammatory responses. Here, we review the immunological mechanisms of organ injury and the role of anesthetic regimens in cardiac surgery.
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Affiliation(s)
- Wiriya Maisat
- Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, USA
- Department of Anaesthesia, Harvard Medical School, Boston, USA
- Department of Immunology, Harvard Medical School, Boston, USA
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Koichi Yuki
- Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, USA
- Department of Anaesthesia, Harvard Medical School, Boston, USA
- Department of Immunology, Harvard Medical School, Boston, USA
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Surgical Site Infections and Perioperative Optimization of Host Immunity by Selection of Anesthetics. BIOMED RESEARCH INTERNATIONAL 2021; 2021:5576959. [PMID: 33763473 PMCID: PMC7963902 DOI: 10.1155/2021/5576959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 02/22/2021] [Accepted: 03/05/2021] [Indexed: 11/17/2022]
Abstract
Surgical site infections are significant health care issues, and efforts to mitigate their occurrence have been ongoing worldwide, mainly focusing to reduce the spillage of microbes to the otherwise sterile tissues. Optimization of host immunity has been also recognized including temperature regulation (normothermia), adequate oxygenation, and glucose management. A number of papers have described the role of anesthetics in host immunity. The role of anesthetics in postoperative outcomes including surgical site infections has been also studied. We will review the current literature and propose the importance of anesthetic selection to potentially mitigate surgical site infections.
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Mitsui Y, Hou L, Huang X, Odegard KC, Pereira LM, Yuki K. Volatile Anesthetic Sevoflurane Attenuates Toll-Like Receptor 1/2 Activation. Anesth Analg 2020; 131:631-639. [PMID: 32149756 DOI: 10.1213/ane.0000000000004741] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Although immunomodulatory effects of anesthetics have been increasingly recognized, their underlying molecular mechanisms are not completely understood. Toll-like receptors (TLRs) are one of the major receptors to recognize invading pathogens and danger signals from damaged host tissues to initiate immune responses. Among the TLR family, TLR2 and TLR4 recognize a wide range of ligands and are considered to be important players in perioperative pathophysiology. Based on our recent finding that volatile anesthetics modulate TLR4 function, we tested our hypothesis that they would also modulate TLR2 function. METHODS The effect of anesthetics isoflurane, sevoflurane, propofol, and dexmedetomidine on TLR2 activation was examined by reporter assays. An anesthetic that affected the activation was subjected to in silico rigid docking simulation on TLR2. To test our prediction that sevoflurane and a TLR1/TLR2 ligand Pam3CSK4 would compete for the same pocket of TLR2, we performed Pam3CSK4 competitive binding assay to TLR2 using HEK cells stably transfected with TLR2 (HEK-TLR2) with or without sevoflurane. We examined the effect of different anesthetics on the functions of human neutrophils stimulated with TLR2 ligands. Kruskal-Wallis test and Mann-Whitney U test were used for statistical analysis. RESULTS We observed that the attenuation of TLR1/TLR2 activation was seen on sevoflurane exposure but not on isoflurane, propofol, or dexmedetomidine exposure. The attenuation of TLR2/TLR6 activation was not seen in any of the anesthetics tested. The rigid docking simulation predicted that sevoflurane and Pam3CSK4 bound to the same pocket of TLR1/TLR2 complex. The binding of Pam3CSK4 to HEK-TLR2 cells was impaired in the presence of sevoflurane, indicating that sevoflurane and Pam3CSK4 competed for the pocket, as predicted in silico. The stimulation of neutrophils with Pam3CSK4 induced L-selection shedding but did not affect phagocytosis and reactive oxygen species production. L-selectin shedding from neutrophils was attenuated only by sevoflurane, consistent with the result of our reporter assays. CONCLUSIONS We found that TLR1/TLR2 activation was attenuated by sevoflurane, but we found no evidence for attenuation by isoflurane, propofol, or dexmedetomidine at clinically relevant concentrations. Our structural analysis and competition assay supported that sevoflurane directly bound to TLR2 at the interphase of the TLR1/TLR2 complex. Sevoflurane attenuated neutrophil L-selectin shedding, an important step for neutrophil migration.
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Affiliation(s)
- Yusuke Mitsui
- From the Department of Anesthesia, Harvard Medical School.,Cardiac Anesthesia Division, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts.,Department of Anesthesiology and Intensive Care Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Lifei Hou
- From the Department of Anesthesia, Harvard Medical School.,Cardiac Anesthesia Division, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Xiayi Huang
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Kirsten C Odegard
- From the Department of Anesthesia, Harvard Medical School.,Cardiac Anesthesia Division, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Luis M Pereira
- From the Department of Anesthesia, Harvard Medical School.,Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Koichi Yuki
- From the Department of Anesthesia, Harvard Medical School.,Cardiac Anesthesia Division, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
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Hemmings HC, Riegelhaupt PM, Kelz MB, Solt K, Eckenhoff RG, Orser BA, Goldstein PA. Towards a Comprehensive Understanding of Anesthetic Mechanisms of Action: A Decade of Discovery. Trends Pharmacol Sci 2019; 40:464-481. [PMID: 31147199 DOI: 10.1016/j.tips.2019.05.001] [Citation(s) in RCA: 118] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 04/11/2019] [Accepted: 05/03/2019] [Indexed: 12/30/2022]
Abstract
Significant progress has been made in the 21st century towards a comprehensive understanding of the mechanisms of action of general anesthetics, coincident with progress in structural biology and molecular, cellular, and systems neuroscience. This review summarizes important new findings that include target identification through structural determination of anesthetic binding sites, details of receptors and ion channels involved in neurotransmission, and the critical roles of neuronal networks in anesthetic effects on memory and consciousness. These recent developments provide a comprehensive basis for conceptualizing pharmacological control of amnesia, unconsciousness, and immobility.
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Affiliation(s)
- Hugh C Hemmings
- Departments of Anesthesiology, Weill Cornell Medicine, 1300 York Avenue, New York, NY 10065, USA; Departments of Pharmacology, Weill Cornell Medicine, 1300 York Avenue, New York, NY 10065, USA
| | - Paul M Riegelhaupt
- Departments of Anesthesiology, Weill Cornell Medicine, 1300 York Avenue, New York, NY 10065, USA
| | - Max B Kelz
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, 3620 Hamilton Walk, 305 John Morgan, Philadelphia, PA 19104, USA
| | - Ken Solt
- Department of Anaesthesia, Harvard Medical School, GRB 444, 55 Fruit St., Boston, MA 02114, USA; Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Roderic G Eckenhoff
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, 3620 Hamilton Walk, 305 John Morgan, Philadelphia, PA 19104, USA
| | - Beverley A Orser
- Departments of Anesthesia and Physiology, Room 3318 Medical Sciences Building, University of Toronto, Toronto, Ontario M5S 1A8, Canada
| | - Peter A Goldstein
- Departments of Anesthesiology, Weill Cornell Medicine, 1300 York Avenue, New York, NY 10065, USA; Departments of Medicine, Weill Cornell Medicine, 1300 York Avenue, New York, NY 10065, USA.
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Mardini F, Tang JX, Li JC, Arroliga MJ, Eckenhoff RG, Eckenhoff MF. Effects of propofol and surgery on neuropathology and cognition in the 3xTgAD Alzheimer transgenic mouse model. Br J Anaesth 2019; 119:472-480. [PMID: 28969319 DOI: 10.1093/bja/aew397] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2016] [Indexed: 11/12/2022] Open
Abstract
Background Previous work suggests that anaesthesia and surgery amplify the pathology and cognitive impairment of animals made vulnerable via age or specific transgenes. We hypothesized that surgery under propofol anaesthesia, a widely used i.v. general anaesthetic, has minimal delayed cognitive and neuroinflammatory sequelae in a vulnerable mouse transgenic model. Methods We conducted caecal ligation and excision surgery in cognitively presymptomatic (11-month-old) 3xTgAD mice under i.p. propofol anaesthesia. Age-matched 3xTgAD control mice received vehicle or propofol without surgery. Morris water maze testing was conducted 3 and 15 weeks later. Brains were examined with quantitative immunohistochemistry for amyloid β plaques, tau pathology, and microglial activation. Acute changes in neuroinflammatory cytokines were assessed in separate cohorts at 6 h. Results We detected no significant differences between groups in escape latencies at either 3 or 15 weeks, but detected a significant effect of surgery in the probe test at both 3 and 15 weeks. Spatial working memory was unaffected at 16 weeks in any group. No effects of either propofol alone or propofol with surgery were detected on plaque formation, tau aggregates, or neuroinflammation. Acute biochemical assays detected no effects in brain interleukin-10 or interleukin-6 concentrations. Conclusions Surgery in a vulnerable transgenic mouse under propofol anaesthesia was associated with minimal to no changes in short- and long-term behaviour and no changes in neuropathology. This suggests that propofol anaesthesia is associated with better cognitive outcomes in the aged, vulnerable brain compared with inhalation anaesthesia.
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Affiliation(s)
- F Mardini
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - J X Tang
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - J C Li
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - M J Arroliga
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - R G Eckenhoff
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - M F Eckenhoff
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
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Abstract
BACKGROUND Etomidate is a highly potent anesthetic agent that is believed to produce hypnosis by enhancing γ-aminobutyric acid type A (GABAA) receptor function. The authors characterized the GABAA receptor and hypnotic potencies of etomidate analogs. The authors then used computational techniques to build statistical and graphical models that relate the potencies of these etomidate analogs to their structures to identify the specific molecular determinants of potency. METHODS GABAA receptor potencies were defined with voltage clamp electrophysiology using α1β3γ2 receptors harboring a channel mutation (α1[L264T]) that enhances anesthetic sensitivity (n = 36 to 60 measurements per concentration-response curve). The hypnotic potencies of etomidate analogs were defined using a loss of righting reflexes assay in Sprague Dawley rats (n = 9 to 21 measurements per dose-response curve). Three-dimensional quantitative structure-activity relationships were determined in silico using comparative molecular field analysis. RESULTS The GABAA receptor and hypnotic potencies of etomidate and the etomidate analogs ranged by 91- and 53-fold, respectively. These potency measurements were significantly correlated (r = 0.72), but neither measurement correlated with drug hydrophobicity (r = 0.019 and 0.005, respectively). Statistically significant and predictive comparative molecular field analysis models were generated, and a pharmacophore model was built that revealed both the structural elements in etomidate analogs associated with high potency and the interactions that these elements make with the etomidate-binding site. CONCLUSIONS There are multiple specific structural elements in etomidate and etomidate analogs that mediate GABAA receptor modulation. Modifying any one element can alter receptor potency by an order of magnitude or more.
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