Rocuronium Bromide Inhibits Inflammation and Pain by Suppressing Nitric Oxide Production and Enhancing Prostaglandin E2 Synthesis in Endothelial Cells

Optimizing anesthesia strategies to NSCLC patients in VATS procedures: Insights from drug requirements and patient recovery patterns

Understanding the intricate relationship between cancer clinicopathological features and anesthetics dosage is crucial for optimizing patient outcomes and safety during surgery. This retrospective study investigates this relationship in patients with non-small cell lung cancer (NSCLC) undergoing video-assisted thoracic surgery (VATS). A comprehensive analysis of medical records was undertaken for NSCLC patients who underwent VATS with intravenous compound inhalation general anesthesia. Patients were categorized based on histological, chemotherapy, radiotherapy, and epidural anesthesia factors. Statistical analysis was performed to compare the differences between the groups. The results revealed compelling insights. Specifically, patients with lung adenocarcinoma (LUAD) undergoing VATS exhibited higher dosages of rocuronium bromide and midazolam during general anesthesia, coupled with a shorter post-anesthesia care unit (PACU) stay compared to those with squamous cell carcinoma (sqCL). Furthermore, chemotherapy patients undergoing VATS demonstrated diminished requirements for phenylephrine and remifentanil in contrast to their non-chemotherapy counterparts. Similarly, radiotherapy patients undergoing VATS demonstrated a decreased necessity for rocuronium bromide compared to non-radiotherapy patients. Notably, patients who received epidural anesthesia in combination with general anesthesia manifested reduced hydromorphone requirements and prolonged hospital stays compared to those subjected to general anesthesia alone. In conclusion, the findings from this study indicate several important observations in diverse patient groups undergoing VATS. The higher dosages of rocuronium bromide and midazolam in LUAD patients point to potential differences in drug requirements among varying lung cancer types. Additionally, the observed shorter PACU stay in LUAD patients suggests a potentially expedited recovery process. The reduced anesthetic requirements of phenylephrine and remifentanilin chemotherapy patients indicate distinct responses to anesthesia and pain management. Radiotherapy patients requiring lower doses of rocuronium bromide imply a potential impact of prior radiotherapy on muscle relaxation. Finally, the combination of epidural anesthesia with general anesthesia resulted in reduced hydromorphone requirements and longer hospital stays, suggesting the potential benefits of this combined approach in terms of pain management and postoperative recovery. These findings highlight the importance of tailoring anesthesia strategies for specific patient populations to optimize outcomes in VATS procedures.

The Impact of General Anesthesia on Redox Stability and Epigenetic Inflammation Pathways: Crosstalk on Perioperative Antioxidant Therapy

Worldwide, the prevalence of surgery under general anesthesia has significantly increased, both because of modern anesthetic and pain-control techniques and because of better diagnosis and the increased complexity of surgical techniques. Apart from developing new concepts in the surgical field, researchers and clinicians are now working on minimizing the impact of surgical trauma and offering minimal invasive procedures due to the recent discoveries in the field of cellular and molecular mechanisms that have revealed a systemic inflammatory and pro-oxidative impact not only in the perioperative period but also in the long term, contributing to more difficult recovery, increased morbidity and mortality, and a negative financial impact. Detailed molecular and cellular analysis has shown an overproduction of inflammatory and pro-oxidative species, responsible for augmenting the systemic inflammatory status and making postoperative recovery more difficult. Moreover, there are a series of changes in certain epigenetic structures, the most important being the microRNAs. This review describes the most important molecular and cellular mechanisms that impact the surgical patient undergoing general anesthesia, and it presents a series of antioxidant therapies that can reduce systemic inflammation.

Involvement of bradykinin and bradykinin B1 receptor in patients with endometriosis

Endometriosis (EM), a benign aseptic inflammatory disease, is associated with the presence of endometrial foci. Pain, one of its typical symptoms, has been reported as a constant stressor, but the etiology and pathogenesis of EM-associated pain are unclear. In the present study, eutopic and ectopic endometrium samples from women with EM (n=50) and normal endometrium samples from control subjects (n=20) were collected. Serum levels of prostaglandin E2 (PGE2), prostaglandin F2α (PGF2α) and bradykinin (BK) were measured using commercial ELISA kits. The expression of the BKB1 receptor (BKB1R) protein was evaluated by immunohistochemical staining and western blot assay. The mRNA expression of BKB1R was measured by reverse transcription-quantitative PCR. The results revealed that there was a substantial increase in the protein and mRNA expression of BKB1R, as well as the release of PGE2, PGF2α and BK in the blood, in the EM group compared with that in the control group. Moreover, PGE2, PGF2α and BK levels were significantly correlated with each other, as well as with the pain intensity of EM. The increased expression levels of BKB1R protein and mRNA were positively correlated with the pain degree of EM. Thus, these data indicated that BK and BKB1R were involved in the pathological onset of EM-associated pain and that they may play an important role in EM-related pain by inducing PGE2 and PGF2α. The data indicate a potential new therapeutic target for EM-related pain.

The safety of high-dose rocuronium bromide in general anesthesia for spinal surgery and its effects on muscle relaxation

PURPOSE

This study aimed to investigate the effects of high-dose rocuronium bromide in general anesthesia for spinal surgery and analyze its safety.

METHODS

A total of 90 patients with spine diseases who underwent elective spinal surgery in our hospital were enrolled as study subjects, and were divided into 2-fold group (intraoperative administration of 0.6 mg/kg rocuronium bromide, n=30), 3-fold group (0.9 mg/kg rocuronium bromide, n=30) and 4-fold group (1.2 mg/kg rocuronium bromide, n=30). The effects of rocuronium bromide on muscle relaxation, the operative time and the incidence of adverse reactions were compared among the three groups.

RESULTS

The onset time of muscle relaxation in the 4-fold group was significantly lower than that in 2-fold and 3-fold groups. The duration of muscle relaxation and duration of action in the 4-fold group were significantly higher than those in the 2-fold and 3-fold groups (P<0.05). The satisfaction rate in the 4-fold group (100.00%) was significantly higher than that in the 2-fold group (66.67%) and the 3-fold group (86.67%) (P<0.05). The 4-fold group exhibited significantly higher intubating condition score at 1 min and significantly lower operative time than the 2-fold and 3-fold groups (P<0.05). The incidence of adverse reactions in the 4-fold group was 23.33%, slightly higher than those in the 2-fold (20.00%) and 3-fold groups (20.00%) (P>0.05).

CONCLUSION

High-dose rocuronium bromide shortens the onset time of muscle relaxation in patients undergoing spinal surgery, creates better intubation conditions, has longer duration of action, and shortens the patient's operative time, without increasing adverse reactions such as skin flushing, rash, increased airway resistance and bronchospasm, laryngeal edema, etc. Meanwhile, high-dose rocuronium bromide can shorten intubation time, which is conducive to the smooth operation and reduces surgical stress injuries.

Effects of deep neuromuscular block with low-pressure pneumoperitoneum on respiratory mechanics and biotrauma in a steep Trendelenburg position

We hypothesized that deep neuromuscular blockade (NMB) with low-pressure pneumoperitoneum (PP) would improve respiratory mechanics and reduce biotrauma compared to moderate NMB with high-pressure PP in a steep Trendelenburg position. Seventy-four women undergoing robotic gynecologic surgery were randomly assigned to two equal groups. Moderate NMB group was maintained with a train of four count of 1–2 and PP at 12 mmHg. Deep NMB group was maintained with a post-tetanic count of 1–2 and PP at 8 mmHg. Inflammatory cytokines were measured at baseline, at the end of PP, and 24 h after surgery. Interleukin-6 increased significantly from baseline at the end of PP and 24 h after the surgery in moderate NMB group but not in deep NMB group (P_group*time = 0.036). The peak inspiratory, driving, and mean airway pressures were significantly higher in moderate NMB group than in deep NMB group at 15 min and 60 min after PP (P_group*time = 0.002, 0.003, and 0.048, respectively). In conclusion, deep NMB with low-pressure PP significantly suppressed the increase in interleukin-6 developed after PP, by significantly improving the respiratory mechanics compared to moderate NMB with high-pressure PP during robotic surgery.

A Critical Appraisal of the Effects of Anesthetics on Immune-system Modulation in Critically Ill Patients With COVID-19

Purpose

The aim of the present article was to briefly summarize current knowledge about the immunomodulatory effects of general anesthetics and the possible clinical effects of this immunomodulation in patients with COVID-19.

Methods

The PubMed, Scopus, and Google Scholar databases were comprehensively searched for relevant studies.

Findings

The novel coronavirus causes a wide spectrum of clinical manifestations, with a large absolute number of patients experiencing severe pneumonia and rapid progression to acute respiratory distress syndrome and multiple organ failure. In these patients, the equilibrium of the inflammatory response is a major determinant of survival. The impact of anesthetics on immune-system modulation may vary and includes both pro-inflammatory and anti-inflammatory effects.

Implications

Inhibition of the development of severe inflammation and/or the enhancement of inflammation resolution by anesthetics may limit organ damage and improve outcomes in patients with COVID-19.

Protective Effects of Rocuronium Bromide on Ischemia-Reperfusion Injury in Skeletal Muscle Induced by Tourniquet in Patients Undergoing Elective Unilateral Total Knee Arthroplasty: A Prospective, Double Blind, Randomized, Controlled Study

Purpose

To investigate the effects of different doses of rocuronium on ischemia-reperfusion injury in skeletal muscle induced by tourniquet in patients undergoing elective unilateral total knee arthroplasty.

Patients and Methods

A total of 90 patients undergoing elective unilateral knee arthroplasty under general anesthesia combined with femoral nerve block were randomly divided into 3 groups: normal saline group (group S), rocuronium 0.6 mg/kg group (group L), and rocuronium 1.2 mg/kg group (group H). The primary outcome was the expression of dystrophin in skeletal muscle at 60 min after ischemia. Secondary outcomes included the concentration of malondialdehyde (MDA) and neuronal nitric oxide synthase (nNOS) in blood at 5 min and 30 min after reperfusion. In addition, thigh girth at 24 h and 48 h after operation, the leaving bed time, the incidence of tourniquet-related hypertension and short-term (3 days after operation) complications (nausea and vomiting, swelling, blister, wound infection) and long-term (3 months after operation) complications (joint instability, stiffness, nerve paralysis, pain) were recorded.

Main Results

The expression of dystrophin in the rocuronium group was higher than that in group S after ischemia (P <0.05). The concentration of MDA in the rocuronium 1.2 mg/kg group was lower at 30 min after reperfusion (P < 0.05). There was no significant difference in nNOS among groups at each time point (P > 0.05). The change of thigh girth was the smallest in the rocuronium 1.2 mg/kg group after operation (P<0.05). The leaving bed time was significantly earlier after operation in the rocuronium group than that in group S (P <0.05).

Conclusion

Rocuronium can protect skeletal muscle from ischemia-reperfusion injury induced by tourniquet. The mechanism may be related to the fact that rocuronium can reduce the loss of dystrophin in skeletal muscle and have the effects of anti-oxidation and anti-stress.

Trial Registration

The study was registered at http://www.chictr.org.cn (ChiCTR1800019221, registered on 2018-10-31).

The efficacy of Antipyretic Analgesics administration intravenously for Preventing Rocuronium-Associated Pain/Withdrawal Response: a systematic review and meta-analysis

Background

Rocuronium-associated injection pain/withdrawal response (RAIPWR) was non-ideal but occurred frequently when injection intravenously during anesthesia induction. Many studies had reported that pretreating with antipyretic analgesics (AAs) could reduce the occurrence of RAIPWR, but there was no consensus yet. Therefore, this meta-analysis was designed to systematically evaluate the benefits of AAs on RAIPWR in patients.

Methods

PubMed, Cochrane Library, Ovid, EMbase, Chinese National Knowledge Infrastructure (CNKI), Wan Fang Data were searched by January 1st 2019 for randomized controlled trials (RCTs) applying AAs to alleviate RAIPWR in patients who underwent elective surgery under general anesthesia. Two investigators assessed quality of RCTs and extracted data respectively and the meta-analysis was carried on Revman 5.3 software. Moreover, we compared AAs in pros and cons directly with lidocaine, the most reported medicine to prevent RAIPWR.

Results

Data were analyzed from 9 RCTs totaling 819 patients. The results of Meta-analysis showed that compared to the control group, pretreating with AAs could prevent the total occurrence of RAIPWR [Risk ratio (RR), 0.52; 95% confidence interval (CI), 0.42 to 0.66; P < 0.0001], and took effect on moderate (RR, 0.56; 95%CI, 0.43 to 0.73; P < 0.0001) and severe RAIPWR (RR = 0.14; 95%CI, 0.08 to 0.24; P < 0.00001). When compared to lidocaine, the preventive effect was not so excellent as the latter but injection pain induced by prophylactic occurred less.

Conclusion

The currently available evidence suggested that pretreating with AAs intravenously could alleviate RAIPWR.

Trial registration

PROSPERO CRD42019129776.

The analgesic efficacy and duration of lidocaine on vascular pain induced by hypertonic saline infusion: a double-blinded, randomized control trial

PURPOSE

To determine the analgesic efficacy and analgesic duration of lidocaine 20 mg and 40 mg on eliminating the vascular pain associated with hypertonic saline infusion.

METHOD

Patients who complained pain during infusion of hypertonic saline were randomized into three groups. They received normal saline (Group C), or lidocaine 20 mg (Group L20), or lidocaine 40 mg (Group L40). An electronic stopwatch was used to record the time to onset (T1) and the time to termination (T2) of the analgesic effect, and the analgesic duration (AD) was calculated as T2 - T1.

RESULTS

The incidence of pain elimination was significantly higher in both of the lidocaine groups (83.3 and 56.1% in Groups L40 and L20, respectively) than in the saline group (16.3%). Furthermore, lidocaine 40 mg was significantly more effective than 20 mg in eliminating the pain. The analgesic duration was significantly longer in Group L40 than in Group L20 (211.4 ± 50.2 vs. 130.3 ± 39.5 s, P < 0.001) and Group C (211.4 ± 50.2 vs. 45.1 ± 14.5 s, P < 0.001), and the analgesic duration in Group L20 was significantly longer than in Group C (P < 0.001). The incidence of transient tinnitus/dizziness was significantly higher in Group L40 than in Group L20 (19.0 vs. 2.4%, P < 0.05).

CONCLUSION

A single bolus of Lidocaine was effective in eliminating the pain induced by hypertonic saline infusion, but just for a short period of time. Lidocaine (without venous occlusion) only provides a short analgesic duration for local vein.

Diosgenin improves functional recovery from sciatic crushed nerve injury in rats

Peripheral nerve injuries are commonly encountered clinical problem and often result in chronic pain and severe functional deficit. Diosgenin is a plant steroidal saponin and has anti-inflammatory and anticancer effects. In the present study, we investigated the effect of diosgenin on functional recovery following sciatic crushed nerve injury in rats. Walking track analysis for the functional recovery which can be quantified with the sciatic function index (SFI) was conducted. Immunohistochemistry for c-Fos in the ventrolateral periaqueductal gray (vlPAG) and paraventricular nucleus (PVN) and western blot for brain-derived neurotrophic factor (BDNF), tyrosine kinase B (TrkB), cyclooxygenase-2 (COX-2), and inducible nitric oxide synthesis (iNOS) in the sciatic nerve were performed. The right sciatic nerve was crushed for 30 sec using a surgical clip. The animals in the diosgenin-treated groups received orally once a day at the respective doses for 7 consecutive days, starting one day after surgery. Sciatic crushed nerve injury showed characteristic gait changes showing decrease of SFI value. Diosgenin treatment increased the SFI value and suppressed nerve injury-induced c-Fos expression in the vlPAG and PVN. Diosgenin treatment inhibited nerve injury-induced increase of BDNF, TrkB, COX-2, and iNOS expressions. It is possible that diosgenin can be used as the new therapeutic agent for pain control and functional recovery following peripheral nerve injury.

Effects of muscle relaxants on ischaemia damage in skeletal muscle

Muscle ischaemia is frequently induced intraoperatively by i.e. a surgical tourniquet or during the re-grafting phase of a free muscle transplant. The resulting muscle cell damage may impact on postoperative recovery. Neuromuscular paralysis may mitigate the effects of ischaemia. After ethics approval, 25 male Sprague-Dawley rats were anaesthetized and randomly assigned to 1 of 4 groups: Sham operation, treatment with normal saline, treatment with rocuronium (muscle relaxant) 0.6 or 1 mg kg⁻¹, respectively. In the non-sham groups, ischaemia of one hind leg was achieved by ligation of the femoral vessels. Muscle biopsies were taken at 30 and 90 min, respectively. Cell damage was assessed in the biopsies via the expression of dystrophin, free calcium, as well as the assessment of cell viability. Pre-ischaemia muscle relaxation led to a reduction in ischaemia-induced muscle cell damage when measured by the expression of dystrophin, cell viability and the expression of free calcium even after 90 min of ischaemia (i.e. ratio control/ischaemic site for dystrophin expression after saline 0.58 ± 0.12 vs. after 1 mg/kg rocuronium 1.08 ± 0.29; P < 0.05). Muscle relaxation decreased the degree of ischaemia-induced muscle cell damage. The results may have significant clinical implications.