Outbreak of a new coronavirus: what anaesthetists should know Philip W. H. Peng*, Pak-Leung Ho and Susy S. Hota Department of Anesthesiology and Pain Medicine, University Health Network, University of Toronto, Toronto, ON, Canada, Department of Microbiology and Carol Yu Centre for Infection, University of Hong Kong, Hong Kong, Infection Prevention and Control Department, University Health Network, Toronto, ON, Canada and Department of Medicine, University of Toronto, Toronto, ON, Canada
Mohamed R. El Tahan, Akhilesh Pahade, M. Gómez-Ríos
ERAS programs aim to reduce the length of hospital stays and lower costs, and minimize the risk of postoperative complications and readmissions while enhancing the overall patient experience. BMC Anesthesiology has initiated a new collection on ERAS, urging investigators to conduct large-scale, high-quality studies that address the existing knowledge gap.
Timely monitoring of anesthesia status during surgery is important to prevent an overdose of isoflurane anesthesia. Therefore, in-depth studies of the neural mechanisms of anesthetics are warranted. Hippocampal CA1 plays an important role during anesthesia. Currently, a high spatiotemporal resolution microdevice technology for the accurate detection of deep brain nuclei is lacking. In this research, four-shank 32-channel implantable microelectrode arrays (MEAs) were developed for the real-time recording of single-cell level neural information in rat hippocampal CA1. Platinum nanoparticles were modified onto the microelectrodes to substantially enhance the electrical properties of the microelectrode arrays. The modified MEAs exhibited low impedance (11.5 ± 1 kΩ) and small phase delay (-18.5° ± 2.54°), which enabled the MEAs to record single-cell level neural information with a high signal-to-noise ratio. The MEAs were implanted into the CA1 nuclei of the anesthetized rats, and the electrophysiological signals were recorded under different degrees of anesthesia mediated by low-dose concentrations of isoflurane. The recorded signals were analyzed in depth. Isoflurane caused an inhibition of spike firing rate in hippocampal CA1 neurons, while inducing low-frequency oscillations in CA1, thus enhancing the low-frequency power of local field potentials. In this manner, the spike firing rate and the power of local field potentials in CA1 could characterize the degree of isoflurane anesthesia. The present study provides a technical tool to study the neural mechanisms of isoflurane anesthesia and a research method for monitoring the depth of isoflurane anesthesia in clinical practice.
Precision medicine, characterized by the personalized integration of a patient’s genetic blueprint and clinical history, represents a dynamic paradigm in healthcare evolution. The emerging field of personalized anesthesia is at the intersection of genetics and anesthesiology, where anesthetic care will be tailored to an individual’s genetic make-up, comorbidities and patient-specific factors. Genomics and biomarkers can provide more accurate anesthetic protocols, while artificial intelligence can simplify anesthetic procedures and reduce anesthetic risks, and real-time monitoring tools can improve perioperative safety and efficacy. The aim of this paper is to present and summarize the applications of these related fields in anesthesiology by reviewing them, exploring the potential of advanced technologies in the implementation and development of personalized anesthesia, realizing the future integration of new technologies into clinical practice, and promoting multidisciplinary collaboration between anesthesiology and disciplines such as genomics and artificial intelligence.
Afshin Iranpour, Ramakrishna Boddapati, Sina Naghilou
et al.
Neuraxial anesthesia and analgesia are administered to many patients. The incidence of dural puncture is about 1%, with a higher occurrence in laboring women. Post dural puncture headache (PDPH) develops in 60%-80% of patients after unintentional dural puncture (UDP) which is usually positional and sometimes is accompanied by neck stiffness, photophobia, nausea, or hearing symptoms. It can also drive-up healthcare costs by increasing the length of hospital stay for chronic headache and back pain. PDPH has the potential to cause significant morbidity in the obstetric patients which prolongs the hospital stay. Epidural blood patch (EBP) is considered the gold standard for the management of PDPH. Proper scheduling of analgesics and supporting the patient psychologically as she cares for her newborn is needed. If the intensity of headache is severe, additional agents may be considered. In this review, the different methods and therapeutic approaches for prevention and treatment of PDPH are comprehensively discussed.
Prasanna Udupi Bidkar, Ankita Dey, Protiti Chatterjee
et al.
Target-controlled infusion (TCI) is a novel drug delivery system wherein a microprocessor calculates the rate of drug to be infused based upon the target plasma or effect site concentration set by the operator. It has found its place in the operation theaters and intensive care units (ICUs) for safe administration of intravenous anesthesia and analgosedation using drugs like propofol, dexmedetomidine, opioids, and so on. Operating a TCI device requires the user to have a primitive understanding of drug pharmacokinetics and pharmacodynamics and an awareness of the practical problems that can arise during its administration. Ongoing research supports their usage in other clinical settings and for various other drugs such as antibiotics, vasopressors, and so on. In this article, we review the underlying principles and commonly used drugs for TCI, the practical aspects of its implementation, and the scope of this technology in future. TCI technology is increasingly being used in the field of anesthesiology and critical care due to the myriad advantages it offers when compared to manual infusions. It is, therefore, essential for the reader to understand the relevant principles and practical aspects related to TCI technology, as well as to be aware of the commonly used TCI models.
The current strategy of co-delivering copper ions and disulfiram (DSF) to generate cytotoxic CuET faces limitations in achieving rapid and substantial CuET production, specifically in tumor lesions. To overcome this challenge, we introduce a novel burst-release cascade reactor composed of phase change materials (PCMs) encapsulating ultrasmall Cu2-xSe nanoparticles (NPs) and DSF (DSF/Cu2-xSe@PCM). Once triggered by second near-infrared (NIR-II) light irradiation, the reactor swiftly releases Cu2-xSe NPs and DSF, enabling catalytic reactions that lead to the rapid and massive production of Cu2-xSe-ET complexes, thereby achieving in situ chemotherapy. The mechanism of the burst reaction is due to the unique properties of ultrasmall Cu2-xSe NPs, including their small size, multiple defects, and high surface activity. These characteristics allow DSF to be directly reduced and chelated on the surface defect sites of Cu2-xSe, forming Cu2-xSe-ET complexes without the need for copper ion release. Additionally, Cu2-xSe-ET has demonstrated a similar (to CuET) anti-tumor activity through increased autophagy, but with even greater potency due to its unique two-dimensional-like structure. The light-triggered cascade of interlocking reactions, coupled with in situ explosive generation of tumor-suppressive substances mediated by the size and valence of Cu2-xSe, presents a promising approach for the development of innovative nanoplatforms in the field of precise tumor chemotherapy.
Materials of engineering and construction. Mechanics of materials, Biology (General)
Introduction Patients undergoing major spine surgery usually experience moderate-to-severe postoperative pain. It has been shown that dexamethasone as an adjunct to local anaesthesia (LA) infiltration presented a superior analgesic benefit compared with LA alone in various types of surgeries. However, a recent meta-analysis reported that the overall benefits of dexamethasone infiltration were marginal. Dexamethasone palmitate (DXP) emulsion is a targeted liposteroid. Compared with dexamethasone, DXP has a stronger anti-inflammatory effect, longer duration of action and fewer adverse effects. We hypothesised that the additive analgesic effects of DXP on local incisional infiltration in major spine surgery may have better postoperative analgesic effect, compared with local anaesthetic alone. However, no study has evaluated this so far. The purpose of this trial is to determine whether pre-emptive coinfiltration of DXP emulsion and ropivacaine at surgical site incision will further reduce postoperative opioid requirements and pain scores after spine surgery than that with ropivacaine alone.Methods and analysis This is a prospective, randomised, open-label, blinded endpoint, multicentre study. 124 patients scheduled for elective laminoplasty or laminectomy with no more than three levels will be randomly allocated in a 1:1 ratio into two groups: the intervention group will receive local incision site infiltration with ropivacaine plus DXP; the control group will receive infiltration with ropivacaine alone. All participants will complete a 3 months follow-up. The primary outcome will be the cumulative sufentanil consumption within 24 hours after surgery. The secondary outcomes will include further analgesia outcome assessments, steroid-related side effects and other complications, within the 3 months follow-up period.Ethics and dissemination This study protocol has been approved by the Institutional Review Board of Beijing Tiantan Hospital (KY-2019-112-02-3). All participants will provide a written informed consent. The results will be submitted for publication in a peer-reviewed journals.Trial registration number NCT05693467.
The prevalent use of electronic cigarettes (e-cigarettes) has increased exponentially in recent years, especially in youth who are attracted to flavored e-cigarettes. Indeed, e-cigarette or vaping product use-associated lung injury (EVALI) cases started to emerge in the United States in August 2019, resulting in 2807 hospitalized cases and 68 deaths as of 18 February 2020. In the present study, we investigated, for the first time, whether flavored and nicotine containing e-cigarettes induce endothelial dysfunction to result in impaired angiogenesis and wound healing particularly under diabetic condition. Nicotine containing e-cigarettes with various contents of nicotine (0, 1.2%, 2.4%), and flavored e-cigarettes of classic tobacco, mint, menthol, and vanilla or fruit from BLU (nicotine 2.4%) or JUUL (nicotine 3%), were used to treat endothelial cells in vitro and streptozotocin-induced diabetic mice in vivo. Endothelial cell superoxide production, determined by dihydroethidium (DHE) fluorescent imaging and electron spin resonance (ESR), was markedly increased by exposure to e-cigarette extract (e-CSE) in a nicotine-content dependent manner, while nitric oxide (NO) bioavailability detected by DAF-FM fluorescent imaging was substantially decreased. All of the different flavored e-cigarettes examined also showed significant effects in increasing superoxide production while diminishing NO bioavailability. Endothelial cell apoptosis evaluated by caspase 3 activity was markedly increased by exposure to e-CSE prepared from flavored and nicotine containing e-cigarettes. Endothelial monolayer wound assays revealed that nicotine-containing and flavored e-cigarettes induced impaired angiogenic wound repair of endothelial cell monolayers. Furthermore, vascular endothelial growth factor (VEGF) stimulated wound healing in diabetic mice was impaired by exposure to e-CSEs prepared from nicotine-containing and flavored e-cigarettes. Taken together, our data demonstrate for the first time that flavored and nicotine-containing e-cigarettes induce endothelial dysfunction through excessive ROS production, resulting in decreased NO bioavailability, increased endothelial cell apoptosis, and impairment in angiogenesis and wound healing, especially under diabetic condition. These responses of endothelial dysfunction likely underlie harmful effects of e-cigarettes in endothelial-rich organs, such as heart and lungs. These data also indicate that rigorous regulation on e-cigarette use should be enforced in diabetic and/or surgical patients to avoid severe consequences from impaired angiogenesis/wound healing.
Sohila Esfandiari, Abdolrasoul Anvaripour, Kamran Mirzaei
et al.
Background: Delayed awakening is one of the biggest challenges after general anesthesia and surgery. Hypothermia is common after coronary artery bypass surgery, and even mild hypothermia can cause severe complications after surgery. It is important to know the effective methods in accelerating awakening and correcting hypothermia.
Materials and Methods: In this randomized clinical trial, Warm Touch forced air warming system was compared with routine method (a blanket) in increasing tympanic temperature and FOUR score in patients after elective coronary artery bypass surgery. A total of102 patients were equally divided into intervention and control groups. Tympanic temperature and FOUR Score were checked and recorded every 15 minutes for 225 minutes.
Results: Tympanic temperature and FOUR Score were significantly higher in the intervention group (P<0.001).
Conclusion: Forced air warming system was more effective in increasing tympanic temperature and FOUR Score compared to the routine method. Awakening time was shorter and tympanic temperature increased faster.
Background: Most previous reports have used questionnaires to investigate patient satisfaction regarding anesthesia-related care. We retrospectively investigated the dissatisfaction rate for anesthesia and the contributing factors for it using a questionnaire including anesthesia-related adverse events and a simplified patient satisfaction scale. Methods: This is a retrospective review of an institutional registry containing 21,606 anesthesia cases. We conducted multivariate logistic analysis in 9,429 patients using the incidence of dissatisfaction as a dependent variable and other covariates, including items of anesthesia registry and a postoperative questionnaire, as independent variables to investigate factors significantly associated with the risk of dissatisfaction with anesthesia. Results: In the study population, 549 patients rated the anesthesia service as dissatisfactory. Multivariate analysis identified the preoperative presence of coexisting disease [odds ratio (OR), 1.29; 95% confidence interval (CI), 1.05–1.59], combination of regional anesthesia (OR, 1.44; 95% CI, 1.10–1.88), self-reported awareness (OR, 1.99; 95% CI, 1.29–3.06), postoperative nausea and vomiting (PONV) (OR, 1.54; 95% CI, 1.25–1.90), occurrence of nightmares (OR, 1.96; 95% CI, 1.52–2.53), and the number of days taken to visit a postoperative anesthesia consultation clinic (OR, 1.01; 95% CI, 1.00–1.02) to be independently associated with dissatisfaction with anesthesia service. Conclusions: Patients with coexisting disease, undergoing a combination of regional anesthesia, with self-reported awareness, experiencing PONV, suffering from nightmares, and who took longer to visit a postoperative anesthesia consultation clinic tended to rate our anesthesia service as dissatisfactory. Although the exact reasons for the factors contributing to dissatisfaction are unknown, this study suggests that there is room to improve our service.
Background: The most critically ill patients with coronavirus disease 2019 (COVID-19) may require advanced support modalities, such as veno-venous extracorporeal membrane oxygenation (VV-ECMO). A systematic, methodical approach to a respiratory pandemic on a state and institutional level is critical. Methods: We conducted retrospective review of our institutional response to the COVID-19 pandemic, focusing on the creation of a dedicated airlock biocontainment unit (BCU) to treat patients with refractory COVID-19 acute respiratory distress syndrome (CARDS). Data were collected through conversations with staff on varying levels in the BCU, those leading the effort to make the BCU and hospital incident command system, email communications regarding logistic changes being implemented, and a review of COVID-19 patient census at our institution from March through June 2020. Results: Over 2100 patients were successfully admitted to system hospitals; 29% of these patients required critical care. The response to this respiratory pandemic augmented intensive care physician staffing, created a 70-member nursing team, and increased the extracorporeal membrane oxygenation (ECMO) capability by nearly 200%. During this time period, 40 COVID-19 patients on VV-ECMO were managed in the BCU. Challenges in an airlock unit included communication, scarcity of resources, double-bunking, and maintaining routine care. Conclusions: Preparing for a surge of critically ill patients during a pandemic can be a daunting task. The implementation of a coordinated, system-level approach can help with the allocation of resources as needed. Focusing on established strengths of hospitals within the system can guide triage based on individual patient needs. The management of ECMO patients is still a specialty care, and a systematic and hospital based approach requiring an ECMO team composed of multiple experienced individuals is paramount during a respiratory viral pandemic.
Terje Jansson Timan, Gustav Hagberg, Ninni Sernert
et al.
Abstract Background Emergency laparotomy (EL) is a central, high-risk procedure in emergency surgery. Patients in need of an EL present an acute pathology in the abdomen that must be operated on in order to save their lives. Usually, the underlying condition produces an affected physiology. The perioperative management of this critically ill patient group in need of high-risk surgery and anaesthesia is challenging and related to high mortality worldwide. However, outcomes in Sweden have yet to be studied. This retrospective cohort study explores the perioperative management and outcome after 710 ELs by investigating mortality, overall length of stay (LOS) in hospital, need for care at the intensive care unit (ICU), surgical complications and a general review of perioperative management. Methods Medical records after laparotomy was retrospectively analysed for a period of 38 months (2014–2017), the emergency cases were included. Children (< 18 years), aortic surgery, second look and other expected reoperations were excluded. Demographic, management and outcome data were collected after an extensive analysis of the cohort. Results A total of 710 consecutive operations, representing 663 patients, were included in the cohort (mean age 65.6 years). Mortality (30 days/1 year) after all operations was 14.2% and 26.6% respectively. The mean LOS in hospital was 12 days, while LOS in the ICU was five days. Of all operations, 23.8% patients were admitted at any time to the ICU postoperatively and the 30-day mortality seen among ICU patients was 37.9%. Mortality was strongly correlated to existing comorbidity, high ASA classification, ICU care and faecal peritonitis. The mean/median time from notification to operate until the first incision was 3:46/3:02 h and 87% of patients had their first incision within 6 h of notification. Conclusions In this present Swedish study, high mortality and morbidity were observed after emergency laparotomy, which is in agreement with other recent studies. Trial registration: The study has been registered with ClinicalTrials.gov (NCT03549624, registered 8 June 2018).
Akiko Ito, Masahiro Fukaya, Takeyuki Sugawara
et al.
Group I metabotropic glutamate receptors (mGluRs), mGluR1 and mGluR5, in the spinal cord are implicated in nociceptive transmission and plasticity through G protein-mediated second messenger cascades leading to the activation of various protein kinases such as extracellular signal-regulated kinase (ERK). In this study, we demonstrated that cytohesin-2, a guanine nucleotide exchange factor for ADP ribosylation factors (Arfs), is abundantly expressed in subsets of excitatory interneurons and projection neurons in the superficial dorsal horn. Cytohesin-2 is enriched in the perisynapse on the postsynaptic membrane of dorsal horn neurons and forms a protein complex with mGluR5 in the spinal cord. Central nervous system-specific cytohesin-2 conditional knockout mice exhibited reduced mechanical allodynia in inflammatory and neuropathic pain models. Pharmacological blockade of cytohesin catalytic activity with SecinH3 similarly reduced mechanical allodynia and inhibited the spinal activation of Arf6, but not Arf1, in both pain models. Furthermore, cytohesin-2 conditional knockout mice exhibited reduced mechanical allodynia and ERK1/2 activation following the pharmacological activation of spinal mGluR1/5 with 3,5-dihydroxylphenylglycine (DHPG). The present study suggests that cytothesin-2 is functionally associated with mGluR5 during the development of mechanical allodynia through the activation of Arf6 in spinal dorsal horn neurons.