A comparative study of intravenous lignocaine, dexamethasone and combination of lignocaine-dexamethasone in attenuating propofol induced pain

Background: General anesthesia is preferred during surgeries to reduce the pain stimuli in patients and to increase the precision of surgical procedure. Propofol is amongst the most widely used general anesthetic agent with limitation of induced pain during administration. Current study was conducted to compare the effect of intravenous pre-administration of various drugs in attenuating propofol induced pain. Methods: A comparative observational study was conducted on patients of either sex and aged between 18-60 years. Patients were divided in three groups, who received intravenous lignocaine, dexamethasone and combination of lignocaine-dexamethasone respectively to attenuate propofol induced pain. Different variables like HR, SBP, DBP, MAP, RR SpO2 and any adverse events were monitored in all the patients. Results: The 46.66% and 53.33% patients who received lignocaine and dexamethasone alone perceived propofol induced mild to moderate pain; while only 23.33% patients who received lignocaine and dexamethasone in combination perceived mild propofol induced pain. The propofol induced pain event was persistent in only 2 out of 30 patients after a time lapse of 30 seconds for the group receiving lignocaine and dexamethasone in combination. Whereas, the pain event was present even after time lapse of 30 seconds in 08 and 07 out of 30 patients of groups receiving lignocaine and dexamethasone alone.Conclusions: Pre-administration of lignocaine and dexamethasone in combination attenuated the propofol induced pain more significantly in comparison to single administration of mentioned drugs. No significant adverse events except perianal irritation were observed in some patients who received combination of lignocaine and dexamethasone intravenously.

GABAA Receptors in Astrocytes Are Targets for Commonly Used Intravenous and Inhalational General Anesthetic Drugs

Background: Perioperative neurocognitive disorders (PNDs) occur commonly in older patients after anesthesia and surgery. Treating astrocytes with general anesthetic drugs stimulates the release of soluble factors that increase the cell-surface expression and function of GABAA receptors in neurons. Such crosstalk may contribute to PNDs; however, the receptor targets in astrocytes for anesthetic drugs have not been identified. GABAA receptors, which are the major targets of general anesthetic drugs in neurons, are also expressed in astrocytes, raising the possibility that these drugs act on GABAA receptors in astrocytes to trigger the release of soluble factors. To date, no study has directly examined the sensitivity of GABAA receptors in astrocytes to general anesthetic drugs that are frequently used in clinical practice. Thus, the goal of this study was to determine whether the function of GABAA receptors in astrocytes was modulated by the intravenous anesthetic etomidate and the inhaled anesthetic sevoflurane.Methods: Whole-cell voltage-clamp recordings were performed in astrocytes in the stratum radiatum of the CA1 region of hippocampal slices isolated from C57BL/6 male mice. Astrocytes were identified by their morphologic and electrophysiologic properties. Focal puff application of GABA (300 μM) was applied with a Picospritzer system to evoke GABA responses. Currents were studied before and during the application of the non-competitive GABAA receptor antagonist picrotoxin (0.5 mM), or etomidate (100 μM) or sevoflurane (532 μM).Results: GABA consistently evoked inward currents that were inhibited by picrotoxin. Etomidate increased the amplitude of the peak current by 35.0 ± 24.4% and prolonged the decay time by 27.2 ± 24.3% (n = 7, P < 0.05). Sevoflurane prolonged current decay by 28.3 ± 23.1% (n = 7, P < 0.05) but did not alter the peak amplitude. Etomidate and sevoflurane increased charge transfer (area) by 71.2 ± 45.9% and 51.8 ± 48.9% (n = 7, P < 0.05), respectively.Conclusion: The function of astrocytic GABAA receptors in the hippocampus was increased by etomidate and sevoflurane. Future studies will determine whether these general anesthetic drugs act on astrocytic GABAA receptors to stimulate the release of soluble factors that may contribute to PNDs.

Gastroschisis: Impact of Bedside Closure on Ventilator-Associated Outcomes

Aim In our practice, preformed silos are routine rather than reserved for difficult cases. We aimed to identify whether silo and bedside closure can minimize: general anesthetic (GA) exposure, need for intubation and ventilation, or days intubated for neonates with simple gastroschisis (SG). Methods After approval, patients were identified via the neonatal discharge log (April 2010 to April 2019). Data were collected by case-note review and analyzed with respect to GA, ventilation, and core outcomes. Results Of 104 patients (50 female, mean birth weight 2.43 kg, mean gestational age 36 + 2 weeks), 85 were SG and 19 complex. Silo application was initial management in 70 SG, 57 completed successful bedside closure (by day 4 of life—median). Fifteen SG had initial operative closure.Of the 70 SG managed with silo, 46 (66%) had no GA as neonates. Twelve required GA for line insertion. Thirteen patients with initial silo had closure in theater (7 opportunistic at time of GA for line). Nine required intubation and ventilation out-with the operating theater during neonatal management. Seven had already been intubated at delivery; 3 because of meconium aspiration.One-hundred percent of those treated with operative closure had GA, 1 patient subsequently required surgery for subglottic stenosis. Time to full feeds did not differ between groups. Conclusion Silo and bedside closure allow the majority of SG neonates to avoid GA or intubation in the neonatal period, without increased risk of complication. However, it is important that the nursing expertise required to manage these patients safely is not underestimated.

Effects of Sevoflurane on Apoptosis of Myocardial Cells in IRI Rats

Background. Cardiomyocyte apoptosis functions essentially in ischemia/reperfusion- (I/R-) induced myocardial injury. It is suggested that autophagy is widely implicated in the regulation of cell survival and death. Sevoflurane, as a largely used inhalational general anesthetic, has been shown to have a protective effect on cardiomyocytes. However, it was yet elusive on the underlying mechanisms. Aim. The objective of this study is to investigate the association of sevoflurane-mediated cardioprotective effects with autophagy regulation. Methods. An in vitro hypoxia model was established in primary cardiomyocytes from fresh myocardial tissue of the rats. The apoptosis rate of myocardial cells treated with hypoxia and treated with sevoflurane was measured. Western blot and immunocytochemical assay were used to measure the protein expression. The cell proliferation rate and cell apoptosis were measured using the MTT assay and flow cytometry, respectively. Results. The expression of apoptotic proteins including B cell lymphoma-2 (Bcl-2), CCAAT/enhancer-binding protein homologous protein (CHOP), glucose-regulated protein 78 (GRP78), and Bcl-2-associated X protein (BAX) in myocardium treated with sevoflurane was significantly lower than that in myocardium treated with hypoxia. The expression of adhesion proteins such as intercellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1), and E-selectin in myocardium treated with sevoflurane was higher than that in myocardium treated with hypoxia, suggesting better connectivity of the myocardium. Conclusion. Sevoflurane treatment reduced the apoptosis of myocardial cells after hypoxia treatment.

ATPase Inhibitory Factor 1 Is Critical for Regulating Sevoflurane-Induced Microglial Inflammatory Responses and Caspase-3 Activation

Postoperative delirium (POD) is one of the most important complications after surgery with general anesthesia, for which the neurotoxicity of general anesthetics is a high-risk factor. However, the mechanism remains largely unknown, which also hinders the effective treatment of POD. Here, we confirmed that a clinical concentration of the general anesthetic sevoflurane increased the expression of inflammatory factors and activated the caspase-3 by upregulating ATPase inhibitory factor 1 (ATPIF1) expression in microglia. Upregulation of ATPIF1 decreased the synthesis of ATP which is an important signaling molecule secreted by microglia. Extracellular supplementation with ATP attenuated the microglial inflammatory response and caspase-3 activation caused by sevoflurane or overexpression of ATPIF1. Additionally, the microglial inflammatory response further upregulated ATPIF1 expression, resulting in a positive feedback loop. Animal experiments further indicated that intraperitoneal injection of ATP significantly alleviated sevoflurane anesthesia-induced POD-related anxiety behavior and memory damage in mice. This study reveals that ATPIF1, an important protein regulating ATP synthesis, mediates sevoflurane-induced neurotoxicity in microglia. ATP supplementation may be a potential clinical treatment to alleviate sevoflurane-induced POD.

Unexpected difficult extubation of double lumen bronchial intubation: a case report

Background The anesthetist and other members of the perioperative team need to be extremely cautious for successful completion of any surgery. If the final step of any general anesthetic-extubation is not sufficiently well planned, it can lead to critical airway incidents during the extubation and hinder transportation of the patient to the post-anesthesia care unit. Case presentation A 48-year-old female underwent video-assisted thoracoscopic surgery (VATS) combined with left lower lobectomy. The distal end of the left branch of the tracheal tube was lodged by surgical sutures. In this case, the respiratory physician burned the sutures using an argon electrode, after discussion with the thoracic surgery experts. Conclusions Teamwork is essential when caring for a patient with a shared airway. The anesthetist and surgeon must communicate well with each other to achieve optimal surgical outcomes. Importantly, testing the patency of the ETT prior to extubation should be a regular procedure, which is practical significance to guide safe extubation.

Monitoring Temperature in Children Under General Anesthesia: Nasopharynx Versus Carotid Artery Surface

Continuous body temperature monitoring during anesthesia in children is very important. Hypothermia in children may lead to higher morbidity and mortality. Measurement points to detect the temperature of core body are not simply accessible. In this study we measured the skin temperature over the carotid artery and compared it with the nasopharynx. Totally, 84 children of 2-10 years undergoing elective surgery were selected. Temperature over the carotid artery and nasopharynx was measured during anesthesia. Mean temperature of these points was compared which each other, and the effects of age, sex, and weight change of temperature during anesthesia were evaluated. The mean age of patients was 5.4±2.6 years s. 37% of patients were female, and 63% were male. The mean weight was 20±7 kg. The mean duration of surgery was 60.45±6.65 min. The temperature of the skin and nasopharynx was decreased during surgery as after 60 min, the deference between skin over the carotid artery and the nasopharyngeal area was 1° C. The bodyweight has a significant effect on carotid skin temperature in regression model. Skin temperature over the carotid artery, with a simple correction factor of+1° C, provides a viable noninvasive estimate of nasopharyngeal temperature in children during elective surgery with a general anesthetic.

The incidence of postoperative cardiac arrest and pre-resuscitation factors associated with post- cardiopulmonary resuscitation mortality: a single-center study in Thailand

Background: The author aimed to determine the incidence of in-hospital postoperative cardiac arrest requiring cardiopulmonary resuscitation (CPR), postoperative CPR mortality and pre-resuscitation factors associated with post CPR mortality. Method: A retrospective cohort study was conducted at King Chulalongkorn Memorial Hospital in Thailand from September 2018 through August 2020. A total of 34,590 adult patients underwent surgical procedures under anesthesia were recruited by electronic data recorded review. A subset of patients with postoperative CPR was collected for demographic data, comorbidities, ASA classification, operative time, functional class, types of surgery, postoperative complications, the number of deaths and survival, and SOS score at 4 hours preceding cardiac arrest. Results: A total of 34,590 adult surgical patients were recruited. In-hospital postoperative cardiac arrest incidence was 12 patients per 10,000 surgeries and predominated in emergency operation (28 per 10,000 surgeries; P< 0.0001). Risk ratio of emergency operation resulted in postoperative CPR was 3.15 (95% CI 1.72-5.77; P<0.001). Postoperative cardiac arrest patients aged 64.07 ± 16.58. The BMI was 23.46 ± 5.83. Mostly they were in ASA category 3 (44.2%). Everyone had general anesthetic procedures. The most common comorbidity was hypertension. In-hospital postoperative CPR mortality was 62.8%. Factors possibly predisposed to it were functional class < 4 METS, colorectal surgery and SOS score at 4 hours prior to cardiac arrest of at least 8. Conclusion: Incidence of in-hospital postoperative cardiac arrest and mortality after CPR in the study tended to be lower than that of previous studies. Emergency operations predisposed to cardiac arrest. SOS score was possibly valuable as a prognostication tool, ICU triage, as well as, a part of the early warning score to prevent the overwhelming crisis. Surveillance for patient’s deterioration, effective rapid response system, and comprehensive preoperative rehabilitation should be emphasized.

The Role of General Anesthetic Drug Selection in Cancer Outcome

Cancer remains to be the leading cause of death globally. Surgery is a mainstay treatment for solid tumors. Thus, it is critical to optimize perioperative care. Anesthesia is a requisite component for surgical tumor resection, and general anesthesia is given in the vast majority of tumor resection cases. Because anesthetics are growingly recognized as immunomodulators, it is critical to optimize anesthetic regimens for cancer surgery if the selection can affect outcomes. Here, we reviewed the role of volatile and intravenous anesthesia used for cancer surgery in cancer recurrence.

Unexpected Anesthetic Circuit Leak Attributed to Improper Use of a Tube Holder: A Case Report

Leaks involving the anesthesia circuit can cause significant complications including hypoxia and hypoventilation. We present a case of a circuit leak caused by damage to the corrugated tubing attributed to improper use of the tube holder. A 58-year-old male was scheduled for resection of a palatal tumor under an intubated general anesthetic. After successful nasotracheal intubation, the anesthesiologist inserted the corrugated tubing of the anesthetic circuit into the tube holder. A leaking sound was heard and a tear in the corrugated tubing was promptly discovered. The corrugated tubing of the anesthetic circuit presumably tore because it was inserted into the groove of the tube holder at an inappropriate angle with excessive force. Anesthesiologists should be aware of potential leaks if the anesthesia circuit is damaged, which may be caused by improper use of tube holders.