Modifying the Stress Response - Perioperative Considerations and Controversies

Surgical Stress and Non-Surgery Related Stress Synergistically Trigger Meningeal CD8+ T Cells Accumulation and Subsequent Brain Dysfunction in Mice

Patients are usually highly stressed during the immediate perioperative period. It remains unclear whether increased stress contributes to postoperative brain dysfunction. Here, the clinical perioperative setting was mimicked via exploratory laparotomy and perioperative restraint stress. The stress response was assessed by measuring the levels of stress hormones and IL-6 in peripheral blood. Behaviors were evaluated with the open field, novel object recognition, and Barnes maze tests. We found that surgical stress and non-surgery-related stress synergistically trigger meningeal CD8+T cell accumulation, brain dysfunction, and increased stress hormone and IL-6 levels in the peripheral blood of adult mice, but simple surgical stress or non-surgery-related stress had no significant effect on these parameters. Limiting meningeal CD8+ T cell accumulation with an anti-CD8 antibody alleviated the impact of surgery plus perioperative stress on brain function, neuroinflammation, and neurogenesis. The partial elimination of microglia before surgery alleviated postoperative meningeal CD8+ T cell accumulation, cognitive dysfunction, and decreased hippocampal chemotactic factor levels. Our findings indicate that the synergistic effect of surgical stress and non-surgery-related stress contributes to postoperative brain dysfunction by triggering meningeal CD8+ T cell accumulation, suggesting the potential of limiting non-surgery-related stress as a preventive method for postoperative brain dysfunction.

Effect of Remimazolam- Vs Propofol-Based Intravenous Anesthesia on Surgical Stress Response and Post-Operative Immune Function in Patients with Gastric Radical Surgery

PURPOSE

This study aimed to compare the impact of remimazolam-based versus propofol-based intravenous anesthesia on surgical stress and post-operative immune function in patients undergoing gastric radical surgery.

PATIENTS AND METHODS

Sixty-eight patients aged 50 to 80 undergoing gastric radical surgery were randomly assigned to the remimazolam group (group R) or the propofol group (group P), receiving remimazolam or propofol-based intravenous anesthesia, respectively. The primary outcome measured was peri-operative serum stress indicators and lymphocyte subtypes. Secondary outcomes included hemodynamic vitals, recovery quality, postoperative pain profiles and potential adverse effects.

RESULTS

The demographic and surgical characteristics of the 60 analyzed patients were comparable. The absolute counts of CD3+CD4+ and CD3+CD8+ cell decreased significantly on POD1 compared with baseline. On POD3, the numbers of CD3+CD4+ cells in group R were lower than baseline and Group P, whereas the CD3+CD8+ cell counts in both groups were lower than baseline, with group R higher than group P. The CD3-CD16+CD56+ cell numbers in both groups on POD1 and POD3 decreased significantly compared to baseline with group P lower than group R on POD3. The serum levels of IL-1β, IL-6, TNF-α, ACTH and COR rose sharply 2 hours after the beginning of surgery compared to baseline. Notably, all these parameters in group R were higher than those in group P. Additionally, blood pressure and intra-operative vasoactive drug frequency in group R were higher than that in group P. No significant differences in recovery quality, postoperative pain profiles, and potential adverse effects were observed.

CONCLUSION

Remimazolam-based intravenous anesthesia might favour the recovery of cellular immune function in early postoperative period compared to propofol. On the contrary, remimazolam was inferior to propofol in suppressing surgical stress. Further studies with larger sample sizes are needed to confirm our findings.

Comprehensive review of perioperative factors influencing ferroptosis

The perioperative period encompasses all phases of patient care from the decision to perform surgery until full recovery. Ferroptosis, a newly identified type of regulated cell death, influences a wide array of diseases, including those affecting the prognosis and regression of surgical patients, such as ischemia-reperfusion injury and perioperative cognitive dysfunction. This review systematically examines perioperative factors impacting ferroptosis such as surgical trauma-induced stress, tissue hypoxia, anesthetics, hypothermia, and blood transfusion. By analyzing their intrinsic relationships, we aim to improve intraoperative management, enhance perioperative safety, prevent complications, and support high-quality postoperative recovery, ultimately improving patient outcomes.

Systemic inflammation and acute kidney injury after colorectal surgery

BACKGROUND

In this retrospective review, the relative importance of systemic inflammation among other causes of acute kidney injury (AKI) was investigated in 1224 consecutive colorectal surgery patients. A potential benefit from reducing excessive postoperative inflammation on AKI might then be estimated.

METHODS

AKI was determined using the Kidney Disease Improving Global Outcomes (KDIGO) criteria. The entire population (mixed group), composed of patients with or without sepsis, and a subpopulation of patients without sepsis (aseptic group) were examined. Markers indicative of inflammation were procedure duration, the first postoperative white blood cell (POD # 1 WBC) for the mixed population, and the neutrophil-to-lymphocyte ratio (POD #1 NLR) for the aseptic population. Multivariable logistic regression was then performed using significant (P < 0.05) predictors. The importance of inflammation among independent predictors of AKI and AKI-related complications was then assessed.

RESULTS

AKI occurred in 24.6% of the total population. For the mixed population, there was a link between inflammation (POD # 1 WBC) and AKI (P = 0.0001), on univariate regression. Medications with anti-inflammatory properties reduced AKI: ketorolac (P = 0.047) and steroids (P = 0.038). Similarly, in an aseptic population, inflammation (POD # 1 NLR) contributed significantly to AKI (P = 0.000). On multivariable analysis for the mixed and aseptic population, the POD #1 WBC and the POD #1 NLR were independently associated with AKI (P = 0.000, P = 0.022), as was procedure duration (P < 0.0001, P < 0.0001). Inflammation-related parameters were the most significant contributors to AKI. AKI correlated with complications: postoperative infections (P = 0.016), chronic renal insufficiency (CRI, P < 0.0001), non-infectious complications (P = 0.010), 30-day readmissions (P = 0.001), and length of stay (LOS, P < 0.0001). Inflammation, in patients with or without sepsis, was similarly a predictor of complications: postoperative infections (P = 0.002, P = 0.008), in-hospital complications (P = 0.000, P = 0.002), 30-day readmissions (P = 0.012, P = 0.371), and LOS (P < 0.0001, P = 0.006), respectively.

CONCLUSIONS

Systemic inflammation is an important cause of AKI. Limiting early postsurgical inflammation has the potential to improve postoperative outcomes.

Perioperative safety and efficacy of robot-assisted total hip arthroplasty in ERAS-managed patients: a pilot study

AIMS

Robot-assisted total hip arthroplasty (rTHA) boasts superior accuracy in implant placement, but there is a lack of effective assessment in perioperative management in the context of enhanced recovery after surgery (ERAS). This study aimed to compare the effectiveness and safety of rTHA versus conventional total hip arthroplasty (cTHA) in ERAS-managed patients.

METHODS

In this prospective trial, a total of 60 eligible patients aged between 18 and 80 years were randomly divided into two groups to undergo either rTHA or cTHA. The primary outcomes included blood loss parameters. Secondary outcomes were the duration of the operation, surgical time, WOMAC pain score, WOMAC stiffness score, WOMAC physical function score, Harris score, and postoperative complications.

RESULTS

The study cohort analyzed 59 eligible participants, 30 of whom underwent rTHA and 29 of whom underwent cTHA. Analysis could not be conducted for one patient due to severe anemia. Notably, the cTHA group had a significantly shorter surgical time than the rTHA group (69.49 ± 18.97 vs. 104.20 ± 19.63 min, P < 0.001). No significant differences were observed between the rTHA and cTHA groups for blood loss parameters, including total blood loss (1280.30 ± 404.01 vs. 1094.86 ± 494.39 ml, P = 0.137) and drainage volume (154.35 ± 121.50 vs. 159.13 ± 135.04 ml, P = 0.900), as well as intraoperative blood loss (126.67 ± 38.80 vs. 118.52 ± 60.68 ml, P = 0.544) and hidden blood loss (982.43 ± 438.83 vs. 784.00 ± 580.96 ml, P = 0.206). Only one patient in the cTHA group required allogeneic blood transfusion. At 3 months postoperatively, both groups showed improvements in WOMAC pain score, WOMAC stiffness score, WOMAC physical function score, and Harris score, with no significant differences found between the two groups. Few complications were reported in both groups without significant differences.

CONCLUSIONS

Despite the longer surgical time, rTHA did not negatively affect blood loss, pain, or functional recovery or lead to an increased risk of complications in ERAS-managed patients, suggesting that rTHA can be safely and effectively incorporated into an ERAS program for primary THA.

Role of Crystalloids in the Perioperative Setting: From Basics to Clinical Applications and Enhanced Recovery Protocols

Perioperative fluid management, a critical aspect of major surgeries, is characterized by pronounced stress responses, altered capillary permeability, and significant fluid shifts. Recognized as a cornerstone of enhanced recovery protocols, effective perioperative fluid management is crucial for optimizing patient recovery and preventing postoperative complications, especially in high-risk patients. The scientific literature has extensively investigated various fluid infusion regimens, but recent publications indicate that not only the volume but also the type of fluid infused significantly influences surgical outcomes. Adequate fluid therapy prescription requires a thorough understanding of the physiological and biochemical principles that govern the body's internal environment and the potential perioperative alterations that may arise. Recently published clinical trials have questioned the safety of synthetic colloids, widely used in the surgical field. A new clinical scenario has arisen in which crystalloids could play a pivotal role in perioperative fluid therapy. This review aims to offer evidence-based clinical principles for prescribing fluid therapy tailored to the patient's physiology during the perioperative period. The approach combines these principles with current recommendations for enhanced recovery programs for surgical patients, grounded in physiological and biochemical principles.

Anesthetic management of epilepsy surgery in a patient previously diagnosed with Takotsubo cardiomyopathy: A case report

RATIONALE

Takotsubo cardiomyopathy (TC), also known as stress cardiomyopathy, apical ballooning syndrome, octopus pot cardiomyopathy and broken heart syndrome, is characterized by wall motion abnormalities of the left ventricle.

PATIENT CONCERNS

Here, we reported a 73-year-old woman diagnosed with TC induced by epilepsy before 3 months presented to the authors' hospital with generalized tonic-clonic seizure. She was scheduled for intracranial tumor resection to cure the epilepsy.

DIAGNOSIS

She was diagnosed with epilepsy and TC. Interventions: Anesthesia management plays an important role in patients with a past history of TC.

OUTCOMES

At the 1-week follow-up, she had fully recovered without obvious abnormalities.

LESSONS SUBSECTIONS

We emphasize the importance of individualized anesthesia management in patients with a past history of TC.