Long-term Outcome After Anesthesia and Surgery: Remarks on the Biology of a Newly Emerging Principle in Perioperative Care

Utilization of Supplemental Regional Anesthesia in Lobectomy for Lung Cancer in the United States: A Retrospective Study

Background

Pulmonary lobectomy is the standard of care for the treatment of early-stage non-small cell lung cancer. This study investigated the rate of utilization of supplemental anesthesia in patients undergoing video-assisted thoracoscopic surgery (VATS) or open lobectomy using a national database and assessed the effect of regional block (RB) on postoperative outcomes.

Methods

Patients who underwent lobectomy for lung cancer between 2014–2019 were identified in the American College of Surgeons National Surgical Quality Improvement Program. The patients’ primary mode of anesthesia and supplemental anesthesia were recorded. Preoperative characteristics and postoperative outcomes were compared between 2 surgical groups those who underwent general anesthesia (GA) alone versus GA with RB. Multivariable regression analyses were performed on the outcomes of interest.

Results

In total, 13,578 patients met the study criteria, with 87% undergoing GA and the remaining 13% receiving GA and RB. The use of neuraxial anesthesia decreased over the years, while RB use increased up to 20% in 2019. Age, body mass index, and preoperative comorbidities were comparable between groups. Patients who underwent VATS were more likely to receive RB than those who underwent thoracotomy. RB was most often utilized by thoracic surgeons. An adjusted analysis showed that RB use was associated with shorter hospital stays and a reduced likelihood of prolonged length of stay, but a higher rate of surgical site infections (SSIs).

Conclusion

In a large surgical database, there was underutilization of supplemental anesthesia in patients undergoing lobectomy for lung cancer. RB utilization was associated with a shorter length of hospital stay and an increase in SSI incidence.

Effects of two formulations containing Phyllanthus emblica and Tinospora cordifolia with and without Ocimum sanctum in immunocompromised mice

Background

Current pandemic has led us to explore the role of traditional system of medicine to look for formulations that enhance immunity.

Objective

The obejctive of this experimental study was to evaluate the immunomodulatory effects of two formulations, Tinospora cordifolia (Tc) and Phyllanthus emblica (Pe) with and without coating of Ocimum sanctum (Os).

Materials and methods

After obtaining Institutional Animal Ethics Committee approval, present experimental study was conducted to evaluate the immunomodulatory effects of plant drug formulations against infection induced in mice subjected to major surgical stress. Hemisplenectomy was selected to induce major stress and the procedure for hemisplenectomy was standardized. A model of secondary fungal infection after hemisplenectomy was established followed by the treatment of mice with plant drugs and controls. They were subjected to hemisplenectomy or sham operation and 10⁵ C. albicans were injected intravenously. The therapy continued for next 14 days. Kidneys were isolated to estimate fungal load. Fungal load of the kidneys was estimated on post-operative Day 15.

Results

The test formulations Tc + Pe and Tc + Pe + Os showed significant reduction in the fungal burden of kidneys as compared to hemisplenectomized control group. However, Tc alone exerted better degree of protection as compared to Tc + Pe and Tc + Pe + Os.

Conclusion

The formulations, Tc + Pe and Tc + Pe + Os that were developed on the basis of theoretical concepts were not found to be superior to Tc. Though the individual ingredients have been shown to possess immunnostimulant activities, in combination, Pe and Os blunted the effects of Tc. The basis for this drug interaction needs further exploration. Thus, the current experimental study validates immunomodulatory role of Tc. However, the addition of Pe with bhavana of Os does not lead to any augmentation of immunomodulatory activity of Tc. This study also underlines the need to generate data on Ayurveda formulations to understand the rationality of the multi-ingredient Ayurvedic formulations.

Influence of postoperative complications on long-term outcome after oncologic lung resection surgery. Substudy of a randomized control trial

Lung resection surgery (LRS) causes an intense local and systemic inflammatory response. There is a relationship between inflammation and postoperative complications (POCs). Also, it has been proposed that the inflammation and complications related with the surgery may promote the recurrence of cancer and therefore deterioration of survival. We investigated the association between inflammatory biomarkers, severity of POCs and long-term outcome in patients who were discharged after LRS. This is a prospective substudy of a randomized control trial. We established three groups based in the presence of POCs evaluated by Clavien-Dindo (C-D) classification: Patients with no postoperative complications (No-POCs group) (C-D = 0), patients who developed light POCs (L-POCs group) (C-D = I-II), and major POCs (M-POCs group) (C-D = III, IV, or V). Kaplan-Meier curves and Cox regression model were created to compare survival and oncologic recurrence in those groups. Patients who developed POCs (light or major) had an increase in some inflammatory biomarkers (TNF-α, IL-6, IL-7, IL-8) compared with No-POCs group. This pro-inflammatory status plays a fundamental role in the appearance of POCs and therefore in a shorter life expectancy. Individuals in the M-POCs group had a higher risk of death (HR = 3.59, 95% CI 1.69 to 7.63) compared to individuals in the No-POCs group (p = 0.001). Patients of L-POCs group showed better survival than M-POCs group (HR = 2.16, 95% CI 1.00 to 4.65, p = 0.049). Besides, M-POCs patients had higher risk of recurrence in the first 2 years, when compared with L-POCs (p = 0,008) or with No-POCs (p = 0.002). In patients who are discharged after undergoing oncologic LRS, there is an association between POCs occurrence and long term outcome. Oncologist should pay special attention in patients who develop POCs after LRS.

REGIONAL ANAESTHESIA IN THORACIC AND ABDOMINAL SURGERY

Surgical procedure causes tissue damage which activates systemic inflammatory response and leads to changes in endocrine and metabolic system. Anaesthesia and pain can further disrupt immune performance. Regional anaesthesia causes afferent nerve blockade and in this way mediates immune protection. Thoracic epidural analgesia is the cornerstone of pain relief in thoracic and abdominal surgery. Alternatively thoracic paravertebral block can be used with less side effects and good analgesic properties. Drugs that interfere with blood coagulation obstruct the use of central regional blocks. Surgery has also changed recently from open to minimally invasive. Also pain treatment for this procedures has changed to less aggressive, systemic or locoregional techniques. It was shown that transversus abdominis plane block and epidural analgesia have the same effect on postoperative pain, but transversus abdominis plane block was better regarding hemodynamic stability and hospital stay. Multimodal approach combining regional and systemic analgesia is currently the most appropriate perioperative pain management strategy. More studies should be done to give recommendations.

Isoflurane decreases interleukin-2 production by increasing c-Cbl and Cbl-b expression in rat peripheral blood mononuclear cells

Objective

To evaluate how isoflurane affects T-cell function by assaying interleukin (IL)-2 production and the expression of two Casitas B-lineage lymphoma (Cbl) family proto-oncogenes (c-Cbl and Cbl-b) in rat peripheral blood mononuclear cells (PBMCs).

Methods

Adult male Sprague–Dawley rats were randomly allocated to those that underwent blood collection after brief isoflurane anesthesia (control group), immediately after 4 hours of isoflurane general anesthesia (4I group), and 1 day after 4 hours of isoflurane general anesthesia (1D 4I group). IL-1, IL-2, and IL-6 mRNA levels and c-Cbl and Cbl-b levels in PBMCs were determined by polymerase chain reaction. Ubiquitination of protein kinase Cθ (PKCθ) and phospholipase C-γ1 (PLC-γ1) in PBMCs was assessed by immunoprecipitation.

Results

The IL-2 mRNA level in rat PBMCs was significantly lower in the 4I and 1D 4I groups than in the control group. c-Cbl, Cbl-b, and ubiquitin expression was significantly increased and zeta-chain-associated protein kinase 70, PLC-γ1, and PKCθ protein levels were significantly decreased in the 4I group. Ubiquitination of PLC-γ1 and PKCθ was significantly increased in the 4I group.

Conclusion

Isoflurane influences ubiquitin, c-Cbl, and Cbl-b expression in rat PBMCs, indicating suppression of receptor tyrosine kinase signaling pathways. These results suggest that isoflurane suppresses T-cell function.

Anesthesia in patients with cancer disorders

PURPOSE OF REVIEW

Along with the increasing population of elderly people in developed countries, anesthesiologists have increasing opportunities to anesthetize cancer patients in their routine work. However, no guideline of anesthesia procedures for cancer patients is available even though guidelines of operative procedures have been formulated for different types of cancer. This review provides recent findings related to the optimal choice of anesthetics and adequate anesthesia management for cancer patients.

RECENT FINDINGS

The intrinsic weapon fighting cancer cells is competent immune cells, particularly CD4+ T helper 1-type cells, CD8+ cytotoxic T cells, and natural killer cells. However, surgical inflammation, some anesthetics, and inadvertent anesthesia management suppress these effector cells and induce suppressive immune cells, which render cancer patients susceptible to tumor recurrence and metastasis after surgery.

SUMMARY

Accumulated basic and clinical data suggest that total intravenous anesthesia with propofol, cyclooxygenase antagonists, and regional anesthesia can decrease negative consequences associated with perioperative immunosuppression. Volatile anesthesia, systemic morphine administration, unnecessary blood transfusions, intraoperative hypoxia, hypotension, hypothermia, and hyperglycemia should be avoided.

Postoperative mortality and complications

Recent publications not only underline the risks of age and disease during surgery but also help us quantify the risks with greater precision. Importantly, patient factors often have a stronger association with postoperative mortality than surgical factors. Important factors preoperatively are: age, American Society of Anaesthesiologist (ASA) physical status, emergency surgery, and plasma albumin concentration. There is emerging work on quantifying frailty as a further risk factor for perioperative complication and mortality as well as need for higher level of care after discharge from hospital. Important postoperative complications include sepsis and kidney injury. Preventing, detecting and managing complications and mortality is the greatest challenge facing those caring for surgical patients, including anaesthetists. Evidence for the long term effects of perioperative complications adds further importance to minimizing perioperative complications. Newer approaches in patient care, particularly co-management during the postoperative phase by different specialities are emerging. Managing high-risk patients should also be enhanced with greater surveillance and more rapid and appropriate response; ensuring we do not fail to rescue our patients.

Anti-Emetic Dexamethasone and Postoperative Infection Risk: A Retrospective Cohort Study

Nausea and vomiting are common complications of anaesthesia. Dexamethasone is an effective prophylaxis but is immunosuppressive and may increase postoperative infection risk. This retrospective cohort study examined the association between the administration of a single intraoperative anti-emetic dose of dexamethasone (4 to 8 mg) and postoperative infection in 439 patients undergoing single procedure, non-emergency surgery in a university trauma centre. Exclusion criteria included comorbidities, immunosuppressive medications or procedures that confer an increased infection risk. In the 10-week study period and three-month follow-up period, there were 98 documented infections (22.3% of the cohort), of which 43 were detected only on post-discharge follow-up. Anti-emetic dexamethasone was given to 108 patients (24.6%). Stepwise, multivariate logistic regression modelling identified significant associations between female gender, symptomatic reflux, respiratory disease and the risk of infection. The adjusted odds ratio for dexamethasone was 0.88 (0.5 to 1.5, P=0.656). We did not demonstrate an association between anti-emetic doses of dexamethasone and postoperative infection.

Postoperative complications in elderly patients and their significance for long-term prognosis

PURPOSE OF REVIEW

To outline perioperative risk factors for postoperative mortality in older patients, the relationship of these factors with long-term mortality, and to examine possible strategies to reduce mortality.

RECENT FINDINGS

For patients aged 70 years and over 30-day mortality is about 6%, whereas 20% are likely to have at least one complication during their hospital stay. The mortality risk increases by 10% for every year after age 70. Mortality is also strongly associated with preoperative status and postoperative complications, particularly systemic inflammation and renal impairment. Unplanned postoperative intensive care unit admission is an important predictor for mortality. Requirement for postoperative vasopressors or inotropes is associated with 50% mortality in patients aged 80 years or more. Early postoperative complications are likely to be associated with an increased long-term (a year or more later) mortality. Strategies such as critical care outreach may decrease both 30-day and long-term mortality.

SUMMARY

Strategies are needed to prevent, or at least adequately manage, complications in elderly patients. Agreed international definitions for risks and complications can help in assessing risks and benefits.

Anaesthesia and analgesia: contribution to surgery, present and future

Anaesthetists provide comprehensive perioperative medical care to patients undergoing surgical and diagnostic procedures, including postoperative intensive care when needed. They are involved in the management of perioperative acute pain as well as chronic pain. This manuscript considers some of the recent advances in modern anaesthesia and their contribution to surgery, from the basic mechanisms of action, to the delivery systems for general and regional anaesthesia, to the use of new drugs and new methods of monitoring. It assesses the resulting progress in acute and chronic pain services and looks at patient safety and risk management. It speculates on directions that may shape its future contributions to the management of the patient undergoing surgery.