The Anti-Inflammatory and Antioxidant Effects of Propofol and Sevoflurane in Children With Cyanotic Congenital Heart Disease

Combined administration of dexmedetomidine and propofol mitigates myocardial ischemia/reperfusion injury by modulating the Akt/mTOR/Nrf2 axis to suppress ferroptosis

Myocardial ischemia/reperfusion injury (MIRI) poses a significant threat to human health, necessitating the development of novel therapeutic strategies. Although the protective effects of dexmedetomidine (Dex) and propofol (PPF) in mitigating MIRI have been documented, the mechanisms underlying their synergistic effects remain unclear. In an in vivo model, rats underwent surgical induction of MIRI, followed by intravenous administration of Dex and/or PPF 10 or 20 min before reperfusion. Myocardial function, markers of myocardial injury, and protein expression levels of the protein kinase B (Akt)/mammalian target of rapamycin (mTOR) and nuclear factor erythroid 2-related factor 2 (Nrf2)/glutathione peroxidase 4 (Gpx4) pathways were assessed. In in vitro model, H9C2 cardiomyocytes were subjected to hypoxia/reoxygenation (H/R), and the following parameters were evaluated: protein expression levels of phosphorylated mTOR and the mRNA level of Nrf2 and Nrf2, cell viability, lactate dehydrogenase concentration, and reactive oxygen species levels. Co-immunoprecipitation assays were conducted to investigate the interplay between the Akt/mTOR and Nrf2/Gpx4 signaling pathways (a schematic representation is provided in Figure 1). The combined administration of Dex and PPF demonstrated superior efficacy compared to either agent alone in mitigating MIRI and H/R-induced injuries. This was evidenced by improved myocardial function, reduced myocardial injury, and inhibition of ferroptosis through modulation of the Akt/mTOR and Nrf2/Gpx4 pathways and their interaction. In conclusion, the combination of Dex and PPF alleviates MIRI by modulating the interaction between the Akt/mTOR and Nrf2/Gpx4 pathways to inhibit ferroptosis, providing a promising therapeutic strategy for MIRI.

Esketamine mitigates systemic inflammation via modulating phenotypic transformation of monocytes in patients undergoing thoracic surgery

AIM

To assess esketamine's anti-inflammatory effects during thoracic surgery and its modulation of immune responses.

MATERIAL AND METHODS

In a randomized trial, 64 of 73 patients undergoing thoracic surgery were allocated into the Control (not receiving esketamine) or the ES-KTM group (intraoperative esketamine infusion). Blood routine tests were conducted one day before (T0) and one day after the surgery (T3). Plasma levels of tumor necrosis factor-α (TNF-α) and interleukine-10 (IL-10) were analyzed by ELISA, and cell surface markers including CD14, CD16, CD163, CD40, CX3CR1, CD206 were tested by cytometry at the entry to the surgical room (T1) and the skin closure (T2). For the in vitro study, esketamine at 10 μM was employed to treat the lipopolysaccharide (LPS) stimulated macrophage cell line-Raw264.7, and its effects were tested by cytometry and RNA sequencing analysis.

KEY FINDINGS

Esketamine application reduces the count of neutrophils and monocytes, neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR) and systemic inflammatory index (SII), and enhances the lymphocyte counting and lymphocyte to monocyte ratio (LMR). Then, esketamine application decreases the plasma TNF-α levels, while maintaining the IL-10 level in comparison with the Control group. Additionally, esketamine reduced the proportion of intermediate monocytes, downregulates the expressions of CD16, CD40 and CX3CR1, while upregulates the CD206 expression. Finally, in the in-vitro study, esketamine inhibits the M1 pro-inflammatory markers in LPS-challenged macrophages, and downregulates multiple immune-related pathways.

SIGNIFICANCE

Esketamine mitigates surgery-triggered inflammation by suppressing monocyte/macrophage proinflammatory activity and TNF-α release, offering dual anesthetic and immunomodulatory benefits.

Effects of Sevoflurane and Propofol During Mechanical Ventilation: A Meta-analysis of Randomized Controlled Trials

PURPOSE

To compare the inflammatory response, hemodynamic stability, and postoperative recovery of sevoflurane versus propofol after mechanical ventilation during surgery, to provide references for rational anesthesia utility in clinical practice by meta-analysis.

DESIGN

Systematic review and meta-analysis.

METHODS

Pubmed, Web of Science, Cochrane Library, Wanfang Data, China National Knowledge Infrastructure, and Chinese BioMedical Literature Database were searched by computer for trials on the anesthetic effects of sevoflurane and propofol after mechanical ventilation during surgery. A random- or fixed-effects model was applied to analyze the clinical indicators and adverse impact based on heterogeneity.

FINDINGS

As of April 21, 2023, 912 articles were retrieved, and 36 eligible articles were finally identified after screening, covering 2,691 surgical patients for meta-analysis. The combined results exhibited that the level of tumor necrosis factor (TNF)-α in alveolar lavage was significantly different between the 2 groups (-0.94, 95% confidence interval [CI]: -1.82 to -0.05, P = .038). Compared with sevoflurane, propofol significantly increased TNF-α levels in alveolar lavage. In plasma or serum, propofol significantly increased the levels of interleukin-10 (-0.73, 95% CI: -1.36 to -0.10, P = .023) and TNF-α (-0.65, 95% CI: -1.21 to -0.09, P = .022).

CONCLUSIONS

At alveolar lavage and serum or plasma levels of inflammatory factors, the proinflammatory factor TNF-α was significantly lower in the sevoflurane group than in the propofol group. This indicates that sevoflurane has a certain role in alleviating local and systemic lung inflammation. However, more randomized controlled studies are warranted in the future to confirm whether there is a difference in hemodynamic stability and postoperative recovery of patients.

Effect of combination of remimazolam and sevoflurane on elderly patients' recovery quality from general anesthesia after laparoscopic abdominal surgery: a randomized controlled trial

PURPOSE

Remimazolam toluene sulfonic acid is a short-acting benzodiazepine primarily studied for intravenous anesthesia. To date, few studies have focused on the effects of the combination of remimazolam and inhalation anesthesia or its impact on postoperative recovery. Our study aims to investigate the influence of remimazolam combined with sevoflurane for general anesthesia maintenance on postoperative recovery quality in elderly patients undergoing laparoscopic abdominal surgery.

METHODS

A total of 109 patients, aged 60 to 80 years old, scheduled for laparoscopic gallbladder or hernia surgery were randomly divided into two groups: remimazolam group (Group R) and remimazolam-sevoflurane combination group (Group S). Group R had remimazolam for anesthesia maintenance, while Group S received remimazolam and sevoflurane. Both groups followed the same induction protocol, with bispectral index (BIS) maintained between 40 and 60 during surgery. The primary outcome was assessed with the Quality of Recovery (QoR)-15 score. The secondary outcomes included loss of consciousness (LoC), perioperative hemodynamic variables, extubation time, and the incidence of postoperative adverse events. During the study, 7 patients were lost to follow-up, and finally, 102 patients were included in the statistical analysis. The data will be analyzed in a modified full analysis set.

RESULTS

Group S had higher QoR-15 and physical comfort scores on postoperative day (POD) 1 and POD3 compared to Group R (135.0[8.0] vs. 132.0[11.0], P = 0.004; 143.0[6.0] vs. 141.0[7.0], P = 0.007). Despite using less remifentanil (P = 0.021), Group S had a significantly longer extubation time (P = 0.048). There were no significant differences in induction time, perioperative hemodynamic variables, or postoperative adverse events between the groups.

CONCLUSION

Combining remimazolam with sevoflurane improves postoperative recovery quality in elderly patients undergoing laparoscopic abdominal surgery. This approach ensures optimal anesthesia depth and sedation while minimizing adverse events and complications.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2200065332. Date of registration: 02/11/2022.

Total Intravenous Anesthesia Is Preferred Over Volatile Agents in Cardiac Surgery

The choice of maintenance anesthetic during cardiopulmonary bypass has been a subject of ongoing debate. Systematic reviews on the topic have so far failed to demonstrate a difference between volatile agents and total intravenous anesthesia (TIVA) in terms of mortality, myocardial injury, and neurological outcomes. Studies using animal models and noncardiac surgical populations suggest numerous mechanisms whereby TIVA has been associated with more favorable outcomes. However, even if the different anesthetic methods are assumed to equivalent in terms of patient outcomes in the context of cardiac surgery, additional factors, namely variables of occupational exposure and environmental impact, strongly support the preferred use of TIVA.

The Year in Review: Anesthesia for Congenital Heart Disease 2023

This review highlights published literature in 2023 that is related to the anesthetic management of patients with congenital heart disease (CHD). Though not inclusive of all topics, 31 articles are discussed and four primary themes emerged: transfusion and hemostasis, outcomes and risk assessment, monitoring, and pharmacology.

Plasma cytokine levels in spinal surgery with sevoflurane or total intravenous propofol anesthesia - A post hoc analysis of a randomized controlled trial

Surgical tissue trauma stimulates an inflammatory response resulting in increased levels of cytokines which could contribute to acute kidney injury (AKI). It is not clear if anesthetic modality affects this response. We aimed to investigate the role of anesthesia in a healthy surgical population on the inflammatory response and the correlation to plasma creatinine. This study is a post hoc analysis of a published randomized clinical trial. We analyzed plasma from patients who underwent elective spinal surgery randomized to either total intravenous propofol anesthesia (n = 12) or sevoflurane anesthesia (n = 10). The plasma samples were collected before anesthesia, during anesthesia, and 1 h after surgery. Plasma cytokine levels after surgery were analyzed for correlations with duration of surgical insult and change in plasma creatinine concentration. The cytokine interleukin-6 (IL-6) was increased after surgery compared with preoperatively. IL-6 was higher in the sevoflurane group than the propofol group after surgery. No patient developed AKI, but plasma creatinine was increased postoperatively in the sevoflurane group. There was a significant association between surgical time and plasma IL-6 postoperatively. No significant correlation between change in plasma creatinine and IL-6 was detected. The cytokines IL-4, IL-13, Eotaxin, Interferon γ-Induced Protein 10 (IP-10), Granulocyte Colony-Stimulating Factor (G-CSF), Macrophage Inflammatory Protein-1β (MIP-1β), and Monocyte Chemoattractant Protein 1 (MCP-1) were lower postoperatively than before surgery independent of anesthetic modality. This post hoc analysis revealed that plasma IL-6 was increased after surgery and more so in the sevoflurane group than the propofol group. Postoperative plasma IL-6 concentration was associated with surgical time.

Postoperative acute kidney injury after volatile or intravenous anesthesia: a meta-analysis

Postoperative acute kidney injury (AKI) is a common complication after surgery. The pathophysiology of postoperative AKI is complex. One potentially important factor is anesthetic modality. We, therefore, conducted a meta-analysis of the available literature regarding anesthetic modality and incidence of postoperative AKI. Records were retrieved until January 17, 2023, with the search terms ("propofol" OR "intravenous") AND ("sevoflurane" OR "desflurane" OR "isoflurane" OR "volatile" OR "inhalational") AND ("acute kidney injury" OR "AKI"). A meta-analysis for common effects and random effects was performed after exclusion assessment. Eight records were included in the meta-analysis with a total of 15,140 patients (n = 7,542 propofol and n = 7,598 volatile). The common and random effects model revealed that propofol was associated with a lower incidence of postoperative AKI compared with volatile anesthesia [odds ratio: 0.63 (95% confidence interval: 0.56-0.72) and 0.49 (95% confidence interval: 0.33-0.73), respectively]. In conclusion, the meta-analysis revealed that propofol anesthesia is associated with a lower incidence of postoperative AKI compared with volatile anesthesia. This may motivate choosing propofol-based anesthesia in patients with increased risk of postoperative AKI due to preexisting renal impairment or surgery with a high risk of renal ischemia.NEW & NOTEWORTHY This study analyzed the available literature on anesthetic modality and incidence of postoperative AKI. The meta-analysis revealed that propofol is associated with lower incidence of AKI compared with volatile anesthesia. It might therefore be considerable to use propofol anesthesia in surgeries with increased susceptibility for developing renal injuries such as cardiopulmonary bypass and major abdominal surgery.