The cortisol stress response induced by surgery: A systematic review and meta-analysis

Effects and mechanisms of perioperative medications on the hypothalamic pituitary adrenal response to surgical injury: A narrative review

The adrenal gland is a vital endocrine organ, and adrenal steroid synthesis and secretion are closely regulated by the hypothalamic-pituitary-adrenal (HPA) axis in response to various stimuli. Surgery or trauma can activate the HPA axis and induce the secretion of cortisol. Different cortisol responses vary with the grade of surgery. Perioperative medications have the potential to decrease the cortisol level in the body, and both excessive and insufficient cortisol levels after surgery are disadvantageous. The effect of perioperative medications on the HPA response to surgery can be divided into three levels: "adrenal insufficiency (AI)", "stress response inhibition", and "uncertainty". The clinical presentation of AI includes fatigue, nausea, vomiting, abdominal pain, muscle cramps, hypotension, hypovolemic shock and prerenal failure, which may result in fatal consequences. Stress response inhibition can reduce postoperative complications, such as pain and cognitive dysfunction. This is protective to patients during perioperative and postoperative periods. The aim of the present review is to shed light on current evidence regarding the exact effects and mechanisms of perioperative medications on the HPA response to surgical injury and provide the applicable guidance on clinical anesthesia.

Cortisol Levels During First Admission Day Are Associated With Clinical Outcomes in Surgical Critically Ill Patients

IMPORTANCE

To explore the correlation between cortisol levels during first admission day and clinical outcomes.

OBJECTIVES

Although most patients exhibit a surge in cortisol levels in response to stress, some suffer from critical illness-related corticosteroid insufficiency (CIRCI). Literature remains inconclusive as to which of these patients are at greater risk of poor outcomes.

DESIGN

A retrospective study.

SETTING

A surgical ICU (SICU) in a tertiary medical center.

PARTICIPANTS

Critically ill patients admitted to the SICU who were not treated with steroids.

MAIN OUTCOMES AND MEASURES

Levels of cortisol taken within 24 hours of admission (day 1 [D1] cortisol) in 1412 eligible patients were collected and analyzed. Results were categorized into four groups: low (0-10 µg/dL), normal (10-25 µg/dL), high (25-50 µg/dL), and very high (above 50 µg/dL) cortisol levels. Primary endpoint was 90-day mortality. Secondary endpoints were the need for organ support (use of vasopressors and mechanical ventilation [MV]), ICU length of stay (LOS), and duration of MV.

RESULTS

The majority of patients (63%) had high or very high D1 cortisol levels, whereas 7.6% had low levels and thus could be diagnosed with CIRCI. There were statistically significant differences in 90-day mortality between the four groups and very high levels were found to be an independent risk factor for mortality, primarily in patients with Sequential Organ Failure Assessment (SOFA) less than or equal to 3 or SOFA greater than or equal to 7. Higher cortisol levels were associated with all secondary endpoints. CIRCI was associated with favorable outcomes.

CONCLUSIONS AND RELEVANCE

In critically ill surgical patients D1 cortisol levels above 50 mcg/dL were associated with mortality, need for organ support, longer ICU LOS, and duration of MV, whereas low levels correlated with good clinical outcomes even though untreated. D1 cortisol level greater than 50 mcg/dL can help discriminate nonsurvivors from survivors when SOFA less than or equal to 3 or SOFA greater than or equal to 7.

COVID-19 and Mortality in the Global Surgical Population: A Systematic Review and Meta-Analysis

INTRODUCTION

To date, no systematic review or meta-analysis has comprehensively estimated the risk of mortality by surgery type on an international scale. We aim to delineate the risk of mortality in patients with COVID-19 who undergo surgery.

METHODS

PubMed (MEDLINE), Scopus, OVID, the World Health Organization Global Literature on Coronavirus Disease, and Corona-Central databases were searched from December 2019 through January 2022. Studies providing data on mortality in patients undergoing surgery were included. The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines for abstracting data were followed and performed independently by two reviewers. The main outcome was mortality in patients with COVID-19.

RESULTS

Of a total of 4023 studies identified, 46 studies with 80,015 patients met our inclusion criteria. The mean age was 67 y; 57% were male. Surgery types included general (14.9%), orthopedic (23.4%), vascular (6.4%), thoracic (10.6%), and urologic (8.5%). Patients undergoing surgery with COVID-19 elicited a nine-fold increased risk of mortality (relative risk [RR] 8.99, 95% confidence interval [CI] 4.96-16.32) over those without COVID-19. In low-income and middle-income countries (RR: 16.04, 95% CI: 4.59-56.12), the mortality risk was twice as high compared to high-income countries (RR: 7.50, 95% CI: 4.30-13.09).

CONCLUSIONS

Mortality risk in surgical patients with COVID-19 compared to those without is increased almost 10-fold. The risk was highest in low-income and middle-income countries compared to high-income countries, suggesting a disproportionate effect of the pandemic on resource-constrained regions.

No requirement of perioperative glucocorticoid replacement in patients with endogenous Cushing's syndrome - a pilot study

PURPOSE

Surgical therapy represents the first-line treatment for endogenous Cushing's syndrome (CS). While postoperative glucocorticoid replacement is mandatory after surgical remission, the role of perioperative glucocorticoid therapy is unclear.

METHODS

We recruited patients with central or adrenal CS in whom curative surgery was planned and patients who underwent pituitary surgery for other reasons than CS as a control group. Patients did not receive any perioperative glucocorticoids until the morning of the first postoperative day. We performed blood samplings in the morning of surgery, immediately after surgery, in the evening of the day of surgery, and in the morning of the first and third postoperative day before any morning glucocorticoid intake. We continued clinical and biochemical monitoring during the following outpatient care.

RESULTS

We recruited 12 patients with CS (seven with central CS, five with adrenal CS) and six patients without CS. In patients with CS, serum cortisol concentrations <5.0 µg/dL (<138 nmol/L) were detected in the morning of the first and third postoperative day in four (33%) and six (50%) patients, respectively. Morning serum cortisol concentrations on the third postoperative day were significantly lower when compared to preoperative measurements (8.5 ± 7.6 µg/dL vs. 19.9 ± 8.9 µg/dL [235 ± 210 nmol/L vs. 549 ± 246 nmol/L], p = 0.023). No patient developed clinical or biochemical signs associated with hypocortisolism. During follow-up, we first observed serum cortisol concentrations >5.0 µg/dL (>138 nmol/L) after 129 ± 97 days and glucocorticoids were discontinued after 402 ± 243 days. Patients without CS did not require glucocorticoid replacement at any time.

CONCLUSION

Perioperative glucocorticoid replacement may be unnecessary in patients with central or adrenal CS undergoing curative surgery as first-line treatment.

Energy Expenditure, a New Tool for Monitoring Surgical Stress in Colorectal Oncological Patients: A Prospective, Monocentric Study

BACKGROUND

Surgical stress response in colorectal surgery consists of a neurohormonal and an immunological response and influences oncological outcomes. The intensity of surgical trauma influences mortality, morbidity, and metastasis' occurrence in colorectal neoplasia. Energy expenditure (EE) stands for the body's energy consumed to keep its homeostasis and can be either calculated or measured by direct or indirect calorimetry.

AIM

The present study attempted to evaluate surgical stress response using EE measurement and compare it to the postoperative cortisol dynamic.

METHODS

A prospective, monocentric study was conducted over a period of one year in the Anesthesiology Department including 21 patients from whom serum cortisol values were collected in the preoperative period and on the first postoperative day, and EE was measured and recorded every 15 minutes throughout surgery using the indirect calorimetry method. The study compared EE values' dynamic registered 30 minutes after intubation and 30 minutes before extubating (after abdominal closure) to cortisol perioperative dynamic.

RESULTS

We enrolled 21 patients and 84 measurements were recorded, 42 probes of serum cortisol and 42 measurements of EE. The mean value of the first measurement of serum cortisol was 13.60±3.6 µg and the second was 16.21±6.52 µg. The average value of the first EE recording was 1273.9±278 kcal and 1463.4±398.2 kcal of the second recording. The bivariate analysis performed showed a good correlation between cortisol variation and EE's variation (Spearman coefficient=0.666, p<0.001, CI=0.285, 0.865). In nine cases (42.85%), cortisol value at 24 hours reached the baseline or below the baselines preoperative value. In eight cases (38.09%), patients' EE at the end of the surgery was lower than that recorded at the beginning of the surgery.

CONCLUSIONS

Intraoperative EE variation correlated well with cortisol perioperative dynamic and stood out in this study as a valuable and accessible predictor of surgical stress in colorectal surgery.

11-beta-hydroxysteroid dehydrogenase type 1 (HSD11B1) gene expression in muscle is linked to reduced skeletal muscle index in sarcopenic patients

BACKGROUND

Glucocorticoids play a significant role in metabolic processes and pathways that impact muscle size, mass, and function. The expression of 11-beta-hydroxysteroid dehydrogenase type 1 (HSD11B1) has been previously described as a major regulator of skeletal muscle function in glucocorticoid-induced muscle atrophy and aging humans. Our study aimed to investigate glucocorticoid metabolism, including the expression of HSD11B1 in skeletal muscle, in patients with sarcopenia.

METHODS

Muscle biopsies were taken from the vastus lateralis muscle of thirty-three patients over 60 years of age with hip fractures. Sarcopenia status was assessed according to the criteria of the European Working Group on Sarcopenia in Older People 2. Skeletal muscle mass was measured by bioelectrical impedance analysis. Cortisol and cortisone concentrations were measured in serum. Gene expression analysis of HSD11B1, NR3C1, FBXO32, and TRIM63 in muscle biopsies was performed. Serial cross sections of skeletal muscle were labeled with myosin heavy chain slow (fiber type-1) and fast (fiber type-2) antibodies.

RESULTS

The study included 33 patients (21 women) with a mean age of 82.5 ± 6.3 years, 17 patients revealed sarcopenic (n = 16 non-sarcopenic). Serum cortisone concentrations were negatively correlated with muscle mass (ß =  - 0.425; p = 0.034) and type-2 fiber diameter (ß =  - 0.591; p = 0.003). Gene expression of HSD11B1 (ß =  - 0.673; p = 0.008) showed a negative correlation with muscle mass in the sarcopenic group. A significant correlation was found for the non-sarcopenic group for NR3C1 (ß = 0.548; p = 0.028) and muscle mass.

CONCLUSION

These findings suggest a pathogenetic role of HSD11B1 in sarcopenic muscle.

Instrument shank-assisted ovariohysterectomy: a randomized clinical trial of surgical and pain alleviation efficiency of a single-person modified technique

Objectives

To evaluate a modified ovariohysterectomy (OHE) technique performed by a single person and compare it with the conventional method based on time efficiency, trauma, and postoperative pain.

Methods

In a prospective, randomized, experimental study, 18 healthy, large, deep-chested, mixed-breed intact female dogs were randomly allocated to conventional (n = 9) and instrument shank-assisted (n = 9) groups. On the basis of video recordings, the various surgical step durations were analyzed: total surgery time (TST), pedicle intervention time (PIT), suspensory release time (SRT), shanking time (ShT), clamping time (ClpT), ligating time (LigT), and closure time (CT). The Glasgow composite pain scale short-form (GCMPS-SF), university of Melbourne pain scale (UMPS), and Visual Analogue Scales (VAS) were used to measure pain. C-reactive protein (CRP) fluctuation was also investigated. These evaluations were completed before and 6, 24, 48, and 72 h postoperatively.

Results

Instrument shank-assisted OHE was less time-consuming than conventional OHE (p = 0.005), improved PIT by 30.7% (6.44 min for both pedicles, p = 0.014), and correlated strongly with TST (ρ = 0.862, p = 0.003 and ρ = 0.955, p = 0.000, respectively). The two method's surgical step durations were also TST = 47.40 ± 9.9 vs. 34.70 ± 6.7 min, PIT = 20.96 ± 5.78 vs. 14.52 ± 3.73 min, SRT = 78.97 ± 69.10 vs. ShT = 20.39 ± 8.18 s (p = 0.035), ClpT = 50.66 ± 45.04 vs. 63.55 ± 37.15 s (p = 0.662), LigT = 12.82 ± 3.37 vs. 8.02 ± 3.11 min (p = 0.005), and CT = 16.40 ± 4.5 vs. 11.60 ± 2.5 min (p = 0.013), respectively. While both techniques inflicted pain on the animals, the novel approach resulted in a reduction of pain at T6 (GCMPS-SF, p = 0.015 and VAS, p = 0.002), T24 (UMPS, p = 0.003), and T48 (GCMPS-SF, p = 0.015 and UMPS, p = 0.050). Both methods exhibited a peak in CRP level after 24 h, which subsequently returned to baseline after 48 h. However, the shank-assisted method demonstrated a significantly lower reduction in CRP level at the 48-h compared to the other group (p = 0.032).

Conclusion

Instrument shank-assisted technique permitted ovarian removal without an assistant, less damage to animals and reducing its time when compared to a conventional technique, and resulting in an alternative that causes less surgical stress and fatigue. Further research with a larger population size is required to determine the serum CRP levels as an alternative pain biomarker.

Taming Postoperative Delirium with Dexmedetomidine: A Review of the Therapeutic Agent's Neuroprotective Effects following Surgery

Postoperative delirium (POD) represents a perioperative neurocognitive disorder that has dreaded ramifications on a patient's recovery from surgery. Dexmedetomidine displays multiple mechanisms of neuroprotection to assist in preventing POD as a part of a comprehensive anesthetic care plan. This review will cover dexmedetomidine's pharmacological overlap with the current etiological theories behind POD along with pre-clinical and clinical studies on POD prevention with dexmedetomidine. While the body of evidence surrounding the use of dexmedetomidine for POD prevention still requires further development, promising evidence exists for the use of dexmedetomidine in select dosing and circumstances to enhance recovery from surgery.

General anesthesia combined with bilateral 2-level erector spinae plane block may accelerate postoperative gastrointestinal function recovery and rehabilitation process in patients undergoing posterior lumbar surgery: A randomized controlled trial

BACKGROUND

This randomized controlled trial explored whether bilateral 2-level erector spinae plane block could accelerate postoperative gastrointestinal function and rehabilitation in patients undergoing posterior lumbar surgery.

METHODS

A total of 80 adult patients undergoing posterior lumbar surgery between March 2021 and August 2021 were randomized to either ultrasound-guided bilateral 2-level erector spinae plane block (group E) or not (group C). General anesthesia was routinely performed. The primary outcome was the time of the first flatus after surgery. We also recorded the first food and liquid intake, first off-bed activity, days of hospital stay, and postoperative complications. Postoperative visual analog scale score and opioid consumption were also recorded. A venous blood sample was taken to measure the serum concentration of lipopolysaccharides, c-reactive protein, tumor necrosis factor-alpha, interleukin-6, and blood glucose before induction of anesthesia, immediately after, and 24 and 48 hours after surgery.

RESULTS

Seventy-seven patients, 39 in group C and 38 in group E, finished the trial. Patients in group E had a significantly shorter time to first flatus (16.2 ± 3.2 vs 19.7 ± 3.0 hours, P < .05), earlier liquid intake (1.7 ± 0.2 vs 1.9 ± 0.3 hours, P < .05), earlier food intake (1.9 ± 0.2 vs 2.1 ± 0.3 hours, P < .05), and first off-bed activity (27.9 ± 3.2 vs 31.4 ± 3.3 h, P < .05). Patients in group E had shorter postoperative hospital stay (4.6 [4.2-5.5] d vs 5.4 [4.5-6.3], P < .05). We found that patients in group E had less pain and total sufentanil consumption (129 [120-133] vs 138 [132-147] μg, P < .05) within 24 hours after surgery. At 24 hours after surgery, the serum concentrations of lipopolysaccharides, tumor necrosis factor-alpha, interleukin-6, and C-reactive protein in group E were significantly decreased compared to group C (P < .05).

CONCLUSION

Bilateral 2-level erector spinae plane block can accelerate gastrointestinal function recovery and shorten the length of hospital stay in patients undergoing open posterior lumbar surgery. The potential mechanism may attribute to the opioids-sparing effects and anti-stress-related anti-inflammatory effects of bilateral 2-level erector spinae plane block.

Stress hormone response to instrumented elective lumbar spine fusion surgery

PURPOSE

To understand the systemic effect of major spine surgery, we investigated stress, anabolic and catabolic hormonal levels and their association with interleukin 6 (IL-6) in patients undergoing elective lumbar spine fusion surgery.

METHODS

Blood samples were collected preoperatively, and at 1, 3, 42, 90 days postoperatively (POD) from 49 patients who underwent elective lumbar spine fusion surgery.

RESULTS

Serum concentration of cortisol was below the preoperative value at POD 1 but did not differ from the baseline values thereafter. Adrenocorticotropic hormone (ACTH) decreased at PODs 1 and 3. Testosterone decreased at PODs 1 and 3 in men, and at POD 3 in women. Sex hormone-binding globulin decreased at PODs 1 and 3 in both genders. No changes were observed in free testosterone or growth hormone concentrations. Insulin-like growth factor 1 increased significantly above the preoperative level at PODs 42 and 90 in women, and at POD 42 in men. IL-6 was significantly elevated at PODs 1 and 3. Increases in IL-6 from the preoperative level to POD 1 correlated significantly with decreases of cortisol at POD 1 but not with ACTH.

CONCLUSIONS

There were only short-term stress hormonal changes after elective lumbar spine fusion surgery. Cortisol changes after elective lumbar spine surgery are transient and might be partly cytokine induced and non-ACTH driven since there was association between cortisol and IL-6 but not with ACTH and IL-6.

Post-Traumatic Stress Response and Appendicitis in Children-Clinical Usefulness of Selected Biomarkers

Acute appendicitis is an inflammatory process which is one of the most frequent global causes of surgical interventions in children. The goal of the study was to determine whether acute phase proteins, that is, C-reactive protein (CRP), procalcitonin (PCT) and neutrophil gelatinase-associated lipocalin (NGAL), interleukin 6 (IL-6), transforming growth factor-beta1 (TGF-β1) and cortisol (HC) play a role in the pathomechanism of post-trauma stress response of the organism and to establish the impact of the applied surgical procedure and/or of inflammation on their concentrations. An additional purpose was to establish the clinical usefulness of the studied biomarkers in the diagnostics of appendicitis. CRP concentrations were quantified via the immunoturbidimetric method, while the levels of IL-6 and PCT were assessed using a bead-based multiplexed immunoassay system in a microplate format (Luminex xMAP technology); NGAL, TGF-β1 and cortisol concentrations were determined via the enzyme-linked immunosorbent assay (ELISA) technique. All the investigated biomarkers were assayed twice, i.e., immediately before the surgery and 12-24 h after its completion. Significant increases in CRP, IL-6 and PCT concentrations were found in all children subjected to laparoscopic surgeries (p = 0.001, p = 0.006, and p = 0.009, respectively) and open (classic) surgeries (p = 0.001, p = 0.016, and p = 0.044, respectively) compared to the initial concentrations. The patients undergoing classical surgery moreover presented with significant (p = 0.002, and p = 0.022, respectively) increases in NGAL and TGF-β1 levels after the procedures. In a group of children undergoing laparoscopic surgery, the appendicitis induced an increase in cortisol concentration, whereas in patients undergoing classical surgery the increase in the levels of this biomarker was caused by the type of performed surgical procedure. Simultaneously assaying the levels of CRP, NGAL and IL-6 (p = 0.008, p = 0.022, and p = 0.000, respectively) may prove useful in clinical practice, enabling the diagnosis of appendicitis in paediatric patients reporting to a hospital with abdominal pains, in addition to data from anamnesis and from clinical or ultrasound examination. The performed study confirms the participation of examined biomarkers in the pathomechanism of post-injury stress reaction of the organism to surgical trauma.

Evaluation of the stress-reducing effect of trace mineral injection in beef calves

BACKGROUND

Little is known about the effects of trace mineral supplementation on the stress response in beef calves.

OBJECTIVES

To investigate the effect of injectable trace mineral supplementation (ITM) on the stress response in beef calves exposed to different types of stress.

ANIMALS

Thirty weaned Angus and Angus crossbred calves.

METHODS

The enrolled calves were randomly assigned to 2 groups: ITM, 15 calves received modified-live virus vaccine (MLV) and ITM SC and 15 calves received MLV and saline SC (CONT). The calves were exposed to 3 types of stress: the stress of MLV vaccination (d0), nasal aerosol with bovine viral diarrhea virus-2 (BVDV-2) challenge (d5), and liver biopsy (d26). The calves' body weights and health status were monitored. Leukocyte counts, serum cortisol concentration ([cort]), BVDV-2 serum neutralizing antibodies (SNA), and percentages of CD4⁺ , CD8⁺ , WC1⁺ _, and CD25⁺ T-lymphocytes were measured.

RESULTS

Serum cortisol concentration ([cort]) showed strong associations with the percentage of CD8⁺ (r_s  = .50), BVDV2-SNA (r_s  = -.43), and WC1CD25⁺ (r_s  = .41) cells, and rectal temperature (r_s  = .40). The highest [cort] was reported 3 days after aerosol BVDV-2 challenge. Serum [cort] was decreased in ITM-treated calves 3 days post-BVDV-2 challenge, compared with CONT calves, with an average decrease of 18.5 ng/μL (95% confidence interval [CI], -6.07 to -31.3). The ITM-treated calves were heavier and healthier (P < .01) than the CONT calves.

CONCLUSIONS AND CLINICAL IMPORTANCE

Trace mineral supplementation appears to have stress mitigation effects in beef cattle that may reflect positively on growth and health performance. Viral exposure is associated with a high degree of stress, which is considered a major welfare concern.

Intergenerational Perioperative Neurocognitive Disorder

Accelerated neurocognitive decline after general anesthesia/surgery, also known as perioperative neurocognitive disorder (PND), is a widely recognized public health problem that may affect millions of patients each year. Advanced age, with its increasing prevalence of heightened stress, inflammation, and neurodegenerative alterations, is a consistent contributing factor to the development of PND. Although a strong homeostatic reserve in young adults makes them more resilient to PND, animal data suggest that young adults with pathophysiological conditions characterized by excessive stress and inflammation may be vulnerable to PND, and this altered phenotype may be passed to future offspring (intergenerational PND). The purpose of this narrative review of data in the literature and the authors' own experimental findings in rodents is to draw attention to the possibility of intergenerational PND, a new phenomenon which, if confirmed in humans, may unravel a big new population that may be affected by parental PND. In particular, we discuss the roles of stress, inflammation, and epigenetic alterations in the development of PND. We also discuss experimental findings that demonstrate the effects of surgery, traumatic brain injury, and the general anesthetic sevoflurane that interact to induce persistent dysregulation of the stress response system, inflammation markers, and behavior in young adult male rats and in their future offspring who have neither trauma nor anesthetic exposure (i.e., an animal model of intergenerational PND).

Reconstruction of a partial esophageal defect using tunica vaginalis and buccal mucosa autograft: an experimental study in mongrel dogs

In veterinary clinics, esophageal reconstruction is essential in many clinical situations. In this study, two autografts, the tunica vaginalis (TV) and the buccal mucosa (BM), were proposed to reconstruct a semi-circumferential cervical esophageal defect in dogs. This study aimed to verify whether these two grafts could successfully patch esophageal defects. Twelve male mongrel dogs were divided into two groups. Following cervical esophagoplasty, the defective area was patched with either a TV or a BM graft. Comprehensive clinical, serum biochemical, and histological analyses were performed to evaluate the two grafts. Throughout the study (120 days), the dogs survived the procedure well with minor complications. The lumen of the patched areas was covered with mucosa, with slight scar retraction. Compared with that of the natural esophagus, the average relative luminal diameter was not significantly decreased. Importantly, the measured cortisol and inflammatory marker levels returned to the preoperative levels after 14 days. Although histological examination revealed that both grafts repaired the esophageal defect with complete re-epithelialization, the BM graft showed a histological structure similar to that of the natural esophagus. Both grafts effectively repaired the esophageal defect with minor complications; therefore, both are recommended as promising low-cost clinical alternatives for cervical esophagoplasty in dogs.

Postoperative systemic inflammatory dysregulation and corticosteroids: a narrative review

In some patients, the inflammatory-immune response to surgical injury progresses to a harmful, dysregulated state. We posit that postoperative systemic inflammatory dysregulation forms part of a pathophysiological response to surgical injury that places patients at increased risk of complications and subsequently prolongs hospital stay. In this narrative review, we have outlined the evolution, measurement and prediction of postoperative systemic inflammatory dysregulation, distinguishing it from a healthy and self-limiting host response. We reviewed the actions of glucocorticoids and the potential for heterogeneous responses to peri-operative corticosteroid supplementation. We have then appraised the evidence highlighting the safety of corticosteroid supplementation, and the potential benefits of high/repeated doses to reduce the risks of major complications and death. Finally, we addressed how clinical trials in the future should target patients at higher risk of peri-operative inflammatory complications, whereby corticosteroid regimes should be tailored to modify not only the a priori risk, but also further adjusted in response to markers of an evolving pathophysiological response.

Serum and hair steroid profiles in patients with nonfunctioning pituitary adenoma undergoing surgery: A prospective observational study

Patients who undergo transsphenoidal surgery (TSS) experience perioperative hormonal changes, but there are few studies on the perioperative changes of serum and hair steroid profiles. This study investigated the perioperative changes in steroid metabolic signatures in patients with nonfunctioning pituitary adenoma (NFPA) who underwent transsphenoidal surgery (TSS). A total of 55 participants who underwent TSS for NFPA at a single center between July 2017 and October 2018 were enrolled. Fifteen serum steroids and their metabolic ratios were profiled using gas chromatography-mass spectrometry (GC-MS) before and 1 day, 1 week, and 3 months after TSS. Five steroids from hair samples collected 1 day and 3 months after TSS were also quantitatively compared. Serum cortisol and its A-ring reductive metabolites, as well as 6β-hydroxycortisol, increased dramatically 1 day after TSS and then gradually decreased. Seven serum steroids, including adrenal androgens and mineralocorticoids, and hair cortisone levels were significantly lower in patients with preoperative adrenocorticotropic hormone (ACTH) deficiency (N = 7) than in those without ACTH deficiency (N = 48). Serum levels of dehydroepiandrosterone (DHEA) levels 1 week after TSS predicted ACTH deficiency 3 months after TSS, with 100 % sensitivity and 86 % specificity. A significant positive correlation between the preoperative serum and hair DHEA levels (r = 0.356, P = 0.008) was observed. These findings suggest that the levels of DHEA in both the serum and hair could be an early marker of ACTH deficiency after TSS. In addition, hair cortisone may be a useful preoperative indicator of chronic ACTH deficiency.

Risk factor analysis and construction of prediction models for short-term postoperative complications in patients undergoing gastrointestinal tract surgery

Purpose

To identify risk factors associated with short-term postoperative complications in patients with gastrointestinal cancer and develop and validate prediction models to predict the probability of complications.

Methods

A total of 335 patients enrolled in the primary cohort of this study were divided into training and validation sets in a chronological order. Using univariate and multivariate logistic regression analyses, the risk factors for postoperative complications were determined, and nomogram prediction models were constructed. The performance of the nomogram was assessed with respect to the receiver operator characteristic and calibration curves.

Results

Patients with complications had a stronger postoperative stress response and a longer duration of daily fluid intake/output ratio >1 after surgery. Logistic analysis revealed that body mass index (BMI), body temperature on POD4 (T.POD4), neutrophil percentage on POD4 (N.POD4), fasting blood glucose on POD4 (FBG.POD4), and the presence of fluid intake/output ratio <1 within POD4 were risk factors for POD7 complications, and that BMI, T.POD7, N.POD7, FBG.POD4, FBG.POD7, and the duration of daily fluid intake/output ratio >1 were risk factors for POD30 complications. The areas under the curve of Nomogram-A for POD7 complications were 0.867 and 0.833 and those of Nomogram-B for POD30 complications were 0.920 and 0.918 in the primary and validation cohorts, respectively. The calibration curves showed good consistency in both cohorts.

Conclusion

This study presented two nomogram models to predict short-term postoperative complications in patients with gastrointestinal cancer. The results could help clinicians identify patients at high risk of complications within POD7 or POD30.

Perioperative Evaluation and Management of Patients on Glucocorticoids

Myriad questions regarding perioperative management of patients on glucocorticoids (GCs) continue to be debated including which patients are at risk for adrenal insufficiency (AI), what is the correct dose and duration of supplemental GCs, or are they necessary for everyone? These questions remain partly unanswered due to the heterogeneity and low quality of data, studies with small sample sizes, and the limited number of randomized trials. To date, we know that although all routes of GC administration can result in hypothalamic-pituitary-adrenal (HPA) axis suppression, perioperative adrenal crisis is rare. Correlation between biochemical testing for AI and clinical events is lacking. Some of the current perioperative management recommendations based on daily GC dose and duration of therapy may be difficult to follow in clinical practice. The prospective and retrospective studies consistently report that continuing the daily dose of GCs perioperatively is not associated with a higher risk for adrenal crises in patients with GC-induced AI. Considering that oral GC intake may be unreliable in the early postoperative period, providing the daily GC plus a short course of IV hydrocortisone 25 to 100 mg per day based on the degree of surgical stress seems reasonable. In patients who have stopped GC therapy before surgery, careful assessment of the HPA axis is necessary to avoid an adrenal crisis. In conclusion, our literature review indicates that lower doses and shorter duration of supplemental GCs perioperatively are sufficient to maintain homeostasis. We emphasize the need for well-designed randomized studies on this frequently encountered clinical scenario.

Effects of midazolam co-induction to general anesthesia: A randomized clinical trial

BACKGROUND

This study aimed to determine the potential advantages of midazolam co-induction with general anesthesia (GA) over the use of propofol alone.

METHODS

We conducted a randomized, placebo-controlled, single-blinded clinical trial of 102 patients, aged 18 to 65, American Society of Anesthesiologists II and III, who underwent elective laparoscopic gallbladder surgery. Patients were randomly divided into 3 groups: the placebo group (C) received 1 mL of 0.9% saline intravenously and the test groups received intravenous midazolam at doses of 0.03 mg/kg (M1) or 0.06 mg/kg (M2) before induction of GA. We assessed effects of midazolam co-induction on arterial pressure and heart rate (HR) in the early stage of GA prior to surgical incision and effects on perioperative and postoperative glycemia and cortisol levels. Systolic/mean/diastolic (SAP/MAP/DAP) arterial pressure and HR were measured 4 times (preoperative, on the third, sixth and ninth minute after atracurium administration). Cortisol was measured on 3 occasions (preoperatively, 60 minutes after surgical incision, and the following morning) and glucose on 4 occasions (preoperatively, 15 and 60 minutes after incision, and the following morning). We also assessed the incidence of postoperative anxiety, postoperative nausea and vomiting (PONV), and propofol requirement for induction.

RESULTS

SAP/MAP/DAP were significantly higher in M2 immediately after induction compared to the other study groups (P = .002/.004/.013). Midazolam co-induction led to a significant reduction in postoperative anxiety (P = .03), reduced cortisol concentration 60 minutes after surgical incision (P < .001) and propofol requirements (P < .001).

CONCLUSION SUBSECTIONS

Midazolam co-induction prevented a marked decline in SAP/MAP/DAP immediately after induction of GA, led to reduced postoperative anxiety and cortisol response to surgery, and reduced propofol requirements for induction.

Monocyte response after colorectal surgery: A prospective cohort study

BACKGROUND

Tumor resection is the common approach in patients with colorectal malignancy. Profound insight into inflammatory changes that accompany the normal post-operative stress response will establish reference parameters useful for identification of putative complications. Alterations in circulating monocytes might be indicative as these cells are considered to be the most responsive leukocytes to trauma. Therefore, the aim of this study is to assess the monocyte subset kinetic and phenotypic changes in response to surgery.

METHODS

Fifty patients undergoing colorectal tumor resection were included in a multicenter prospective cohort study. Blood samples were collected early in the morning prior to surgery and the next days through postoperative day three for flowcytometric analysis. Leukocyte subtypes were identified and expression of activation stage-related markers by monocyte subsets was quantified.

RESULTS

Changes in leukocyte subset composition and monocyte subset phenotypes were most prominent at the first day postoperatively, after which these parameters typically returned to normal or near-normal preoperative values. The immunophenotypic alterations after surgery were most notable in classical and intermediate monocytes. These included up-regulation of activation markers CD64 and CD62L, but down-regulation of HLA-DR and CD54. Markers of de-activation, CD163 and CD206, were consistently increasingly expressed.

DISCUSSION/CONCLUSION

The current study gives detailed insight into the peripheral blood leukocyte response after colorectal cancer surgery. This form of short-term stress induces a rapid and significant redistribution of immune cells. Immunophenotypic alterations in monocytes as a response to surgery suggest a mixed profile of cellular activation and de-activation.

Reduction of postoperative nausea and vomiting risk in the second stage during bilateral total knee arthroplasty with a 1-week interval

PURPOSE

Total knee arthroplasty (TKA) is often performed sequentially on both sides during a single hospital stay. Patients who experience postoperative nausea and vomiting (PONV) after the first operation are concerned about PONV recurrence after the second operation. However, there are few studies regarding the incidence of PONV in staged bilateral TKA with a ≥ 1-week interval. This study aimed to identify the differences in (1) PONV incidence, (2) use of rescue antiemetics, and (3) the amount of opioid consumption between the first and second operations for staged bilateral TKA with a 1-week interval. Based on our anecdotal experience, the hypothesis of this study was that during staged bilateral TKA at a 1-week interval, the PONV incidence and rescue antiemetic requirement after the second operation will be lower than those after the first operation, regardless of opioid consumption.

METHODS

Fifty-eight consecutive patients who underwent staged bilateral TKA with a 1-week interval were retrospectively reviewed. All second-stage operations were performed with the same anaesthesia protocol and perioperative patient management protocol as the first-stage operation. PONV incidence was the primary outcome. The requirement for rescue antiemetic drugs and the amount of opioid consumption were secondary outcome variables. The outcome variables were recorded during three postoperative days (Days 0-2) for each stage and were compared between the first and second operations.

RESULTS

The incidence rates of nausea and vomiting on Day 0 (p = 0.001 and p = 0.004, respectively) and nausea on Day 1 (p = 0.008) were significantly lower after the second operation. Rescue antiemetic use on Day 0 was significantly lower after the second operation (p = 0.001). The total opioid consumption 72 h after surgery was significantly higher after the second operation (61.76 vs. 34.28 mg, p < 0.001).

CONCLUSION

During staged bilateral TKA with a 1-week interval, PONV incidence was lower after the second operation, even with increased opioid consumption.

LEVEL OF EVIDENCE

III.

Immune dysfunction following severe trauma: A systems failure from the central nervous system to mitochondria

When a traumatic injury exceeds the body's internal tolerances, the innate immune and inflammatory systems are rapidly activated, and if not contained early, increase morbidity and mortality. Early deaths after hospital admission are mostly from central nervous system (CNS) trauma, hemorrhage and circulatory collapse (30%), and later deaths from hyperinflammation, immunosuppression, infection, sepsis, acute respiratory distress, and multiple organ failure (20%). The molecular drivers of secondary injury include damage associated molecular patterns (DAMPs), pathogen associated molecular patterns (PAMPs) and other immune-modifying agents that activate the hypothalamic-pituitary-adrenal (HPA) axis and sympathetic stress response. Despite a number of drugs targeting specific anti-inflammatory and immune pathways showing promise in animal models, the majority have failed to translate. Reasons for failure include difficulty to replicate the heterogeneity of humans, poorly designed trials, inappropriate use of specific pathogen-free (SPF) animals, ignoring sex-specific differences, and the flawed practice of single-nodal targeting. Systems interconnectedness is a major overlooked factor. We argue that if the CNS is protected early after major trauma and control of cardiovascular function is maintained, the endothelial-glycocalyx will be protected, sufficient oxygen will be delivered, mitochondrial energetics will be maintained, inflammation will be resolved and immune dysfunction will be minimized. The current challenge is to develop new systems-based drugs that target the CNS coupling of whole-body function.

Effects of the Ultrasound-Guided Stellate Ganglion Block on Hemodynamics, Stress Response, and Gastrointestinal Function in Postoperative Patients with Colorectal Cancer

Objective

The aim of the study was to study the effects of the ultrasound-guided stellate ganglion block on hemodynamics, stressful response, and postoperative gastrointestinal functions in patients with colorectal cancer.

Methods

A total of 100 patients with colorectal cancer hospitalized from January 2021 to December 2021 were selected. After anesthesia induction, the right stellate ganglion block was performed under ultrasound guidance in the research group and the general anesthesia was performed in the control group. The heart rate (HR), mean arterial pressure (MAP), epinephrine, cortisol, self-rating anxiety scale (SAS), Ramsay sedation score (RSS), postoperative bowel sound recovery time, anal exhaust time, and the incidence of gastrointestinal adverse reactions 24 hours after operation were studied pre-and post-24-hour anesthesia induction.

Results

Following 24-hour operation, the HR and MAP values were largely reduced (p < 0.05). Following 24-hour operation, epinephrine and cortisol became obviously higher (p < 0.05). After 24-hour operation, the levels of epinephrine and cortisol in the research group were greatly lower. The score of the SAS in the study cohort was less than that of the controls (p < 0.05). The RSS of the research group was obviously increased (p < 0.05). The recovery time of intestinal sound and the anal exhaust time of the study cohort became remarkably shorter (p < 0.05). The incidence of gastrointestinal adverse reactions 24 hours after operation of the study cohort was much less common (p < 0.05).

Conclusion

The ultrasound-guided stellate ganglion block can reduce the fluctuation of blood circulation during radical resection of colorectal cancer, reduce postoperative gastrointestinal dysfunction and stress reaction, relieve patients' anxiety, and contribute to the recovery of gastrointestinal function.

Analgesia and stress attenuation of ultrasound-guided modified pectoral nerve block type-II with different volumes of 0.3% ropivacaine in patients undergoing modified radical mastectomy for breast cancer: A prospective parallel randomized double-blind controlled clinical trial

WHAT IS KNOWN AND OBJECTIVE

A previous randomized clinical trial concluded that an optimal concentration of 0.3% ropivacaine could provide satisfactory analgesia for breast cancer patients undergoing modified radical mastectomy. We wondered if a smaller volume (30 ml vs. 40 ml) of 0.3% ropivacaine could still provide adequate analgesia in an ultrasound-guided PECS II block in modified radical mastectomy.

METHODS

We performed a prospective parallel randomized double-blind controlled clinical trial. Eligible patients were assigned to either the P₃₀ or P₄₀ group (30 or 40 ml of 0.3% ropivacaine, respectively). The skin area of hypoesthesia, anaesthetic plane determined with ultrasound, pain visual analogue scale (VAS), anaesthetic dosages, and complications were recorded. Serum levels of interleukin-1β and interleukin-6 were measured postoperatively.

RESULTS AND DISCUSSION

A total of 40 patients completed the trials, with 20 patients in each group. Although the skin area of hypoesthesia and the anaesthetic planes were significantly larger in the P₄₀ group compared with the P₃₀ group (p < 0.05), the VAS, analgesic and opioid doses, serum cytokine levels, anaesthetic toxicity, and complications had no significant differences between the two groups.

WHAT IS NEW AND CONCLUSION

Compared with 40 ml, 30 ml of 0.3% ropivacaine could provide adequate analgesia and reduce surgical stress in patients undergoing modified radical mastectomy for breast cancer.

Early Weaning and Milk Substitutes Affect the Gut Microbiome, Metabolomics, and Antibody Profile in Goat Kids Suffering From Diarrhea

Early weaning and milk substitutes increase the incidence of diarrhea in young ruminants, which may modify their gut microbiota, metabolism, immunity, and health. The aim of the study was to determine if early weaning and milk substitutes affect the gut microbiota, metabolism, and immunological status of goat kids suffering from diarrhea. The 16S rRNA gene and metagenomic sequencing in feces and serum metabolomics of early-weaned and artificially reared goat kids suffering from diarrhea (DK group) and healthy goat kids reared by their mothers (HK group) were analyzed. The serum biochemistry and immunoglobulin concentration were also determined. Several probiotics, such as Streptococcus and Lactobacillus, were higher in the feces of the DK group than in feces of the HK group. Ruminococcus sp. was elevated in the feces of HKs, likely being a biomarker for goat health. Taking all the carbohydrate-active enzyme (CAZyme) families into consideration, 20 CAZyme families were different between the groups. Compared with the DK group, the relative quantity of glycoside hydrolases (GH) and glycosyltransferase (GT) families in the HK group decreased. GT70 was only identified in HK kids participating in the activity of β-glucuronosyltransferase during the carbohydrate metabolism. Overall, 24 metabolites were different between the groups, which were mainly involved in protein digestion and absorption, cyanoamino acid metabolism, and cholesterol metabolism. The concentrations of immunoglobulins G and M were significantly lower in the DK than in the HK group. In conclusion, our study characterized the fecal microbiota, metabolism, and immunological status of early-weaned and artificially reared goat kids suffering from diarrhea.

Approach to the Patient With Glucocorticoid-induced Adrenal Insufficiency

Glucocorticoid-induced adrenal insufficiency is caused by exogenous glucocorticoid suppression of the hypothalamic-pituitary-adrenal axis and is the most prevalent form of adrenal insufficiency. The condition is important to diagnose given the risk of life-threatening adrenal crisis and impact on patients' quality of life. The diagnosis is made with a stimulation test such as the ACTH test. Until now, testing for glucocorticoid-induced adrenal insufficiency has often been based on clinical suspicion rather than routinely but accumulating evidence indicates that a significant number of cases will remain unrecognized. During ongoing oral glucocorticoid treatment or initially after withdrawal, ~50% of patients have adrenal insufficiency, but, outside clinical studies, ≤ 1% of patients have adrenal testing recorded. More than 70% of cases are identified during acute hospital admission, where the diagnosis can easily be missed because symptoms of adrenal insufficiency are nonspecific and overlap those of the underlying and intercurrent conditions. Treatment of severe glucocorticoid-induced adrenal insufficiency should follow the principles for treatment of central adrenal insufficiency. The clinical implications and thus indication to treat mild-moderate adrenal deficiency after glucocorticoid withdrawal has not been established. Also, the indication of adding stress dosages of glucocorticoid during ongoing glucocorticoid treatment remains unclear. In patients with established glucocorticoid-induced adrenal insufficiency, high rates of poor confidence in self-management and delayed glucocorticoid administration in the acute setting with an imminent adrenal crisis call for improved awareness and education of clinicians and patients. This article reviews different facets of glucocorticoid-induced adrenal insufficiency and discusses approaches to the condition in common clinical situations.

Effects and duration of exercise-based prehabilitation in surgical therapy of colon and rectal cancer: a systematic review and meta-analysis

Purpose

Functional capacity is an independent indicator of morbidity in colon and rectal cancer surgery. This systematic review describes the evaluated and synthesized effects of exercise prehabilitation depending on the duration of interventions on functional and postoperative outcomes in colon and rectal cancer surgery.

Methods

Three electronic databases (MEDLINE Pubmed, Web of Sciences, and Cochrane Registry) were systematically searched (January 2022) for controlled trials that investigated the effects of prehabilitation prior to colo-rectal cancer resection.

Results

Twenty-three studies were included in this systematic review and 14 in our meta-analyses assessing these outcomes: the 6 min walk distance (6MWD), postoperative overall complications, and length of stay (LOS). We observed a significant improvement in preoperative functional capacity as measured with 6MWD (mean difference: 30.8 m; 95% CI 13.3, 48.3; p = 0.0005) due to prehabilitation. No reductions in LOS (mean difference: – 0.27 days; 95% CI – 0.93, 0.40; p = 0.5) or postoperative overall complications (Odds ratio: 0.84; 95% CI 0.53, 1.31; p = 0.44) were observed. Prehabilitation lasting more than 3 weeks tended to lower overall complications (Odds ratio: 0.66; 95% CI 0.4, 1.1; p = 0.11). However, the prehabilitation time periods differed between colon and rectal carcinoma resections.

Conclusion

Prehabilitation while the patient is preparing to undergo surgery for colorectal carcinoma improves functional capacity; and might reduce postoperative overall complications, but does not shorten the LOS. The studies we reviewed differ in target variables, design, and the intervention’s time period. Multicenter studies with sufficient statistical power and differentiating between colon and rectal carcinoma are needed to develop implementation strategies in the health care system.

Registration

PROSPERO CRD42022310532

When to operate after SARS-CoV-2 infection? A review on the recent consensus recommendation of the DGC/BDC and the DGAI/BDA

Since the eruption of the worldwide SARS-CoV-2 pandemic in late 2019/early 2020, multiple elective surgical interventions were postponed. Through pandemic measures, elective operation capacities were reduced in favour of intensive care treatment for critically ill SARS-CoV-2 patients. Although intermittent low-incidence infection rates allowed an increase in elective surgery, surgeons have to include long-term pulmonary and extrapulmonary complications of SARS-CoV-2 infections (especially “Long Covid”) in their perioperative management considerations and risk assessment procedures. This review summarizes recent consensus statements and recommendations regarding the timepoint for surgical intervention after SARS-CoV-2 infection released by respective German societies and professional representatives including DGC/BDC (Germany Society of Surgery/Professional Association of German Surgeons e.V.) and DGAI/BDA (Germany Society of Anesthesiology and Intensive Care Medicine/Professional Association of German Anesthesiologists e.V.) within the scope of the recent literature. The current literature reveals that patients with pre- and perioperative SARS-CoV-2 infection have a dramatically deteriorated postoperative outcome. Thereby, perioperative mortality is mainly caused by pulmonary and thromboembolic complications. Notably, perioperative mortality decreases to normal values over time depending on the duration of SARS-CoV-2 infection.

Patterns and Determinants of Change in Cortisol Levels and Thyroid Function as a Function of Cardiac Risk in Children Undergoing Cardiac Surgery

Background

Children undergoing cardiac surgery with cardiopulmonary bypass (CPB) are exposed to the risk of hormonal imbalances resulting from acute stress, which may eventually result in high postoperative mortality and morbidity.

Objective

We assessed adrenal and thyroid hormonal changes and their determinants following cardiac surgery in children and explored their prognostic value in predicting cardiac outcomes. Study Design and Methods. A prospective cohort study was conducted at King Abdulaziz University Hospital (KAUH), between 2017 and 2018. The study involved 46 children aged 14 years or younger who underwent elective cardiac surgery with cardiopulmonary bypass. Serum levels of cortisol, TSH, fT3, and fT4 were measured preoperatively and 24, 48, and 72 hours after surgery. The cardiac risk was assessed using the risk adjustment for congenital heart surgery (RACHS) scale. A composite cardiovascular outcome was analyzed as a numerical variable and calculated as the number of cardiovascular events.

Results

Overall, the changes in thyroid function parameters resulted in a U-shaped curve, while cortisol levels yielded a bell-shaped curve. The most significant changes occurred at 24 hours postop, including a decrease in mean TSH by 2.08 μIU/L (p < 0.001), fT3 by 2.39 pmol/L (p < 0.001), and fT4 by 2.45 pmol/L (p < 0.001) and an increase in cortisol levels by 406.48 nmol/L (p < 0.001) with respect to the baseline. Cortisol concentration peaked higher and recovered slower among patients with high cardiac risk than their counterparts. Cardiovascular outcomes were independently predicted by the extent of the decline in fT4 and TSH at 48 and 72 hours postop, with reference to the baseline, and by the cortisol level at 24 h postop, independent of the baseline, besides the RACHS category.

Conclusion

Cardiac surgery among children yields a high adrenocortical response and a high incidence of nonthyroidal illness syndrome, increasing cardiovascular risk. A preventive management strategy involves improving surgical techniques to minimize trauma-related stress.

Glucocorticoid-induced Fingerprints on Visceral Adipose Tissue Transcriptome and Epigenome

CONTEXT

Chronic glucocorticoid (GC) overexposure, resulting from endogenous Cushing's syndrome (CS) or exogenous GC therapy, causes several adverse outcomes, including persistent central fat accumulation associated with a low-grade inflammation. However, no previous multiomics studies in visceral adipose tissue (VAT) from patients exposed to high levels of unsuppressed GC during active CS or after remission are available yet.

OBJECTIVE

To determine the persistent VAT transcriptomic alterations and epigenetic fingerprints induced by chronic hypercortisolism.

METHODS

We employed a translational approach combining high-throughput data on endogenous CS patients and a reversible CS mouse model. We performed RNA sequencing and chromatin immunoprecipitation sequencing on histone modifications (H3K4me3, H3K27ac, and H3K27me3) to identify persistent transcriptional and epigenetic signatures in VAT produced during active CS and maintained after remission.

RESULTS

VAT dysfunction was associated with low-grade proinflammatory status, macrophage infiltration, and extracellular matrix remodeling. Most notably, chronic hypercortisolism caused a persistent circadian rhythm disruption in VAT through core clock genes modulation. Importantly, changes in the levels of 2 histone modifications associated to gene transcriptional activation (H3K4me3 and H3K27ac) correlated with the observed differences in gene expression during active CS and after CS remission.

CONCLUSION

We identified for the first time the persistent transcriptional and epigenetic signatures induced by hypercortisolism in VAT, providing a novel integrated view of molecular components driving the long-term VAT impairment associated with CS.

Cesarean delivery is associated with suppressed activities of the stress axes

Maternal pre- and post-delivery stress levels might be different for vaginal or cesarean deliveries. This study aimed to investigate the effects of type of delivery (vaginal or cesarean) and time of delivery (pre- and post-delivery) on the stress axes of the body, namely the hypothalamic-pituitary adrenal axis (HPA) and autonomic nervous system (ANS).Ninety-one pregnant women were volunteered to participate this prospective study. In these women, pre- and post-delivery HPA and ANS activities were measured noninvasively by salivary cortisol and heart rate variability (HRV), respectively. HRV was measured by 5-min electrocardiogram recording and time- and frequency-domain parameters were computed.Salivary cortisol concentration and HRV parameters were higher in women having vaginal delivery than those having cesarean delivery (p < 0.05). Cortisol levels did not differ between pre- and post-delivery (p > 0.05) but the time-domain parameters of HRV decreased post-delivery (p < 0.05). No interactions were observed between the types and times of delivery (p > 0.05).HPA and ANS axes had different activity patterns throughout the delivery process and they were higher during vaginal delivery, suggesting that they are integral parts of normal birth process and that cesarean delivery perturbs the activity of both axes.

Inflammatory Biomarker Levels After Propofol or Sevoflurane Anesthesia: A Meta-analysis

BACKGROUND

The perioperative inflammatory response may be implicated in adverse outcomes including neurocognitive dysfunction and cancer recurrence after oncological surgery. The immunomodulatory role of anesthetic agents has been demonstrated in vitro; however, its clinical relevance is unclear. The purpose of this meta-analysis was to compare propofol and sevoflurane with respect to biomarkers of perioperative inflammation. The secondary aim was to correlate markers of inflammation with clinical measures of perioperative cognition.

METHODS

Databases were searched for randomized controlled trials examining perioperative inflammation after general anesthesia using propofol compared to sevoflurane. Inflammatory biomarkers investigated were interleukin (IL)-6, IL-10, tissue necrosis factor alpha (TNF-α), and C-reactive protein (CRP). The secondary outcome was incidence of perioperative neurocognitive disorders. Meta-analysis with metaregression was performed to determine the difference between propofol and sevoflurane.

RESULTS

Twenty-three studies were included with 1611 participants. Studies varied by surgery type, duration, and participant age. There was an increase in the mean inflammatory biomarker levels following surgery, with meta-analysis revealing no difference in effect between propofol and sevoflurane. Heterogeneity between studies was high, with surgery type, duration, and patient age contributing to the variance across studies. Only 5 studies examined postoperative cognitive outcomes; thus, a meta-analysis could not be performed. Nonetheless, of these 5 studies, 4 reported a reduced incidence of cognitive decline associated with propofol use.

CONCLUSIONS

Surgery induces an inflammatory response; however, the inflammatory response did not differ as a function of anesthetic technique. This absence of an effect suggests that patient and surgical variables may have a far more significant impact on the postoperative inflammatory responses than anesthetic technique. The majority of studies assessing perioperative cognition in older patients reported a benefit associated with the use of propofol; however, larger trials using homogenous outcomes are needed to demonstrate such an effect.

Bone Metabolism in the Healing Process of Lumbar Interbody Fusion: Temporal Changes of Bone Turnover Markers

STUDY DESIGN

Prospective longitudinal study.

OBJECTIVE

The aim of this study was to evaluate temporal changes of bone turnover markers (BTMs) after lumbar spinal fusion in patients without osteoporosis.

SUMMARY OF BACKGROUND DATA

Radiological studies are the standard method to monitor bony fusion, but they do not allow a timely assessment of bone healing. BTMs react rapidly to changes in bone metabolism during fusion process and could be an additional tool to monitor this process.

METHODS

A total of 78 nonosteoporosis patients who had undergone one- or two-level transforaminal lumbar interbody fusion were included. Fusion status was assessed using computed tomography sagittal and coronal images. Serum levels of bone-specific alkaline phosphatase (BAP), procollagen type 1 amino-terminal propeptide (P1NP), and osteocalcin (OC) were measured to assess bone formation, and tartrate-resistant acid phosphatase 5b (TRACP-5b) was measured to assess bone resorption. Serum samples were obtained before surgery and at 1, 2, 4, 8, 13, 26, 39, and 52 weeks after surgery.

RESULTS

A solid fusion was achieved in 71 of 78 patients (91%), and seven patients resulted in pseudarthrosis. In the fusion group, the level of all BTMs once decreased at 1 postoperative week. Then, BAP and P1NP reached a peak at 4 weeks after surgery, and TRACP-5b and OC peaked at 8 weeks. Thereafter, the level of P1NP and TRACP-5b gradually got closer to the baseline over a year, and BAP kept high until 52 postoperative weeks. In the pseudarthrosis group, peak level of BTMs was significantly higher and the increased level of BAP and P1NP was kept until 52 weeks.

CONCLUSION

The present study demonstrated dynamics of BTMs after lumbar spinal fusion in patients without osteoporosis. These normal population data contribute as a baseline to evaluate the effect of osteogenic agents on bone metabolism after spinal fusion.Level of Evidence: 2.

Cerebral and Systemic Stress Parameters in Correlation with Jugulo-Arterial CO2 Gap as a Marker of Cerebral Perfusion during Carotid Endarterectomy

Intraoperative stress is common to patients undergoing carotid endarterectomy (CEA); thus, impaired oxygen and metabolic balance may appear. In this study, we aimed to identify new markers of intraoperative cerebral ischemia, with predictive value on postoperative complications during CEA, performed in regional anesthesia. A total of 54 patients with significant carotid stenosis were recruited and submitted to CEA. Jugular and arterial blood samples were taken four times during operation, to measure the jugulo-arterial carbon dioxide partial pressure difference (P(j-a)CO₂), and cortisol, S100B, L-arginine, and lactate levels. A positive correlation was found between preoperative cortisol levels and all S100B concentrations. In addition, they are positively correlated with P(j-a)CO₂ values. Conversely, postoperative cortisol inversely correlates with P(j-a)CO₂ and postoperative S100B values. A negative correlation was observed between maximum systolic and pulse pressures and P(j-a)CO₂ after carotid clamp and before the release of clamp. Our data suggest that preoperative cortisol, S100B, L-arginine reflect patients' frailty, while these parameters postoperatively are influenced by intraoperative stress and injury. As a novelty, P(j-a)CO₂ might be an emerging indicator of cerebral blood flow during CEA.

Glucocorticoid modulation of synaptic plasticity in the human temporal cortex of epilepsy patients: Does chronic stress contribute to memory impairment?

OBJECTIVE

Memory impairment is common in patients with temporal lobe epilepsy and seriously affects life quality. Chronic stress is a recognized cofactor in epilepsy and can also impair memory function. Furthermore, increased cortisol levels have been reported in epilepsy patients. Animal models have suggested that aggravating effects of stress on memory and synaptic plasticity were mediated via glucocorticoids. The aim of this study was, therefore, to investigate the effect of glucocorticoid receptor (GR) modulation on synaptic plasticity in the human cortex of epilepsy patients.

METHODS

We performed field potential recordings in acute slices from the temporal neocortex of patients who underwent surgery for drug-resistant temporal lobe epilepsy. Synaptic plasticity was investigated by a theta-burst stimulation (TBS) protocol for induction of long-term potentiation (LTP) in the presence of GR modulators.

RESULTS

LTP was impaired in temporal cortex from epilepsy patients. Pretreatment of the slices with the GR antagonist mifepristone (RU486) improved LTP induction, suggesting that LTP impairment was due to baseline GR activation in the human cortex. The highly potent GR agonist dexamethasone additionally weakened synaptic strength in an activity-dependent manner when applied after TBS.

SIGNIFICANCE

Our results show a direct negative glucocorticoid effect on synaptic potentiation in the human cortex and imply chronic activation of GRs. Chronic stress may therefore contribute to memory impairment in patients with temporal lobe epilepsy. Furthermore, the activity-dependent acute inhibitory effect of dexamethasone suggests a mechanism of synaptic downscaling by which postictally increased cortisol levels may prevent pathologic plasticity upon seizures.

Stress and autonomic nerve dysfunction monitoring in perioperative gastric cancer patients using a smart device

Background

Heart rate variability (HRV), a sensitive marker of stress and autonomic nervous disorders, was significantly decreased in cardiovascular disease, inflammation, and surgical injury. However, the effect of radical gastrectomy on HRV parameters needs to be further investigated.

Methods

A prospective, observational study including 45 consecutive enrolled patients undergoing radical gastrectomy in our enhanced recovery after surgery (ERAS) programs was conducted. Frequency‐ and time‐domain parameters of HRV from 1 day prior to operation to 4 days postoperatively were continuously measured. Meanwhile, plasma cortisol and inflammatory markers were recorded and correlated to HRV parameters.

Results

Heart rate variability showed a solidly circadian rhythm. Anesthesia severely disturbed HRV parameters, resulting in a reduction of most of the HRV parameters. Frequency‐domain parameter (including VLF) and time‐domain parameters (including the SDNN, SDANN, and triangular index) of HRV demonstrated a significant reduction compared to preoperative values on the postoperative day 1 (Pod1), and these HRV parameters could return to baseline on Pod2 or Pod3, indicating surgical stress and autonomic nerve dysfunction existed in the early postoperative period. Inflammatory biomarkers were significantly elevated on Pod1 and Pod3. Plasma cortisol decreased significantly on Pod1 and Pod3. Both inflammatory biomarkers and plasma cortisol had no significant correlation with HRV parameters.

Conclusions

Compared with plasma cortisol and inflammation biomarkers, HRV is more sensitive to detect surgical stress and autonomic nervous dysfunction induced by radical gastrectomy in patients with gastric cancer.

Effects of Transcutaneous Electrical Acupoint Stimulation on Stress Response during Intubation and Extubation in Patients Undergoing Video-Assisted Thoracoscopic Surgery: A Prospective, Randomized Controlled Trial

Objective

The study aimed to evaluate the effect of transcutaneous electrical acupoint stimulation (TEAS) on the stress response during intubation and extubation in patients undergoing video-assisted thoracoscopic surgery (VATS).

Methods

122 patients undergoing VATS lobectomy were randomly divided into two groups: the TEAS group (n = 62) and the control group (n = 60). Patients in the TEAS group underwent electroacupuncture stimulation of bilateral Neiguan (PC6), Hegu (L14), Lieque (LU7), and Chize (LU5) acupoints from 30 min before anesthesia to the end of surgery. The patients in the control group did not undergo stimulation. The primary endpoints were the hemodynamic parameters and plasma concentrations of epinephrine, norepinephrine, and cortisol. The secondary endpoints were the consumption of remifentanil and propofol, Ramsay sedation score and arousal time, extubation quality score, and postoperative complications.

Results

The hemodynamic variables and plasma concentrations of epinephrine, norepinephrine, and cortisol during intubation and extubation were lower in the TEAS group at T1, T3, and T4 compared with the control group. TEAS led to a reduction in the consumption of remifentanil (P < 0.01), as well as a reduction in the incidence of postoperative complications. The extubation quality score was lower (P < 0.01) while the Ramsay sedation score was higher (P < 0.01) in the TEAS group than in the control group. However, the arousal time and consumption of propofol were not significantly different between the two groups.

Conclusion

TEAS can maintain hemodynamic stability, reduce the stress response during intubation and extubation, improve the quality of anesthesia recovery, and decrease the incidence of postoperative complications in patients undergoing VATS.

Postoperative adrenal insufficiency in Conn's syndrome-does it occur frequently?

Primary aldosteronism (PA) is the most frequent form of endocrine hypertension. Recently, frequent clinically significant adrenal insufficiency after adrenalectomy in subjects with PA has been reported, which may make the early postsurgical management difficult. We retrospectively searched for possible adrenal insufficiency in subjects who underwent adrenalectomy for PA and have measured cortisol in the early postoperative course. We included subjects with confirmed diagnosis of PA who underwent either posture testing (blood draw at 06:00 and 08:00) and/or adrenal venous sampling (AVS) (blood draw between 08:00 and 09:00) and have also measured cortisol after surgery (cortisol measured approximately at 07:00). Cortisol was measured by immunoassay. In this study, we identified 150 subjects (age 48.5 ± 10.3 years) with available cortisol values in the early postoperative course (median [25th percentile, 75th percentile]) 6 [5,6] days. Postoperative cortisol values (551 ± 148 nmol/l) were normal and significantly higher, compared to preoperative standing cortisol values (404 ± 150 nmol/l; (P < 0.001) and AVS cortisol values (493 ± 198 nmol/l; P = 0.009), and did not significantly differ from preoperative supine cortisol values. Postsurgical cortisol values were not different among subjects with or without abnormal dexamethasone suppression test or elevated urinary free cortisol pre-surgery, and were significantly higher in subjects with abnormal diurnal cortisol variability compared with subjects with normal diurnal variability. No patient presented with adrenocortical crisis in the later follow-up. In conclusion, postoperative cortisol values did not indicate any suspicion of possible adrenal insufficiency. To exclude possible adrenal insufficiency, it may be sufficient to measure morning cortisol in the early postoperative course.

Peri-operative steroid management in the paediatric population

BACKGROUND

Patients with adrenal insufficiency are at risk of adrenal crisis, a potentially life-threatening emergency in the peri-operative period due to their attenuated ability to mount a cortisol response. There is a lack of standardization regarding peri-operative stress-dose glucocorticoids in paediatric clinical practice with the absence of agreed protocols. For the individual patient, the risk of adrenal crisis must be weighed against the potential adverse clinical outcomes associated with unnecessary or supra-physiologic glucocorticoid dosing in susceptible patients. Specific clinical concerns in the paediatric population include osteopenia, growth restriction and increased risk of cardiovascular disease in adulthood. This review aimed to identify and evaluate available literature in the field of peri-operative stress-dose glucocorticoids.

METHODS

A comprehensive literature search was conducted to construct a narrative review.

RESULTS

The outcome of this review identified that paediatric patients, unlike adults, do not show a graded response to surgical stress with implications for glucocorticoid stress dose regimens for general anaesthesia and less invasive surgical procedures. The studies highlight a lack of information on physiological steroid responses to stress situations and differences in the approach to glucocorticoid replacement strategies in the paediatric population.

CONCLUSION

The review identified there is a lack of high-quality paediatric-specific studies evaluating appropriate stress-dose glucocorticoid regimens in paediatric patients with or at risk of adrenal insufficiency. Further research is needed to establish clear evidence-based clinical guidelines for paediatric peri-operative practice regarding steroid stress dosing in adrenal insufficiency. Current knowledge would suggest that a balanced view of risks and benefits should be taken appropriate to the clinical context, to dictate peri-operative stress-dose glucocorticoids use that permits safe perioperative management.

Geriatric Implications of Surgical Oncology

Surgical oncology is cancer care that focuses on using surgery to diagnose, stage, and treat cancer and is one of the main treatments for malignancy. Patients older than 65 years are generally considered geriatric. The incidence of cancer in geriatric patients is increasing annually. Candidacy for surgical intervention depends on factors such as cancer type, size, location, grade and stage of the tumor, and the patient's overall health status and age. Despite increasing agreement that age should not limit treatment options, geriatric patients tend to be undertreated. Cancer in geriatric patients has different features than in younger patients. As such, treatment options may be dissimilar in these 2 cohorts. Here, care of the geriatric patient undergoing surgical oncology interventions is discussed.

Obesity, metabolic syndrome, and inflammation: an update for anaesthetists caring for patients with obesity

Our understanding of chronic inflammation in obesity is evolving. Suggested mechanisms include hypoxia of adipose tissue and a subsequent increase in circulating cytokines. It is now known that adipose tissue, far from being an inert tissue, produces and secretes multiple peptides that influence inflammation and metabolism, including substrates of the renin-angiotensin-aldosterone system (RAAS). RAAS blocking antihypertensive medication and cholesterol-lowering agents are now being evaluated for their metabolic and inflammation-modulating effects. Surgery also has pro-inflammatory effects, which may be exacerbated in patients with obesity. This narrative review will summarise the recent literature surrounding obesity, metabolic syndrome, inflammation, and interplay with the RAAS, with evidence-based recommendations for the optimisation of patients with obesity, prior to surgery and anaesthesia.

The potential role of stress and sex steroids in heritable effects of sevoflurane

Most surgical procedures require general anesthesia, which is a reversible deep sedation state lacking all perception. The induction of this state is possible because of complex molecular and neuronal network actions of general anesthetics (GAs) and other pharmacological agents. Laboratory and clinical studies indicate that the effects of GAs may not be completely reversible upon anesthesia withdrawal. The long-term neurocognitive effects of GAs, especially when administered at the extremes of ages, are an increasingly recognized health concern and the subject of extensive laboratory and clinical research. Initial studies in rodents suggest that the adverse effects of GAs, whose actions involve enhancement of GABA type A receptor activity (GABAergic GAs), can also extend to future unexposed offspring. Importantly, experimental findings show that GABAergic GAs may induce heritable effects when administered from the early postnatal period to at least young adulthood, covering nearly all age groups that may have children after exposure to anesthesia. More studies are needed to understand when and how the clinical use of GAs in a large and growing population of patients can result in lower resilience to diseases in the even larger population of their unexposed offspring. This minireview is focused on the authors' published results and data in the literature supporting the notion that GABAergic GAs, in particular sevoflurane, may upregulate systemic levels of stress and sex steroids and alter expressions of genes that are essential for the functioning of these steroid systems. The authors hypothesize that stress and sex steroids are involved in the mediation of sex-specific heritable effects of sevoflurane.

Investigation of the Hypothalamo-pituitary-adrenal (HPA) axis: a contemporary synthesis

The hypothalamo-pituitary-adrenal (HPA) axis is one of the main components of the stress system. Maintenance of normal physiological events, which include stress responses to internal or external stimuli in the body, depends on appropriate HPA axis function. In the case of severe cortisol deficiency, especially when there is a triggering factor, the patient may develop a life-threatening adrenal crisis which may result in death unless early diagnosis and adequate treatment are carried out. The maintenance of normal physiology and survival depend upon a sufficient level of cortisol in the circulation. Life-long glucocorticoid replacement therapy, in most cases meeting but not exceeding the need of the patient, is essential for normal life expectancy and maintenance of the quality of life. To enable this, the initial step should be the correct diagnosis of adrenal insufficiency (AI) which requires careful evaluation of the HPA axis, a highly dynamic endocrine system. The diagnosis of AI in patients with frank manifestations is not challenging. These patients do not need dynamic tests, and basal cortisol is usually enough to give a correct diagnosis. However, most cases of secondary adrenal insufficiency (SAI) take place in a gray zone when clinical manifestations are mild. In this situation, more complicated methods that can simulate the response of the HPA axis to a major stress are required. Numerous studies in the assessment of HPA axis have been published in the world literature. In this review, the tests used in the diagnosis of secondary AI or in the investigation of suspected HPA axis insufficiency are discussed in detail, and in the light of this, various recommendations are made.

Regulation of Cortisol in Patients Undergoing Total Joint Arthoplasty

Osteoarthritis is a condition in which joint cartilage and bone degenerate progressively over time. Total joint arthroplasty is a definitive treatment. Cortisol is a hormone that is associated with pain and inflammation. This study aims to investigate the cortisol levels in patients undergoing total joint arthroplasty. Plasma samples were collected from 71 total joint arthroplasty (TJA) patients at baseline (pre-surgery), 24 hours post-operation, and 5 days post-operation. Cortisol levels were measured in each sample using a commercially available ELISA kit. All results were compiled as group means ± SD. The plasma cortisol level at baseline were 218.5 ± 12 ng/mL. The 24-hour post-surgical samples showed a marked increase in cortisol levels 240.7 ± 15 ng/mL. The blood samples drawn at the 5th day after surgery showed a downward trend (74 ± 12 ng/mL). At 5 days post-operation, cortisol levels were significantly lower than at baseline or 24 hours post-operation. These results point to the fact that prior to surgery, the patient’s emotional stress contributes to increased serum cortisol levels. The higher level of cortisol persists at 24 hours post-operation due to inflammation from the procedure. This data also suggests that at 5 days post-operation, the inflammatory response from the surgery and emotional stress subside, resulting in a near normalization of the cortisol levels. Cortisol is a hormone that plays a major role in the body’s response to surgery. The relevance between cortisol and different points in the surgical timeline has the potential to prognosticate and improve recovery measures.

Ultrasound-guided stellate ganglion block alleviates stress responses and promotes recovery of gastrointestinal function in patients

BACKGROUND

This study aimed to investigate the effect of preoperative ultrasound-guided stellate ganglion block (SGB) on the perioperative stress responses and gastrointestinal functions of patients undergoing laparoscopic colorectal cancer surgery.

METHODS

A total of 60 colorectal cancer patients were enrolled in study and were randomized to be treated with or without SGB therapy. In the SGB group, patients were injected with 7 mL 0.5% ropivacaine in stellate ganglion under ultrasound guidance before anesthesia. Mean artery pressure (MAP), heart rate (HR), recovery of bowel sound and first exhaust, as well as levels of motilin, gastrin, norepinephrine, cortisol, interleukin-6 (IL-6) and C-reactive protein (CRP) were recorded at various time points.

RESULTS

26 patients in the SGB group and 27 patients in the control group were analyzed. No significant differences in MAP or HR were observed between the two groups before, during and after the surgery. SGB promoted recovery of gastrointestinal functions, as evidenced by earlier recovery of bowel sound and first exhaust, as well as increased motilin and gastrin levels. SGB also attenuated stress responses, as shown in reduced norepinephrine, cortisol, IL-6 and CRP levels.

CONCLUSIONS

SGB promotes the recovery of gastrointestinal functions and reduces stress responses of colorectal patients undergoing laparoscopic colorectal cancer surgery.

Anesthesia and Long-term Oncological Outcomes: A Systematic Review and Meta-analysis

BACKGROUND

Whether propofol elicits a survival benefit over volatile anesthetics during cancer surgery remains inconclusive. The primary aim of this systematic review and meta-analysis is to compare the effects of propofol-based total intravenous anesthesia (TIVA) with any volatile anesthesia on long-term oncological outcomes. The secondary aim is to compare propofol-based TIVA with specific volatile agents on long-term oncological outcomes.

METHODS

We searched PubMed, Embase, Scopus, Web of Science, and Cochrane Library from inception through March 3, 2020. Randomized control trials and observational studies that compared the effects of propofol-based TIVA and volatile anesthesia on long-term oncological outcomes, which also reported hazard ratios (HR) as effect estimates, were considered eligible for inclusion. Using the inverse variance method with a random-effects model, HR and 95% confidence intervals (CI) were calculated. Trial sequential analysis was incorporated to test if the results were subject to a type I or type II error.

RESULTS

Nineteen retrospective observational studies were included. Patients who received propofol-based TIVA during cancer surgery were associated with significantly better overall survival than those who received volatile anesthesia (HR = 0.79, 95% CI, 0.66-0.94, P = .008, I2 = 82%). In contrast, no statistically significant difference was observed in recurrence-free survival between patients who received propofol-based TIVA and volatile anesthesia during cancer surgery (HR = 0.81, 95% CI, 0.61-1.07, P = .137, I2 = 85%). In the subgroup analysis by different volatile anesthetics, patients who received propofol-based TIVA were associated with better overall survival than those who received desflurane (HR = 0.54, 95% CI, 0.36-0.80, P = .003, I2 = 80%). In contrast, there was no statistically significant difference in overall survival between patients who received propofol-based TIVA and those who received sevoflurane (HR = 0.92, 95% CI, 0.74-1.14, P = .439, I2 = 70%). In the trial sequential analysis of overall survival, the cumulative Z curve reached the required heterogeneity-adjusted information size and crossed the traditional significance boundary. In contrast, in the trial sequential analysis of recurrence-free survival, the cumulative Z curve did not cross the traditional significance boundary. However, the required heterogeneity-adjusted information size has not yet been reached.

CONCLUSIONS

Propofol-based TIVA is generally associated with better overall survival than volatile anesthesia during cancer surgery. Further large-scaled, high-quality randomized control trials are warranted to confirm our findings.