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Cao SJ, Zhang Y, Zhang YX, Zhao W, Pan LH, Sun XD, Jia Z, Ouyang W, Ye QS, Zhang FX, Guo YQ, Ai YQ, Zhao BJ, Yu JB, Liu ZH, Yin N, Li XY, Ma JH, Li HJ, Wang MR, Sessler DI, Ma D, Wang DX. Long-term survival in older patients given propofol or sevoflurane anaesthesia for major cancer surgery: follow-up of a multicentre randomised trial. Br J Anaesth 2023; 131:266-275. [PMID: 37474242 DOI: 10.1016/j.bja.2023.01.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 12/21/2022] [Accepted: 01/17/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND Experimental evidence indicates that i.v. anaesthesia might reduce cancer recurrence compared with volatile anaesthesia, but clinical information is observational only. We therefore tested the primary hypothesis that propofol-based anaesthesia improves survival over 3 or more years after potentially curative major cancer surgery. METHODS This was a long-term follow-up of a multicentre randomised trial in 14 tertiary hospitals in China. We enrolled 1228 patients aged 65-90 yr who were scheduled for major cancer surgery. They were randomised to either propofol-based i.v. anaesthesia or to sevoflurane-based inhalational anaesthesia. The primary endpoint was overall survival after surgery. Secondary endpoints included recurrence-free and event-free survival. RESULTS Amongst subjects randomised, 1195 (mean age 72 yr; 773 [65%] male) were included in the modified intention-to-treat analysis. At the end of follow-up (median 43 months), there were 188 deaths amongst 598 patients (31%) assigned to propofol-based anaesthesia compared with 175 deaths amongst 597 patients (29%) assigned to sevoflurane-based anaesthesia; adjusted hazard ratio 1.02; 95% confidence interval (CI): 0.83-1.26; P=0.834. Recurrence-free survival was 223/598 (37%) in patients given propofol anaesthesia vs 206/597 (35%) given sevoflurane anaesthesia; adjusted hazard ratio 1.07; 95% CI: 0.89-1.30; P=0.465. Event-free survival was 294/598 (49%) in patients given propofol anaesthesia vs 274/597 (46%) given sevoflurane anaesthesia; adjusted hazard ratio 1.09; 95% CI 0.93 to 1.29; P=0.298. CONCLUSIONS Long-term survival after major cancer surgery was similar with i.v. and volatile anaesthesia. Propofol-based iv. anaesthesia should not be used for cancer surgery with the expectation that it will improve overall or cancer-specific survival. CLINICAL TRIAL REGISTRATIONS ChiCTR-IPR-15006209; NCT02660411.
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Affiliation(s)
- Shuang-Jie Cao
- Department of Anesthesiology, Peking University First Hospital, Beijing, China
| | - Yue Zhang
- Department of Anesthesiology, Peking University First Hospital, Beijing, China; Clinical Research Institute, Shenzhen Peking University-The Hong Kong University of Science & Technology Medical Center, Shenzhen, China
| | - Yu-Xiu Zhang
- Department of Anesthesiology, Peking University First Hospital, Beijing, China
| | - Wei Zhao
- Department of Anesthesiology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Ling-Hui Pan
- Department of Anesthesiology, Guangxi Medical University Cancer Hospital, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Xu-De Sun
- Department of Anesthesiology, Tangdu Hospital, Air Force Medical University (Fourth Military Medical University), Xi'an, Shaanxi, China
| | - Zhen Jia
- Department of Anesthesiology, Affiliated Hospital of Qinghai University, Xining, Qinghai, China
| | - Wen Ouyang
- Department of Anesthesiology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Qing-Shan Ye
- Department of Anesthesiology, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan, Ningxia Hui Autonomous Region, China
| | - Fang-Xiang Zhang
- Department of Anesthesiology, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China
| | - Yong-Qing Guo
- Department of Anesthesiology, Shanxi Provincial People's Hospital, Taiyuan, Shanxi, China
| | - Yan-Qiu Ai
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Bin-Jiang Zhao
- Department of Anesthesiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Jian-Bo Yu
- Department of Anesthesiology and Critical Care Medicine, Tianjin Nankai Hospital, Tianjin Medical University, Tianjin, China
| | - Zhi-Heng Liu
- Department of Anesthesiology, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen, Guangdong, China
| | - Ning Yin
- Department of Anesthesiology, Zhongda Hospital, Medical School of Southeast University, Nanjing, Jiangsu, China; Department of Anesthesiology, Sir Run Run Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Xue-Ying Li
- Department of Biostatistics, Peking University First Hospital, Beijing, China
| | - Jia-Hui Ma
- Department of Anesthesiology, Peking University First Hospital, Beijing, China
| | - Hui-Juan Li
- Peking University Clinical Research Institute, Peking University Health Science Center, Beijing, China
| | - Mei-Rong Wang
- Peking University Clinical Research Institute, Peking University Health Science Center, Beijing, China
| | - Daniel I Sessler
- Outcomes Research Consortium, Cleveland Clinic, Cleveland, OH, USA; Department of Outcomes Research, Anesthesiology Institute, OH, USA
| | - Daqing Ma
- Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea and Westminster Hospital, London, UK; National Clinical Research Center for Child Health, Hangzhou, China
| | - Dong-Xin Wang
- Department of Anesthesiology, Peking University First Hospital, Beijing, China; Outcomes Research Consortium, Cleveland Clinic, Cleveland, OH, USA.
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Cao SJ, Zhang Y, Zhang YX, Zhao W, Pan LH, Sun XD, Jia Z, Ouyang W, Ye QS, Zhang FX, Guo YQ, Ai YQ, Zhao BJ, Yu JB, Liu ZH, Yin N, Li XY, Ma JH, Li HJ, Wang MR, Sessler DI, Ma D, Wang DX. Delirium in older patients given propofol or sevoflurane anaesthesia for major cancer surgery: a multicentre randomised trial. Br J Anaesth 2023; 131:253-265. [PMID: 37474241 DOI: 10.1016/j.bja.2023.04.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 04/04/2023] [Accepted: 04/14/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND Delirium is a common and disturbing postoperative complication that might be ameliorated by propofol-based anaesthesia. We therefore tested the primary hypothesis that there is less delirium after propofol-based than after sevoflurane-based anaesthesia within 7 days of major cancer surgery. METHODS This multicentre randomised trial was conducted in 14 tertiary care hospitals in China. Patients aged 65-90 yr undergoing major cancer surgery were randomised to either propofol-based anaesthesia or to sevoflurane-based anaesthesia. The primary endpoint was the incidence of delirium within 7 postoperative days. RESULTS A total of 1228 subjects were enrolled and randomised, with 1195 subjects included in the modified intention-to-treat analysis (mean age 71 yr; 422 [35%] women); one subject died before delirium assessment. Delirium occurred in 8.4% (50/597) of subjects given propofol-based anaesthesia vs 12.4% (74/597) of subjects given sevoflurane-based anaesthesia (relative risk 0.68 [95% confidence interval {CI}: 0.48-0.95]; P=0.023; adjusted relative risk 0.59 [95% CI: 0.39-0.90]; P=0.014). Delirium reduction mainly occurred on the first day after surgery, with a prevalence of 5.4% (32/597) with propofol anaesthesia vs 10.7% (64/597) with sevoflurane anaesthesia (relative risk 0.50 [95% CI: 0.33-0.75]; P=0.001). Secondary endpoints, including ICU admission, postoperative duration of hospitalisation, major complications within 30 days, cognitive function at 30 days and 3 yr, and safety outcomes, did not differ significantly between groups. CONCLUSIONS Delirium was a third less common after propofol than sevoflurane anaesthesia in older patients having major cancer surgery. Clinicians might therefore reasonably select propofol-based anaesthesia in patients at high risk of postoperative delirium. CLINICAL TRIAL REGISTRATION Chinese Clinical Trial Registry (ChiCTR-IPR-15006209) and ClinicalTrials.gov (NCT02662257).
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Affiliation(s)
- Shuang-Jie Cao
- Department of Anesthesiology, Peking University First Hospital, Beijing, China
| | - Yue Zhang
- Department of Anesthesiology, Peking University First Hospital, Beijing, China; Clinical Research Institute, Shenzhen Peking University-The Hong Kong University of Science and Technology Medical Center, Shenzhen, Guangdong, China
| | - Yu-Xiu Zhang
- Department of Anesthesiology, Peking University First Hospital, Beijing, China
| | - Wei Zhao
- Department of Anesthesiology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Ling-Hui Pan
- Department of Anesthesiology, Guangxi Medical University Cancer Hospital, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Xu-De Sun
- Department of Anesthesiology, Tangdu Hospital, Air Force Medical University (Fourth Military Medical University), Xi'an, Shaanxi, China
| | - Zhen Jia
- Department of Anesthesiology, Affiliated Hospital of Qinghai University, Xining, Qinghai, China
| | - Wen Ouyang
- Department of Anesthesiology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Qing-Shan Ye
- Department of Anesthesiology, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan, Ningxia Hui Autonomous Region, China
| | - Fang-Xiang Zhang
- Department of Anesthesiology, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China
| | - Yong-Qing Guo
- Department of Anesthesiology, Shanxi Provincial People's Hospital, Taiyuan, Shanxi, China
| | - Yan-Qiu Ai
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Bin-Jiang Zhao
- Department of Anesthesiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Jian-Bo Yu
- Department of Anesthesiology and Critical Care Medicine, Tianjin Nankai Hospital, Tianjin Medical University, Tianjin, China
| | - Zhi-Heng Liu
- Department of Anesthesiology, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen, Guangdong, China
| | - Ning Yin
- Department of Anesthesiology, Zhongda Hospital, Medical School of Southeast University, Nanjing, Jiangsu, China; Department of Anesthesiology, Sir Run Run Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Xue-Ying Li
- Department of Biostatistics, Peking University First Hospital, Beijing, China
| | - Jia-Hui Ma
- Department of Anesthesiology, Peking University First Hospital, Beijing, China
| | - Hui-Juan Li
- Peking University Clinical Research Institute, Peking University Health Science Center, Beijing, China
| | - Mei-Rong Wang
- Peking University Clinical Research Institute, Peking University Health Science Center, Beijing, China
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Outcomes Research Consortium, Cleveland, OH, USA
| | - Daqing Ma
- Division of Anesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea and Westminster Hospital, London, UK; The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Dong-Xin Wang
- Department of Anesthesiology, Peking University First Hospital, Beijing, China; Outcomes Research Consortium, Cleveland, OH, USA.
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Aghababaie Z, Wang THH, Nisbet LA, Matthee A, Dowrick J, Sands GB, Paskaranandavadivel N, Cheng LK, O'Grady G, Angeli-Gordon TR. Anaesthesia by intravenous propofol reduces the incidence of intra-operative gastric electrical slow-wave dysrhythmias compared to isoflurane. Sci Rep 2023; 13:11824. [PMID: 37479717 PMCID: PMC10362009 DOI: 10.1038/s41598-023-38612-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 07/11/2023] [Indexed: 07/23/2023] Open
Abstract
Gastric motility is coordinated by bioelectrical slow-wave activity, and abnormal electrical dysrhythmias have been associated with nausea and vomiting. Studies have often been conducted under general anaesthesia, while the impact of general anaesthesia on slow-wave activity has not been studied. Clinical studies have shown that propofol anaesthesia reduces postoperative nausea and vomiting (PONV) compared with isoflurane, while the underlying mechanisms remain unclear. In this study, we investigated the effects of two anaesthetic drugs, intravenous (IV) propofol and volatile isoflurane, on slow-wave activity. In vivo experiments were performed in female weaner pigs (n = 24). Zolazepam and tiletamine were used to induce general anaesthesia, which was maintained using either IV propofol (n = 12) or isoflurane (n = 12). High-resolution electrical mapping of slow-wave activity was performed. Slow-wave dysrhythmias occurred less often in the propofol group, both in the duration of the recorded period that was dysrhythmic (propofol 14 ± 26%, isoflurane 43 ± 39%, P = 0.043 (Mann-Whitney U test)), and in a case-by-case basis (propofol 3/12, isoflurane 8/12, P = 0.015 (Chi-squared test)). Slow-wave amplitude was similar, while velocity and frequency were higher in the propofol group than the isoflurane group (P < 0.001 (Student's t-test)). This study presents a potential physiological biomarker linked to recent observations of reduced PONV with IV propofol. The results suggest that propofol is a more suitable anaesthetic for studying slow-wave patterns in vivo.
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Affiliation(s)
- Zahra Aghababaie
- Auckland Bioengineering Institute, University of Auckland, Private Bag 92019, Auckland, New Zealand
| | - Tim Hsu-Han Wang
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Linley A Nisbet
- Auckland Bioengineering Institute, University of Auckland, Private Bag 92019, Auckland, New Zealand
| | - Ashton Matthee
- Auckland Bioengineering Institute, University of Auckland, Private Bag 92019, Auckland, New Zealand
| | - Jarrah Dowrick
- Auckland Bioengineering Institute, University of Auckland, Private Bag 92019, Auckland, New Zealand
| | - Gregory B Sands
- Auckland Bioengineering Institute, University of Auckland, Private Bag 92019, Auckland, New Zealand
| | | | - Leo K Cheng
- Auckland Bioengineering Institute, University of Auckland, Private Bag 92019, Auckland, New Zealand
| | - Gregory O'Grady
- Auckland Bioengineering Institute, University of Auckland, Private Bag 92019, Auckland, New Zealand
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Timothy R Angeli-Gordon
- Auckland Bioengineering Institute, University of Auckland, Private Bag 92019, Auckland, New Zealand.
- Department of Surgery, University of Auckland, Auckland, New Zealand.
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Barreto Chang OL, Possin KL, Maze M. Age-Related Perioperative Neurocognitive Disorders: Experimental Models and Druggable Targets. Annu Rev Pharmacol Toxicol 2023; 63:321-340. [PMID: 36100220 DOI: 10.1146/annurev-pharmtox-051921-112525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
With the worldwide increase in life span, surgical patients are becoming older and have a greater propensity for postoperative cognitive impairment, either new onset or through deterioration of an existing condition; in both conditions, knowledge of the patient's preoperative cognitive function and postoperative cognitive trajectory is imperative. We describe the clinical utility of a tablet-based technique for rapid assessment of the memory and attentiveness domains required for executive function. The pathogenic mechanisms for perioperative neurocognitive disorders have been investigated in animal models in which excessive and/or prolonged postoperative neuroinflammation has emerged as a likely contender. The cellular and molecular species involved in postoperative neuroinflammation are the putative targets for future therapeutic interventions that are efficacious and do not interfere with the surgical patient's healing process.
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Affiliation(s)
- Odmara L Barreto Chang
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA;
| | - Katherine L Possin
- Memory and Aging Center, Department of Neurology, and Global Brain Health Institute, University of California San Francisco, San Francisco, California, USA
| | - Mervyn Maze
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA; .,Center for Cerebrovascular Research, University of California San Francisco, San Francisco, California, USA
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Alam A, Rampes S, Patel S, Hana Z, Ma D. Anesthetics or anesthetic techniques and cancer surgical outcomes: a possible link. Korean J Anesthesiol 2021; 74:191-203. [PMID: 33596628 PMCID: PMC8175878 DOI: 10.4097/kja.20679] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Revised: 01/24/2021] [Accepted: 02/16/2021] [Indexed: 12/24/2022] Open
Abstract
As of 2018 cancer is responsible for almost 9.6 million deaths annually and, with an aging population, the incidence of cancer is expected to continue to rise. Surgery is an important treatment modality for patients with solid organ cancers. It has been postulated that, due to potentially overlapping processes underlying the development of malignancy and the therapeutic pathways of various anesthetic agents, the choice of anesthetic type and method of administration may affect post-operative outcomes in patients with cancer. This is a literature review of the most recent evidence extracted from various databases including PubMed, EMBASE, and the Cochrane, as well as journals and book reference lists. The review highlights the pathophysiological processes underpinning cancer development and the molecular actions of anesthetic agents, pre-clinical and retrospective studies investigating cancer and anesthetics, as well as ongoing clinical trials. Overall, there are conflicting results regarding the impact of regional vs. general anesthesia on cancer recurrence, whilst the majority of data suggest a benefit of the use of intravenous propofol over inhalational volatile anesthetics. The biological changes associated with the surgical inflammatory response offer a unique opportunity to intervene to counteract any potentially cancer-promoting effects.
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Affiliation(s)
- Azeem Alam
- Division of Anesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea & Westminster Hospital, London, UK
| | - Sanketh Rampes
- Division of Anesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea & Westminster Hospital, London, UK
| | - Sonam Patel
- Division of Anesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea & Westminster Hospital, London, UK
| | - Zac Hana
- Division of Anesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea & Westminster Hospital, London, UK
| | - Daqing Ma
- Division of Anesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea & Westminster Hospital, London, UK
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Yuan Y, Song Y, Wang G, Jia Y, Zhou Y, Mi X, Jia X, Wang X, Liu C, Li Y, Shi C, Han Y, Guo X, Zhang W, Li Z. Effects of general versus regional anaesthesia on circadian melatonin rhythm and its association with postoperative delirium in elderly patients undergoing hip fracture surgery: study protocol for a prospective cohort clinical trial. BMJ Open 2021; 11:e043720. [PMID: 33579771 PMCID: PMC7883867 DOI: 10.1136/bmjopen-2020-043720] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Postoperative delirium (POD) is a common neurological complication after hip fracture surgery and is associated with high morbidity and mortality in elderly patients. Although the specific mechanism of POD remains unclear, circadian rhythm disruptions have recently drawn increased attention. To date, only limited postoperative time points of plasma melatonin level measurements were recorded in previous studies, and such data cannot represent a comprehensive melatonin rhythm. The process of anaesthesia (either general anaesthesia (GA) or regional anaesthesia (RA)) is known to influence the melatonin rhythm. However, how these two anaesthesia methods differently affect the postoperative melatonin rhythm is still unknown. Therefore, we hypothesise that RA may attenuate the disruption of the melatonin rhythm, which might decrease the incidence of POD in elderly patients undergoing hip surgery. METHODS AND ANALYSIS In this prospective cohort clinical trial, 138 patients scheduled for hip fracture surgery will be divided into two groups to receive either GA or RA. The primary aim is to compare the circadian rhythm of melatonin secretion between the two groups and explore its association with the incidence of POD. ETHICS AND DISSEMINATION The study has been approved by the Medical Science Research Ethics Committees of Beijing Jishuitan Hospital (JLKS201901-04). The results of the study will be published in peer-reviewed international journals. TRIAL REGISTRATION NUMBER ChiCTR1900027393.
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Affiliation(s)
- Yi Yuan
- Department of Anesthesiology, Beijing Jishuitan Hospital, Beijing, China
| | - Yanan Song
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
| | - Geng Wang
- Department of Anesthesiology, Beijing Jishuitan Hospital, Beijing, China
| | - Yunyang Jia
- Department of Orthopaedics & Traumatology, Beijing Jishuitan Hospital, Beijing, China
| | - Yang Zhou
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
| | - Xinning Mi
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
| | - Xixi Jia
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
| | - Xiaoxiao Wang
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, China
| | - Chang Liu
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
| | - Yue Li
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
| | - Chengmei Shi
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
| | - Yongzheng Han
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
| | - Xiangyang Guo
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
| | - Wenchao Zhang
- Department of Anesthesiology, Beijing Jishuitan Hospital, Beijing, China
| | - Zhengqian Li
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
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Perioperative probiotic treatment decreased the incidence of postoperative cognitive impairment in elderly patients following non-cardiac surgery: A randomised double-blind and placebo-controlled trial. Clin Nutr 2020; 40:64-71. [PMID: 32451125 DOI: 10.1016/j.clnu.2020.05.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 04/01/2020] [Accepted: 05/04/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Given that population aging is a global health challenge, the high prevalence of postoperative neurocognitive impairment in elderly patients necessitates the development of novel simple and effective prevention methods. OBJECTIVE To evaluate the effects of perioperative application of oral probiotic as a prophylaxis for cognitive impairment in elderly patients following non-cardiac surgery. METHODS This randomised double-blind and placebo-controlled trial included 120 elderly patients (in a modified intention-to-treat analysis) scheduled for elective orthopaedic or colorectal surgery. Patients were assigned to receive either probiotics or a placebo from hospital admission until discharge. The primary endpoint was the incidence of postoperative cognitive impairment, defined as a decrease of ≥3 points in the Mini-Mental State Examination (MMSE) scores from admission baseline to the 7th day post-surgery. Secondary endpoints included changes in plasma interleukin-6 (IL-6) and cortisol, postoperative pain intensity, postoperative sleep quality, gastrointestinal function recovery, and faecal microbiota composition. RESULTS The incidence of postoperative cognitive impairment in the probiotic group was significantly lower than in the control group (3 of 59 patients [5.1%] vs. 10 of 61 patients [16.4%], P = 0.046). In addition, compared to pre-surgery, the levels of plasma IL-6 and cortisol in the probiotic group decreased more than in the control group 5-7 days after surgery (IL-6: -117.90 ± 49.15 vs. -14.93 ± 15.21, P = 0.044; cortisol: -158.70 ± 53.52 vs. 40.98 ± 72.48, P = 0.010). Relative abundance at the genus level in the faeces of the probiotic group also changed more than in that of the control group during the perioperative period. In contrast, postoperative pain intensity, sleep quality, and gastrointestinal function recovery did not differ significantly between the two groups. CONCLUSION Perioperative application of oral probiotic prevents postoperative cognitive impairment in elderly patients following non-cardiac surgery, possibly via the limitation of peripheral inflammation and the stress response.
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Gao X, Mi Y, Guo N, Luan J, Xu H, Hu Z, Wang N, Zhang D, Gou X, Xu L. The mechanism of propofol in cancer development: An updated review. Asia Pac J Clin Oncol 2020; 16:e3-e11. [DOI: 10.1111/ajco.13301] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 11/25/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Xingchun Gao
- Institute of Basic Medical Sciences & Shaanxi Key Laboratory of Brain DisordersShaanxi Key Laboratory of Ischemic Cardiovascular DiseaseXi'an Medical University Xi'an China
- State Key Laboratory of Military StomatologyDepartment of AnesthesiologySchool of StomatologyThe Fourth Military Medical University Xi'an China
| | - Yajing Mi
- Institute of Basic Medical Sciences & Shaanxi Key Laboratory of Brain DisordersShaanxi Key Laboratory of Ischemic Cardiovascular DiseaseXi'an Medical University Xi'an China
- State Key Laboratory of Military StomatologyDepartment of AnesthesiologySchool of StomatologyThe Fourth Military Medical University Xi'an China
| | - Na Guo
- Institute of Basic Medical Sciences & Shaanxi Key Laboratory of Brain DisordersShaanxi Key Laboratory of Ischemic Cardiovascular DiseaseXi'an Medical University Xi'an China
| | - Jing Luan
- Institute of Basic Medical Sciences & Shaanxi Key Laboratory of Brain DisordersShaanxi Key Laboratory of Ischemic Cardiovascular DiseaseXi'an Medical University Xi'an China
- State Key Laboratory of Military StomatologyDepartment of AnesthesiologySchool of StomatologyThe Fourth Military Medical University Xi'an China
| | - Hao Xu
- Institute of Basic Medical Sciences & Shaanxi Key Laboratory of Brain DisordersShaanxi Key Laboratory of Ischemic Cardiovascular DiseaseXi'an Medical University Xi'an China
- State Key Laboratory of Military StomatologyDepartment of AnesthesiologySchool of StomatologyThe Fourth Military Medical University Xi'an China
| | - Zhifang Hu
- Institute of Basic Medical Sciences & Shaanxi Key Laboratory of Brain DisordersShaanxi Key Laboratory of Ischemic Cardiovascular DiseaseXi'an Medical University Xi'an China
| | - Ning Wang
- Institute of Basic Medical Sciences & Shaanxi Key Laboratory of Brain DisordersShaanxi Key Laboratory of Ischemic Cardiovascular DiseaseXi'an Medical University Xi'an China
| | - Dian Zhang
- Institute of Basic Medical Sciences & Shaanxi Key Laboratory of Brain DisordersShaanxi Key Laboratory of Ischemic Cardiovascular DiseaseXi'an Medical University Xi'an China
| | - Xingchun Gou
- Institute of Basic Medical Sciences & Shaanxi Key Laboratory of Brain DisordersShaanxi Key Laboratory of Ischemic Cardiovascular DiseaseXi'an Medical University Xi'an China
| | - Lixian Xu
- Institute of Basic Medical Sciences & Shaanxi Key Laboratory of Brain DisordersShaanxi Key Laboratory of Ischemic Cardiovascular DiseaseXi'an Medical University Xi'an China
- State Key Laboratory of Military StomatologyDepartment of AnesthesiologySchool of StomatologyThe Fourth Military Medical University Xi'an China
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Fowler E, Ghamrawi RI, Ghiam N, Liao W, Wu JJ. Risk of tuberculosis reactivation during interleukin-17 inhibitor therapy for psoriasis: a systematic review. J Eur Acad Dermatol Venereol 2020; 34:1449-1456. [PMID: 32012384 DOI: 10.1111/jdv.16254] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 01/22/2020] [Indexed: 12/12/2022]
Abstract
Immunosuppressive therapies, effective in treating inflammatory disorders such as psoriasis, increase the risk of serious infections, such as tuberculosis (TB). For example, tumour necrosis factor (TNF)-alpha inhibitors significantly increase the risk of TB reactivation in patients with latent TB infection (LTBI), which has led clinicians to routinely test for TB prior to initiation of these medications. This protocol has since extended to other, newer immunomodulatory therapies for psoriasis, such as interleukin (IL)-17 inhibitors, including secukinumab, ixekizumab and brodalumab. We conducted a systematic review to examine whether there is any evidence that IL-17 inhibitor therapy for psoriasis increases the risk of TB reactivation. Using PubMed and EMBASE, our literature search resulted in 139 total articles. After manually reviewing each article for the discussion of IL-17 inhibitors for psoriasis, with data originating from clinical trials, and assessment for incidence of TB reactivation, 23 articles met the full inclusion criteria for our review. Overall, we found no cases of TB reactivation in patients treated with IL-17 inhibitors for psoriasis. This suggests that IL-17 inhibitors may be safely used in psoriasis patients with LTBI who receive appropriate LTBI treatment. However, long-term real-world studies are warranted to further evaluate this risk.
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Affiliation(s)
- E Fowler
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - R I Ghamrawi
- Edward Via College of Osteopathic Medicine, Auburn, AL, USA
| | - N Ghiam
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - W Liao
- Department of Dermatology, University of California San Francisco, San Francisco, CA, USA
| | - J J Wu
- Dermatology Research and Education Foundation, Irvine, CA, USA
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Zhang Y, Shan GJ, Zhang YX, Cao SJ, Zhu SN, Li HJ, Ma D, Wang DX. Propofol compared with sevoflurane general anaesthesia is associated with decreased delayed neurocognitive recovery in older adults. Br J Anaesth 2018; 121:595-604. [DOI: 10.1016/j.bja.2018.05.059] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Revised: 04/24/2018] [Accepted: 05/26/2018] [Indexed: 02/03/2023] Open
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11
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Lim A, Braat S, Hiller J, Riedel B. Inhalational versus Propofol-Based Total Intravenous Anaesthesia: Practice Patterns and Perspectives among Australasian Anaesthetists. Anaesth Intensive Care 2018; 46:480-487. [DOI: 10.1177/0310057x1804600509] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Increasing evidence suggests that total intravenous anaesthesia (TIVA) may be the preferred anaesthetic for cancer resection surgery. To assist the preparation of a randomised controlled trial (RCT) examining Volatile (versus TIVA) Anaesthesia and Perioperative Outcomes Related to Cancer (VAPOR-C) we developed an 18-question electronic survey to investigate practice patterns and perspectives (emphasising indications, barriers, and impact on cancer outcomes) of TIVA versus inhalational general anaesthesia in Australasia. The survey was emailed to 1,000 (of 5,300 active Fellows) randomly selected Australian and New Zealand College of Anaesthetists (ANZCA) Fellows. The response rate was 27.5% (n=275). Of the respondents, 18% use TIVA for the majority of cases. In contrast, 46% use TIVA 20% of the time or less. Respondents described indications for TIVA as high risk of nausea, neurosurgery, and susceptibility to malignant hyperthermia. Lack of equipment, lack of education and cost were not considered barriers to TIVA use, and a significant proportion (41%) of respondents would use TIVA more often if setup were easier. Of the respondents, 43% thought that TIVA was associated with less cancer recurrence than inhalational anaesthesia, while 46% thought that there was no difference. Yet, only 29% of respondents reported that they use TIVA often or very often for cancer surgery. In Australasia, there is generally a low frequency of TIVA use despite a perception of benefit when compared with inhalational anaesthesia. Anaesthetists are willing to use TIVA for indications where sufficient evidence supports a meaningful level of improvement in clinical outcome. The survey explores attitudes towards use of TIVA for cancer surgery and demonstrates equipoise in anaesthetists’ opinions regarding this indication. The inconsistent use of TIVA in Australasia, minimal barriers to its use, and the equipoise in anaesthetists’ opinions regarding the effect of TIVA versus inhalational anaesthesia on cancer outcomes support the need for a large prospective RCT.
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Affiliation(s)
- A. Lim
- Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre, Melbourne, Victoria
| | - S. Braat
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria
| | - J. Hiller
- Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre; The University of Melbourne; Faculty of Medicine, Nursing and Health Sciences, Monash University; Melbourne, Victoria
| | - B. Riedel
- Director, Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre; The University of Melbourne; Melbourne, Victoria
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12
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Zhang Y, Shan GJ, Zhang YX, Cao SJ, Zhu SN, Li HJ, Ma D, Wang DX. Preoperative vitamin D deficiency increases the risk of postoperative cognitive dysfunction: a predefined exploratory sub-analysis. Acta Anaesthesiol Scand 2018; 62:924-935. [PMID: 29578249 DOI: 10.1111/aas.13116] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 02/23/2018] [Accepted: 03/04/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Vitamin D is important for maintaining physiological functions including cognition and its deficiency is associated with the occurrence of cognitive impairment. This study was to explore the association between preoperative vitamin D status and the occurrence of postoperative cognitive dysfunction (POCD) in elderly patients undergoing major surgery. METHODS This was a predefined exploratory sub-analysis of one-centre data from a randomized controlled trial. In all, 123 elderly (≥ 65 years) patients who were scheduled to undergo major cancer surgery were recruited. Serum 25-hydroxyvitamin D concentration was measured before surgery. In total, 59 nonsurgical control subjects with comparable age and education level were also enrolled. A battery of neuropsychological tests was administered the day before and the 7th day after surgery in patients or at the same time interval in control subjects. POCD was diagnosed according to the ISPOCD1 definition. RESULTS 71.5% (88/123) of elderly patients had vitamin D deficiency (serum 25-hydroxyvitamin D concentration < 12 ng/ml) before surgery; 24.4% (30/123) of them developed cognitive dysfunction at 1 week after surgery. After adjusting for confounding factors, high preoperative serum 25-hydroxyvitamine D concentration was related to a decreased risk of POCD (odds ratio [OR]: 0.829, 95% confidence interval [CI]: 0.708-0.971; P = 0.020), whereas preoperative vitamin D deficiency was associated with an increased risk of POCD (OR: 8.427, 95% CI: 1.595-44.511; P = 0.012). CONCLUSIONS Vitamin D deficiency is prevalent in elderly patients undergoing major cancer surgery and increases the risk of early POCD development. Whether prophylactic vitamin D supplementation can reduce POCD in the elderly deserves further study.
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Affiliation(s)
- Y. Zhang
- Department of Anaesthesiology and Critical Care Medicine; Peking University First Hospital; Beijing China
| | - G.-J. Shan
- Department of Anaesthesiology and Critical Care Medicine; Peking University First Hospital; Beijing China
| | - Y.-X. Zhang
- Department of Anaesthesiology and Critical Care Medicine; Peking University First Hospital; Beijing China
| | - S.-J. Cao
- Department of Anaesthesiology and Critical Care Medicine; Peking University First Hospital; Beijing China
| | - S.-N. Zhu
- Department of Biostatics; Peking University First Hospital; Beijing China
| | - H.-J. Li
- Peking University Clinical Research Institute; Beijing China
| | - D. Ma
- Section of Anaesthetics, Pain Medicine and Intensive Care; Department of Surgery and Cancer; Faculty of Medicine; Chelsea and Westminster Hospital; Imperial College London; London UK
| | - D.-X. Wang
- Department of Anaesthesiology and Critical Care Medicine; Peking University First Hospital; Beijing China
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