Search Results (81)

Background and Objectives: Postoperative delirium (POD) is a common complication in elderly patients undergoing major surgery, associated with systemic inflammation and potentially influenced by anesthetic techniques. This study investigated whether remimazolam-based total intravenous anesthesia (R-TIVA) reduces the level of systemic inflammatory biomarkers and the incidence of POD more compared to inhalational anesthesia (IA) or balanced anesthesia (BA) in patients aged ≥ 65 years undergoing major non-neurosurgical, non-cardiac surgery. Materials and Methods: This retrospective cohort study analyzed the medical records of 340 patients categorized by anesthesia type: R-TIVA (n = 111), IA (n = 117), or BA (n = 112). Propensity score matching (PSM) created POD (n = 104) and No POD (n = 106) cohorts. Systemic inflammatory biomarkers—the systemic immune–inflammation index (SII), the neutrophil-to-lymphocyte ratio (NLR), the platelet-to-lymphocyte ratio (PLR), and C-reactive protein (CRP)—were measured pre- and postoperatively. POD was identified by clinical symptoms or the postoperative use of antipsychotics/sedatives. Results: The incidence of POD did not significantly differ among the R-TIVA, IA, and BA groups. However, the postoperative SII, NLR, PLR, and CRP levels were significantly lower in the R-TIVA group compared to those in the IA group (p < 0.05). Both the preoperative (r_pb = 0.72, p < 0.01) and postoperative (r_pb = 0.58, p < 0.01) NLRs were strongly correlated with POD. Higher NLR values predicted the incidence of POD, with odds ratios of 1.71 for preoperative and 1.32 for postoperative measurements. Conclusions: While R-TIVA did not significantly reduce the incidence of POD compared to that of IA or BA, it was associated with reduced levels of postoperative inflammatory biomarkers. The preoperative and postoperative NLRs emerged as strong predictors of POD, suggesting their potential utility in guiding prophylactic strategies for older surgical patients. These findings underscore the interplay between anesthesia type, systemic inflammation, and delirium risk. Full article

Background and Objectives: After transcatheter aortic valve implantation (TAVI), transvalvular gradients increase immediately following the procedure up to 24 h afterward. While factors such as anesthesia type and fluid status have been suggested as potential contributors, the underlying cause remains unclear. With advancements in TAVI techniques, there has been a shift in anesthesia protocols from general anesthesia (GA) to monitored anesthesia care (MAC). This study aimed to assess the impact of GA and MAC on the increase in transvalvular gradients observed 24 h post-TAVI. Methods: A retrospective, single-center analysis was conducted on patients who underwent TAVI at our institution between 2011 and 2023 (n = 744, males = 421). The patients were divided into two groups: those who received GA (n = 201) and those who received MAC (n = 543). The GA group received either inhaled anesthetics, with or without propofol infusions, or propofol infusions at a rate of ≥100 mcg/kg/min. The MAC group received bolus doses and continuous infusions of dexmedetomidine. Transvalvular gradients were compared between immediate and 24 h post-procedure echocardiograms. Results: The average age of patients in the GA group (78 years [IQR 71–83]) was similar to that of the MAC group (77 years [IQR 71–83]). The GA group had a higher prevalence of comorbidities at baseline. Both groups exhibited stable, normotensive blood pressure levels during the procedure, though the GA group required more vasopressors and intravenous fluid. The GA group showed a 24 h post-TAVI mean transvalvular gradient change of +5.1 mmHg [IQR 3–8.1], while the MAC group had a 24 h mean transvalvular gradient change of +5.8 mmHg [IQR 3.2–9], with no significant difference between the groups (p = 0.139). Conclusions: Despite the greater cardiovascular depressive effects and increased need for vasopressors and fluid resuscitation in the GA group, there was no significant difference in the increase in transvalvular gradients between the GA and MAC groups at 24 h post-TAVI. Further research is needed to fully understand the reasons behind the increase in gradients observed after TAVI. Full article

Background: Chronic cough is a common symptom in patients with interstitial lung diseases (ILDs), which significantly affects health-related quality of life (HRQoL). The prevalence of chronic cough varies from 30% to almost 90% in different ILDs, with the highest rate in patients with idiopathic pulmonary fibrosis. However, the pathophysiology of cough in ILDs remains poorly understood, with multiple proposed mechanisms contributing to its development. This knowledge gap complicates both clinical assessment and treatment, as current therapeutic strategies target general cough mechanisms rather than ILD-specific pathways. This review synthesizes existing data to clarify distinct cough mechanisms across ILD subtypes and identify opportunities for more targeted therapeutic strategies in this challenging patient population. Moreover, cough can be a clinical marker of disease severity and a predictor of ILD progression and transplant-free survival. Effective cough-specific therapeutic options that consider potential mechanisms, comorbidities, and individual effects on HRQoL are needed for cough associated with ILD. Therefore, the aim of this review was to analyze the prevalence, the impact on HRQoL, the pathophysiology, and the management of chronic cough in ILDs. Methods: We performed a comprehensive search in PubMed, MEDLINE, Embase, and the Cochrane Library. This review included randomized clinical trials, observational studies, systematic reviews, and meta-analyses in adults with chronic cough comparing ILD types. The following were excluded: commentaries, letters, case reports and case series, conference abstracts, and studies and publications lacking cough-specific outcomes. Results: Several approaches to reduce cough frequency and severity were described: antifibrotic agents, neuromodulators, opiates, inhaled local anesthetics, oxygen, speech therapy, and anti-reflux therapy. Some therapeutic approaches, such as oral corticosteroids and thalidomide, can cause significant side effects. Novel agents, such as P2X3 receptor antagonists, which are in phase III trials (COUGH-1/2), show promising results for refractory cough and may benefit ILD-related cough. Conclusions: Thus, a comprehensive assessment of cough is required for effective cough treatment in patients with ILDs considering possible mechanisms and individual impact on QoL. Full article

Background: With renewed interest in long-duration space missions, there is growing exploration into synthetic torpor as a countermeasure to mitigate physiological stressors. Sedative agents, particularly those used in clinical anesthesia, have been proposed to replicate aspects of natural torpor, including reduced metabolic rate, core temperature, and brain activity. Objectives: This systematic review aims to evaluate the potential of sedative agents to induce torpor-like states suitable for extended spaceflight. The review specifically investigates their pharmacokinetics, pharmacodynamics, and performance under space-related stressors such as microgravity and ionizing radiation. Methods: We conducted a comprehensive search across multiple databases (e.g., PubMed, Scopus, Web of Science) for studies published from 1952 to 2024. Eligible studies included experimental, preclinical, and clinical investigations examining sedative agents (especially inhalation anesthetics) in the context of metabolic suppression or space-relevant conditions. Screening, selection, and data extraction followed PRISMA guidelines. Results: Out of the screened records, 141 studies met the inclusion criteria. These were thematically grouped into seven categories, including torpor physiology, anesthetic uptake, metabolism, and inhalation anesthetics. Sedative agents showed variable success in inducing torpor-like states, with inhalation anesthetics demonstrating promising metabolic effects. However, concerns remain regarding delivery methods, safety, rewarming, and the unknown effects of prolonged use in space environments. Conclusions: Sedative agents, particularly volatile anesthetics, hold potential as tools for inducing synthetic torpor in space. Nevertheless, significant knowledge gaps and technical challenges persist. Further targeted research is required to optimize these agents for safe, controlled use in spaceflight settings. Full article

Background/Objectives: Transurethral resection of bladder tumor (TURBT) is commonly performed in elderly patients and often requires repeated procedures. A high proportion of non-procedural time in TURBT affects operating room utilization, highlighting the need for a safe and efficient anesthesia method. This study aimed to compare remimazolam-based monitored anesthesia care (MAC) guided by analgesia nociception index (ANI) monitoring to inhalation-based general anesthesia (GA) for TURBT, focusing on induction and emergence time (IAET). Methods: Forty-six patients who underwent TURBT were randomly assigned into either the MAC group or GA group. The primary outcome was the IAET. The secondary outcomes included hospital and anesthesia charges, safety (intraoperative hypotension and desaturation), and feasibility (surgeon and patient satisfaction) of both anesthetic methods. Results: The MAC group demonstrated a significantly shorter IAET (14 vs. 25 min, p < 0.001) and lower anesthesia cost (USD 152 vs. USD 195, p < 0.001). The MAC group showed better hemodynamic stability with a lower incidence of hypotension (29% vs. 73%, p = 0.004). Seven patients (33%) in the MAC group experienced intraoperative desaturation; all patients recovered without complications through the jaw-thrust maneuver. Patient satisfaction was equally high in both groups, and surgeon satisfaction, though slightly lower with MAC (71% vs. 100% rating “excellent”, p = 0.009), remained acceptable. Conclusions: Remimazolam-based MAC, guided by ANI monitoring, offers significant advantages including shorter IAET, reduced costs, and improved safety for TURBT, particularly in patients with small tumors. These findings support MAC as a promising alternative to GA for TURBT, as it enhances perioperative outcomes and operating room efficiency. Full article

Background and Objectives: Postoperative delirium (POD) is a transient but significant complication in geriatric patients following hip or femur surgery. POD occurs in 19–65% of patients after hip surgeries, with notable risks associated with augmented morbidity, mortality, and prolonged hospitalization. The perioperative administration of benzodiazepines, particularly midazolam, is associated with an increased incidence of POD. Remimazolam, a novel ultra-short-acting benzodiazepine, has potential benefits, such as hemodynamic stability and ease of reversal, but its effect on POD occurrence remains unclear. Materials and Methods: This retrospective study investigated patients who were aged 65 years old and older who underwent hip or femur surgery. Following the application of exclusion criteria, 502 patients were grouped according to whether anesthesia was maintained with remimazolam (R group) or sevoflurane (S group). Data regarding patients’ baseline characteristics, anesthetic details, and postoperative outcomes, including the incidence of POD, were gathered and analyzed. Propensity score matching and logistic regression were conducted to identify factors associated with POD and compare outcomes between the two groups. Results: Among the 502 patients, POD was observed in 161 (32%). The POD incidence was not statistically significantly different between the groups (p = 1.000). A multivariable logistic regression analysis indicated that remimazolam was not a determinant of POD (p = 0.860), whereas being male and polypharmacy were (p = 0.022; p = 0.047). Initial disparities in age and comorbid conditions between the groups were rectified through matching, demonstrating that remimazolam had a similar POD risk to sevoflurane. Conclusions: This study showed that remimazolam did not exacerbate the risk of POD in elderly patients undergoing hip or femur surgery. Remimazolam is a reliable anesthetic option for this vulnerable demographic. Also, this study’s results indicated that polypharmacy and being male are POD risk factors, suggesting that meticulous perioperative medication management may help alleviate the risk of POD. Full article

The introduction of general anesthetics in the mid-19th century is considered one of the greatest contributions to medical practice. It was the first time that complicated surgical interventions became feasible, without putting an excessive strain on the patient. The first general anesthetics—diethyl ether, chloroform, and nitrous oxide—were limited by often severe adverse reactions and a narrow therapeutic window. They were later succeeded by modern anesthetics, with high anesthetic effect along with diminished toxicity. As with other medical drugs, many anesthetic compounds contain chiral centers in their molecules. Although currently used as racemates, the pharmacological activity of the respective enantiomerically pure antipodes can vary considerably, as can their adverse effects. Herein, we report on the available studies into the differences in bioactivity and toxicity between the enantiomers of chiral anesthetic agents. Both inhalational and intravenous anesthetics are discussed. Aspects of pharmacodynamics and pharmacokinetics are surveyed as well. The results could stimulate further research into the potential application of single-enantiomer anesthetics in clinical practice. Full article

There is a growing concern worldwide about the potential harmful effects of anesthesia on brain development, based on studies in both humans and animals. In infants, repeated anesthesia exposure is linked to learning disabilities and attention disorders. Similarly, laboratory studies in mice show that neonates exposed to general anesthesia experience long-term cognitive and behavioral impairments. Inhaled anesthetics affect the postsynaptic density (PSD)-95, discs large homolog, and zona occludens-1 (PDZ) domains. The disruption of the synaptic PSD95-PDZ2 domain-mediated protein interactions leads to a loss of spine plasticity and cognitive deficits in juvenile mice. The nitric oxide-mediated protein kinase-G signaling pathway enhances synaptic plasticity also by activating extracellular signal-regulated kinase, which subsequently phosphorylates cAMP-response element binding protein, a crucial transcription factor for memory formation. Exposure to isoflurane or postsynaptic density-95-PDZ2-wildtype peptides results in decreased levels of phosphorylated extracellular signal-regulated kinase (p-ERK) and phosphorylated cAMP-response element binding protein (p-CREB), which are critical for synaptic plasticity and memory formation. Pizotifen treatment after isoflurane or postsynaptic density-95-PDZ2-wildtype peptide exposure in mice prevented decline in p-ERK levels, preserved learning and memory functions at 5 weeks of age, and maintained mushroom spine density at 7 weeks of age. Protein kinase-G activation by components of the nitric oxide signaling pathway leads to the stabilization of dendritic spines and synaptic connections. Concurrently, the ERK/CREB pathway, which is crucial for synaptic plasticity and memory consolidation, is supported and maintained by pizotifen, thereby preventing cognitive deficits caused in response to isoflurane or postsynaptic density-95-PDZ2-wildtype peptide exposure. Activation of ERK signaling cascade by pizotifen helps to prevent cognitive impairment and spine loss in response to postsynaptic density-95-PDZ2 domain disruption. Full article

Background: Climate change poses significant challenges to global health, At the same time, the healthcare sector itself, with its high resource demands, also contributes substantially to global warming. Anesthesia, particularly through the use of volatile inhalation anesthetics, is a key contributor in this respect. The present exploratory study examines staff perceptions of precycling and recycling strategies aimed at reducing the environmental impact of anesthetic gases at the General Hospital Vienna, Austria. This large institution has recently implemented major changes, including the shutdown of the centralized nitrous oxide supply and the introduction of anesthetic gas recycling systems on anesthesia machines, alongside other precycling measures. Methods: We conducted a cross-sectional online survey of anesthesia team members (n = 103, 61.2% females) to assess current perceptions related to anesthetic gas usage, focusing on precycling and recycling aspects, and their willingness to engage in further sustainability efforts. Results: We found that participants expressed an, in general, positive attitude towards environmental protection measures and a high willingness to make additional efforts to recycle anesthetics. Thus, the anesthesia team members in our institution may be inclined to support strategies like minimizing the use of volatile anesthetics. Conclusions: These preliminary insights could inform actionable recommendations for advancing sustainable practices in anesthesiology at our hospital. Full article

Postoperative neurocognitive dysfunction (PND) is a prevalent and debilitating complication in elderly surgical patients, characterized by persistent cognitive decline that negatively affects recovery and quality of life. As the aging population grows, the rising number of elderly surgical patients has made PND an urgent clinical challenge. Despite increasing research efforts, the pathophysiological mechanisms underlying PND remain inadequately characterized, underscoring the need for a more integrated framework to guide targeted interventions. To better understand the molecular mechanisms and therapeutic targets of PND, this narrative review synthesized evidence from peer-reviewed studies, identified through comprehensive searches of PubMed, Embase, Cochrane Library, and Web of Science. Key findings highlight neuroinflammation, oxidative stress, mitochondrial dysfunction, neurotransmitter imbalances, microvascular changes, and white matter lesions as central to PND pathophysiology, with particular parallels to encephalocele- and sepsis-associated cognitive impairments. Among these, neuroinflammation, mediated by pathways such as the NLRP3 inflammasome and blood–brain barrier disruption, emerges as a pivotal driver, triggering cascades that exacerbate neuronal injury. Oxidative stress and mitochondrial dysfunction synergistically amplify these effects, while neurotransmitter imbalances and microvascular alterations, including white matter lesions, contribute to synaptic dysfunction and cognitive decline. Anesthetic agents modulate these interconnected pathways, exhibiting both protective and detrimental effects. Propofol and dexmedetomidine demonstrate neuroprotective properties by suppressing neuroinflammation and microglial activation, whereas inhalational anesthetics like sevoflurane intensify oxidative stress and inflammatory responses. Ketamine, with its anti-inflammatory potential, offers promise but requires further evaluation to determine its long-term safety and efficacy. By bridging molecular insights with clinical practice, this review highlights the critical role of personalized anesthetic strategies in mitigating PND and improving cognitive recovery in elderly surgical patients. It aims to inform future research and clinical decision-making to address this multifaceted challenge. Full article

Background: Anesthesia can significantly impact positron emission tomography (PET) neuroimaging in preclinical studies. Therefore, understanding these effects is crucial for accurate interpretation of the results. In this experiment, we investigate the effect of [¹⁸F]-labeled glucose analog fluorodeoxyglucose ([¹⁸F]FDG) uptake in the brains of rats anesthetized with two commonly used anesthetics for rodents: isoflurane, an inhalation anesthetic, and Hypnorm–Dormicum, a combination injection anesthetic. Materials and Methods: Female adult Sprague Dawley rats were randomly assigned to one of two anesthesia groups: isoflurane or Hypnorm–Dormicum. The rats were submitted to dynamic [¹⁸F]FDG PET scan. The whole brain [¹⁸F]FDG standard uptake value (SUV) and the brain voxel-based analysis were performed. Results: The dynamic [¹⁸F]FDG data revealed that the brain SUV was 38% lower in the isoflurane group after 40 min of image (2.085 ± 0.3563 vs. 3.369 ± 0.5577, p = 0.0008). In voxel-based analysis between groups, the maps collaborate with SUV data, revealing a reduction in [¹⁸F]FDG uptake in the isoflurane group, primarily in the cortical regions, with additional small increases observed in the midbrain and cerebellum. Discussion and Conclusions: The observed differences in [¹⁸F]FDG uptake in the brain may be attributed to variations in metabolic activity. These results underscore the necessity for careful consideration of anesthetic choice and its impact on neuroimaging outcomes in future research. Full article

Cancer recurrence and metastasis remain critical challenges following surgical resection, influenced by complex perioperative mechanisms. This review explores how surgical stress triggers systemic changes, such as neuroendocrine responses, immune suppression, and inflammation, which promote the dissemination of residual cancer cells and circulating tumor cells. Key mechanisms, such as epithelial–mesenchymal transition and angiogenesis, further enhance metastasis, while hypoxia-inducible factors and inflammatory responses create a microenvironment conducive to tumor progression. Anesthetic agents and techniques modulate these mechanisms in distinct ways. Inhaled anesthetics, such as sevoflurane, may suppress immune function by increasing catecholamines and cytokines, thereby promoting cancer progression. In contrast, propofol-based total intravenous anesthesia mitigates stress responses and preserves natural killer cell activity, supporting immune function. Opioids suppress immune surveillance and promote angiogenesis through the activation of the mu-opioid receptor. Opioid-sparing strategies using NSAIDs show potential in preserving immune function and reducing recurrence risk. Regional anesthesia offers benefits by reducing systemic stress and immune suppression, though the clinical outcomes remain inconsistent. Additionally, dexmedetomidine and ketamine exhibit dual effects, both enhancing and inhibiting tumor progression depending on the dosage and context. This review emphasizes the importance of individualized anesthetic strategies to optimize long-term cancer outcomes. While retrospective studies suggest potential benefits of propofol-based total intravenous anesthesia and regional anesthesia, further large-scale trials are essential to establish the definitive role of anesthetic management in cancer recurrence and survival. Full article

The development of inhaled anesthetics (IAs) has a rich history dating back many centuries. In modern times they have played a pivotal role in anesthesia and critical care by allowing deep sedation during periods of critical illness and surgery. In addition to their sedating effects, they have many systemic effects allowing for therapy beyond surgical anesthesia. In this narrative review we chronicle the evolution of IAs, from early volatile agents such as ether to the contemporary use of halogenated hydrocarbons. This is followed by a discussion of the mechanisms of action of these agents which primarily involve the modulation of lipid membrane properties and ion channel activity. IAs’ systemic effects are also examined, including their effects on the cardiovascular, respiratory, hepatic, renal and nervous systems. We discuss of the role of IAs in treating systemic disease processes including ischemic stroke, delayed cerebral ischemia, status epilepticus, status asthmaticus, myocardial ischemia, and intensive care sedation. We conclude with a review of the practical and logistical challenges of utilizing IAs outside the operating room as well as directions for future research. This review highlights the expanding clinical utility of IAs and their evolving role in the management of a diverse range of disease processes, offering new avenues for therapeutic exploration beyond anesthesia. Full article

Considerable attention has recently been given to the contribution of the greenhouse gas (GHG) emissions of the healthcare sector to climate change. GHGs used in medical practice are regularly released into the atmosphere and contribute to elevations in global temperatures that produce detrimental effects on the environment and human health. Consequently, a comprehensive assessment of their global warming potential over 100 years (GWP) characteristics, and clinical uses, many of which have evaded scrutiny from policy makers due to their medical necessity, is needed. Of major interest are volatile anesthetics, analgesics, and inhalers, as well as fluorinated gases used as tamponades in retinal detachment surgery. In this review, we conducted a literature search from July to September 2024 on medical greenhouse gases and calculated estimates of these gases’ GHG emissions in metric tons CO₂ equivalent (MTCO₂e) and their relative GWP. Notably, the anesthetics desflurane and nitrous oxide contribute the most emissions out of the major medical GHGs, equivalent to driving 12 million gasoline-powered cars annually in the US. Retinal tamponade gases have markedly high GWP up to 23,500 times compared to CO₂ and long atmospheric lifetimes up to 10,000 years, thus bearing the potential to contribute to climate change in the long term. This review provides the basis for discussions on examining the environmental impacts of medical gases with high GWP, determining whether alternatives may be available, and reducing emissions while maintaining or even improving patient care. Full article

Malignant hyperthermia (MH) is a genetic disorder triggered by depolarizing muscle relaxants or halogenated inhalational anesthetics in genetically predisposed individuals who have a chronic elevated intracellular Ca²⁺ concentration ([Ca²⁺]_i) in their muscle cells. We have reported that the muscle dysregulation of [Ca²⁺]_i impairs glucose uptake, leading to the development of insulin resistance in two rodent experimental models. In this study, we simultaneously measured the [Ca²⁺]_i and glucose uptake in single enzymatically isolated hippocampal pyramidal neurons from wild-type (WT) and MH-R163C mice. The [Ca²⁺]_i was recorded using a Ca²⁺-selective microelectrode, and the glucose uptake was assessed utilizing the fluorescent glucose analog 2-NBDG. The MH-R163C hippocampal neurons exhibited elevated [Ca²⁺]_i and impaired insulin-dependent glucose uptake compared with the WT neurons. Additionally, exposure to isoflurane exacerbated these deficiencies in the MH-R163C neurons, while the WT neurons remained unaffected. Lowering [Ca²⁺]_i using a Ca²⁺-free solution, SAR7334, or dantrolene increased the glucose uptake in the MH-R163C neurons without significantly affecting the WT neurons. However, further reduction of the [Ca²⁺]_i below the physiological level using BAPTA decreased the insulin-dependent glucose uptake in both genotypes. Furthermore, the homogenates of the MH-R163C hippocampal neurons showed an altered protein expression of the PI3K/Akt signaling pathway and GLUT4 compared with the WT mice. Our study demonstrated that the chronic elevation of [Ca²⁺]_i was sufficient to compromise the insulin-dependent glucose uptake in the MH-R163C hippocampal neurons. Moreover, reducing the [Ca²⁺]_i within a specific range (100–130 nM) could reverse insulin resistance, a hallmark of type 2 diabetes mellitus (T2D). Full article