Effects of driving pressure-guided ventilation on postoperative pulmonary complications in patients with COVID-19 undergoing abdominal surgery: A post-hoc propensity score-matched analysis.

Background: Application of individualized positive end-expiratory pressure (PEEP) based on minimum driving pressure facilitates to prevent from postoperative pulmonary complications (PPCs). Whether lung protective ventilation strategy can reduce the risk of PPCs in COVID-19 patients remains unclear. In this study, we compared the effects of driving pressure-guided ventilation with conventional mechanical ventilation on PPCs in patients with COVID-19. Methods: Patients infected COVID-19 within 30-day before surgery were retrospectively enrolled consecutively. Patients were divided into two group: driving pressure-guided lung protective ventilation strategy group (LPVS group) and conventional mechanical ventilation group (Control group). Propensity score matching for variables selected was used by logistic regression with the nearest-neighbor method. The outcomes were the incidence of PPCs and hypoxemia in post-anesthesia care unit. Results: There was no significant difference in the baseline data between both groups (P > 0.05). The incidence of PPCs (12.73 % vs 36.36 %, χ2 = 7.068, P = 0.008) and hypoxemia [18.18 % vs 38.18 %, χ2 = 4.492, P = 0.034], and lung ultrasound scores [4.68 ± 1.60 vs 8.39 ± 1.87, t = 8.383, P < 0.001] in LPVS group were lower than control group. The PEEP, airway pressure and plateau pressure in LPVS group were higher than control group, but driving pressure and tidal volume was lower than control group, the difference was statistically significant (P < 0.05). Conclusion: Individualized PEEP ventilation strategy guided by minimum driving pressure could improve oxygenation and reduce the incidence of PPCs in surgical patients with COVID-19.

An optimal tracheal tube preshaping strategy for endotracheal intubation using video laryngoscopy: a randomized controlled trial.

Although video laryngoscopy solves the problem of glottis exposure, it is difficult to deliver the tube to the glottic opening when the tracheal tube is unevenly shaped. This study aimed to compare the effects of different tube shapes on the first-pass success (FPS) rate in patients undergoing video laryngoscopy-assisted tracheal intubation. Three hundred patients above 18 years of age who underwent general anaesthesia and required endotracheal intubation were included in the study. The participants were randomly allocated to three groups with 100 participants in each group as follows: Group A, video laryngoscopes with a self-equipped stylet are used for tube preshaping; Group B: curvature of the video laryngoscope blade is modelled for tube preshaping; Group C: tube preshaping angle is consistent with the video laryngoscope blade, and the bending point is set 1 cm above the tracheal tube cuff. The primary outcome was FPS rates. The secondary outcomes included time to tracheal intubation, haemodynamic responses and adverse events. No significant differences in patient characteristics or airway assessments were noted (P > 0.05). Compared with Groups A, Group B and Group C exhibited a higher FPS rate (68% vs. 86% vs. 92%; P < 0.001). However, there is no significant difference in FPS rate between Group B and Group C (P > 0.05). And the time to tracheal intubation in Group C was significantly less than that in Group A and Group B (22.21 ± 4.01 vs. 19.92 ± 4.11 vs. 17.71 ± 3.47; P < 0.001). The straight-to-cuff stylet preshape angulation of curvature of the blade could provide a higher FPS rate and shorter time to tracheal intubation during video laryngoscopy-assisted endotracheal intubation. Trial registration: Chinese Clinical Trial Registry, ChiCTR1900026019.

Rivaroxaban versus aspirin in prevention of venous thromboembolism following total joint arthroplasty or hip fracture surgery: a meta-analysis.

OBJECTIVE: To evaluates the efficacy and safety of rivaroxaban versus aspirin in prevention of venous thromboembolism (VTE) following total hip (THA) or knee arthroplasty (TKA) or hip fracture surgery. METHODS: Major databases were systematically searched for all relevant studies published in English up to October 2020. The meta-analysis was conducted using RevMan 5.3 software. RESULTS: In total, 7 studies were retrieved which contained 5133 patients. Among these patients, 2605 patients (50.8%) received rivaroxaban, whereas 2528 patients (49.2%) received aspirin. There were no statistical difference between aspirin and rivaroxaban for reducing VTE (RR = 0.75, 95% CI 0.50-1.11, I2 = 36%, p = 0.15), major bleeding (RR = 0.94, 95% CI 0.45-2.37, I2 = 21%, p = 0.95), and all-cause mortality (RR = 0.88, 95% CI 0.12-6.44, I2 = 0%, p = 0.90) between the two groups. Compared with aspirin, rivaroxaban significantly increased nonmajor bleeding (RR = 1.29, 95% CI 1.05-1.58, I2 = 0%, p = 0.02). CONCLUSION: There was no significant difference between aspirin and rivaroxaban in prevention of venous thromboembolism following total joint arthroplasty or hip fracture surgery. Aspirin may be an effective, safe, convenient, and cheap alternative for prevention of VTE. Further large randomized studies are required to confirm these findings.

Could preprocedural ultrasound increase the first-pass success rate of neuraxial anesthesia in obstetrics? A systematic review and meta-analysis of randomized controlled trials.

Neuraxial anesthesia is a common practice in obstetrics. Evidence suggests that preprocedural ultrasound versus the conventional landmark location method accurately identifies a given intervertebral space and predicts the needle insertion depth required to reach the spinal canal. However, whether the preprocedural ultrasound examination improves the first-pass success (FPS) rate remains elusive. Major databases were systematically searched for all relevant studies published in English up to June 2019. Eighteen randomized controlled trials including 1844 patients were enrolled. The quality of eligible studies was assessed, and predefined outcomes were synthesized by meta-analysis. The primary results showed that preprocedural ultrasound increased the FPS rate in patients with predicted puncture difficulty but not in patients who were easily punctured. Preprocedural ultrasound reduced the number of redirections and punctures and decreased the incidence of vascular puncture and backache. There was no evidence of a reduction in failed punctures. We also noted that preprocedural ultrasound prolonged the identification time but not the procedure time. Thus, this systematic review provides evidence that preprocedural ultrasound does not improve the FPS rate of neuraxial anesthesia in patients who are easily palpated, although it increases the FPS rate in patients who are difficult to palpate.

The midline approach for endotracheal intubation using GlideScope video laryngoscopy could provide better glottis exposure in adults: a randomized controlled trial.

BACKGROUND: Previous studies have demonstrated that the common laryngoscopic approach (right-sided) and midline approach are both used for endotracheal intubation by direct laryngoscopy. Although the midline approach is commonly recommended for video laryngoscopy (VL) in the clinic, there is a lack of published evidences to support this practice. This study aimed to evaluate the effects of different video laryngoscopic approaches on intubation. METHODS: Two hundred sixty-two patients aged 18 years who underwent elective surgery under general anaesthesia and required endotracheal intubation were included in the present prospective, randomized, controlled study. The participants were randomly and equally allocated to the right approach (Group R) or midline approach (Group M). All the intubations were conducted by experienced anaesthetists using GlideScope video laryngoscopy. The primary outcomes were Cormack-Lehane laryngoscopic views (CLVs) and first-pass success (FPS) rates. The secondary outcomes were the time to glottis exposure, time to tracheal intubation, haemodynamic responses and other adverse events. Comparative analysis was performed between the groups. RESULTS: Finally, 262 patients completed the study, and all the tracheas were successfully intubated. No significant differences were observed in the patient characteristics and airway assessments (P > 0.05). Compared with Group R, Group M had a better CLV (χ2 = 14.706, P = 0.001) and shorter times to glottis exposure (8.82 ± 2.04 vs 12.38 ± 1.81; t = 14.94; P < 0.001) and tracheal intubation (37.19 ± 5.01 vs 45.23 ± 4.81; t = 13.25; P < 0.001), but no difference was found in the FPS rate (70.2% vs 71.8%; χ2 = 0.074; P = 0.446) and intubation procedure time (29.86 ± 2.56 vs 30.46 ± 2.97, t = 1.75, P = 0.081). Between the groups, the rates of hoarseness or sore throat, minor injury, hypoxemia and changes in SBP and HR showed no significant difference (P > 0.05). CONCLUSION: Although the FPS rate did not differ based on the laryngoscopic approach, the midline approach could provide better glottis exposure and shorter times to glottis exposure and intubation. The midline approach should be recommended for teaching in VL-assisted endotracheal intubation. TRIAL REGISTRATION: The study was registered on May 18, 2019 in the Chinese Clinical Trial Registry ( ChiCTR1900023252 ).

The protective effects of dexmedetomidine on ischemic brain injury: A meta-analysis.

BACKGROUND: Intracranial lesions, trauma or surgery-related damage activate immune inflammation and neuroendocrine responses, causing ischemic brain injury. Studies have shown that inflammatory cascade mediated by neuroendocrine hormones and proinflammatory mediators is implicated in the pathophysiology of ischemic brain injury. Alpha2-adrenoceptor agonists, dexmedetomidine, is widely used as neuroprotectants in anesthesia practice. However, it is still lack of a comprehensive meta-analysis to evaluate the neuroprotection of dexmedetomidine against ischemic brain injury via suppressing these two physiological responses. METHOD: Searched the Cochrane Library, Pub-Med, EMBASE, EBSCO, Ovid, Chinese biological and medical database (CBM). Related literatures published in English or Chinese before January 2017 were enrolled. We assessed the quality of eligible studies and synthesized predefined outcomes with a random-effects model or fixed-effects model. RESULT: Nineteen Randomized Controlled Trials including 879 patients were included. Findings for meta-analysis of various outcomes were summarised. Primary results shown that compared with placebo, dexmedetomidine reduced a surge of TNF-α [SMD=-2.34, 95%CI (-3.25, -1.44)], IL-6 [SMD=-2.44, 95%CI (-3.40, -1.47)], S100-ß [SMD=-2.73, 95%CI (-3.65, -1.82)], NSE [SMD=-1.69, 95%CI (-2.77, -0.61)], cortisol [SMD=-2.48, 95%CI (-3.38, -1.58)] and glucose [SMD=-1.44, 95%CI (-1.85, -1.04)]; maintained the level of SOD [SMD=1.36, 95%CI (0.62, 2.10)]; decreased the rise in CRP level at postoperative one day. In response to stress reaction, dexmedetomidine attenuated the stress-related increasing of MAP, HR and intracranial pressure without significant effects on cerebral oxygen metabolism. CONCLUSION: Alpha2-adrenoceptor agonists, dexmedetomidine, could reduce the release of inflammatory mediators and neuroendocrine hormones as well as maintain intracranial homoeostasis, alleviating ischemic brain injury and exerting an effect on brain protection.

Noradrenergic activity regulated dexamethasone-induced increase of 5-HT3 receptor-mediated glutamate release in the rat's prelimbic cortex.

Stress hormone, glutamatergic system, serotonergic system and the noradrenergic system are involved in depressive disorders. However, the relationship among these is still unclear. The present study examined the effect of dexamethasone (DEX) on the presynaptic glutamate release of synaptosomes from the rat's prelimbic cortex by using biochemical methods combined with pharmacological approaches. The results showed that dexamethasone increased the glutamate release of synaptosomes in a dose-dependent manner. The concentration-response relationship of this effect of DEX was inverse U-shaped with a maximum at 3 µm. Further study showed that glucocorticoid receptor (GR) antagonist and GR siRNA had no effect on the DEX-induced glutamate release but 5-HT3 receptor antagonist could block the DEX-induced glutamate release which suggested that DEX produced the increased effect on the glutamate release not by GR, but through the activation of the 5-HT3 receptors which led to the influx of extrasynaptosomal Ca²âº. Moreover, ß3 adrenergic receptor agonist could block the DEX-induced glutamate release. This result suggested that the effect of DEX on the glutamate release could be regulated by noradrenergic system. The mechanism study showed that ß(3) adrenergic receptors regulated the DEX-induced glutamate release via Gs protein-adenylate cyclase (AC)-protein kinase A (PKA) signal transduction pathway.

[Protective effect of ulinastatin on lung injury induced by simultaneous pancreas-kidney transplantation in piglet].

OBJECTIVE: To evaluate the effects of ulinastatin (UTI) on lung injury induced by simultaneous pancreas-kidney transplantation in piglet. METHODS: With reproduction of simultaneous pancreas-kidney transplantation model in piglets, 12 couples of piglets were randomly divided into two groups (n=12). Piglets in UTI group were given a constant infusion of UTI 15 kU x kg(-1) x h(-1) by means of a pump during operation. Control group were treated with constant pumped infusion of 0.9% saline in equal volume. The blood samples were collected to measure the plasma concentrations of superoxide dismutase (SOD), malondialdehyde (MDA), tumor necrosis factor-alpha (TNF-alpha) and interleukin-8 (IL-8) before operation (baseline levels, T0), at the time of re-establishment of circulation with successful an anastomosis of arteries and veins (T1), at 1 hour and 2 hours after re-establishment of circulation (T2 and T3), and at the end of operation (T4). The pathological changes in the lungs were examined. RESULTS: In control group, plasma MDA concentration was significantly increased from T1 till T4 as compared with T0 (all P<0.05), whereas in group UTI it did not change significantly (all P>0.05). In group UTI, SOD activity was significantly increased at T1-2 and T4 as compared with T0 (all P<0.05), whereas in control group it did not change significantly (all P>0.05). The plasma MDA concentration was significantly decreased at T1 and T2, and SOD activity was increased at T2 in group UTI than those in control group (all P<0.05). In control group, plasma TNF-alpha concentration was significantly increased from T2 to T4 as compared with T0 (all P<0.05), whereas it did not change significantly in group UTI (all P>0.05). The plasma IL-8 concentration was significantly decreased at T1-2 and T4 in group UTI compared with those in control group (both P<0.05). CONCLUSION: UTI can inhibit neutrophil aggregation in lungs and expression of harmful inflammatory cytokines, and it reduces production of oxygen free radical, so that it can protect lung tissue from injury induced by simultaneous pancreas-kidney transplantation.