OBJECTIVES:This non-inferiority trial compared intravenous esketamine with erector spinae plane block (ESPB) for postoperative recovery quality and analgesic efficacy in patients undergoing video-assisted thoracoscopic surgery (VATS). DESIGN:Randomized controlled non-inferiority study. SETTING:Single-center, university hospital. PARTICIPANTS:One hundred twelve patients undergoing VATS. INTERVENTIONS:The esketamine group received intravenous esketamine (0.25-mg/kg bolus + 0.25-mg/kg/h infusion) combined with a sham ESPB (25 mL of saline solution). The ESPB group received active ESPB (25 mL of 0.375% ropivacaine) plus intravenous saline solution. MEASUREMENTS AND MAIN RESULTS:Outcomes included 15-item quality of recovery (Quality of Recovery-15 [QoR-15]) scores, postoperative pain scores, Hospital Anxiety and Depression Scale (HADS) scores, and perioperative hemodynamic changes. The differences in the QoR-15 scores between the groups on postoperative day 1 (mean difference, 1.0; 95% confidence interval [CI], -2.9 to 4.8; p = 0.622) and postoperative day 2 (mean difference, 0.4; 95% CI, -3.4 to 4.3; p = 0.833) met the non-inferiority criterion (-6 points). The ESPB group showed significantly lower pain scores during coughing at 4 hours (p = 0.026) and 8 hours (p = 0.006) postoperatively. The esketamine group had lower HADS scores and a lower incidence of hypotension. CONCLUSIONS:Intravenous esketamine provides postoperative recovery quality that is non-inferior to ESPB after VATS, primarily because of its beneficial effects on mood, which compensates for its weaker early analgesia. Thus, esketamine may serve not as a direct analgesic substitute for ESPB, but as a rescue option when ESPB is not feasible, or as an analgesic adjunct with anxiolytic and antidepressant effects.

The pathogenesis of cerebral ischemia-reperfusion injury centers on neuroinflammation and oxidative stress-induced programmed cell death. Although remimazolam(REM) is a clinically used benzodiazepine sedative, its neuroprotective effects against various cell death modalities remain incompletely characterized. Cerebral ischemia-reperfusion injury induced significant cerebral edema, marked oxidative stress, elevated inflammatory factor expression, and substantial blood-brain barrier disruption. REM treatment significantly improved neurological deficits, reduced cerebral infarction volume, enhanced ZO-1 and occludin expression in the cerebral cortex, decreased Evans blue leakage, protected blood-brain barrier integrity, In the hippocampus, REM treatment also significantly inhibited neuroinflammation and oxidative stress, lowered pro-inflammatory factors (TNF-α and IL-1β), mitigated ROS-induced damage, blocked NLRP3 inflammasome activation, suppressed caspase-1 cleavage and GSDMD channel formation, downregulated RIP3/MLKL expression, reduced necroptosis, and improved motor function in rats. REM ameliorates cerebral ischemia-reperfusion injury through dual inhibition of the neuroinflammatory-oxidative stress cascade and concurrent blockade of both NLRP3/GSDMD-mediated pyroptosis and RIP3/MLKL-driven necroptosis.

Cardiac arrest (CA) remains a leading cause of mortality and morbidity worldwide. Cognitive deficits are common neurological sequelae among CA survivors. Preclinical and clinical studies have confirmed that therapeutic hypothermia (TH) is an effective intervention for mitigating brain injury following CA. Hypothermia induces the expression of specific small proteins, including RNA-binding motif protein 3 (RBM3), which provides neuroprotection under stress conditions. However, the role of RBM3 in TH after CA has not been fully elucidated. In this study, we investigated the role of RBM3 in attenuating cognitive deficits following hypothermic brain resuscitation. We constructed a rat model of CA and resuscitation, and used shRNA transfection to interfere with RBM3 expression to explore the underlying mechanisms of TH's effects on cognitive alterations. Rats were randomly assigned to one of five groups: sham group (Sham), CA group (CA), TH group (TH), adeno-associated virus (AAV)-shRNA-RBM3 transfection group (shRNA-RBM3), and AAV-shRNA-negative control transfection group (shRNA-control). Key synaptic regulatory proteins, dendritic spines, and synaptic ultrastructures were examined. The rats exhibited spatial learning and memory impairments in the Morris water maze test and novel object recognition task. Hypothermia increased RBM3 expression in hippocampal neurons, mitigated early brain injury, preserved dendritic spine integrity and synaptic ultrastructure, upregulated key synaptic regulatory proteins, and ameliorated cognitive impairment following resuscitation. When RBM3 expression in the hippocampus was inhibited, the beneficial effects of therapeutic hypothermia were partially reversed. Overall, our findings provide new insights into the mechanisms of hypothermia-induced neuroprotection, demonstrating that neuroplasticity and rehabilitation can be achieved following global cerebral ischemia-reperfusion injury after CA. Therefore, the RBM3-mediated cold shock pathway represents a potential target for enhancing neuroprotection and neurorehabilitation through hypothermia.

BACKGROUND:CO2 embolism has been documented in a range of laparoscopic procedures, and cerebral CO2 embolism is an extremely rare but lethal incidence of CO2 embolism, which may ultimately result in coma, stroke, disability, and mortality. CASE PRESENTATION:This paper presents an uncommon case of cerebral CO2 embolism that occurred during laparoscopic surgery, along with a thorough examination of existing literature. The patient (56-year-old Chinese female) experienced a loss of consciousness, generalized tonic-clonic seizures, and neurological impairments after undergoing a laparoscopic partial adrenalectomy. Multiple low-density lesions were detected by brain magnetic resonance imaging. The patient exhibited improvement and gradual recovery after undergoing therapies such as continuous hyperbaric oxygen therapy, hypothermic brain protection, hormone therapy, and anticoagulation. CONCLUSION:We emphasize that cerebral CO2 embolism is a significant complication that must be given great importance in laparoscopic surgery. The comprehension of cerebral CO2 embolism, and effective communication between surgeons and anesthesiologists, play a crucial role in its diagnosis and avoiding inadequate treatment.

Autonomic dysfunction is a risk factor for hypotension after anesthesia induction. Deceleration capacity of heart rate (DC) is a new method to evaluate autonomic function. This prospective observational study was designed to evaluate whether the deceleration capacity of heart rate measured by a 5-min preoperative Electrocardiogram (ECG) can reliably predict post-induction hypotension (PIH). Patients aged 18 to 65 undergoing elective surgery with lower ASA status I or II were included in this study. DC, root mean square density (RMSSD) and low frequency/high frequency ratio (LF/HF) were calculated from 5-min segments of ECG measured in the quiet state before surgery. PIH was defined as mean arterial pressure (MAP) < 65 mmHg or a decrease of > 30

Postoperative delirium (POD) is a common and serious complication in elderly patients undergoing general anesthesia, particularly with cardiac surgery. Identifying risk factors for POD and developing predictive tools are essential for improving patient outcomes. This retrospective cohort study analyzed data from 238 consecutive elderly patients (aged 60 or older) who underwent elective cardiac surgery at our hospital between January 2021 and December 2024. The study aimed to identify factors contributing to postoperative delirium and to develop a predictive nomogram. Patients were divided into delirium and non-delirium groups based on the occurrence of delirium within 72 hours post-surgery. Statistical analysis was performed using multivariate logistic regression, and a nomogram was developed to predict the risk of POD. Significant factors associated with postoperative delirium included age, Charlson Comorbidity Index, cardiopulmonary bypass, and intraoperative hypotension. The nomogram based on these factors demonstrated strong discriminatory ability with an area under the curve of 0.869 and a sensitivity of 76.21% and specificity of 88.51%. The internal validation showed a high C-index of 0.889, indicating excellent calibration. Decision curve analysis confirmed the model's clinical utility. The study identified key risk factors for POD in elderly cardiac surgery patients and developed a nomogram with strong discriminatory ability and clinical applicability. This tool could help clinicians identify high-risk patients and improve management to reduce the incidence of POD.

Purpose:Thoracic surgery is one of the postoperative surgical procedures with the most severe pain. This study aimed to assess whether intraoperative subanesthetic esketamine could reduce the proportion of elderly patients experiencing moderate-to-severe pain following thoracoscopic lung resection. Patients and Methods:A total of 136 elderly patients undergoing thoracoscopic pulmonary surgery were randomly assigned to two groups: the esketamine group (0.25 mg/kg loading, 0.25 mg/kg/h infusion) and the control group (received normal saline). The primary outcome was the proportion of patients experiencing moderate-to-severe pain on the first postoperative day (POD1), defined as a Numerical Rating Scale (NRS) pain score ≥4 during coughing. The secondary outcomes were the postoperative Athens Insomnia Scale (AIS), Hospital Anxiety and Depression Scale (HADS) scores, opioid consumption, hemodynamics, and adverse events. Results:The primary outcome incidence was lower in the esketamine group (51.5% [35/68]) than in the control group (69.1% [47/68]; relative risk [RR], 0.75; 95% confidence interval [CI], 0.56-0.99; P = 0.035). The proportion of patients with moderate-to-severe pain in the esketamine group decreased by 25.5%. The analysis revealed an absolute risk reduction (ARR) of 17.6% and a number needed to treat (NNT) of 5.7 (rounded to 6). The incidence of postoperative sleep disturbance (PSD) on POD1 (23.5% vs 44.1%; RR, 0.53; 95% CI, 0.32-0.88; P = 0.011) is lower in patients who receive esketamine. Compared to the control group, the esketamine group demonstrated lower HADS scores and reduced opioid consumption, without significant differences in hemodynamic parameters or an increased incidence of neuropsychiatric adverse events. Conclusion:This study demonstrated that intraoperative subanesthetic esketamine reduced the proportion of moderate-to-severe pain in elderly patients after thoracoscopic surgery, decreased the incidence of sleep disturbances, improved anxiety and depression scores, and lowered opioid consumption, without increasing neuropsychiatric adverse events.

Ciprofol (CIP) for procedural sedation and analgesia (PSA) for painless gastrointestinal endoscopy (GE) can cause respiratory or cardiovascular complications. The literature suggests that intravenous (IV) lidocaine infusion can alleviate visceral pain and enhance humans’ ventilator response to CO2. Therefore, it was hypothesized that IV lidocaine could reduce the CIP dose for painless GE and improve recovery time. This randomized placebo-controlled trial included 40 patients undergoing GE. After CIP titration for unconsciousness, patients in group L were given IV lidocaine (1.5 mg/kg bolus dose, then a 2 mg/kg/h continuous infusion); the same volume saline as placebo was given for N group patients. The primary endpoint was the required CIP dose. Secondary endpoints were: endoscopic examination time, awakening time, post-anesthesia care unit (PACU) discharge time, pain and fatigue after awakening, adverse events, and endoscopist’s and patient’s satisfaction. Both cohorts had comparable demographic characteristics. Group L’s CIP consumption was decreased by 23.0

Acute postoperative pain is common in surgical patients, and intraoperative noise isolation has been shown to reduce pain for up to 24 h postoperatively. However, acute postoperative pain primarily occurs during the first three days after surgery, and it remains unclear whether intraoperative noise isolation affects the incidence of moderate-to-severe acute postoperative pain during this period. Therefore, this study aimed to investigate whether the use of noise-cancelling earmuffs during laparoscopic surgery reduces the incidence of moderate-to-severe acute postoperative pain. A single-center clinical randomised controlled trial was conducted in Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University. The study included 86 patients aged 18–65 years who underwent elective laparoscopic surgery under general anaesthesia, had an ASA classification I-III, and received patient-controlled intravenous analgesia (PCIA). Participants were randomly assigned to either a noise isolation group or a control group. The noise isolation group wore noise-cancelling earmuffs to attenuate intraoperative noise from induction until the end of surgery, while the control group received conventional anaesthesia management without earmuffs. The primary outcome was the incidence of numeric rating scale (NRS, 0–10) pain scores ≥ 4 at 72 h postoperatively, measured using a 10-point numeric rating scale. Secondary outcomes included the incidence of NRS pain scores ≥ 4 at 24 h and 48 h postoperatively and the proportion of different tiers of NRS pain scores (mild [1–3], moderate [4–6] and severe [7–10]), daily frequency of additional rescue analgesic use over postoperative days 1–3, the maximum resting pain score and the maximum movement-evoked pain score at 24, 48, and 72 h postoperatively and total opioid consumption during the first 72 h postoperatively. The noise isolation group had a significantly lower incidence of moderate-to-severe pain on the third postoperative day (7.1

Abstract Background Perioperative hypotension is frequently observed following the initiation of general anesthesia administration, often associated with adverse outcomes. This study assessed the effect of subclavian vein (SCV) diameter combined with perioperative fluid therapy on preventing post-induction hypotension (PIH) in patients with lower ASA status. Methods This two-part study included patients aged 18 to 65 years, classified as ASA physical status I or II, and scheduled for elective surgery. The first part (Part I) included 146 adult patients, where maximum SCV diameter (dSCVmax), minimum SCV diameter (dSCVmin), SCV collapsibility index (SCVCI) and SCV variability (SCVvariability) assessed using ultrasound. PIH was determined by reduction in mean arterial pressure (MAP) exceeding 30% from baseline measurement or any instance of MAP < falling below 65 mmHg for ≥ a duration of at least 1 min during the period from induction to 10 min after intubation. Receiver Operating Characteristic (ROC) curve analysis was employed to determine the predictive values of subclavian vein diameter and other relevant parameters. The second part comprised 124 adult patients, where patients with SCV diameter above the optimal cutoff value, as determined in Part I study, received 6 ml/kg of colloid solution within 20 min before induction. The study evaluated the impact of subclavian vein diameter combined with perioperative fluid therapy by comparing the observed incidence of PIH after induction of anesthesia. Results The areas under the curves (with 95% confidence intervals) for SCVCI and SCVvariability were both 0.819 (0.744–0.893). The optimal cutoff values were determined to be 45.4% and 14.7% (with sensitivity of 76.1% and specificity of 86.7%), respectively. Logistic regression analysis, after adjusting for confounding factors, demonstrated that both SCVCI and SCVvariability were significant predictors of PIH. A threshold of 45.4% for SCVCI was chosen as the grouping criterion. The incidence of PIH in patients receiving fluid therapy was significantly lower in the SCVCI ≥ 45.4% group compared to the SCVCI < 45.4% group. Conclusions Both SCVCI and SCVvariability are noninvasive parameters capable of predicting PIH, and their combination with perioperative fluid therapy can reduce the incidence of PIH.

Background: This study was devised to assess the efficacy and utility of bispectral index (BIS) monitoring as an adjunct to ciprofol-based sedation in patients undergoing gastrointestinal endoscopy, based on the hypothesis that BIS monitoring would reduce ciprofol consumption and shorten the time required for recovery. Methods: A total of 140 patients scheduled to undergo painless gastrointestinal endoscopy procedures were enrolled in this study. Patients were intraoperatively randomized into BIS or control groups. The dose of ciprofol required was the primary study endpoint, while secondary endpoints included intraoperative SpO2 changes, induction time, the duration of endoscopic examination, time to awakening, time to post-anesthesia care unit (PACU) discharge, adverse event incidence, and satisfaction levels for both patients and endoscopists. Results: The demographic characteristics of both enrolled cohorts were comparable. A significantly lower level of ciprofol consumption was observed for the BIS group relative to the control group (62.27±14.38 mg vs. 66.92±11.66 mg, respectively, P=0.037). The BIS group also presented with a shorter time to awakening (P<0.001) and PACU discharge (P<0.001), together with greater endoscopist satisfaction relative to the control group (P=0.029). The incidence of unfavorable outcomes was similar in both groups (P >0.05 for all). Conclusions: These results show that BIS monitoring, when employed as an adjunct to outpatient ciprofol sedation, was associated with a significantly lower level of ciprofol consumption during gastrointestinal endoscopy procedures, together with reductions in the time to patient awakening and PACU discharge. This monitoring strategy may also lead to greater satisfaction among endoscopists. Trial registration: This trial has been submitted to the Chinese Clinical Trial Registry (registration number: ChiCTR2300069868, registration date: 28/03/2023).

BACKGROUND: Dreaming is often reported by patients who undergo propofol-based sedation, but there have not been any studies to date focused on the incidence of dreaming and factors associated therewith following the administration of ciprofol anesthesia in patients undergoing painless gastroscopy. The present study was thus developed with the goal of assessing the incidence of dreaming. METHODS: In total, this study enrolled 200 patients undergoing painless gastroscopy. During the procedure, patients' and PETCO2 were monitored. When their MOAA/S score reached five after the procedure, patients were administered questionnaires including the Brice questionnaire and a five-point Likert Scale, and the content of any recalled dreams RESULTS: Overall, 27.5% of the participants in this study reported dreaming during the procedure, with most having experienced simple, pleasant dreams about everyday life. Identified predictors of dreaming during painless gastroscopy included lower ASA grade, preoperative knowledge of painless examination, a higher frequency of dreams in the month before the procedure, poor sleep quality during the month before the procedure, and shorter awakening time. Dreamers showed significantly lower BIS values at 2 min after endoscope insertion and following endoscope removal, and also showed lower minimum BIS values compared with non-dreamers. CONCLUSIONS: The postoperative dream recall incidence in this study was 27.5% among patients undergoing painless for painless gastroscopy. Minerva Anestesiol 2024;90:271-9. DOI: 10.23736/S0375-9393.24.17845-5)

目的 分析脑膜瘤切除术患者苏醒期高血压的严重程度和持续时间对术后并发症的影响.方法 回顾性分析 2019 年1 月-2021 年6 月于东部战区总医院接受脑膜瘤切除术患者临床资料.以Clavien-Dindo分级法(≥Ⅱ级)评估的术后并发症为研究主要结局.按苏醒期SBP和DBP分层设置血压阈值,以 5 种方法描述血压持续时间.单因素分析比较并发症组和对照组患者的术前、麻醉和手术方面及术后临床特征.筛选出P＜0.1 的变量纳入多因素Logistic回归模型,以调整潜在混杂变量,评估苏醒期高血压的升高幅度和持续时间对脑膜瘤术后并发症和术后住院天数的影响.结果 共 529 例患者纳入分析,脑膜瘤切除术后并发症发生率为 27.2%.多因素Logistic回归分析结果显示,苏醒期SBP≥160 mmHg总累积持续时间延长会增加术后并发症的发生风险[aOR =1.16(1.00～1.34),P=0.049].与无苏醒期高血压组相比,术后并发症风险与SBP≥160 mmHg长持续时间显著相关[aOR =2.78(1.23～6.28),P=0.014],而与SBP较基线血压增加＞30%无关联.苏醒期SBP≥160 mmHg累积持续时间和单次最长持续时间增加会延长患者的术后住院时间.结论 苏醒期高血压特别是SBP≥160 mmHg持续时间大于 15 min可显著增加脑膜瘤患者术后并发症的发生风险.

Abstract Purpose Acute postoperative hypertension (APH) is a common complication during the anesthesia recovery period that can lead to adverse outcomes, including cardiovascular and cerebrovascular accidents. Identification of risk factors for APH will allow for preoperative optimization and appropriate perioperative management. This study aimed to identify risk factors for APH. Patients and methods In this retrospective single-center study, 1,178 cases were included. Data was entered by two investigators, and consistency analysis was performed by another. Patients were divided into APH and non-APH groups. A predictive model was built by multivariate stepwise logistic regression. The predictive ability of the logistic regression model was tested by drawing the receiver operating characteristic (ROC) curve and calculating the area under the curve (AUC). Hosmer and Lemeshow goodness-of-fit (GOF) test was performed to reflect the goodness of fit of the model. Calibration curve was created to represent the relationship between predicted risk and observed frequency. Sensitivity analysis was performed to evaluate the robustness of the results. Results Multivariate logistic regression analysis showed that age over 65 years (OR = 3.07, 95% CI: 2.14 ~ 4.42, P < 0.001), female patients (OR = 1.37, 95% CI: 1.02 ~ 1.84, P = 0.034), presence of intraoperative hypertension (OR = 2.15, 95% CI: 1.57 ~ 2.95, P < 0.001), and use of propofol in PACU (OR = 2.14, 95% CI: 1.49 ~ 3.06, P < 0.001) were risk factors for APH. Intraoperative use of dexmedetomidine (OR = 0.66, 95% CI: 0.49 ~ 0.89, P = 0.007) was a protective factor. Higher baseline SBP (OR = 0.90, 95% CI: 0.89 ~ 0.92, P < 0.001) also showed some correlation with APH. Conclusions The risk of acute postoperative hypertension increased with age over 65 years, female patients, intraoperative hypertension and restlessness during anesthesia recovery. Intraoperative use of dexmedetomidine was a protective factor for APH.

article: Ultrasound evaluation of the distal radial artery for arterial cannulation in Chinese patients: a prospective observational study - Minerva Anestesiologica 2023 January-February;89(1-2):113-4 - Minerva Medica - Journals

To the Editor: Unanticipated hypertension during emergence refers to acutely elevated blood pressure following general anesthesia in individuals with normal preoperative baseline blood pressure.[1] Due to their normal preoperative blood pressure, inadequate attention was paid to this population. Acute postoperative hypertension, if left untreated, has been linked to serious postoperative consequences such as vascular anastomosis rupture, and cardiovascular and cerebrovascular accidents, affecting the outcome of critically ill and surgical patients.[2] Few studies have revealed the risk factors for unanticipated hypertension after general anesthesia. We performed this retrospective study to identify the factors responsible for unexpected hypertension in adult surgical patients resuscitated from anesthesia based on real-world data from an anesthesia center in eastern China, to provide evidence for perioperative management within this surgical patient population. The research protocol was reviewed and approved by the Ethics Committee of Jinling Hospital, affiliated with the Medical School of Nanjing University (No. 2022NZKY-010-01), which stated that patients' written informed consent was not required given the study's retrospective nature since all the data being collected were routine records. Basic demographic, clinical characteristics, intraoperative and postoperative outcome details of patients who underwent non-cardiac surgery under general anesthesia between September and October 2020 were retrieved. The patients whose records were retrieved met the following inclusion criteria: the patients had been admitted into the post-anesthesia care unit (PACU) for recovery and had a normal preoperative baseline blood pressure. The exclusion criteria included: (1) patients whose PACU blood pressure data and other medical records were incomplete; (2) an New York Heart Association (NYHA) rating of III or higher; (3) a second operation within 30 days, those younger than 18 years of age; (4) an ASA (American Society of Anesthesiologists) classification of IV or higher. All adult surgical patients were separated into two groups based on whether they developed unanticipated hypertension during emergence from general anesthesia (case group) or not (control group). The diagnostic criteria for unanticipated hypertension were as follows: normal preoperative blood pressure at admission (systolic blood pressure [SBP] <140 mmHg and diastolic blood pressure [DBP] <90 mmHg) and an incremental ratio of 30% of the highest blood pressure to baseline blood pressure during the recovery period.[1] Baseline blood pressure is the non-invasive blood pressure measured by the nurse after the patient's admission to the hospital. After patients were admitted to the PACU, non-invasive arterial blood pressure values were measured and recorded at 5-min intervals. The patient's baseline blood pressure and the PACU blood pressure were both obtained using non-invasive cuff manometry. Patient clinical information was collected using the EpiData version 3.1 (The EpiData Association, Odense, Denmark) database. Rigorous data quality control was demonstrated by the fact that clinical data were recorded independently by two investigators and checked and corrected by a third investigator for consistency and completeness of the original data. The sample size of outcome events for the logistic regression model was 15–20 times the number of independent variables. The multivariate logistic regression initially included 300 patients and 16 possible covariates. The prevalence of unanticipated hypertension upon emergence from anesthesia was 23.0%, requiring a sample size of 1063 cases for our study, considering that 2% of patients rate of lost to follow up. Multiple imputations were used to fill in missing values. Quantitative variables were described as the mean ± standard deviation (SD) or the median (interquartile range [IQR]) and were performed using unpaired t-test or Mann–Whitney test. Categorical variables were summarized using count (percentage) and were evaluated, if appropriate, using Chi-squared test or Fisher exact test. A multivariate logistic regression model was applied incorporating variables with P <0.1. We also included variables of clinical significance to determine whether these factors were independent. The crude odds ratio (COR) and the adjusted odds ratio (AOR) with their respective 95% confidence intervals (CIs) were calculated in the final model. Data analyses were conducted using SPSS Statistics version 26.0 (IBM Corp., Armonk, NY, USA), and data graphing was performed using GraphPad Prism 8.0.0 (GraphPad Software, San Diego, California, USA). A P value <0.05 was considered statistically significant. A total of 1078 patients were included and 245 (22.7%) of the patients developed unanticipated hypertension upon emergence from anesthesia. The patients had a median age of 50.0 ±15.2 years and a male/female (M/F) ratio of 1.09:1.00. The patients' preoperative, intraoperative, and postoperative data were available in Supplementary Tables 1–3, https://links.lww.com/CM9/B673. The backward stepwise multivariate logistic regression demonstrated that age ≥65 years (odds ratio [OR] = 1.550, 95% CI: 1.087–2.210, P = 0.015), female (OR = 1.548, 95% CI: 1.149–2.086, P = 0.004), intraoperative hypertension (OR = 1.419, 95% CI: 1.035–1.947, P = 0.030), supplemental analgesics in the PACU (OR = 2.221, 95% CI: 1.088–4.533, P = 0.028), and supplemental propofol in the PACU (OR = 1.630, 95% CI: 1.147–2.317, P = 0.006) were independent risk factors of unanticipated hypertension during emergence from anesthesia, while intraoperative use of dexmedetomidine (OR = 0.992, 95% CI: 0.987–0.998, P = 0.011) was a protective factor [Table 1]. A forest plot was presented to show the relative statistical power of the factors, separately [Supplementary Figure 1, https://links.lww.com/CM9/B673]. Table 1 - Logistic regression analysis for predictive factors of unanticipated hypertension during emergence from general anesthesia. Univariate logistic regression Multivariate logistic regression Variables Crude OR (95% CI) P value Adjusted OR (95% CI) P values Age ≥65 years 1.641 (1.166–2.310) 0.005 1.550 (1.087–2.210) 0.015 Gender (female) 1.456 (1.094–1.939) 0.010 1.548 (1.149–2.086) 0.004* ASA classification I 1.000 – – – II 1.375 (0.797–2.372) 0.253 – – III 2.541 (1.237–5.222) 0.011 – – Hypertension 1.159 (0.828–1.622) 0.390 – – Meningioma 0.255 (0.060–1.084) 0.064 – – Preoperative hypotensive drugs 1.256 (0.901–1.751) 0.180 – – Intraoperative hypertension 1.590 (1.175–2.151) 0.003 1.419 (1.035–1.947) 0.030 Intraoperative use of dexmedetomidine 0.659 (0.488–0.888) 0.006 0.670 (0.492–0.912) 0.011 Catheter 1.334 (0.911–1.955) 0.139 – – Extubation 1.005 (1.000–1.010) 0.057 – – Supplemental analgesics in the PACU 2.464 (1.225–4.953) 0.011 2.221 (1.088–4.533) 0.028 Supplemental propofol in the PACU 1.635 (1.164–2.296) 0.005 1.630 (1.147–2.317) 0.006* *P <0.01. ASA: American Society of Anesthesiologists; CI: Confidence interval; OR: Odds ratio; PACU: Post-anesthesia care unit; –: Not available. Patients with unanticipated hypertension stayed longer in the PACU (103 min vs. 97 min) and had an increased risk of delayed postoperative extubation (26.1% vs. 19.8%) and a magnitude of blood pressure variability [Supplementary Table 4, https://links.lww.com/CM9/B673]. The specific effect of unanticipated hypertension on delayed extubation was consistent across subgroups of age, sex, ASA classification, and preoperative comorbidities, as shown in Supplementary Figure 2, https://links.lww.com/CM9/B673. Our study showed that age ≥65 years, female, intraoperative hypertension, postoperative pain, and agitation were independent risk factors of unanticipated hypertension during emergence from anesthesia, while intraoperative use of dexmedetomidine was a protective factor. Evidence revealed that geriatric patients were more vulnerable to drastic changes in blood pressure and were at a high risk of adverse events postoperatively. This might be due to the weaker compensatory ability of the circulatory system. Gan et al[3] reported that aging and perimenopausal estrogen withdrawal in female patients were risk factors for hypertension by conducting a retrospective analysis of 382 elderly patients. We, therefore, hypothesized that female aging and estrogen withdrawal might explain the gender differences in unanticipated hypertension during emergence. As determined by multivariate regression analysis, intraoperative hypertension increased unanticipated hypertension (OR = 1.419). Intraoperative blood pressure elevation will increase intraoperative blood loss, often accompanied by postoperative organ damage.[2] In a cohort study by Abebe et al,[4] they revealed that intraoperative blood pressure was strongly associated with hemodynamic instability in the PACU. Compared to age and females, intraoperative hypertension as a potential risk factor could be moderated. Our research examined the effect of intraoperative dexmedetomidine use. Dexmedetomidine is a highly selective α2-adrenoceptor agonist, acting on the central and peripheral nervous system, with sedative, analgesic, and anti-sympathetic effects.[5] It exhibits an anti-sympathetic tone through the activation of α2-A receptors in the medulla oblongata; it acts on spinal cord α2 receptors to inhibit the upward transmission of injurious stimulus signals to the brain, producing an analgesic effect. Furthermore, it acts on brainstem blue spot α2 receptors to maintain a state of non-motorized sleep, producing a sedative effect. Therefore, we hypothesize that dexmedetomidine may reduce the postoperative blood pressure elevation caused by painful stimulation or insufficient depth of sedation. Considering that the usage of supplementary analgesics in the PACU was significantly related to postoperative pain, this variable was used in our study as a factor reflecting the patient's postoperative pain. A total of 34 of our patients received additional analgesics in the PACU. There was no difference in the dose of analgesics. Our findings revealed an OR value of 2.221 for postoperative pain, which showed the largest effect value compared with other risk factors. This may indicate that postoperative pain has the most significant effect on unanticipated hypertension compared to several other factors. Prior studies have examined that postoperative pain greatly increases the risk of elevated blood pressure throughout the recovery period, possibly because postoperative pain causes sympathetic excitatory stress, leading to elevated blood pressure.[6] Emergence agitation (EA) is one of the common postoperative complications from general anesthesia and may lead to unintentional injury due to tracheal tube removal.[7] Given the additional propofol for sedation as a treatment for agitation, the supplemental propofol in the PACU was considered a factor representing the occurrence of postoperative agitation. Previous studies determined a strong relationship between postoperative agitation and elevated blood pressure in the PACU and coincided with our findings. Therefore, postoperative pain and agitation prevention through effective intraoperative management are favorable for patients and may lower the frequency of unanticipated hypertension during emergence. Interestingly, we also found that patients with unanticipated hypertension stayed longer in the PACU. Subgroup analysis suggested that unanticipated hypertension increased the risk of delayed postoperative extubation and was consistent across each subgroup. Compared with SBP and DBP values, the blood pressure coefficient of variation indicated the degree of blood pressure fluctuation, which had a greater predictive value for organ damage. In our study, patients with unanticipated hypertension exhibited greater blood pressure fluctuations, increasing the risk of postoperative complications. In conclusion, we found that age ≥65 years, female, intraoperative hypertension, postoperative pain, and agitation increased the risk of unanticipated hypertension during emergence from general anesthesia, whereas intraoperative use of dexmedetomidine reduced the occurrence of unanticipated hypertension to some extent. Conflicts of interest None.

ObjectiveTo test agreement and interchangeability between distal (dRA) and forearm radial arterial (RA) pressures (AP) during general anesthesia (GA) for prone spinal surgery.MethodsThis prospective observational study involved 40 patients scheduled for GA spinal surgery. The right dRA and left forearm RA were cannulated in all patients to continuously measure invasive blood pressures (IBP). We compared the agreement and trending ability of systolic AP (SAP), diastolic AP (DAP), and mean AP (MAP) at each site 15 minutes after tracheal intubation, start of surgery, 30 and 60 minutes after the start of surgery, and after skin suturing.ResultsPaired BP values (n = 184) (37 cases) were analyzed. The bias (standard deviation), limits of agreement, and percentage error were: SAP: 0.19 (3.03), -5.75 to 6.12, and 5.04%; DAP: -0.06 (1.75), -3.50 to 3.38, and 5.10%; and MAP: 0.08 (1.52), -2.90 to 3.05, and 3.54%, respectively. The linear regression coefficients of determination were 0.981, 0.982, and 0.988 for SAPs, DAPs, and MAPs, respectively; four-quadrant plot concordance rates were 95.11%, 92.03%, and 92.66%, respectively.ConclusionAll arterial BPs showed good agreement and trending capabilities for both the dRA and RA. The dRA may be substituted for the RA in IBP monitoring.

Abstract Background The novel distal radial artery (dRA) approach is a popular arterial access route for interventional cardiology and neurointerventions. We explored the dRA as an alternative site to the classic forearm radial artery (RA) for perioperative blood pressure monitoring. We hypothesized that dRA catheterization is noninferior to RA for the first attempt success rate. Methods This was a single-center, prospective, randomized controlled, noninferiority study. Adult patients who underwent elective surgery at the Jinling Hospital from May 2021 to August 2021 were enrolled. The primary endpoint was to test the noninferiority of the first attempt success rate between the groups. Secondary endpoints included anatomical characteristics, catheterization time, arterial posterior wall puncture rate, postoperative compression time, dampened arterial pressure waveforms, and complications. Results Totally, 161 patients who received either dRA (n = 81) or RA (n = 80) catheterization were analyzed. The first attempt success rates were 87.7 and 91.3% in the dRA and RA groups, respectively, with a mean difference of − 3.6% (95% CI, − 13.1 to 5.9%). The dRA diameter and cross-sectional area were significantly smaller than those of the RA (P < 0.001). The subcutaneous depth of dRA was significantly greater than that of the RA (P < 0.001). The dRA had a longer catheterization time (P = 0.008) but a shorter postoperative compression time (P < 0.001). The arterial posterior wall puncture rate of dRA was significantly higher than that of the RA (P = 0.006). The dRA had fewer dampened arterial waveforms than RA (P = 0.030) perioperatively. Conclusions The dRA is a rational alternative approach to RA for perioperative arterial pressure monitoring and provides a noninferior first attempt success rate. Trial registration This study is registered in the Chinese Clinical Trials Registry (registration number: ChiCTR2100043714 , registration date: 27/02/2021).

Objective To evaluate the effects of hydrogen-rich liquid on the expression of NOD-like receptor thermoprotein domain-associated protein 3（NLRP3） inflammsome in the hippocampus of rats with cerebral injury after cardiac arrest/cardiopulmonary resuscitation（CPR）.Methods A total of 80 healthy male SD rats weighing 280-350 g and aged 8-10 weeks were selected. According to the random number table method, they were divided into three groups: a sham operation（Sham） group（n=20）, a cardiopulmonary resuscitation（I/R） group（n=30） and a hydrogen-rich liquid（H） group（n=30）. A cardiopulmonary resuscitation model of cardiac arrest was established through transesophageal electrical stimulation.Group S was subjected to endotracheal intubation and arteriovenous puncture alone, followed by intraperitoneal injection of 5 ml/kg hydrogen-rich solution immediately after recovery of spontaneous circulation（ROSC） and 6 h after ROSC. The other two groups were intraperitoneally injected with an equal volume of normal saline. Their neurological function score（NDS） was evaluated 48 h after ROSC. The CA1 area and pyramidal cell count were observed by H-E staining. The expression of NLRP3, pro-caspase-1 and apoptosis-associated speck-like protein containinga caspase recruitment domain（ASC） in the hippocampus were detected by Western blot. Results Compared with the Sham group, the I/R and H groups showed decreases in the neurological function score and pyramidal cell count 48 h after ROSC（P＜0.05）, with up-regulated expression of NLRP3, pro-caspase-1 and ASC in the hippocampus（P＜0.05）. Compared with the I/R group, the H group presented increases in neurological function score（P＜0.05） and pyramidal cells count（P＜0.05）, as well as down-regulated expression of NLRP3, pro-caspase-1 and ASC（P＜0.05）. Conclusions Hydrogen-rich fluid can alleviate brain injury in rats with cardiac arrest/cardiopulmonary resuscitation, which may be related to inhibiting the activation of NLRP3 inflammsomeand alleviating inflammatory response.

Abstract Background Individuals affected by autonomic dysfunction are at a higher risk of developing hypotension following anesthesia induction. Dynamic pupillometry has previously been employed as a means of assessing autonomic function. This prospective observational study was developed to determine whether pupillary light reflex (PLR) parameters can reliably predict post-induction hypotension (PIH). Methods This study enrolled patients with lower ASA status (I-II) undergoing elective surgery. PLR recordings for these patients prior to anesthesia induction were made with an infrared pupil camcorder, with a computer being used to assess Average Constriction Velocity (ACV), Maximum Constriction Velocity (MCV), and Constriction Ratio (CR). PIH was defined by a > 30% reduction in mean arterial pressure (MAP) or any MAP recording < 65 mmHg for at least 1 min from the time of induction until 10 minutes following intubation. Patients were stratified into PIH and non-PIH groups based on whether or not they developed hypotension. Results This study enrolled 61 total patients, of whom 31 (50.8%) exhibited one or more hypotensive episodes. Patients in the PIH group exhibited significantly smaller ACV (P = 0.003) and MCV values (P < 0.001), as well as a higher CR (P = 0.003). Following adjustment for certain factors (Model 2), MCV was identified as a protective factor for PIH (Odds Ratio: 0.369). Receiver operating characteristic (ROC) analyses revealed that relative to CR (AUC: 0.695, 95% CI: 0.563–0.806; P = 0.004), the reciprocal of MCV (1/MCV) offered greater value as a predictor of PIH (AUC: 0.803,95%CI: 0.681–0.894; P < 0.001). Conclusion These results indicate that pupil maximum constriction velocity is a reliable predictor of post-induction hypotension in individuals of ASA I-II status undergoing elective surgery. Trial registration This study was registered with the Chinese Clinical Trial Registry (registration number: ChiCTR2200057164, registration date: 01/03/2022).