Daily Anesthesiology Research Analysis

BACKGROUND: Remote ischaemic preconditioning (RIPC) might reduce acute kidney injury after cardiac surgery. Protective effects appear to be restricted to patients with early and transient increases in two cell cycle arrest markers, tissue inhibitor of metalloproteinases-2 (TIMP-2) and insulin-like growth factor-binding protein 7 (IGFBP7), in urine. Studies suggest that propofol can attenuate the preconditioning effect on the myocardium. This study investigated whether propofol diminishes the renoprotective effect associated with the early transient increases in TIMP-2 and IGFBP7. METHODS: This was a single-centre, prospective randomised double-blind 2×2 factorial clinical trial of high-risk patients undergoing cardiac surgery. Patients were randomised to receive either propofol+sham-RIPC, propofol+RIPC, sevoflurane+sham-RIPC, or sevoflurane+RIPC. The primary outcome measure was the change in the product of urinary concentrations of TIMP-2 and IGFBP7 ([TIMP-2]·[IGFBP7]) from before to after the intervention. RESULTS: We enrolled 160 participants in the trial (propofol+sham-RIPC: n=20, propofol+RIPC: n=60, sevoflurane+sham-RIPC: n=20, sevoflurane+RIPC: n=60). The median change in [TIMP-2]·[IGFBP7] as an indicator of response to RIPC was greater in participants receiving sevoflurane (0.070; interquartile range, -0.120 to 0.418) compared with those receiving propofol (-0.015; interquartile range, -0.138 to 0.068; P=0.022). Conversely, elevated [TIMP-2]·[IGFBP7] as a sign of renal stress in response to surgery was detected in all groups except for sevoflurane+RIPC (P=0.001). There were no statistically significant differences in patient-centred outcomes between groups. CONCLUSIONS: Transient increases in [TIMP-2]·[IGFBP7] induced by RIPC, which were associated with renoprotective effects, were only seen with sevoflurane anaesthesia, but not when propofol was used. The association of biomarker concentrations and choice of anaesthetic agent suggests that propofol can attenuate the renoprotective effects of remote ischaemic preconditioning. CLINICAL TRIAL REGISTRATION: DRKS00014989.

BACKGROUND: The continuous interscalene brachial plexus block (ISB) is widely used for regional anesthesia in shoulder surgeries. Although the continuous costoclavicular brachial plexus block (CCB) has been proposed, its comparative efficacy and safety remain unclear. This randomized, single-blind trial aimed to determine whether the CCB offers non-inferior postoperative analgesia compared to the ISB while mitigating hemidiaphragmatic paresis (HDP). METHODS: patients underwent rotator cuff repair received continuous ISB or CCB followed by 0.2% ropivacaine infusion postoperatively. The primary outcome was the resting numerical rating scale (NRS) pain score 24 h postoperatively. Secondary outcomes included block-related parameters, dynamic and resting pain scores, HDP incidence, opioid consumption, rescue analgesia requirements, and satisfaction scores. RESULTS: Resting NRS scores at 24 h demonstrated the non-inferiority of the CCB compared to the ISB (2.41 ± 0.59 vs. 2.00 ± 0.81; mean difference: 0.41; 95% CI: 0.1-0.73). The CCB significantly reduced the incidence of early complete HDP (30 min post-block: 7.3% vs. 41.5%; P < 0.001), with no incidence of complete HDP at 24 h. The CCB had longer block times (19.2 ± 3.7 vs. 17.2 ± 3.6 min; P = 0.013) and sensory onet (24.0 [21.0-24.0] vs. 18.0 [18.0-21.0] min; P < 0.001). Total ropivacaine consumption, rescue analgesia, or satisfaction scores were comparable. CONCLUSIONS: The continuous CCB is non-inferior to the ISB in terms of postoperative analgesia after rotator cuff repair and substantially decreases the risk of HDP. These findings support the CCB as a clinically advantageous alternative for shoulder surgery analgesia.

BACKGROUND: Intraoperative hypotension (IOH) is an important risk factor for major adverse cardiac events (MACE) in patients undergoing noncardiac surgery. However, the IOH threshold in older adult patients remains controversial. OBJECTIVE: This study aimed to explore an appropriate IOH threshold in older adult patients to decrease the risk of MACE. METHODS: This study involved older adult patients undergoing noncardiac surgery (age ≥65 y) from January 2012 to August 2019 in the Chinese People's Liberation Army General Hospital (PLAGH; 35,262 patients) and Shanghai Changhai Hospital from January 2024 to December 2024 (13,418 patients). Univariate moving-average plots and multivariate restricted cubic splines were used to determine the IOH thresholds associated with an increased risk of MACE. The relationship between the IOH threshold and MACE was assessed using univariate and multivariate logistic regression analyses by 3 different hypotension exposure forms (duration, area, and time-weighted average mean arterial pressure [MAP]). RESULTS: Out of 35,262 patients, 874 developed MACE in PLAGH, and 296 of 13,418 patients developed MACE in Changhai Hospital. In PLAGH, MAP below an absolute threshold of 70 mm Hg was associated with MACE. When the IOH absolute threshold was 70 mm Hg, the risk of MACE demonstrated a "dose-increasing" effect with changes in IOH exposure, and the risk of MACE was significantly increased when the duration lasted >15 minutes (odds ratio 1.51, 95% CI 1.22-1.88; P<.001). The stratified analysis showed that in patients younger than 80 years, when intraoperative MAP dropped below 70 mm Hg for more than 15 minutes, the odds ratio was 1.38 (95% CI 0.86-2.28), P<.01. In Changhai hospital, intraoperative MAP <70 mm Hg was also significantly associated with MACE. Furthermore, IOH lasting longer than 15 minutes substantially increased the risk of MACE. CONCLUSIONS: For older adult patients undergoing noncardiac surgery, intraoperative MAP should be kept above 70 mm Hg to reduce the risk of postoperative MACE.