Anesthesia Ventilation Research Articles

ANI-моніторинг для оцінки ефективності варіантів анестезіологічного забезпечення пластичної хірургії носа

Метою роботи було вивчення ANI-моніторингу для оцінки періопераційної аналгезії і контролю балансу ноцицепції/антиноцицепції при різних варіантах анестезіологічного забезпечення пластичної хірургії носа. Матеріали та методи. Було обстежено 116 пацієнтів віком від 18 до 60 років з викривленням перегородки носа, яким проводилася септопластика в умовах комбінованої анестезії, що включала тотальну внутрішньовенну анестезію зі штучною вентиляцією легенів і місцевою анестезією лідокаїном. Усі пацієнти були розподілені на 4 групи: 1-ша група (n = 28) (контрольна) — зі стандартним комбінованим анестезіологічним забезпеченням; 2-га група (n = 31) — стандартне анестезіологічне забезпечення доповнювалося внутрішньовенною інфузією парацетамолу за 30 хвилин до початку операції в дозі 15 мг/кг (але не більше 1000 мг) одноразово; 3-тя група (n = 30) — проводилася інфузія дексмедетомідину, що починалася за 10 хвилин до індукції анестезії в дозі 0,7 мкг/кг/год і закінчувалася за 10 хвилин до завершення операції; 4-та група (n = 27) — проводилася інфузія дексмедетомідину, що починалася за 10 хвилин до індукції анестезії в дозі 0,7 мкг/кг/год і закінчувалася за 10 хвилин до завершення операції, в комбінації з внутрішньовенною інфузією парацетамолу за 30 хвилин до початку операції в дозі 15 мг/кг (але не більше 1000 мг) одноразово. Проводилася реєстрація АNI-індексу. Після операції реєструвалися рівень болю за візуально-аналоговою шкалою (ВАШ) і частота розвитку післяопераційної нудоти і блювання. Реєструвалася оцінка пацієнтами якості анестезії за допомогою шкали Iowa Satisfaction with Anesthesia Scale. Результати. У контрольній групі ANI-індекс на етапі інтубації, початку операції, на етапі найбільш травматичного моменту операції був нижче 50 одиниць, що, можливо, пов’язано з недостатнім рівнем аналгезії. У 2-й групі з використанням парацетамолу ANI-індекс в момент інтубації знижувався до 50 одиниць, але потім перебував у межах 50–70 одиниць. У 3-й групі з застосуванням дексмедетомідину ANI-індекс на етапі індукції анестезії та в момент пробудження пацієнта був вище 70 одиниць. У 4-й групі з комбінованим використанням дексмедетомідину і парацетамолу ANI-індекс на всіх етапах, крім початку операції, був вище 70 одиниць. При аналізі рівня післяопераційної аналгезії за ВАШ найбільш оптимальний рівень спостерігався у 2-й і 4-й групах пацієнтів. Частота розвитку післяопераційної нудоти і блювання була нижче в основних групах дослідження: 2-га група — 17 %, 3-тя група — 12 %, 4-та група — 14 % порівняно з пацієнтами контрольної групи — 20 %. При оцінці пацієнтами якості проведеної анестезії за Iowa Satisfaction with Anesthesia Scale кращі результати були отримані в 4-й групі пацієнтів, у якій 25 % оцінили якість анестезії як добру, а 75 % — як відмінну. Найгірші результати були отримані в 1-й групі пацієнтів, 30 % з яких оцінили якість анестезії як задовільну. Висновки. Використання АNI-індексу в анестезіологічній практиці дозволяє з високим ступенем специфічності в режимі онлайн мониторувати рівень сприйняття болю в інтра- і післяопераційному періоді і забезпечити поліпшення періопераційної аналгезії. Застосування парацетамолу і дексмедетомідину забезпечує більш надійну і повноцінну періопераційну аналгезію.

Computed tomographic assessment of lung aeration at different positive end-expiratory pressures in a porcine model of intra-abdominal hypertension and lung injury

BackgroundIntra-abdominal hypertension (IAH) is common in critically ill patients and is associated with increased morbidity and mortality. High positive end-expiratory pressures (PEEP) can reverse lung volume and oxygenation decline caused by IAH, but its impact on alveolar overdistension is less clear. We aimed to find a PEEP range that would be high enough to reduce atelectasis, while low enough to minimize alveolar overdistention in the presence of IAH and lung injury.MethodsFive anesthetized pigs received standardized anesthesia and mechanical ventilation. Peritoneal insufflation of air was used to generate intra-abdominal pressure of 27 cmH2O. Lung injury was created by intravenous oleic acid. PEEP levels of 5, 12, 17, 22, and 27 cmH2O were applied. We performed computed tomography and measured arterial oxygen levels, respiratory mechanics, and cardiac output 5 min after each new PEEP level. The proportion of overdistended, normally aerated, poorly aerated, and non-aerated atelectatic lung tissue was calculated based on Hounsfield units.ResultsPEEP decreased the proportion of poorly aerated and atelectatic lung, while increasing normally aerated lung. Overdistension increased with each incremental increase in applied PEEP. “Best PEEP” (respiratory mechanics or oxygenation) was higher than the “optimal CT inflation PEEP range” (difference between lower inflection points of atelectatic and overdistended lung) in healthy and injured lungs.ConclusionsOur findings in a large animal model suggest that titrating a PEEP to respiratory mechanics or oxygenation in the presence of IAH is associated with increased alveolar overdistension.

Tidal volume measurements via transthoracic impedance waveform characteristics: The effect of age, body mass index and gender. A single centre interventional study

Background and aimMeasuring tidal volumes (TV) during bag-valve ventilation is challenging in the clinical setting. The ventilation waveform amplitude of the transthoracic impedance (TTI-amplitude) correlates well with TV for an individual, but poorer between patients. We hypothesized that TV to TTI-amplitude relations could be improved when adjusted for morphometric variables like body mass index (BMI), gender or age, and that TTI-amplitude cut-offs for ventilations with adequate TV (>400ml) could be established. Materials and methodsTwenty-one consenting adults (9 female, and 9 overall overweight) during positive pressure ventilation in anaesthesia before scheduled surgery were included. Seventeen ventilator modes were used (⩾ five breaths per mode) to adjust different TVs (150–800 ml), ventilation frequencies (10–30 min−1) and insufflation times (0.5–3.5 s). TTI from the defibrillation pads was filtered to obtain ventilation TTI-amplitudes. Linear regression models were fitted between target and explanatory variables, and compared (coefficient of determination, R2). ResultsThe TV to TTI-amplitude slope was 1.39 Ω/l (R2=0.52), with significant differences (p<0.05) between male/female (1.04 Ω/l vs 1.84 Ω/l) and normal/overweight subjects (1.65 Ω/l vs 1.04 Ω/l). The median (interquartile range) TTI-amplitude cut-off for adequate TV was 0.51 Ω(0.14–1.20) with significant differences between males and females (0.58 Ω/0.39 Ω), and normal and overweight subjects (0.52 Ω/0.46 Ω). The TV to TTI-amplitude model improved (R2=0.66) when BMI, age and gender were included. ConclusionsTTI-amplitude to TV relations were established and cut-offs for ventilations with adequate TV determined. Patient morphometric variables related to gender, age and BMI explain part of the variability in the measurements.

Recent Insights into the Measurement of Carbon Dioxide Concentrations for Clinical Practice in Respiratory Medicine.

In the field of respiratory clinical practice, the importance of measuring carbon dioxide (CO2) concentrations cannot be overemphasized. Within the body, assessment of the arterial partial pressure of CO2 (PaCO2) has been the gold standard for many decades. Non-invasive assessments are usually predicated on the measurement of CO2 concentrations in the air, usually using an infrared analyzer, and these data are clearly important regarding climate changes as well as regulations of air quality in buildings to ascertain adequate ventilation. Measurements of CO2 production with oxygen consumption yield important indices such as the respiratory quotient and estimates of energy expenditure, which may be used for further investigation in the various fields of metabolism, obesity, sleep disorders, and lifestyle-related issues. Measures of PaCO2 are nowadays performed using the Severinghaus electrode in arterial blood or in arterialized capillary blood, while the same electrode system has been modified to enable relatively accurate non-invasive monitoring of the transcutaneous partial pressure of CO2 (PtcCO2). PtcCO2 monitoring during sleep can be helpful for evaluating sleep apnea syndrome, particularly in children. End-tidal PCO2 is inferior to PtcCO2 as far as accuracy, but it provides breath-by-breath estimates of respiratory gas exchange, while PtcCO2 reflects temporal trends in alveolar ventilation. The frequency of monitoring end-tidal PCO2 has markedly increased in light of its multiple applications (e.g., verify endotracheal intubation, anesthesia or mechanical ventilation, exercise testing, respiratory patterning during sleep, etc.).

Dopamine Reverses Lung Function Deterioration After Cardiopulmonary Bypass Without Affecting Gas Exchange

To investigate the effects of dopamine on the adverse pulmonary changes after cardiopulmonary bypass. A prospective, nonrandomized clinical investigation. A university hospital. One hundred fifty-seven patients who underwent elective cardiac surgery that required cardiopulmonary bypass. Fifty-two patients were administered intravenous infusion of dopamine (3 µg/kg/min) for five minutes after weaning from cardiopulmonary bypass; no intervention was applied in the other 105 patients. Measurements were performed under general anesthesia and mechanical ventilation before cardiopulmonary bypass, after cardiopulmonary bypass, and after the intervention. In each protocol stage, forced oscillatory lung impedance was measured to assess airway and tissue mechanical changes. Mainstream capnography was performed to assess ventilation- and/or perfusion-matching by calculating the normalized phase-3 slopes of the time and volumetric capnograms and the physiologic deadspace. Arterial and central venous blood samples were analyzed to characterize lung oxygenation and intrapulmonary shunt. After cardiopulmonary bypass, dopamineinduced marked improvements in airway resistance and tissue damping, with relatively small decreases in lung tissue elastance. These changes were associated with decreases in the normalized phase-3 slopes of the time and volumetric capnograms. The inotrope had no effect on physiologic deadspace, intrapulmonary shunt, or lung oxygenation. Dopamine reversed the complex detrimental lung mechanical changes induced by cardiopulmonary bypass and alleviated ventilation heterogeneities without affecting the physiologic deadspace or intrapulmonary shunt. Therefore, dopamine has a potential benefit on the gas exchange abnormalities after weaning from cardiopulmonary bypass.

Controlled mechanical ventilation in equine anaesthesia: Classification of ventilators and practical considerations (Part 2)

SummaryControlled mechanical ventilation (CMV) is routinely used in equine anaesthesia, with many different options available to facilitate the delivery of mechanical breaths. The complexity of equine respiratory pathophysiology and the wide range of devices available is described in the two parts of this scoping review. The second part of this review provides an overview of commercially available and hand‐made devices that can be used to deliver CMV in large animals. A short overview of basic physics for mechanical ventilation is given. Working principles are discussed and, where relevant, connected to the pathophysiological background of equine ventilation. The objective of this review is to demystify ventilation modes and ventilators used in equine anaesthesia over the last two decades. In addition, this review aims to provide a practical guide to what the anaesthetist needs to consider before using CMV, how CMV can be delivered and monitored, and which principles need to be applied are included. Comparison of the clinical effects between spontaneous breathing and CMV is included.

Perioperative Provider Safety in Low- and Middle-income Countries During the COVID-19 Pandemic: A Call for Renewed Investments in Resources and Training.

Perioperative Provider Safety in Low- and Middle-income Countries During the COVID-19 Pandemic: A Call for Renewed Investments in Resources and Training.

Phrenic nerve block during nonintubated video-assisted thoracoscopic surgery: a single-centre, double-blind, randomized controlled trial

There has been interest in the use of nonintubated techniques for video-assisted thoracoscopic surgery (VATS) in both awake and sedated patients. The authors’ centre developed a nonintubated technique with spontaneous ventilation for use in a patient under general anaesthesia using a phrenic nerve block. This treatment was compared with a case-matched control group. The authors believe that this technique is beneficial for optimizing anaesthesia for patients undergoing VATS. The patients were randomly allocated (1:1) to the phrenic nerve block (PNB) group and the control group. Both groups of patients received a laryngeal mask airway (LMA) that was inserted after anaesthetic induction, which permitted spontaneous ventilation and local anaesthesia in the forms of a paravertebral nerve block, a PNB and a vagal nerve block. However, the patients in the PNB group underwent procedures with 2% lidocaine, whereas saline was used in the control group. The primary outcome included the propofol doses. Secondary outcomes included the number of propofol boluses, systolic blood pressure (SBP), pH values of arterial blood gas and lactate (LAC), length of LMA pulled out, length of hospital stay (length of time from the operation to the time of discharge) and complications after 1 month. Intraoperatively, there were increases in lactate (F = 12.31, P = 0.001) in the PNB group. There was less propofol (49.20 ± 8.73 vs. 57.20 ± 4.12, P = 0.000), fewer propofol boluses (P = 0.002), a lower pH of arterial blood gas (F = 7.98, P = 0.006) and shorter hospital stays (4.10 ± 1.39 vs. 5.40 ± 1.22, P = 0.000) in the PNB group. There were no statistically significant differences in the length of the LMA pulled out, SBP or complications after 1 month between the groups. PNB optimizes the anaesthesia of nonintubated VATS.

Norepinephrine and dobutamine improve cardiac index equally by supporting opposite sides of the heart in an experimental model of chronic pulmonary hypertension

BackgroundPulmonary hypertension is a significant risk factor in patients undergoing surgery. The combined effects of general anaesthesia and positive pressure ventilation can aggravate this condition and cause increased pulmonary blood pressures, reduced systemic blood pressures and ventricular contractility. Although perioperative use of inotropic support or vasopressors is almost mandatory for these patients, preference is disputed. In this study, we investigated the effects of norepinephrine and dobutamine and their ability to improve the arterio-ventricular relationship and haemodynamics in pigs suffering from chronic pulmonary hypertension.MethodPulmonary hypertension was induced in five pigs by banding the pulmonary artery at 2–3 weeks of age. Six pigs served as controls. After 16 weeks of pulmonary artery banding, the animals were re-examined under general anaesthesia using biventricular conductance catheters and a pulmonary artery catheter. After baseline measurements, the animals were exposed to both norepinephrine and dobutamine infusions in incremental doses, with a stabilising period in between the infusions. The hypothesis of differences between norepinephrine and dobutamine with incremental doses was tested using repeated two-way ANOVA and Bonferroni multiple comparisons post-test.ResultsAt baseline, pulmonary artery-banded animals had increased right ventricular pressure (+ 39%, p = 0.04), lower cardiac index (− 23% p = 0.04), lower systolic blood pressure (− 13%, p = 0.02) and reduced left ventricular end-diastolic volume (− 33%, p = 0.02). When incremental doses of norepinephrine and dobutamine were administered, the right ventricular arterio-ventricular coupling was improved only by dobutamine (p < 0.05). Norepinephrine increased both left ventricular end-diastolic volume and left ventricular contractility to a greater extent (p < 0.05) in pulmonary artery-banded animals. While the cardiac index was improved equally by norepinephrine and dobutamine treatments in pulmonary artery-banded animals, norepinephrine had a significantly greater effect on mean arterial pressure (p < 0.05) and diastolic arterial pressure (p < 0.05).ConclusionWhile norepinephrine and dobutamine improved cardiac index equally, it was obtained in different manners. Dobutamine significantly improved the right ventricular function and the arterio-ventricular coupling. Norepinephrine increased systemic resistance, thereby improving arterial pressures and left ventricular systolic function by maintaining left ventricular end-diastolic volume.

Comparison of intravenous lignocaine and intravenous dexmedetomidine in attenuating pressor response to laryngoscopy and endotracheal intubation in controlled hypertensive patients

Background: Laryngoscopy and endotracheal intubation form the basis of controlling the patient’s airway during general anaesthesia or artificial ventilation which may have deleterious respiratory, neurological, cardiovascular effects associated with hemodynamic changes. These transient cardiovascular responses are usually well tolerated by normotensive patients and may cause no deleterious consequences in them. Patients with hypertension are known to exhibit exaggerated pressor response and complications like cardiac failure, myocardial infarction and cerebral haemorrhage. So, our aim was to evaluate the effect of intravenous preservative free 2 % Lignocaine (1.5 mg/kg) in attenuating the pressor response to laryngoscopy and tracheal intubation compared to intravenous Dexmedetomidine (1 mcg/kg).Methodology: In this study, 60 patients, aged between 40-60 years of either sex k/c/o Hypertension taking some antihypertensive medications belonging to ASA class II included and randomly allocated in 2 groups each of 30. In Group L, patients had received preservative free 2 % Lignocaine 1.5 mg/kg IV 3 minutes before intubation. In Group D, patients had received Dexmedetomidine 1mcg/kg IV diluted to 50 ml NS as an infusion over 10 minutes before induction. Result: The study revealed that there is significant difference between (p value < 0.05) the two groups during laryngoscopy and endotracheal intubation with respect to heart rate, systolic, diastolic and mean arterial BP. Conclusion: IV Dexmedetomidine significantly attenuates intubation response to laryngoscopy and endotracheal intubation with haemodynamic stability as compared with IV Lignocaine in controlled hypertensive patients.

Atelectasis, Shunt, and Worsening Oxygenation Following Reduction of Respiratory Rate in Healthy Pigs Undergoing ECMO: An Experimental Lung Imaging Study

Rationale: Reducing the respiratory rate during extracorporeal membrane oxygenation (ECMO) decreases the mechanical power, but it might induce alveolar de-recruitment. Dissecting de-recruitment due to lung edema vs. the fraction due to hypoventilation may be challenging in injured lungs.Objectives: We characterized changes in lung physiology (primary endpoint: development of atelectasis) associated with progressive reduction of the respiratory rate in healthy animals on ECMO.Methods: Six female pigs underwent general anesthesia and volume control ventilation (Baseline: PEEP 5 cmH2O, Vt 10 ml/kg, I:E = 1:2, FiO2 0.5, rate 24 bpm). Veno-venous ECMO was started and respiratory rate was progressively reduced to 18, 12, and 6 breaths per minute (6-h steps), while all other settings remained unchanged. ECMO blood flow was kept constant while gas flow was increased to maintain stable PaCO2.Measurements and Main Results: At Baseline (without ECMO) and toward the end of each step, data from quantitative CT scan, electrical impedance tomography, and gas exchange were collected. Increasing ECMO gas flow while lowering the respiratory rate was associated with an increase in the fraction of non-aerated tissue (i.e., atelectasis) and with a decrease of tidal ventilation reaching the gravitationally dependent lung regions (p = 0.009 and p = 0.018). Intrapulmonary shunt increased (p < 0.001) and arterial PaO2 decreased (p < 0.001) at lower rates. The fraction of non-aerated lung was correlated with longer expiratory time spent at zero flow (r = 0.555, p = 0.011).Conclusions: Progressive decrease of respiratory rate coupled with increasing CO2 removal in mechanically ventilated healthy pigs is associated with development of lung atelectasis, higher shunt, and poorer oxygenation.

Pulmonary Complications after Airway Management with Laryngeal Masks or Endotracheal Intubation in Geriatric Patients Having Elective Surgery: The POLMA-EP Multi-Centre Randomized Trial

Background: Postoperative pulmonary complications are serious, and especially common in geriatric surgical patients. Laryngeal mask airways and endotracheal intubation and are the two most common airway approaches for patients who require general anaesthesia. Laryngeal mask airways are less invasive than intubation and easier to insert, but do not protect the airway from aspiration. Which approach is preferable remains unknown. We therefore tested the primary hypothesis that a composite of in-hospital postoperative pulmonary complications is less common with laryngeal mask airways than after endotracheal intubation in patients having elective noncardiac surgery with general anaesthesia and mechanical ventilation. Methods: We enrolled patients ≥ 70 years old who required general anaesthesia for elective noncardiac surgery in 17 Chinese clinical centres. Patients were randomly assigned to airway management with endotracheal intubation or laryngeal masks. The primary outcome was the incidence of in-hospital postoperative pulmonary complications. Secondary outcomes included pulmonary complication grades and diagnoses, mortality, number of insertion attempts, treatments for pulmonary complications, time in the post-anaesthesia care unit, need for intensive care, duration of hospitalization, positive blood/sputum cultures, and hospital cost. Findings: Among 2,900 randomized patients, the median age was 74 years, 49% were women, and 39% had abdominal surgery. Pulmonary complications occurred in 342 of 1,364 evaluable patients (25·1%) assigned to endotracheal intubation and 270 of 1387 evaluable patients (19·5%) assigned to a laryngeal mask airway: absolute difference, -5·6% [95%CI, -8·7% to -2·5%]; risk ratio, 0·78 [95% CI, 0·67 to 0·89], P<0·001. There were no significant between-group differences in pneumonia, atelectasis, pleural effusion, systemic inflammatory response syndrome, sepsis, acute lung injury/acute respiratory distress syndrome.InterpretationAmong geriatric patients having elective surgery with general anaesthesia and intraoperative mechanical ventilation, there were fewer pulmonary complications with laryngeal mask airways than after endotracheal intubation. Laryngeal mask airways may be preferable in many patients. Trial Registration: ClinicalTrials.gov Identifier: NCT02240901. Funding: The Science and Technology Commission of Shanghai Municipality, the Shanghai Hospital Development Center, Investigative Doctor Program (2017) of Shanghai Jiao Tong University School of Medicine, the Shanghai Municipal Key Clinical Specialty, the Innovation Program of Shanghai Municipal Education Commission. Declaration of Interest: All authors declare no competing interests. Ethical Approval: Our trial was conducted in 17 Chinese hospitals (Supplement 1) from August 2016 to April 2020. The study protocol was approved by ethics committees of all participating centres. Written informed consent was obtained from participating patients.

Controlled mechanical ventilation in equine anaesthesia: Physiological background and basic considerations (Part 1)

SummaryControlled mechanical ventilation (CMV) is routinely used in equine anaesthesia, with many different options available to mechanically deliver breaths. The complexity of respiratory pathophysiology in anaesthetised horses and the wide range of devices available is described in this scoping review. The first part of the review outlines basic equine respiratory physiology and pathophysiology during anaesthesia to illustrate what makes horses prone to inefficient gas exchange and ventilation when they are recumbent. The difference between spontaneous ventilation and CMV is reviewed and basic considerations of CMV are explored in more detail.

Observational Study of Dynamic Ventilation Parameters during Xenon Anesthesia

Background: The aim of this study was to observe dynamic pressure and flow measurements during the breathing cycle with different concentrations of xenon in patients without pulmonary disease to provide a better understanding of the mechanical-physiological effects of gas mixtures for anesthesia and other potential applications. Ventilation and respiratory data monitoring of flow rate, pressure at the Y-piece of the ventilator circuit, inhaled volume, and concentration of oxygen, xenon, and carbon dioxide for three concentrations of xenon (0, 30, and 60%) were recorded on the anesthetic ventilator station and downloaded to a portable computer. Main Findings: The overall effects of gas concentration are compared in the superimposed flow and pressure curves recorded from the ventilator. Airway resistance increases with xenon concentration for both inspiration (p=0.0028) and expiration (p=0.0007) as expected. The compliance increased with increasing xenon concentration, but only to statistical significance between 100% oxygen and 60% xenon (p=0.0344). The percentage of pressure drop due to the breathing circuit were about 70% for all the groups (no differences statistically, p=0.8161). Conclusions: The results show that the dominant source of the pressure loss is from the breathing circuit compared to the respiratory tract in patients without respiratory disease during inspiration.

The Mechanism of Penehyclidine Hydrochloride and Its Effect on the Inflammatory Response of Lung Tissue in Rats with Chronic Obstructive Pulmonary Disease During Mechanical Ventilation.

BackgroundPenehyclidine hydrochloride is a selective antagonist of M1 and M3 receptors. Clinical studies suggest that it is a potential drug for the treatment of chronic obstructive pulmonary disease (COPD). The purpose of this study was to evaluate the effect of penehyclidine hydrochloride on the inflammatory response of lung tissue during mechanical ventilation in rats with COPD and explore the role of the c-Jun N-terminal kinase/stress-activated protein kinase (JNK/SAPK) signaling pathway.MethodsEight-week-old male Sprague Dawley rats were exposed to cigarette smoke for 30 minutes every day for two months, and on the first and thirtieth days, 200 ug of lipopolysaccharide was injected into the trachea. Two months later, the rats were randomly divided into the control group (C), model group (M), model + normal saline group (N), and penehyclidine hydrochloride group (H) to undergo anesthesia and mechanical ventilation. In group H, 1 mg/kg of penehyclidine hydrochloride was injected intravenously.ResultsThe results showed that: ① Compared with group C, the other groups all showed typical chronic obstructive pathological changes in the lung tissue; their wet/dry weight ratio (W/D), TNF-α, JNK, and p-JNK levels increased (P < 0.05), and their interleukin (IL)-10 levels decreased (P < 0.05). ② Compared with group M, there was no significant change in the lung tissue indexes in group N (P > 0.05). ③ Compared with group N, the W/D, TNF-α, JNK, and p-JNK levels in group H decreased (P < 0.05), while the levels of IL-10 increased (P < 0.05).ConclusionPenehyclidine hydrochloride can alleviate the pulmonary inflammatory response in rats with COPD undergoing mechanical ventilation. The JNK/SAPK signaling pathway may be involved in this process.

Endoscopic management of idiopathic subglottic stenosis in pregnancy

To describe the use of laser, endoscopic balloon dilatation with jet ventilation anaesthesia in the treatment of pregnant women with idiopathic subglottic stenosis. This is a case review of pregnant women with idiopathic subglottic stenosis, presenting to a tertiary referral centre with worsening breathlessness. Data were extracted from patient case notes. Four women underwent surgical management of subglottic stenosis in pregnancy. One patient required two procedures during the course of their pregnancy due to restenosis. All women had improvement in symptoms post-operatively and went on to deliver healthy babies at term. Endoscopic balloon dilatation of idiopathic subglottic stenosis is a safe and viable treatment option in pregnancy and should be offered as first-line treatment in symptomatic women.

Perioperative lung ultrasound pattern changes in patients undergoing gynecological procedures - a prospective observational study.

General anesthesia and positive pressure ventilation are associated with perioperative pulmonary complications. Lung ultrasound (LUS) is a method used to evaluate lung parenchyma. The purpose of this study was to evaluate LUS patterns in a cohort of women undergoing gynecological surgery with uncomplicated general anesthesia. Patients were assessed according to the 8-zone LUS assessment protocol used to detect lung sliding, A-lines, B-lines, interstitial syndrome and lung consolidation. Each patient was screened at specific time intervals: before induction of anesthesia, at induction, 30 and 60 minutes after induction and within two hours after recovery. A total of 99 patients undergoing gynecological surgery with uneventful anesthesia from November 2017 to November 2018 were included in this study. A total of 426 LUS records were retained for further analysis. Overall, no significant changes to patients' A-line appearance were detected, regardless of the time of assessment. There was, however, an increase in the number of B-lines at the screening times of 30 and 60 minutes after induction, as compared to initial assessments (p = 0.011 and p < 0.001 respectively), and an increase in the number of positive regions (≥ 3 B-lines) at 30 and 60 minutes after induction and after recovery, as compared to initial assessment (p < 0.001; p < 0.001 and p = 0.001 respectively). An uneventful anesthesia may predispose to abnormal LUS findings and should be considered while interpreting of LUS results in cases with perioperative pulmonary complications.

Evaluation of the Complications Effectiveness and Frequency When Using Second-Generation Supraglottic Airways in Laparoscopic Interventions in the Trendelenburg Position

Relevance. The supraglottic airways (SA) are now more and more often used as devices of the first choice for providing ventilation during surgical interventions of low trauma and duration, during laparoscopic operations as well. Nevertheless, some concerns remain about the possibility of using these devices in operations accompanied by a significant increase in intra-abdominal pressure, for example, when performing laparoscopy, especially in the Trendelenburg position.Aim of study. Comparison of the efficiency and safety of ventilation, the incidence of postoperative complications when using two different types of SA during laparoscopic surgical interventions performed in the Trendelenburg position.Material and methods. Eighty-three gynecological patients who were scheduled to undergo laparoscopic surgery in the Trendelenburg position were randomly assigned to two groups. In the 1st group, a laryngeal tube was installed for general anesthesia, in the 2nd group patients had a laryngeal mask. The adequacy of ventilation, gas exchange rates, oropharyngeal leakage pressure, rate of successful placement, mean and peak airway pressure at various stages of surgery, as well as the frequency of intra- and postoperative complications were assessed.Results. In all observations, there were normal indicators of gas exchange and capnography, no leakage of the breathing mixture from the circuit. The level of oropharyngeal leakage pressure was statistically different in the groups and was 32 (28; 35) in the 1st group and 28.5 (27; 31.8) cm of water column in the 2nd group. (p=0.007). The time to the onset of ventilation was 19s (18; 21) in the laryngeal tube group, 21s (19; 22.5) in the laryngeal mask group; statistically significant differences were not obtained by this criterion (p=0.059). The first installation attempt was successful in 40 cases (93%) in the 1st group and in 38 cases (95%) in the 2nd group; there was no significant difference in this indicator (p=0.94). The peak and mean airway pressure at the stages of surgery also did not differ. The study did not reveal such intraoperative complications as dislocation of the airway and aspiration of gastric contents. When analyzing postoperative complications, statistical differences were obtained in terms of the level of sore throat 3 hours after removal of SA. In terms of sore throat after 5 minutes, 6, 12, 24 hours, the frequency of hoarseness, no differences were found.Conclusion. 1. The use of different types of 2nd generation supraglottic airways with inflatable cuff (s) provides reliable protection of the upper airway during anesthesia and effective ventilation during laparoscopic surgery in the Trendelenburg position. 2. The laryngeal mask and laryngeal tube did not differ significantly in the frequency of successful insertion, ventilation efficiency, airway pressure levels at various stages of surgery, and the incidence of intra- and postoperative complications. 3. The use of a laryngeal tube provided a higher level of oropharyngeal leakage pressure, while the differences with the laryngeal mask for this indicator were statistically significant.

CEREBROSPINAL FLUID SAMPLING IN A BOTTLENOSE DOLPHIN (TURSIOPS TRUNCATUS) UNDER GENERAL ANESTHESIA

Brucella ceti, associated with neurobrucellosis, has been isolated from cerebrospinal fluid (CSF) of postmortem cetaceans. A 106-kg, stranded female bottlenose dolphin (Tursiops truncatus) presented with serum antibodies to Brucella spp. via competitive enzyme-linked immunosorbent assay and fluorescence polarization assay. Polymerase chain reaction (PCR) and culture of whole blood, bronchoalveolar fluid, and rectal, nasal, and genital swabs for Brucella spp. were consistently negative. Serial computed tomography revealed mild focal dilatation of brain ventricles. CSF sampling was warranted to exclude neurobrucellosis. Sedation was achieved with 30 mg diazepam (0.28 mg/kg) orally 2.5 hours prior to arrival in hospital, followed by 5.3 mg midazolam (0.05 mg/kg) intramuscularly, and anesthetic induction with 2.5 mg midazolam (0.02 mg/kg) and 200 mg propofol (2 mg/kg) administered slowly intravenously, followed by intubation and maintenance on sevoflurane using controlled mechanical and apneustic anesthesia ventilation. The atlanto-occipital joint was opened by flexing the upper cervical region with the animal in left lateral recumbency. A 20-ga × 6-inch spinal needle was advanced into the cisterna magna using radiographic guidance. CSF was collected successfully with no neurological deficits appreciable on recovery. Brucella spp. was not identified via PCR or culture. This represents the first report of an antemortem CSF tap in a cetacean.

Comparative study of Intraoperative Haemodynamics and recovery characteristics of desflurane and sevoflurane in patients receiving General Anaesthesia

Background: Inhaled anesthetics used for general anaesthesia have a rapid onset and offset of action. The Induction and recovery depends on anaesthetic drug solubility, cardiac output and minute ventilation. Sevoflurane and desflurane have low blood gas partition coefficients, and therefore share the advantage of faster onset and recovery from anaesthesia when compared to other inhaled anesthetics. Hence, we designed this prospective randomized study to compare the intraoperative haemodynamic parameters and recovery characteristics of desflurane and sevoflurane. Methods: Sixty patients aged between 18-50 years belonging to ASA I and II scheduled for elective general anaesthesia were enrolled in the study and randomly divided into two groups to receive desflurane(group D) and sevoflurane(group S) for the maintenance of anaesthesia. Both groups were premedicated, pre oxygenated and induced with propofol. Muscle relaxation maintained with vecuronium. Desflurane and sevoflurane concentrations were adjusted according to entropy parameters and clinical variables like HR, NIBP, MAP and SPO2. Neuromuscular blockade reversed with neostigmine and glycopyrrolate. Recovery characteristics assessed using modified Aldrete scoring. Results: The intraoperative haemodynamics was similar with both desflurane and sevoflurane, and was maintained within 20% of baseline values. However, early recovery characteristics were significantly better in group D. Time to eye opening was 6.63 + 2.17 min in group S versus 4.77 + 1.41 min in group D (P&lt; 0.001). Time to Extubation was 8.03 + 2.54 min in group S and 5.93 + 1.44 min in group D (P &lt; 0.001). Response to verbal commands was 8.77 + 3.01 min in group S and 6.97 + 1.67 min in group D (P &lt; 0.001). Modified Aldrete score were significantly better in group D than group S at 1st min, 2nd min and 3rd min. Thereafter, modified Aldrete score assessed at 5, 10, 15, 30 and 60 min were similar in both groups. Conclusion: Both desflurane and sevoflurane produce similar stable haemodynamic profile. Despite the faster early recovery with desflurane, no significant differences were found between the two volatile anaesthetics after 5 minutes during intermediate recovery period.