Yize Li

Background/Objectives: Point-of-care ultrasound of the antral cross-sectional area (CSA) assesses perioperative aspiration risk. However, the standard 340mm² cut-off derived from healthy populations is inappropriate for chronic hepatitis B (CHB) patients due to disease-induced gastrointestinal alterations. This study aimed to determine a disease-specific CSA cut-off to confirm an empty stomach in CHB patients and identify factors influencing baseline CSA. Methods: In this prospective cohort study, 223 CHB patients underwent ultrasound CSA measurement in the right lateral decubitus (RLD) position. This was immediately followed by endoscopic gastric fluid aspiration (gold standard), defining an "empty stomach" as < 0.8 mL/kg. Receiver operating characteristic (ROC) curves evaluated diagnostic performance, while multivariate regression identified independent factors affecting the CSA. Results: Among 214 analyzed patients, the area under the ROC curve was 0.763 (95% confidence interval [CI]: 0.685–0.842). The optimal RLD CSA cut-off for an empty stomach was 835 mm², yielding 86.1% sensitivity, 61.1% specificity, 94.4% positive predictive value (PPV), and 36.3% negative predictive value (NPV). Multivariate analysis identified cholinesterase (CHE) and albumin (ALB) as independent predictors of baseline CSA. Conclusions: RLD antral CSA cut-off of 835 mm² provides excellent diagnostic confidence (94.4% PPV) for confirming an empty stomach in CHB patients. Utilizing this disease-specific threshold can optimize perioperative airway management and prevent unwarranted defensive anesthetic interventions.

Protectin DX (PDX) is a member of the superfamily of specialized proresolving mediators and exerts anti-inflammatory actions in animal models; however, its signaling mechanism remains unclear. Here, we demonstrate the analgesic actions of PDX in a mouse model of tibial fracture–induced postoperative pain (fPOP). Intravenous early- and late-phase treatment of PDX (100 ng/mouse) effectively alleviated fPOP. Compared with protectin D1 (PD1)/neuroprotectin D1, DHA, steroids, and meloxicam, PDX provided superior pain relief. While dexamethasone and meloxicam prolonged fPOP, PDX shortened the pain duration. The analgesic effects of PDX were abrogated in Gpr37 ^−/− mice, which displayed deficits in fPOP resolution. PDX was shown to bind GPR37 and induce calcium responses in peritoneal macrophages. LC-MS/MS–based lipidomic analysis revealed that endogenous PDX levels were approximately 10-fold higher than those of PD1 in muscle at the fracture site. PDX promoted macrophage polarization via GPR37-dependent phagocytosis and efferocytosis through calcium signaling in vitro, and it further enhanced macrophage viability and efferocytosis in vivo via GPR37. Finally, PDX rapidly modulated nociceptor neuron responses by suppressing C-fiber–induced muscle reflex in vivo and calcium responses in DRG neurons ex vivo and by reducing TRPA1/TRPV1-induced acute pain and neurogenic inflammation in vivo. Our findings highlight multiple benefits of PDX to manage postoperative pain and promote perioperative recovery.

Protectin DX (PDX) is a member of the superfamily of specialized pro-resolving mediators (SPMs) and exerts anti-inflammatory actions in animal models; but the specific signaling pathways involved in its actions have not been fully elucidated. Here we demonstrate the analgesic actions of PDX in a mouse model of tibial fracture-induced postoperative pain (fPOP) via activation of GPR37. Intravenous early-phase and late-phase treatment of PDX (100 ng/mouse) effectively alleviated fPOP. Compared to protectin D1/neuroprotectin D1, DHA, steroid, and meloxicam, PDX produced superior pain relief. While dexamethasone and meloxicam prolonged fPOP, PDX shortened the pain duration. The analgesic effects of PDX were abrogated in Gpr37 ^−/− mice, which displayed deficits in fPOP resolution. PDX binds GPR37 and induces calcium responses in peritoneal macrophages. LC-MS-MS-based lipidomic analysis revealed that endogenous PDX levels were ∼10-fold higher than PD1 in muscle at the fracture site. PDX promotes macrophage polarization via GPR37-dependent phagocytosis and efferocytosis through calcium signaling in vitro , and it further enhances macrophage viability and efferocytosis in vivo via GPR37. Finally, PDX rapidly modulates nociceptor neuron responses by suppressing C-fiber-induced muscle reflex in vivo and calcium responses in DRG neurons ex vivo and reducing TRPA1/TRPV1-induced acute pain and neurogenic inflammation in vivo . Our findings highlight multiple benefits of PDX to manage postoperative pain and promote perioperative recovery.

Background: Remimazolam, a novel ultra-short-acting benzodiazepine, is a potential sedative for non-general anesthesia surgery in the elderly. This study aimed to investigate the appropriate sedative dosage of remimazolam and its effects on perioperative cognitive function in elderly patients undergoing non-general anesthesia surgery.Methods: This multicenter, placebo-controlled trial enrolled 330 elderly patients undergoing non-general anesthesia procedures at eight centers in China from July 2021 to February 2022, with 238 ultimately completing the study. The primary endpoints were the dose of successful sedation with remimazolam and the changes in perioperative cognitive function. Adverse events were recorded to assess drug safety.Results: The induction dose of remimazolam for sedation in spinal anesthesia in elderly patients was 5.38 mg (95% confidence interval [CI], 5.20–5.56), maintained at a rate of 0.223 mg·kg⁻¹·h⁻¹ (95% CI, 0.201–0.237) with no serious adverse effects. Compared with the standard saline group, there was no statistical difference in the MMSE scores on Day 2 morning (P = 0.886), Day 2 afternoon (P = 0.864), and Day 7 (P = 0.613), and no statistical difference in the MoCA scores on Day 2 morning (P = 0.687), Day 2 afternoon (P = 0.827), and Day 7 (P = 0.483) in remimazolam group.Conclusion: Remimazolam besylate is an effective sedative for elderly patients undergoing neuraxial anesthesia. It was successfully induced at a dose of 5.38 mg and maintained at 0.223 mg·kg⁻¹·h⁻¹, demonstrating a good safety profile without affecting short-term postoperative cognitive function.Clinical Trial Registration: http://www.chictr.org.cn (ChiCTR2100048744).

Older adults with anesthesia and surgery often suffer from postoperative cognitive dysfunction (POCD), which puts a heavy burden on rehabilitation. Preoperative sleep disorder, a common phenomenon in elderly anesthesia patients, is closely associated with POCD, but the underlying mechanism is still not fully understood. Hippocampal gamma-aminobutyric acid (GABA)ergic neurotransmission has been reported to play an important role in sleep disorder and cognitive impairment. The aim of this study was to elucidate the effect of preoperative acute sleep deprivation (SD) on anesthesia/surgery-induced POCD and the potential mechanism of hippocampal GABAergic neurotransmission. In the aged (18–20-month-old) male mice, we used a rotating rod to deprive sleep for 24 h and induced a POCD model using sevoflurane exposure combined with laparotomy exploration. A sequential set of behavioral tests, including open field test (OFT), Y-maze, and novel object recognition (NOR), was conducted to assess cognitive performances. In vivo magnetic resonance imaging (MRI) technique was used to observe hippocampal axonal microstructural changes. The levels of GABAergic neurotransmitter markers glutamic acid decarboxylase (GAD) 67, vesicular GABA transporter (VGAT), GABA transporter (GAT)-1, and GABA in the hippocampus were detected with enzyme-linked immunosorbent assay (ELISA). The reactivity of GABAergic neurons and neuronal damage in different subregions of the hippocampus were observed by immunofluorescence and Nissl staining, respectively. Compared the anesthesia/surgery (A/S) mice, 24-h SD combined with A/S induced shorter stay time in the central area of the open field, less the percent of novel arm preference in the Y maze, and lower recognition index in the NOR, as well as significantly enhanced hippocampal GABAergic neurotransmission, decreased hippocampal axonal integrity and density, and increased GAD67 reactivity and reduced the number of neurons in hippocampal CA1. Preoperative 24-h SD exacerbated anesthesia/surgery-induced POCD in aged mice, with the cumulative effect of abnormal GABAergic neurotransmission and neuronal damage in the hippocampus. Graphical Abstract

Background: Propofol and midazolam are commonly used sedative drugs in mechanically ventilated patients in the Intensive Care Unit (ICU). However, there is still a lack of relevant studies exploring the influence of midazolam and propofol on the prognosis of patients with Sepsis-associated Acute Kidney Injury (S-AKI).Patients and methods: A statistical analysis was conducted on 3,745 patients with S-AKI in the Medical Information Mart for Intensive Care IV database. The patients’ baseline characteristics were grouped based on the use of either propofol or midazolam as sedatives. Cox proportional hazards models, logistic regression models, and subgroup analyses were used to compare the effects of propofol and midazolam on the short-term prognosis of S-AKI patients, including 30-day mortality, ICU mortality, and duration of mechanical ventilation.Results: In the statistical analysis, a total of 3,745 patients were included, with 649 patients using midazolam and 3,096 patients using propofol. In terms of the 30-day mortality, compared to patients using midazolam, S-AKI patients using propofol had a lower ICU mortality (hazard ratio = 0.62, 95% confidence interval: 0.52–0.74, p < 0.001), lower 30-day mortality (hazard ratio = 0.56, 95% confidence interval: 0.47–0.67, p < 0.001), and shorter mechanical ventilation time (odds ratio = 0.72, 95% confidence interval: 0.59–0.88, p < 0.001). Kaplan–Meier curves showed lower survival probabilities in the midazolam group (p < 0.001). Subgroup analyses showed that propofol was strongly protective of short-term prognosis in older, male, smaller SOFA score CCI score, no heart failure, and comorbid chronic kidney disease patients with S-AKI.Conclusion: Compared to midazolam, propofol was considered a protective factor for short-term mortality risk and ICU mortality risk in S-AKI patients. Additionally, S-AKI patients using propofol had a lower risk of requiring prolonged mechanical ventilation. Overall, propofol may be more beneficial for the short-term prognosis of S-AKI patients compared to midazolam.

BACKGROUND Remimazolam, a novel ultra-short-acting benzodiazepine, is a potential sedative for non-general anaesthesia surgery in the elderly. This study aimed to investigate the appropriate sedative dosage of remimazolam and its effects on perioperative cognitive function in elderly patients undergoing non-general anaesthesia surgery. METHODS This multicentre, placebo-controlled trial enrolled 330 elderly patients undergoing non-general anaesthesia procedures at eight centres in China from July 2021 to February 2022, with 238 ultimately completing the study. The primary endpoints were the dose of successful sedation with remimazolam and the changes in perioperative cognitive function. Adverse events were recorded to assess drug safety. RESULTS The induction dose of remimazolam for sedation in spinal anaesthesia in elderly patients was 5.38 mg (95% confidence interval [CI], 5.20 to 5.56), maintained at a rate of 0.223 mg·kg^− 1·h^− 1 (95% CI, 0.201 to 0.237) with no serious adverse effects. Compared with the saline group, there was no statistical difference in the Mini-Mental State Examination scores in the experimental group on Day2 morning (P : 0.886), Day2 afternoon (P : 0.864), and Day7 (P : 0.613), and no statistical difference in the Montreal Cognitive Assessment scores on Day2 morning (P : 0.687), Day2 afternoon (P : 0.827), and Day7 (P : 0.483). CONCLUSIONS Remimazolam besylate is an effective sedative drug during spinal anaesthesia in elderly patients, with a successful induction dose of 5.38 mg (95% CI, 5.20 to 5.56), maintained at a rate of 0.223 mg·kg^− 1·h^− 1 (95% CI, 0.201 to 0.237) and a good safety profile without altering the short-term postoperative cognitive function.

Editorial: Molecular mechanism of neuroimmune modulation and synaptic plasticity in acute and chronic pain

Introduction The adverse effects of general anaesthetic drugs (especially opioids) cannot be ignored. However, current nociceptive-monitoring techniques still lack consistency in guiding the use of opioids. This trial will study the demand for opioid use and patient prognosis in qCON and qNOX-guided general anaesthesia management. Methods and analysis This prospective, randomised, controlled trial will randomly recruit 124 patients undergoing general anaesthesia for non-cardiac surgery in equal numbers to either the qCON or BIS group. The qCON group will adjust intraoperative propofol and remifentanil dosage according to qCON and qNOX values, while the BIS group will adjust according to BIS values and haemodynamic fluctuations. The differences between the two groups will be observed in remifentanil dosing and prognosis. The primary outcome will be intraoperative remifentanil use. Secondary outcomes will include propofol consumption; the predictive ability of BIS, qCON and qNOX on conscious responses, noxious stimulus and body movements; and changes in cognitive function at 90 days postoperatively. Ethics and dissemination This study involves human participants and was approved by the Ethics Committee of the Tianjin Medical University General Hospital (IRB2022-YX-075-01). Participants gave informed consent to participate in the study before taking part. The study results will be published in peer-reviewed journals and presented at relevant academic conferences. Trial registration number ChiCTR2200059877