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To compare the incidence of postoperative cognitive dysfunction (POCD) in elderly surgical patients (>60years) receiving different anesthetics (propofol, sevoflurane, or isoflurane) and to identify potential biomarkers of POCD in this patient population. Prospective, randomized, double-blind clinical trial. University-affiliated teaching hospital. One hundred and fifty elderly patients scheduled for laparoscopic cholecystectomy. Elderly patients undergoing laparoscopic cholecystectomy were randomly assigned to receive propofol, sevoflurane, or isoflurane anesthesia. Measurements: Cognitive function was assessed using neuropsychological tests at baseline (1day before surgery [D0]), and on postoperative day 1 (D1) and day 3 (D3). Plasma S-100β and Aβ1–40 protein, IL-1β, IL-6 and TNF-α concentrations were assessed before induction of anesthesia (T0), after extubation (T1), and 1h (T2) and 24h (T3) postoperatively. The incidence of POCD was significantly lower in the propofol group compared to the isoflurane group and the sevoflurane group at D1 and D3 (propofol vs. isoflurane: D1 and D3, P<0.001; propofol vs. sevoflurane: D1, P=0.012; D3, P=0.013). The incidence of POCD was significantly lower in the sevoflurane group compared to the isoflurane group at D1 (P=0.041), but not at D3. Postoperatively, plasma S-100β and Aβ1–40 protein, IL-1β, IL-6, and TNF-α concentrations were significantly decreased in the propofol group compared to the isoflurane group. Propofol anesthesia may be an option for elderly surgical patients. •Postoperative cognitive dysfunction is commonly occurred in elderly.•Anesthesia impaired the cognitive function.•Propofol had little effect then inhaled anesthetics.

Postoperative complications after lung surgery are frequent, having a detrimental effect on patients' further course. Complications may lead to an increased length of hospital stay and cause additional costs. Several risk factors have been identified but it is still difficult to predict contemporary which patients are at risk. We hypothesized that patients who show an increased inflammatory response at the time of wound closure and 24 hours after surgery are at risk of postoperative complications within 30 days after surgery. Postoperative complications (pulmonary, cardiac, neurological and renal) of 96 patients scheduled for lung surgery at the Medical Center-University of Freiburg were analyzed in this prospective, clinical study. Blood samples for cytokine analysis (Interleukin (IL)-6, IL-8, IL-10, Tumor necrosis factor [TNF]-α, IL-1ß and IL12p70) were taken before surgery, at wound closure and 24 hours after surgery. Cytokine levels of patients with and without postoperative complications were analyzed by Receiver operating characteristic (ROC) curve analysis. To adjust the results according to existing covariates a multivariate logistic regression analysis was conducted. The complication and non-complication group differed significantly according to nicotine dependency, Angiotensin-receptor-II blocker medication, rate of thoracotomy and preoperative lung function. The intraoperative hemodynamic parameters and therapy did not differ between the groups. Twenty-nine patients (30%) developed postoperative complications within 30 days after surgery. Plasma concentrations of IL-6, IL-10 and IL-8 at the time of wound closure and 24 hours after surgery were higher in the complication group. Multivariate regression analysis on postoperative complications revealed an Odds ratio of 56 for patients with IL-6 and IL-8 levels above the 3rd quartile measured on the first postoperative day. Perioperative detection of increased plasma concentrations of inflammatory cytokines in lung surgery may be used in addition to other clinical predictors to identify patients at risk for postoperative complications. German Clinical Trials Register 00006961.

•Synbiotics given preoperatively reduced inflammation, antibiotic use, and length of stay in postoperative colorectal cancer patients. Objectives: Gastrointestinal microflora is involved in the development and regulation of the immune response. Non-pathogenic bacteria are important to prevent the development and subsequent invasion of enteropathogenic bacteria. Surgical trauma and intestinal preparation can disrupt the intestinal microbiota balance. Modulating the microbiota in the preoperative period in patients with colorectal cancer may have an effect on the occurrence of postoperative complications. The aim of this study was to assess the effect of preoperative synbiotic administration in patients with colorectal cancer subjected to colorectal resection. Methods: This was a prospective, randomized, double-blind, placebo-controlled study of 73 patients with colorectal cancer. Eight days before surgery, patients were randomized to receive either synbiotics (Simbioflora, Farmoquimica, São Paulo, Brazi) or placebo (maltodextrin). The envelopes were identical and labeled A or B. All patients underwent nutritional assessment and measurements of C-reactive protein (CRP), interleukin (IL)-6, serum albumin, and transferrin. Patients were given a diluted envelope in 100 mL of water twice daily for 7 d. The occurrence of infectious or non-infectious complications, time of antibiotic use, duration of hospitalization, and occurrence of deaths were recorded for 30 d postoperatively. Results: Mean age, demographic data, and tumor staging were similar between the groups at baseline. After 7 d of synbiotic intake, there were significant reductions in IL-6 levels (163.2 ± 19.5 versus 138.8 ± 12.5, P < 0.001) and CRP (10 ± 5.2 versus 7.17 ± 3.2, P < 0.001), whereas the control group did not present significant changes I IL-6 levels (154.2 ± 18.3 versus 160.9 ± 18.6, NS) or CRP (10.6 ± 6.18 versus 10.4 ± 6.1, NS). Serum albumin and transferrin did not show significant changes. Postoperative infectious complications occurred in 2.8% of patients in the synbiotic group and in 18.9% of the control group (P = 0.02). The mean antibiotic usage time was 1.42 ± 0.5 d in the synbiotic group and 3.74 ± 4.3 d in the control group (P < 0.001). The mean hospital length of stay was 3 ± 1 d in the synbiotic group and 4 ± 18 in the control group (P < 0.001). Three deaths were reported in the control group and none in the synbiotic group (P = 0.115). Conclusions: The use of synbiotics for 7 d preoperatively in patients with colorectal cancer attenuates the inflammatory state and is associated with reductions in morbidity, hospital length of stay, and use of antibiotics.

Background Tissue inhibitor metalloproteinase-2 (TIMP-2) and insulin-like growth factor binding protein-7 (IGFBP-7) are cell-cycle arrest biomarkers that have been shown to be predictive of acute kidney injury (AKI) in critically ill adults. AKI affects a large proportion (40%) of children following cardiac surgery. The aim of this study was to describe the kinetics of TIMP-2*IGFBP-7 and test its ability to predict AKI in infants following cardiac surgery. Methods A multicenter prospective study was performed in infants undergoing cardiac surgery with cardiopulmonary bypass (CPB) from October 2013 to January 2015. Urine samples were obtained at baseline and at 2, 6, 12, 24, 48 and 72 h after CPB initiation. TIMP-2*IGFBP-7 concentration was measured in urine samples using the Astute 140® meter to determine a risk score for AKI. This risk score is the product of TIMP-2 (ng/mL) and IGFBP-7 (ng/mL) divided by 1000. Results A total of 94 infants with a mean age of 154.2 ± 85.7 days were enrolled in the study, of whom 31 (33%) subsequently developed AKI. The mean time to AKI diagnosis was 25 ± 7 h after CPB initiation. The concentration of TIMP-2*IGFBP-7 was significantly higher in patients with AKI at 12 h after CPB initiation relative to baseline ( p  = 0.006). At 12 h after CPB initiation patients with a TIMP-2*IGFBP-7 concentration of ≥0.78 had a threefold higher odds of developing AKI than those with a TIMP-2*IGFBP-7 concentration of < 0.78 (95% confidence interval 1.47–6.11, p  = 0.001). Conclusion These results demonstration that TIMP-2*IGFBP-7 concentration can be used in infants to predict subsequent serum creatinine-defined AKI following CPB.

The effect of Levosimendan on postoperative natriuretic peptides in noncardiac surgical patients remains unknown. Thus, this study evaluates the effect of a perioperative levosimendan administration on postoperative N-terminal brain pro natriuretic peptide (NT-proBNP) concentrations. In this prospective, double-blinded, parallel group, placebo-controlled, phase III trial 115 patients were assigned to perioperative single-dose of 12.5 mg of levosimendan and 115 to placebo between October 2020 through November 2023 (clinicaltrials.gov: NCT04329624). The primary outcome was postoperative maximum NT-proBNP concentration within the first 3 postoperative days. 228 patients completed the trial. Postoperative maximum NT-proBNP concentrations did not differ significantly between the groups (effect estimate: −64.51 ng.L -1 ; 95% CI −332.66 to 195.56; p = 0.61). Here, we show that perioperative levosimendan administration did not lead to a significantly lower release in postoperative NT-proBNP after noncardiac surgery. Here, the authors investigate the effect of perioperative levosimendan on postoperative subclinical heart failure, evaluated via NT-proBNP measurements in cardiac risk patients undergoing noncardiac surgery, and show no significant difference between levosimendan and placebo on the postoperative maximum NT-proBNP release.

Postoperative fluid overload (FO) after cardiac surgery is common and affects recovery. Predicting FO could help optimize fluid management. This post-hoc analysis of the HERACLES randomized controlled trial evaluated the predictive value of MR-proADM for FO post-cardiac surgery. MR-proADM levels were measured at four different timepoints in 33 patients undergoing elective cardiac surgery. Patients were divided into FO (> 5% weight gain) and no-FO at ICU discharge. The primary outcome was the predictive power of MR-proADM at ICU admission for FO at discharge. Secondary outcomes included the predictive value of MR-proADM for FO on day 6 post-surgery and changes over time. The association between MR-proADM and FO at ICU discharge or day 6 post-surgery was not significant (crude odds ratio (cOR): 4.3 (95% CI 0.5–40.9, p  = 0.201) and cOR 1.1 (95% CI 0.04–28.3, p  = 0.954)). MR-proADM levels over time did not differ significantly between patients with and without FO at ICU discharge ( p  = 0.803). MR-proADM at ICU admission was not associated with fluid overload at ICU discharge in patients undergoing elective cardiac surgery. MR-proADM levels over time were not significantly different between groups, although elevated levels were observed in patients with FO.

Background Cognitive dysfunction is a frequent complication to open-heart surgery. Cerebral inflammation caused by blood-brain barrier (BBB) dysfunction due to a systemic inflammatory response is considered a possible etiology. The effects of the glucocorticoid, methylprednisolone, on cerebrospinal fluid (CSF) markers of BBB function, neuroinflammation, and brain injury in patients undergoing cardiac surgery with cardiopulmonary bypass were studied. Methods In this prospective, randomized, blinded study, 30 patients scheduled for elective surgical aortic valve replacement were randomized to methylprednisolone 15 mg/kg ( n  = 15) or placebo ( n  = 15) as a bolus dose administered after induction of anesthesia. CSF and blood samples were obtained the day before and 24 h after surgery for assessment of systemic and brain inflammation (interleukin-6, interleukin-8, tumor necrosis factor-alpha), axonal injury (total-tau, neurofilament light chain protein), neuronal injury (neuron-specific enolase), astroglial injury (S-100B, glial fibrillary acidic protein), and the BBB integrity (CSF/serum albumin ratio). Results In the control group, there was a 54-fold and 17-fold increase in serum interleukin-6 and interleukin-8, respectively. This systemic activation of the inflammatory cytokines was clearly attenuated by methylprednisolone ( p  < 0.001). The increase of the CSF levels of the astroglial markers was not affected. A postoperative BBB dysfunction was seen in both groups as the CSF/serum albumin ratio increased from 6.4 ± 8.0 to 8.0 in the placebo group ( p  < 0.01) and from 5.6 ± 2.3 to 7.2 in the methylprednisolone group ( p  < 0.01) with no difference between groups ( p  = 0.98). In the CSF, methylprednisolone attenuated the interleukin-6 release ( p  < 0.001), which could be explained by the fall in systemic interleukin-6, and the serum to CSF gradient of IL-6 seen both at baseline and after surgery. In the CSF, methylprednisolone enhanced the interleukin-8 release ( p  < 0.001) but did not affect postoperative changes in CSF levels of tumor necrosis factor alpha. Serum levels of S-100B and neuron-specific enolase increased in both groups with no difference between groups. CSF levels of total tau, neurofilament light chain protein, and neuron-specific enolase were not affected in any of the groups. Conclusions Preventive treatment with high-dose methylprednisolone attenuated the systemic inflammatory response to open-heart surgery with cardiopulmonary bypass, but did not prevent or attenuate the increase in BBB permeability or the neuroinflammatory response. Trial registration Clinical Trials, Identifier: NCT01755338 , registered 24 December 2012

Purpose Statins, 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors have the potential to reduce acute kidney injury (AKI) after cardiac surgery through their pleiotropic properties. Here we studied the preventive effect of atorvastatin on AKI after valvular heart surgery. Methods Two-hundred statin-naïve patients were randomly allocated to receive either statin or placebo. Atorvastatin was administered orally to the statin group according to a dosage schedule (80 mg single dose on the evening prior to surgery; 40 mg on the morning of surgery; three further doses of 40 mg on the evenings of postoperative days 0, 1, and 2). AKI incidence was assessed during the first 48 postoperative hours on the basis of Acute Kidney Injury Network criteria. Results The incidence of AKI was similar in the statin and control groups (21 vs. 26 %, respectively, p  = 0.404). Biomarkers of renal injury including plasma neutrophil gelatinase-associated lipocalin and interleukin-18 were also similar between the groups. The statin group required significantly less norepinephrine and vasopressin during surgery, and fewer patients in the statin group required vasopressin. There were no significant differences in postoperative outcomes. Conclusions Acute perioperative statin treatment was not associated with a lower incidence of AKI or improved clinical outcome in patients undergoing valvular heart surgery. (ClinicalTrials.gov NCT01909739).

Introduction The purpose of this study was to evaluate the clinical relevance of high values of central venous-to-arterial carbon dioxide difference (PCO 2 gap) in high-risk surgical patients admitted to a postoperative ICU. We hypothesized that PCO 2 gap could serve as a useful tool to identify patients still requiring hemodynamic optimization at ICU admission. Methods One hundred and fifteen patients were included in this prospective single-center observational study during a 1-year period. High-risk surgical inclusion criteria were adapted from Schoemaker and colleagues. Demographic and biological data, PCO 2 gap, central venous oxygen saturation, lactate level and postoperative complications were recorded for all patients at ICU admission, and 6 hours and 12 hours after admission. Results A total of 78 (68%) patients developed postoperative complications, of whom 54 (47%) developed organ failure. From admission to 12 hours after admission, there was a significant difference in mean PCO 2 gap (8.7 ± 2.8 mmHg versus 5.1 ± 2.6 mmHg; P  = 0.001) and median lactate values (1.54 (1.1-3.2) mmol/l versus 1.06 (0.8-1.8) mmol/l; P  = 0.003) between patients who developed postoperative complications and those who did not. These differences were maximal at admission to the ICU. At ICU admission, the area under the receiver operating characteristic curve for occurrence of postoperative complications was 0.86 for the PCO 2 gap compared to Sequential Organ Failure Assessment score (0.82), Simplified Acute Physiology Score II score (0.67), and lactate level (0.67). The threshold value for PCO 2 gap was 5.8 mmHg. Multivariate analysis showed that only a high PCO 2 gap and a high Sequential Organ Failure Assessment score were independently associated with the occurrence of postoperative complications. A high PCO 2 gap (≥6 mmHg) was associated with more organ failure, an increase in duration of mechanical ventilation and length of hospital stay. Conclusion A high PCO 2 gap at admission in the postoperative ICU was significantly associated with increased postoperative complications in high-risk surgical patients. If the increase in PCO 2 gap is secondary to tissue hypoperfusion then the PCO 2 gap might be a useful tool complementary to central venous oxygen saturation as a therapeutic target.

Background In patients undergoing total joint arthroplasty (TJA), the administration of dexamethasone may contribute to perioperative blood glucose (BG) disturbances, potentially resulting in complications, even in patients without diabetes. This study aimed to demonstrate the impact of different administration regimens of dexamethasone in postoperative BG levels. Methods In this randomized, controlled, double-blind trial, 136 patients without diabetes scheduled for TJA were randomly assigned to three groups: two perioperative saline injections (Group A, placebo); a single preoperative injection of 20 mg dexamethasone and a postoperative saline injection (Group B), and two perioperative injections of 10 mg dexamethasone (Group C). Primary outcomes were the postoperative fasting blood glucose (FBG) levels. Secondary outcome parameters were the postoperative postprandial blood glucose (PBG) levels. Postoperative complications within 90 days were also recorded. Risk factors for FBG ≥ 140 mg/dl and PBG ≥ 180 mg/dl were investigated. Results Compared to Group A, there were transient increases in FBG and PBG on postoperative days (PODs) 0 and 1 in Groups B and C. Statistical differences in FBG and PBG among the three groups were nearly absent from POD 1 onward. Both dexamethasone regimens did not increase the risk for postoperative FBG ≥ 140 mg/dl or PBG ≥ 180 mg/dl. Elevated preoperative HbA1c levels may increase the risk of postoperative FBG ≥ 140 mg/dl or PBG ≥ 180 mg/dl, respectively. Conclusion Perioperative intravenous high-dose dexamethasone to patients without diabetes has transient effects on increasing BG levels after TJA. However, no differences were found between the split-dose and single high-dose regimens. The elevated preoperative HbA1c, but not the dexamethasone regimens were the risk factor for FBG ≥ 140 mg/dl and PBG ≥ 180 mg/dl. Trial registration Chinese Clinical Trail Registry, ChiCTR2300069473. Registered 17 March 2023, https://www.chictr.org.cn/showproj.html?proj=186760 .