Second Update for Anaesthetists on Clinical Features of COVID-19 Patients and Relevant Management.

The COVID-19 pandemic poses great challenges for healthcare workers around the world, including perioperative specialists. Previously, we provided a first overview of available literature on SARS-CoV-2 and COVID-19, relevant for anaesthetists and intensivists. In the current review, we provide an update of this topic, after a literature search current through May 2020.

Update for Anaesthetists on Clinical Features of COVID-19 Patients and Relevant Management.

When preparing for the outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and the coronavirus infection disease (COVID-19) questions arose regarding various aspects concerning the anaesthetist. When reviewing the literature it became obvious that keeping up-to-date with all relevant publications is almost impossible. We searched for and summarised clinically relevant topics that could help making clinical decisions.

Safety of moderate-to-deep sedation performed by sedation practitioners: A national prospective observational study.

Background: In the Netherlands, a significant proportion of moderate-to-deep sedation is performed by sedation practitioners under the indirect supervision of an anaesthesiologist but there are limited safety data available.

Objective: To estimate the rate of sedation-related adverse events and patient relevant outcomes (PRO).

Design: This was a prospective national observational study.

European implementation of the "2014 ESC/ESA guideline on non-cardiac surgery: cardiovascular assessment and management".

Background: Substandard implementation of a guideline is a major factor contributing to poor guideline adherence and has the potential to result in preventable patient harm. This study aims to quantify the uptake of the European guideline on non-cardiac surgery by European anesthetists.

Methods: This is a questionnaire-based cross-sectional study.

Effect of helium pre- or postconditioning on signal transduction kinases in patients undergoing coronary artery bypass graft surgery.

Background: The noble gas helium induces pre- and postconditioning in animals and humans. Volatile anesthetics induce cardioprotection in humans undergoing coronary artery bypass graft (CABG) surgery. We hypothesized that helium induces pre- and postconditioning in CABG-patients, affecting signaling molecules protein kinase C-epsilon (PKC-ε), p38 mitogen activated protein kinase (p38 MAPK), extracellular signal-regulated kinase 1/2 (ERK-1/2) and heat shock protein 27 (HSP-27) within cardiac tissue, and reducing postoperative troponin levels.

[Cognitive aid for emergencies in the OR--AMC bundle helps ensure that no steps are left out].

Crucial management steps in unexpected perioperative emergencies are frequently omitted by OR teams because of the suboptimal performance of the brain under stress.A cognitive aid is a tool that will help care providers to perform and speed up all the necessary management steps of a critical event. We have created a Dutch adaption of the Stanford Emergency Manual, a bundle of cognitive aids to manage a number of life threatening emergencies in the operating theatre.

In vivo desflurane preconditioning evokes dynamic alterations of metabolic proteins in the heart--proteomic insights strengthen the link between bioenergetics and cardioprotection.

Background: The cardioprotective effect of anaesthetic preconditioning as measured by reduction of ischaemia-reperfusion (I/R) injury is a well described phenomenon. However little is known about the impact on the myocardial proteome. We therefore investigated proteome dynamics at different experimental time points of a preconditioning protocol.

Helium induces preconditioning in human endothelium in vivo.

Aims: Helium protects myocardium by inducing preconditioning in animals. We investigated whether human endothelium is preconditioned by helium inhalation in vivo.

Methods And Results: Forearm ischemia-reperfusion (I/R) in healthy volunteers (each group n = 10) was performed by inflating a blood pressure cuff for 20 min.

Helium-induced cardioprotection of healthy and hypertensive rat myocardium in vivo.

Helium protects healthy myocardium against ischemia/reperfusion injury by early and late preconditioning (EPC, LPC) and postconditioning (PostC). We investigated helium-induced PostC of the hypertensive heart and enhancement by addition of LPC and EPC. We also investigated involvement of signaling kinases glycogen synthase kinase 3 beta (GSK-3β) and protein kinase C-epsilon (PKC-ε).

Age-related loss of cardiac preconditioning: impact of protein kinase A.

Helium induces preconditioning (He-PC) by mitochondrial calcium-sensitive potassium (mK(Ca)) channel-activation, but this effect is lost in the aged myocardium. Both, the upstream signalling pathway of He-PC and the underlying mechanisms for an age-related loss of preconditioning are unknown. A possible candidate as upstream regulator of mK(Ca) channels is protein kinase A (PKA).

Effect of remote ischemic conditioning on atrial fibrillation and outcome after coronary artery bypass grafting (RICO-trial).

Background: Pre- and postconditioning describe mechanisms whereby short ischemic periods protect an organ against a longer period of ischemia. Interestingly, short ischemic periods of a limb, in itself harmless, may increase the ischemia tolerance of remote organs, e.g.

Sevoflurane-induced preconditioning: impact of protocol and aprotinin administration on infarct size and endothelial nitric-oxide synthase phosphorylation in the rat heart in vivo.

Background: Sevoflurane induces preconditioning (SevoPC). The effect of aprotinin and the involvement of endothelial nitric-oxide synthase (NOS) on SevoPC are unknown. We investigated (1) whether SevoPC is strengthened by multiple preconditioning cycles, (2) whether SevoPC is blocked by aprotinin, and (3) whether endothelial NOS plays a crucial role in SevoPC.

Hypoxia induces late preconditioning in the rat heart in vivo.

Background: Although hypoxic late preconditioning (LPC) limits ischemia-reperfusion injury in vitro, its cardioprotective effect is not established in vivo.

Methods: In part 1, rats were exposed to 4 h of hypoxia (16%, 12%, 8% oxygen) before 24 h of reoxygenation. In part 2, normoxic rats received early preconditioning with sevoflurane (1 minimum alveolar concentration [MAC] for 3 × 5 min), continuous administration of 1 MAC sevoflurane, or 11 mg · kg · h propofol.

Effect of a comprehensive surgical safety system on patient outcomes.

Background: Adverse events in patients who have undergone surgery constitute a large proportion of iatrogenic illnesses. Most surgical safety interventions have focused on the operating room. Since more than half of all surgical errors occur outside the operating room, it is likely that a more substantial improvement in outcomes can be achieved by targeting the entire surgical pathway.

Patient safety during anaesthesia: incorporation of the WHO safe surgery guidelines into clinical practice.

Purpose Of Review: WHO makes clear recommendations on how to improve patient safety during surgical procedures by using the WHO Surgical Safety Checklist. We will review the scientific basis of these recommendations and the practical problems encountered during introduction.

Recent Findings: Perioperative severe complications and death are a major health issue in both developed and developing countries.

Morphine induces preconditioning via activation of mitochondrial K(Ca) channels.

Purpose: Mitochondrial calcium sensitive potassium (mK(Ca)) channels are involved in cardioprotection induced by ischemic preconditioning. In the present study we investigated whether morphine-induced preconditioning also involves activation of mK(Ca) channels.

Methods: Isolated rat hearts (six groups; each n = 8) underwent global ischemia for 30 min followed by a 60-min reperfusion.

Postconditioning by xenon and hypothermia in the rat heart in vivo.

Background And Objective: Hypothermia protects against myocardial reperfusion injury. However, inducing hypothermia takes time, which makes it unsuitable as an emergency treatment. Combining mild hypothermia with low-dose xenon, applied either simultaneously or one after the other, protects the neonatal rat brain against reperfusion injury.

Drugs mediating myocardial protection.

The occurrence of myocardial ischaemia will result in either reversible or irreversible myocardial dysfunction. Even when revascularization is successful, some reperfusion injury may occur that transiently impairs myocardial function. Therefore, treatment should not only be directed towards prompt restoration of myocardial blood flow but measures should also be taken to prevent or alleviate the consequences of myocardial reperfusion injury.

Impact of preconditioning protocol on anesthetic-induced cardioprotection in patients having coronary artery bypass surgery.

Objective: Anesthetic preconditioning may contribute to the cardioprotective effects of sevoflurane in patients having coronary artery bypass surgery. We investigated whether 2 different sevoflurane administration protocols can induce preconditioning in patients having coronary artery bypass.

Methods: Thirty patients were randomly allocated to 1 of 3 groups.

Update on inhalational anaesthetics.

Purpose Of Review: Inhalational anaesthetic agents are a cornerstone in modern anaesthetic practice. The currently used compounds are very effective and have a good safety profile. In addition, it has been demonstrated that they possess organ-protective properties that might provide an additional tool in the treatment or prevention of the consequences of organ ischaemia-reperfusion injury or both.

Xenon induces late cardiac preconditioning in vivo: a role for cyclooxygenase 2?

Background: Xenon induces early myocardial preconditioning of the rat heart in vivo, but whether xenon induces late cardioprotection is not known. Cyclooxygenase-2 (COX-2) has been shown to be an important mediator in the signal transduction of myocardial ischemic late preconditioning (i-LPC). We investigated whether xenon induces late preconditioning (Xe-LPC) and whether COX-2 activity and/or expression are involved in mediating this effect.

Helium-induced preconditioning in young and old rat heart: impact of mitochondrial Ca(2+) -sensitive potassium channel activation.

Background: The noble gas helium induces cardiac preconditioning. Whether activation of mitochondrial K(+) channels is involved in helium preconditioning (He-PC) is unknown. The authors investigated whether He-PC (1) is mediated by activation of Ca(2+) -sensitive potassium channels, (2) results in mitochondrial uncoupling, and (3) is age dependent.