Awake Sedation With Propofol Attenuates Intraoperative Stress of Carotid Endarterectomy in Regional Anesthesia

Szabó, Péter M.; Mayer, Mátyás; Horváth‐Szalai, Zoltán; Tóth, Krisztina; Márton, Sándor; Menyhei, Gábor; Sínay, László; Molnár, Tihamér

doi:10.1016/j.avsg.2019.06.047

Cited by 5 publications

(12 citation statements)

References 31 publications

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“…Intraoperative changes in cortisol plasma levels can be part of the systemic stress response due to anesthetic and surgical trauma related to CEA. 2,16 Interestingly, it was associated with increased MMP-9 levels in the early postoperative phase. Although, the explanation of this observation is not clear, serum-and glucocorticoid-inducible kinase 1, a key factor in vascular inflammation, participates in the regulation of monocyte/macrophage migration and MMP-9 transcription via regulation of nuclear factor-jB.…”

Section: Discussionmentioning

confidence: 99%

“…Strategies to reduce periprocedural stress related events 2,7,23 and to optimize the evaluation and management of patients with carotid stenosis should be considered in efforts to reduce both, early and long-term mortality. 24 Our study has several limitations.…”

Section: Discussionmentioning

confidence: 99%

“…Awake carotid endarterectomy (CEA) under regional anesthesia (RA) is a challenging procedure as it is often associated with increased peri-operative stress. 1,2 The stress response to CEA is generally abolished within 24 h. 2,3 Elevated systemic cortisol level reflecting intraoperative stress response, directly correlates with cerebral hypoperfusion during carotid artery cross-clamping. 3 Therefore, attenuation of the stress response to CEA might decrease the incidence of cerebral ischemic events.…”

Section: Introductionmentioning

confidence: 99%

“…3 Therefore, attenuation of the stress response to CEA might decrease the incidence of cerebral ischemic events. 2,3 Carotid surgery-associated adverse events were recently explored.…”

Section: Introductionmentioning

confidence: 99%

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Increased serum level of high sensitivity troponin T even prior to surgery can predict adverse events during carotid endarterectomy

et al. 2021

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Objectives Perioperative stress affects the outcome of carotid endarterectomy performed under regional anesthesia. Here we aimed to explore the temporal profile of the stress marker cortisol and its relationship to high-sensitivity troponin-T, matrix metalloproteinase-9, tissue inhibitor of metalloproteinase-1, and S100B as an indicator of blood–brain barrier alteration in the systemic circulation. Methods Prospective part of the study: a total of 31 patients with significant carotid stenosis scheduled for carotid endarterectomy in regional anesthesia were enrolled. Follow-up part of the study and retrospective analysis of the outcome: each patient was followed up to five years and morbidity as well as mortality data were collected from an electronic database. Blood samples from each patient were serially taken; prior to surgery (T1), at the time of reperfusion (T2), 24 h (T3) and 72 h later postoperatively (T4), then the plasma concentration of each biomarker was measured. Besides, the clinical and surgical factors and perioperative adverse events were recorded. Results More positive correlations were found between: the early change of S100B (T2–T1) and late change in plasma cortisol level (T4–T3) (r = 0.403; p < 0.05); the early change of cortisol (T2–T1) and the early postoperative change of plasma matrix metalloproteinase-9 level (T3–T2) (r = 0.432; p = 0.01); the plasma concentration of tissue inhibitor of metalloproteinase-1 at 24 postoperative hours and the late change in plasma high-sensitivity troponin-T level (T4–T3) (r = 0.705; p < 0.001). Five patients needed an intraoperative shunt in whom the high-sensitivity troponin-T was elevated even prior to surgery, but definitive stroke never occurred. Plasma matrix metalloproteinase-9 concentration at reperfusion independently predicted the five-year mortality with a cut-off value of 456 ng/ml (sensitivity: 86%, specificity: 84%, area 0.887, p = 0.002). Conclusions A higher intraoperative change in S100B level reflecting carotid endarterectomy induced acute silent brain ischemia was associated with more pronounced post-operative change of cortisol. An early elevation of cortisol was found to be associated with a delayed increase of matrix metalloproteinase-9. Importantly, an increased high-sensitivity troponin-T even prior to carotid endarterectomy may predict clamp intolerance, and elevated matrix metalloproteinase-9 at reperfusion suggests a poor outcome.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

“…3 Therefore, attenuation of the stress response to CEA might decrease the incidence of cerebral ischemic events. 2,3 Carotid surgery-associated adverse events were recently explored.…”

Section: Introductionmentioning

confidence: 99%

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Increased serum level of high sensitivity troponin T even prior to surgery can predict adverse events during carotid endarterectomy

et al. 2021

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“…Cortisol’s plasma concentration rises rapidly due to intraoperative stress [ 16 , 17 ]. We described cortisol’s dynamics in the perioperative period of CEA in our previous investigation [ 18 ]. The rate of cellular anaerobic metabolism correlates with serum lactate levels [ 19 ].…”

Section: Introductionmentioning

confidence: 99%

Cerebral and Systemic Stress Parameters in Correlation with Jugulo-Arterial CO2 Gap as a Marker of Cerebral Perfusion during Carotid Endarterectomy

Kovács-Ábrahám

Aczél

Jancsó

et al. 2021

JCM

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Intraoperative stress is common to patients undergoing carotid endarterectomy (CEA); thus, impaired oxygen and metabolic balance may appear. In this study, we aimed to identify new markers of intraoperative cerebral ischemia, with predictive value on postoperative complications during CEA, performed in regional anesthesia. A total of 54 patients with significant carotid stenosis were recruited and submitted to CEA. Jugular and arterial blood samples were taken four times during operation, to measure the jugulo-arterial carbon dioxide partial pressure difference (P(j-a)CO2), and cortisol, S100B, L-arginine, and lactate levels. A positive correlation was found between preoperative cortisol levels and all S100B concentrations. In addition, they are positively correlated with P(j-a)CO2 values. Conversely, postoperative cortisol inversely correlates with P(j-a)CO2 and postoperative S100B values. A negative correlation was observed between maximum systolic and pulse pressures and P(j-a)CO2 after carotid clamp and before the release of clamp. Our data suggest that preoperative cortisol, S100B, L-arginine reflect patients’ frailty, while these parameters postoperatively are influenced by intraoperative stress and injury. As a novelty, P(j-a)CO2 might be an emerging indicator of cerebral blood flow during CEA.

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Effects and mechanisms of perioperative medications on the hypothalamic pituitary adrenal response to surgical injury: A narrative review

Feng,

Chang,

Liu

et al. 2024

Journal of Clinical Anesthesia

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Awake Sedation With Propofol Attenuates Intraoperative Stress of Carotid Endarterectomy in Regional Anesthesia

Cited by 5 publications

References 31 publications

Increased serum level of high sensitivity troponin T even prior to surgery can predict adverse events during carotid endarterectomy

Increased serum level of high sensitivity troponin T even prior to surgery can predict adverse events during carotid endarterectomy

Cerebral and Systemic Stress Parameters in Correlation with Jugulo-Arterial CO2 Gap as a Marker of Cerebral Perfusion during Carotid Endarterectomy

Effects and mechanisms of perioperative medications on the hypothalamic pituitary adrenal response to surgical injury: A narrative review

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