Introduction:
General anesthetics, a class of drugs that can be used to induce general anesthesia, are typically given to patients intravenously or by inhalation. Inhalational (volatile) anesthetics are a common choice of medication in surgery and are administered via inhalation. But in addition to causing unconsciousness, the consequences of these medications on the human body are frequently not well known. Interestingly, research demonstrates connections between anesthetics and receptors or other proteins in immune cells. Autoimmune disease conditions like lupus, rheumatoid arthritis, systemic sclerosis, and Sjogren's syndrome need to be considered and taken into account.
What Are the Effects of Different Types of Anesthetics on Immune System Cytokines?
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Intravenous Anesthetics: Drugs like ketamine and sodium thiopental can decrease pro-inflammatory cytokines and immune cell activity. They may reduce IL-6 levels and increase IL-10, an anti-inflammatory cytokine. Sodium thiopental decreases IFN-γ and IL-4 without affecting IL-2. Propofol has antioxidant and anti-inflammatory properties, but its effects on IL-6 are debated. It can decrease IL-1, TNF-α, and IL-6 while increasing IL-10. Different propofol doses may have varying effects on cytokines. Duration of surgery influences IL-6 levels, and propofol may not significantly impact this response.
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Inhalation Anesthetics: Volatile anesthetics used in general anesthesia can affect the immune system by inhibiting certain cytokines and altering immune cell activity. Intravenous anesthetics like sodium thiopental and ketamine have similar effects on cytokines, with sodium thiopental reducing some cytokine levels and ketamine inhibiting anti-inflammatory cytokine production. Propofol, another intravenous anesthetic, has anti-inflammatory properties and can impact cytokine levels, but findings on its effects on IL-6 are conflicting. Inhalational anesthetics like isoflurane, sevoflurane, and desflurane influence cytokine production, but the results vary.
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Opioid Administration: Opioids used in general anesthesia have complex effects on the immune system. They can both suppress and stimulate immune function. Opioids reduce the levels of pro-inflammatory cytokines like TNF-α, IL-1, and IL-6. Morphine, a common opioid, can affect pain tolerance and alter cytokine concentrations. Long-term opioid use can lead to changes in cytokine levels, with increases in IL-4 and IL-5 and decreases in IL-2 and IFN-γ. Opioids can influence the activities of immune cells, such as NK cells. Fentanyl inhibits NK cell activities, while opioids may enhance NK cell function. Tramadol has shown protective effects on cellular immunity. Different opioids have varying effects on the immune system.
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Benzodiazepine Administration: Benzodiazepines are commonly used sedatives in general anesthesia and intensive care units. Their effects on cytokines still need to be fully understood, with conflicting study results. Midazolam, a commonly used benzodiazepine, can suppress the production of certain cytokines and has an immunosuppressive effect. Diazepam, another benzodiazepine, can trigger an inflammatory response initially, but long-term use can inhibit immune function.
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Controlled Ventilation During Anesthesia: Controlled ventilation is a method used during general anesthesia that can cause damage to lung tissue and lead to the release of inflammatory substances. This can worsen gas exchange after surgery. Hypoxia during surgeries also contributes to lung tissue damage and the release of cytokines. Sevoflurane, an anesthetic agent, has been found to reduce the inflammatory response during one-lung ventilation in chest surgery. It may be preferred for patients with higher levels of pro-inflammatory cytokines.
How to Manage Patients With Autoimmune Disease Who Underwent Cesarean Section by Anesthesia?
When a pregnant woman has a systemic autoimmune disease, her autoantibodies can cross the placenta and affect the baby's cardiovascular system, skin, and liver, leading to neonatal lupus syndrome. Congenital Heart Block (CHB), which is indicated by a fetus's weak heart rate, is the most important aspect of neonatal lupus syndrome. Anti-Ro/SSA and anti-La/SSB autoantibodies, two types of particular autoantibodies, are the main factors linked to this illness. Women who have these antibodies run a 2- to 3-percent risk of developing CHB, and the condition could return in subsequent pregnancies. CHB occurs around 16-24 weeks of pregnancy and is usually irreversible.
Regular fetal heart rate monitoring using fetal echocardiograms and obstetric sonograms is advised starting at 16 weeks of pregnancy to detect CHB. CHB is diagnosed, and medications may be given to the mother to reduce immune responses and fetal cardiac inflammation. Steroids are sometimes used but are ineffective in establishing a complete heart block. Hydroxychloroquine, found to prevent fetal cardiac complications, is a preventive measure.
During delivery, the type of anesthesia used depends on various factors, such as the risks involved and the patient's and anesthesiologist's preferences. Regional anesthesia (e.g., spinal anesthesia) is generally preferred over general anesthesia for cesarean sections, as general anesthesia carries more risks for both the mother and the neonate. In pregnancies of women with systemic autoimmune diseases, specific autoantibodies can cause congenital heart block in the fetus. The baby may need a pacemaker implanted in extreme situations, and medication may be used as a therapeutic option. Close monitoring is necessary both during pregnancy and after birth. Anesthesia choices for delivery should be made carefully, considering the individual situation and risks involved.
What Should Be Considered in Anesthesia for Patients With Antiphospholipid Syndrome (APS)?
General and neuraxial anesthesia (spinal or epidural anesthesia) can be used during surgery on patients with Antiphospholipid Syndrome (APS). Neuraxial anesthesia is often preferred in pregnant women with APS as it benefits both the mother and the baby. However, careful monitoring is required to prevent complications such as spinal hematoma. Compared to other individuals, APS patients don't significantly differ in their anesthetic agent.
During surgery, aggressive measures should be taken to prevent blood clot formation regardless of the patient's risk of recurrent thrombosis. This includes compression stockings and other tools that increase blood flow and prevent blood clots. Maintaining an average body temperature throughout surgery is crucial since hypothermia can interfere with blood coagulation and raise bleeding risks. Proper hydration and avoiding fluid overload are essential considerations as well.
Specific blood components rather than whole blood are advised in the event of a blood transfusion. Invasive monitoring may sometimes be required, and prophylactic antibiotics are administered to prevent infection. It is essential to know that APS patients can develop severe complications if catastrophic APS (CAPS) is triggered during surgery. A rare but fatal syndrome known as CAPS is characterized by multiple organ involvement and an elevated risk of bleeding. If CAPS is suspected, immediate treatment is required.
Pregnant women with APS have a higher risk of obstetric complications and fetal loss. The anesthesiologist is essential to providing safe treatment when these patients have cesarean sections or other procedures. Detailed management protocols should be in place, and the danger of peripartum hemorrhage and other emergency scenarios should be taken into consideration. Emergency cesarean section is identified as a significant risk factor for hemorrhagic complications in APS patients. This emphasizes the need for careful anesthesia management and preparedness for possible hemorrhagic events during emergency procedures.
Careful monitoring and control of anesthesia in APS patients is necessary to avoid blood clot formation, maintain an average body temperature, and reduce the risk of bleeding. Due to the heightened dangers involved, pregnant women with APS who are having surgery, especially emergency cesarean sections, need special attention.
How to Manage Anesthesia in Patients With Rheumatoid Arthritis?
Rheumatoid Arthritis (RA) patients' joint abnormalities can affect managing anesthesia. Firstly, they can make it challenging to position the patient correctly for surgery and may hinder the assessment of blood vessels and the administration of regional anesthesia. More time and support may be needed during surgery to suit the patient's positioning, which could result in postoperative difficulties. Secondly, deformities in the axial joints, such as the neck, can make intubation (insertion of a breathing tube) difficult due to the instability of the cervical spine. Before anesthesia, a thorough evaluation is required because patients with axial joint problems may not always experience symptoms.
Atlanto-Axial Subluxation (AAS), which involves the displacement of the top cervical spine, is one specific joint condition connected to the airway. AAS can cause spinal cord and vertebral artery compression, although neurological complications are rare during airway management. Endotracheal intubation (insertion of a breathing tube) requires anesthesiologists to exercise caution because the usual posture can exacerbate AAS and possibly result in neurological damage. Preoperative imaging of the cervical spine is recommended to assess instability. Temporomandibular joint disorders affecting the jaw joint can also impact airway management and may require special precautions during intubation. Larynx inflammation, known as cricoarytenoid, can make it harder to control the airway and may call for alternative intubation methods.
Other joint conditions in RA patients can make placing the patient during surgery and gaining IV access difficult. Skin lesions or fragile skin can make intravenous assessment difficult, and joint deformities can limit the range of motion and affect patient positioning. To avoid pressure sores and reduce the danger of osteoporosis brought on by prolonged steroid treatment, delicate handling is necessary. Eye care is also important, as RA patients may be at risk of corneal ulceration, especially when placed in a prone position during surgery.
Regional anesthesia, which involves numbing specific body areas, can be an alternative to general anesthesia in patients with joint deformities. Finding the ideal places to place nerve blocks may be difficult due to the abnormalities. Patients on immunosuppressive drugs have a higher risk of infection, so it is crucial to maintain aseptic practices throughout regional anesthesia treatments. Regional anesthesia techniques using Non-Steroidal Anti-inflammatory Drugs (NSAIDs) do not increase the risk of bleeding complications. Joint abnormalities in RA patients can pose challenges in anesthesia management, affecting patient positioning, airway management, intravenous access, and regional anesthesia techniques. Careful assessment and planning are necessary to ensure patient safety and optimize surgical outcomes.
Conclusion:
General anesthesia does not appear to significantly impact the immune system in healthy individuals or during minor procedures, and changes in the immune system appear to be correlated with surgical trauma, particularly during major surgery.
