Influence of anesthesia on lipidomic biomarkers in elderly patients undergoing hip replacement surgery

doi:10.21203/rs.3.rs-3240499/v1

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Influence of anesthesia on lipidomic biomarkers in elderly patients undergoing hip replacement surgery

https://doi.org/10.21203/rs.3.rs-3240499/v1

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Purpose:

The purpose of this study was to examine the effect of anesthesia on biomarkers of lipidomics in elderly patients with hip replacements.

Methods:

Elective hip replacement patients were randomly divided into general anesthesia group (group G) or spinal anesthesia group (group P). In group G, anesthesia was induced intravenously, ventilation was maintained with a laryngeal mask, and anesthesia was maintained with a combination of intravenous and inhaled agents. In group P, a single subarachnoid block with ropivacaine was administered. Venous blood samples(5 ml each) for analysis were collected from all patients before anesthesia, from group G after they fully awoke following surgery, from group P approximately 1 h after surgery.

Results:

In this study, a total of 42 plasma samples (24 from group G and 18 from group P) were analyzed by lipid spectrometry.

A total of 1190 chemical species of lipids were detected, including 619 species of phospholipids, 512 species of glycerol lipids (GLs), 15 species of sphingolipids (SLs), 20 species of free fatty acids (FFAs), and 24 species of sterol lipids (STs).

Compared with group P, group G showed increased levels of phosphatidylethanolamine (PE), phosphatidylserine (PS), and triacylglycerol (TAG) and decreased levels of phosphatidylinositol (PI).

Conclusion:

The plasma lipidomic features of elderly hip arthroplasty patients were changed by anesthesia; these changes included increases in phosphatidylethanolamine (PE), phosphatidylserine (PS), and triacylglycerol (TAG) and a decrease in phosphatidylinositol (PI) in group G compared to group P. The mechanism and pathophysiological correlates of these changes need further clinical study.

Hip Replacement

Lipidomics

Phosphatidylethanolamine (PE)

Anesthesia is a complex state consisting of loss of consciousness, loss of pain sensation, amnesia, reflex inhibition and skeletal muscle relaxation. Bottom-up approaches account for anesthesia through the interactions of anesthetics with receptor proteins in the brain, whereas top-down approaches primarily consider the activity and connectivity of cortical and thalamic networks. In addition to direct interaction with major target receptor proteins in this process, general anesthetics have a dramatic effect on neurotransmitter activity in the brain. They can alter basal neurotransmitter levels by interacting with neuronal activity as well as neurotransmitter synthesis, release, reuptake, and metabolism. In this way, these agents can affect many neurotransmitter systems and receptors ^[1]. A growing number of in vitro and in vivo studies suggest that anesthesia and surgery may be risk factors for later development of cognitive impairment in the aged brain. In rats, general anesthesia has been shown to impair spatial memory, which depends on hippocampal function and postnatal hippocampal neurogenesis. Anesthesia-induced alterations in one or more stages of postnatal hippocampal neurogenesis may partially explain this cognitive impairment after anesthesia ^[2]. In the lipid-rich brain, lipids execute signaling processes related to the control system of the cell cycle, the stress response, and the inflammatory response and maintain brain and cellular homeostasis.

Abnormal lipid metabolism and neuronal damage have also been demonstrated in the brains of small monkeys chronically exposed to sevoflurane, which can significantly downregulate key lipids after prolonged exposure. Luminex protein analysis demonstrated that cytokine levels were abnormal in sevoflurane-exposed brains. Data from the same study demonstrate that a clinically relevant concentration of sevoflurane (2.5%) is able to induce and maintain a deep surgical anesthetic state in developing nonhuman primates, but prolonged exposure for 9 h leads to changes in gene expression, cytokine levels, lipid metabolism, and subsequent neuronal damage. In general, sevoflurane-induced neuronal injury is also associated with changes in lipid content, composition, or both. Specific lipid changes may provide insights into the molecular mechanisms underlying anesthetic-induced neurotoxicity and may be a sensitive biomarker for the early detection of anesthetic-induced neuronal injury ^[3]. Recently, studies have identified lipid profiles associated with age-related neurological diseases, such as Alzheimer's disease ^[4] and multiple system atrophy^[5] as well as the occurrence and development of depression ^[6] and other disorder. Additional stress responses can disrupt brain cholesterol homeostasis, potentially leading to neurological disease ^[7].

Because hip replacement patients are mostly characterized by advanced age, comorbidities, and high postoperative mortality, the optimal modality of anesthesia has also been controversial, with many studies concluding that intravertebral anesthesia has several advantages over general anesthesia such as relatively low postoperative mortality, low incidence of respiratory complications, short hospital stays, and low incidence of wound infection ^{[8, 9]}. Patients experience loss of consciousness during general anesthesia, a modality that has a greater impact on brain function than intravertebral anesthesia, and the effects of general anesthesia on brain injury in the aging brain are controversial and complex. The study of how anesthesia affects brain function has been a major focus, but the relevant effects of anesthesia on patients have not been examined biochemically.

Clinical lipidomics is recognized as a new source of specific biomarkers; this important branch of metabolomics focuses on lipids in tissues, plasma, and cells. The eight major classifications of lipids are as follows: fatty acids, glycerolipids, glycerophospholipids, sphingolipids, sterol lipids, pregnenolone lipids, glycolipids, and polyethylenes. Whether the mode of anesthesia affects the lipid biomarkers in patients is a questions that merits further study. This study was designed to compare the postoperative changes in lipid metabolites between general anesthesia and intravertebral anesthesia in elderly hip replacement patients using a targeted ultra-high-pressure liquid chromatography‒mass spectrometry lipidomic method and further investigate the mechanism to provide guidance for the choice of anesthesia modality in the clinic.

This study has been approved by the hospital Ethics Committee ((2019) No. 46) and registered in the Chinese Clinical Trial Registry (ChiCTR2000030569).

Case selection

Inclusion criteria: ① patients undergoing elective hip replacement, ② age ≥ 65 years, ③ American Society of Anesthesiologists (ASA) grade I∼III, ④ no obvious abnormalities in routine blood test findings, liver and kidney function, or coagulation function.

Exclusion criteria: ① preoperative psychiatric or neurological or psychiatric disease; ② difficult airway; ③ contraindications to neuraxial anesthesia; ④ severe intraoperative hemodynamic fluctuation that necessitated continuous treatment with vasoactive drugs.

Anesthesia

Patients were scheduled for a routine preoperative visit the day before surgery to collect general data such as their name, sex, and age and have them sign an informed consent form. Information was collected regarding each patient's past medical history of hypertension, heart disease, diabetes mellitus, cerebrovascular disease, mental or neurological disorders and previous treatment with medication. Additionally, electrocardiography (ECG), cardiac echocardiography, routine blood tests, liver function tests, renal function tests, and coagulation function tests were performed. Patients were assessed for airway condition to determine whether they had a difficult airway, and they were also assessed for previous history of trauma or lumbar surgery with or without contraindications to intravertebral anesthesia. ASA grading was performed on a patient-by-patient basis to screen for eligibility under the inclusion criteria.

The patients were randomly divided into a general anesthesia group (group G) and an intravertebral anesthesia group (group P). On the day of surgery, they signed an informed consent form explaining the study for their peace of mind and confirming that they had followed standard preoperative precautions regarding food and liquid intake.

Patients entered the operating room immediately for routine monitoring of noninvasive blood pressure, ECG signals, and pulse oxygen saturation. Open venous access was established, along with ultrasound-guided radial artery puncture catheterization with connection of a pressure transducer for invasive monitoring of arterial blood pressure. Ultrasound-guided internal jugular vein puncture catheterization was performed as needed, and patients in group G were connected to an anesthesia depth monitor.

In the general anesthesia group, induction of anesthesia was administered with midazolam 0.05 mg/kg, dezocine 5 mg, etomidate 0.3 mg/kg, rocuronium 0.9 mg/kg, and sufentanil 0.5∼1 µg/kg. To maintain a partial pressure of end-tidal carbon dioxide of 35 to 45 mmHg, a laryngeal mask was placed after the anesthetic drugs had fully taken effect, and an anesthetic machine was connected for mechanical ventilation, maintaining the tidal volume at 6ཞ10 ml/kg, the ventilation frequency at 10 to 15 breaths/min, and the partial pressure of end-tidal carbon dioxide at 35ཞ45 mmHg. Propofol 4ཞ12 mg/kg/h, remifentanil 0.25∼0.5 µg/kg/h, cisatracurium 0.06∼0.18 mg/kg/h, and inhalation of 1% sevoflurane were administered to maintain anesthesia; the pump rate of propofol was adjusted to maintain a patient state index (PSI) of 25∼50 according to electroencephalography (EEG).

Patients in group P were placed in a lateral decubitus position with the affected side up, and subarachnoid blocks were performed using a specific fluid configuration: 1% ropivacaine 2 ml + distilled water 1 ml, administered in the subarachnoid space in a volume of 2∼2.5 ml according to patient height, weight and physical status.

In the perioperative period, patients were maintained in a hemodynamically stable state, as measured by systolic and diastolic blood pressure, diastolic blood pressure, heart rate, and oxygen saturation; the use of vasoactive drugs (methoxyamine, norepinephrine, epinephrine) and atropine to achieve these goals was recorded from patients before anesthesia, 5 minutes after anesthesia, immediately at the end of surgery, and before transfer from the operating room.

Specimen collection and processing

Venous blood samples (5 ml) were drawn from all patients before the start of anesthesia; additionally, samples were drawn from group G when the patients fully regained consciousness after surgery, as well as from group P approximately 1 h after surgery. These samples were placed in tubes of ethylenediaminetetraacetic acid anticoagulant and refrigerated at 4 ℃.

After horizontal centrifugation at 800 G / min at 4°C for 10 min, 2 ml of the yellowish plasma supernatant was aspirated with a pipette gun and placed in a cryogenic storage tube, which was labeled with the specimen number and stored at -80°C.

All samples were taken in equal amounts and mixed together to create a quality control (QC) sample, which was used to assess the stability of the platform during MS monitoring, with QC samples being interspersed between other samples. To examine a sample, the same volume of the QC sample was removed during sample processing.

After the samples were pretreated, they underwent analysis using a Nexera UHPLC LC-30A Ultra Performance Liquid Chromatography system, developed by Waters Corporation in Hercules, California, USA.

Statistical analysis was conducted using SPSS 20.0 software, and the chi-squared test was utilized to compare count data, which were expressed as the mean ± standard deviation (‾ x ± s). Additionally, the paired-samples t test was employed to compare measurement data. A significance criterion of P < 0.05 was established as the threshold for statistical significance.

Comparing General Data of Patients

There were no significant differences in age, weight, ASA grade, intraoperative fluid infusion, blood loss, urine output, or operation time between the two groups.

In this study, a total of 42 plasma samples were examined for lipid profiles, comprising 24 from the general anesthesia group and 18 from the intravertebral anesthesia group.

In total, 1190 lipids were detected, comprising 619 glycerophospholipids, 512 glycerides, 15 sphingolipids, 20 fatty acyls, and 24 sterol lipids.

Of the 619 glycerophospholipids, there were 141 phosphatidylethanolamines (PEs), 78 phosphatidylcholines (PCs), 76 phosphatidylinositols (PIs),
77 phosphatidylserines (PSs), 16 lysophosphatidylcholines (LPCs), 77 phosphatidic acids (PAs), 77 phosphatidylglycerols (PGs),
16 lysophosphatidylethanolamines (LPEs), 16 lysophosphatidylinositols (LPIs), 13 lysophosphatidic acids, 16 lysophosphatidylglycerols (LPGs), and 16 lysophosphatidylserines (LPSs).

Of the 512 glycerides, 445 were triacylglycerols (TAGs), 50 were diacylglycerol (DAGs), and 17 were monoacylglycerol (MAGs).

The 15 sphingolipid species included 2 ceramides (CERs), 12 sphingomyelins (SMs), and 1 sphingoinositide.

All 20 fatty acyls were free fatty acids (FFAs).

The 24 sterol esters comprised 21 cholesteryl esters (CESs) and 3 sterol esters (CHs).

The statistical analysis of the plasma lipid testing results in this study yielded the following(See Figure 1 and 2 )

Figure 1.NEG:

Compared with group P, group G showed elevated levels of 'PE(18:0/18:1)' 'PE(O-16:0/18:1)' 'PE(O-16:0/18:2)' 'PE(O-16:0/22:5)' 'PE(O-18:0/16:1)' 'PE(O-18:0/18:1)' 'PE(O-18:0/18:2)' 'PE(O-18:0/22:5)' 'PE(P-16:0/18:2)''PE(P-18:0/16:0)' 'PE(P-18:1/18:2)' 'PE(P-18:2/18:2)' 'PS(18:0/20:3)'，and along with decreased levels of ‘PI(18:0/20:0).

Compared with group P, group G showed elevated levels of 'TAG44:1-FA16:0'、'TAG44:2-FA16:1'、'TAG44:2-FA18:1'、'TAG46:2-FA18:1'、'TAG46:3-FA14:0'、 'TAG46:3-FA18:1'、'TAG46:3-FA18:2'、'TAG48:4-FA16:0'、'TAG48:5-FA18:3' 'TAG49:2-FA14:0'、'TAG51:4-FA18:3'、'TAG51:5-FA18:2' 、'TAG51:5-FA18:3'、'TAG52:5-FA18:3'、'TAG53:2-FA18:2'、'TAG54:3-FA18:3'、'TAG54:4-FA18:3'、 'TAG54:5-FA18:3'、'TAG54:6-FA18:1'、'TAG54:6-FA18:3'、'TAG54:7-FA18:2'、'TAG54:7-FA18:3'、'TAG54:8-FA18:2'、'TAG54:8-FA18:3' 、'TAG55:3-FA18:1'、'TAG55:3-FA18:2'、'TAG55:4-FA18:2'、'TAG55:5-FA18:2'、and 'TAG56:3-FA20:0'.

Conclusion

Compared with patients in group P, patients in group G had increased PE, PS, and TAG levels and decreased PI levels.

Due to the increased risk of postoperative complications and mortality rates among patients who have undergone hip replacement surgery, the appropriate modality of anesthesia for this procedure remains a topic of debate among anesthesiologists. In this study, we aimed to explore the impact of anesthesia on the physiological function and internal environment of patients, focusing on a lipidomic perspective. Our findings will serve as a valuable reference for selecting an appropriate anesthesia modality to enhance patient outcomes.

Phosphatidylserine (PS) and phosphatidylethanolamine (PE) are two interrelated amino phospholipids. Both phospholipids are components of mammalian cell membranes and play important roles in biological processes such as apoptosis and cell signal transduction. PS is synthesized in mammalian cells by a base exchange reaction in which the polar head groups of preexisting phospholipids are replaced by serine. PS synthase activity is mainly located on mitochondria-associated membranes, and the enzymes are encoded by two different genes. PE is produced in mammalian cells by two completely independent main pathways. In one pathway, PS is converted to PE by the mitochondrial enzyme PS decarboxylase. In addition, PE is produced by the CDP ethanolamine pathway, in which the final reaction occurs on the endoplasmic reticulum and nuclear envelope. The relative importance of these two PE synthesis pathways has been investigated in knockout mice. Although the activity of the unmanipulated pathway is normal, elimination of either pathway is embryonically lethal. PE can also result from base exchange reactions and acylation of lyso-PE. Cellular levels of PS and PE are tightly regulated by multiple compensatory mechanisms ^[10].

PS is a brain phospholipid that is synthesized from phosphatidylcholine or phosphatidylethanolamine by the exchange of serine, a reaction catalyzed by phosphatidylserine synthase 1 and phosphatidylserine synthase 2 in the endoplasmic reticulum. In the plasma membrane, PS can activate key signaling pathways, such as Akt and Raf-1 signaling, to stimulate neuronal survival pathways that process synaptogenesis and growth[11]. PS constitutes 13%∼15% of the phospholipids in the cerebral cortex of humans, and it plays an important role in human cognitive functions, including short-term memory formation, long-term memory consolidation, the ability to create new memories, memory retrieval, the learning and recall of information, concentration, reasoning and problem-solving abilities, language ability, and communication. Additionally, PS supports motor function, especially fast responses and reflexes[12]. The brain is rich in docosahexaenoic acid (DHA), which makes up a large proportion of PS in the brain. By promoting PS synthesis, DHA has the unique ability to expand the pool of PS in neuronal membranes, thereby affecting PS-dependent signaling and protein function. In cognitively impaired subjects supplemented with PS, patients showed improvements in certain memory functions; the mechanisms of these improvements are currently unknown^[13]. Akt, part of the PI3K/Akt signaling pathway, is a key protein in cell survival and proliferation. PS is particularly important in promoting Akt signaling to maintain neuronal survival when PIP3 production is limited. PS also affects neuronal nitric oxide synthase, a key enzyme in regulating the oxidative state of the brain^{[14, 15]}. PS is a potentially sensitive and specific biomarker for diagnosis and prognosis ^[16]. Compared with group P in this study, group G showed an increase in PS (18:0/20:3), the mechanism of which also needs further investigation, but it can at least be confirmed that general anesthesia does not increase the occurrence of postoperative cognitive dysfunction (POCD) compared with intravertebral anesthesia. Additionally, patients should receive postoperative supplementation with lipid-rich foods or drugs that stimulate the synthesis of PS in order to promote nerve growth, preventing POCD.

PI plays very important roles in the morphology, metabolic regulation, signaling, and various physiological functions of the cell, and phosphatidylinositol-3-hydroxykinase catalyzes the phosphorylation of phosphatidylinositol to form phosphatidylinositol-3-phosphate enzymes. 11in signal transduction and plays an important role in cell survival and proliferation. The levels of phospholipids, including PI, are reduced in Alzheimer's disease (AD) brains and are potential biomarkers for AD. Plasma phospholipid levels have also been found to predict transition to amnestic mild cognitive impairment (aMCI) or dementia in cognitively normal older adults; this change in PI may reflect impaired deformability and oxygen carrying capacity of red blood cells in patients with AD and aMCI ^[17]. Lipidomic studies have confirmed the predominance of PIs with 18:0/20:4 acyl chains in cells and organs in a variety of mammals ^[18]. In unstimulated human neutrophils and platelets, 18:0/20:4 is also a major component among acyl chains overall ^[19–21]. However, the phosphatidylinositol (PI (18:0/20:0)) content decreased postoperatively in the general anesthesia group compared with the intravertebral anesthesia group in this study, and the clinical significance of this finding needs further investigation.

Triacylglycerol, i.e., triglyceride, is an ester derived from glycerol and three molecules of fatty acids. In the present study, the level of triglycerides increased after surgery in the general anesthesia group; propofol contained triglycerides, and it has been shown that prolonged infusion of propofol could increase the concentration of triglycerides ^{[22, 23]}. The short-term use of standard doses of propofol in conjunction with other anesthetics may also have a significant effect on serum triglyceride levels in children ^{[24, 25]}. In addition, patients in the general anesthesia group had increased triglyceride levels postoperatively, which might be associated with anesthetic drugs affecting triglyceride metabolism.

Krause B R et al. ^[26] compared triacylglycerol metabolism among anesthetized rats, restrained rats, and freely moving unanesthetized rats. The peak concentration of triacylglycerol appeared at 25 min in the freely moving unanesthetized rats but at 35 and 45 min in the restrained and anesthetized rats, respectively. The fractional catabolic rate of triglycerides was calculated under these different conditions and were found to be lower under general anesthesia than in unanesthetized unconstrained animals with long-term indwelling tubes. The apparent total catabolic rate, calculated from plasma triacylglycerol mass and estimated plasma volume, was reduced by 50% in anesthetized animals. These results, combined with the results of the present study, suggest that general anesthesia might reduce triglyceride metabolism, but the extent of this reduction and the time to full recovery (if applicable) require further study. Additional studies have shown that morphine can affect lipid metabolism in different tissues, with a significant increase in hepatic triglyceride content after 1 and 12 h of morphine treatment in rats, which may indicate that morphine affects cholesterol catabolism ^[27]. In normal or morphine-tolerant rats, intramuscular injection of morphine induces a decrease in free fatty acids (FFAs) and an increase in plasma triglyceride levels ^[28]. This finding is consistent with the present study, in which patients in the general anesthesia group had increased postoperative triglyceride levels and decreased free fatty acid levels compared with those in the intravertebral anesthesia group, indicating that sufentanil and remifentanil may affect their metabolism. Adipose triglyceride lipase (ATGL) is the rate-limiting enzyme responsible for the first step of triglyceride hydrolysis. Morphine reduces triglyceride metabolism by reducing the phosphorylation level of ATGL ser406 in HL-1 cells [29]. In the present study, compared with the intravertebral anesthesia group, the general anesthesia group showed increased levels of 'TAG44:1-FA16:0'、'TAG44:2-FA16:1'、TAG44:2-FA18:1'、'TAG46:2-FA18:1'、'TAG46:3-FA14:0'、 'TAG46:3-FA18:1'、'TAG46:3-FA18:2'、'TAG48:4-FA16:0'、'TAG48:5-FA18:3'、 'TAG49:2-FA14:0'、'TAG51:4-FA18:3'、'TAG51:5-FA18:2' 、'TAG51:5-FA18:3' 、'TAG52:5-FA18:3'、'TAG53:2-FA18:2'、'TAG54:3-FA18:3'、'TAG54:4-FA18:3'、 'TAG54:5-FA18:3'、'TAG54:6-FA18:1'、'TAG54:6-FA18:3'、'TAG54:7-FA18:2' 、'TAG54:7-FA18:3'、'TAG54:8-FA18:2'、'TAG54:8-FA18:3'、'TAG55:3-FA18:1' 、'TAG55:3-FA18:2'、'TAG55:4-FA18:2'、'TAG55:5-FA18:2'、'TAG56:3-FA20:0' postoperatively; the specific mechanisms of these changes merit further research.

Sevoflurane, a commonly used general anesthetic, had a considerable effect on the infant monkey lipidome overall, and lipidomic analysis revealed changes in brain, cerebrospinal fluid (CSF) and serum lipids and their metabolites as well as short-chain acylcarnitines following sevoflurane exposure. These included a decrease in carnitine and acylcarnitine levels, with unchanged triacylglycerol mass but accumulation of 16:0 and 18:1 fatty acyl chains in the triacylglycerol pool, along with a loss of nonesterified fatty acids and polyunsaturated fatty acids from the phospholipid pool. Levels of short chain acylcarnitines were also significantly reduced in the brain and CSF following sevoflurane exposure^[30]. Prefrontal lipids were altered in aged marmosets and rats following sevoflurane exposure, with increases in PE (18:0/22:5), PE (16:0/22:5), PE (18:2/22:5), PE (14:0/22:5) and PE (18:1/22:5) and decreases in TAG 56:5-(FA) 20:4, TAG58:10-FA22:6 and TAG60:10-FA22:6 in aged marmosets. Sevoflurane increased PA(18:1/20:2) and TAG52:5-FA20:4 in aged rats, while PE (14:0/22:4), DAG(16:1/18:2) and LPC (16:1) + AcO were decreased. Although monkeys and rats are considered ideal animals for research, studies have shown species differences in the effects of sevoflurane on lipids ^[31], and the present study suggests that the investigation of human lipids may be more complicated. The lipidomic changes observed in this study were, to some extent, correlated with sevoflurane.

The modality of anesthesia affects the postoperative plasma lipidome of elderly patients undergoing hip replacement, with general anesthesia leading to increased phosphatidylethanolamine (PE), phosphatidylserine (PS), and triacylglycerol (TAG) and decreased phosphatidylinositol (PI) compared to spinal anesthesia. The mechanism and pathophysiological correlates of these changes require further clinical investigation.

Ethics approval and consent to participate

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by the Institutional Ethics Committee of the People’s Hospital of Zhengzhou University（Henan Provincial People's Hospital）and registered in the Chinese Clinical Trial Registry ChiCTR 2000030569). All patients sign informed consent forms.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

Luli, Chen xi Li,Hui Zhang,Wei Zhang contributed to the data collection and editing of the manuscript. Jiaqiang Zhang contributed to the editing of the manuscript and the supervision of the manuscript.All authors read and approved the final manuscript.

Fundings

There is no funding for this study.

Availability of data and materials

Access to the data and the calculation method can be obtained from the authors by email([email protected]).

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No competing interests reported.

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08 Aug, 2023
First submitted to journal
06 Aug, 2023

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Influence of anesthesia on lipidomic biomarkers in elderly patients undergoing hip replacement surgery

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Abstract

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Introduction

Methods

Result

Discussion

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Additional Declarations

Status:

Version 1