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Jones Oguh S, Iyer RS, Yuan I, Missett R, Daly Guris RJ, Johnson G, Babus LW, Massa CB, McClung-Pasqualino H, Garcia-Marcinkiewicz AG, Sequera-Ramos L, Kurth CD. Implementation of an electroencephalogram-guided propofol anesthesia practice in a large academic pediatric hospital: A quality improvement project. Paediatr Anaesth 2024; 34:160-166. [PMID: 37962837 DOI: 10.1111/pan.14791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 10/12/2023] [Accepted: 10/22/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Propofol-based total intravenous anesthesia is gaining popularity in pediatric anesthesia. Electroencephalogram can be used to guide propofol dosing to the individual patient to mitigate against overdosing and adverse events. However, electroencephalogram interpretation and propofol pharmacokinetics are not sufficiently taught in training programs to confidently deploy electroencephalogram-guided total intravenous anesthesia. AIMS We conducted a quality improvement project with the smart aim of increasing the percentage of electroencephalogram-guided total intravenous anesthesia cases in our main operating room from 0% to 80% over 18 months. Balancing measures were number of total intravenous anesthesia cases, emergence times, and perioperative emergency activations. METHODS The project key drivers were education, equipment, and electronic health record modifications. Plan-Do-Study-Act cycles included: (1) providing journal articles, didactic lectures, intraoperative training, and teaching documents; (2) scheduling electroencephalogram-guided total intravenous anesthesia teachers to train faculty, staff, and fellows for specific cases and to assess case-based knowledge; (3) adding age-based propofol dosing tables and electroencephalogram parameters to the electronic health record (EPIC co, Verona, WI); (4) procuring electroencephalogram monitors (Sedline, Masimo Inc). Electroencephalogram-guided total intravenous anesthesia cases and balancing measures were identified from the electronic health record. The smart aim was evaluated by statistical process control chart. RESULTS After the four Plan-Do-Study-Act cycles, electroencephalogram-guided total intravenous anesthesia increased from 5% to 75% and was sustained at 72% 9 months after project completion. Total intravenous anesthesia cases/mo and number of perioperative emergency activations did not change significantly from start to end of the project, while emergence time for electroencephalogram-guided total intravenous anesthesia was greater statistically but not clinically (total intravenous anesthesia without electroencephalogram [16 ± 10 min], total intravenous anesthesia with electroencephalogram [18 ± 9 min], sevoflurane [17 ± 9 min] p < .001). CONCLUSION Quality improvement methods may be deployed to adopt electroencephalogram-guided total intravenous anesthesia in a large academic pediatric anesthesia practice. Keys to success include education, in operating room case training, scheduling teachers with learners, electronic health record modifications, and electroencephalogram devices and supplies.
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Affiliation(s)
- Sheri Jones Oguh
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Rajeev S Iyer
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Ian Yuan
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Richard Missett
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Rodrigo J Daly Guris
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Gregory Johnson
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Lenard W Babus
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Christopher B Massa
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Heather McClung-Pasqualino
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Annery G Garcia-Marcinkiewicz
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Luis Sequera-Ramos
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - C Dean Kurth
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
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Yun WJ, Shin M, Mohaisen D, Lee K, Kim J. Hierarchical Deep Reinforcement Learning-Based Propofol Infusion Assistant Framework in Anesthesia. IEEE Trans Neural Netw Learn Syst 2024; 35:2510-2521. [PMID: 35853065 DOI: 10.1109/tnnls.2022.3190379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
This article aims to provide a hierarchical reinforcement learning (RL)-based solution to the automated drug infusion field. The learning policy is divided into the tasks of: 1) learning trajectory generative model and 2) planning policy model. The proposed deep infusion assistant policy gradient (DIAPG) model draws inspiration from adversarial autoencoders (AAEs) and learns latent representations of hypnotic depth trajectories. Given the trajectories drawn from the generative model, the planning policy infers a dose of propofol for stable sedation of a patient under total intravenous anesthesia (TIVA) using propofol and remifentanil. Through extensive evaluation, the DIAPG model can effectively stabilize bispectral index (BIS) and effect site concentration given a potentially time-varying target sequence. The proposed DIAPG shows an increased performance of 530% and 15% when a human expert and a standard reinforcement algorithm are used to infuse drugs, respectively.
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Xue L, Han D. Comparison of Two Anesthetic Regimens on Extubation Time and Postoperative Recovery in Children Undergoing Ambulatory Adenoidectomy: A Retrospective Study. J Perianesth Nurs 2024; 39:66-72. [PMID: 37768264 DOI: 10.1016/j.jopan.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 06/05/2023] [Accepted: 06/09/2023] [Indexed: 09/29/2023]
Abstract
PURPOSE This aim of this study was to compare two anesthetic regimens in terms of extubation time and postoperative recovery in children undergoing ambulatory adenoidectomy. DESIGN A retrospective cohort study with propensity score matching. METHODS The medical charts of 452 children aged between 3 and 8 years undergoing ambulatory adenoidectomy were retrieved for analysis, of which 438 were eligible to participate in this study. A majority (n = 327) were children exposed to a conventional propofol-pronounced general anesthetic regimen (high-dose propofol plus low-dose remifentanil, labeled as group P), while n = 111 were administered a modified remifentanil-pronounced anesthetic regimen (low-dose propofol plus high-dose remifentanil, namely group R). Propensity score matching was employed to adjust for confounders, resulting in 69 matched patients in each group. The primary endpoint of this study was extubation time. The secondary endpoints were total intraoperative fluid volume, length of stay in the postanesthesia care unit (PACU), postoperative pain rating, the incidence of emergence agitation, nausea and vomiting, as well as the level of consciousness (fully awake or waking by gentle patting) when transferred out of PACU, and any major complications (wound bleeding, reintubation, readmission, and overnight stay). FINDINGS No major complications were observed in both groups. Compared to group P, group R had significantly shorter extubation time (8.2 ± 1.4 minutes vs 13.3 ± 2.4 minutes, P < .001), shorter length of stay in the PACU (14.1 ± 3.1 minutes vs 20.2 ± 3.4 minutes, P < .001), and a higher proportion of cases being fully awake when transferred out of the PACU (91% vs 46%, P < .001). Lastly, the pain rating, frequency of oropharyngeal airway usage, incidence of emergence agitation, and nausea and vomiting were comparable between the two groups (P > .05 for all). CONCLUSIONS Remifentanil-pronounced anesthesia was superior to propofol-pronounced anesthesia in children undergoing ambulatory adenoidectomy, given that the former was associated with a faster recovery time from anesthesia without jeopardizing patient safety.
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Affiliation(s)
- Lichao Xue
- Department of Anesthesiology, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
| | - Ding Han
- Department of Anesthesia, Children's Hospital affiliated to Capital Institute of Pediatrics, Beijing, China.
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Ji JY, Seo YH, Jung HS, Chun HR, Park JS, Kim WJ, Ahn JM, Park YJ, Shin YE, Park CH. Coronary Artery Occlusion with Sharp Blood Pressure Drop during General Anesthesia Induction: A Case Report. Medicina (Kaunas) 2024; 60:232. [PMID: 38399520 PMCID: PMC10890261 DOI: 10.3390/medicina60020232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 01/24/2024] [Accepted: 01/25/2024] [Indexed: 02/25/2024]
Abstract
Most anesthetics reduce cardiac functions and lower blood pressure (BP), potentially causing excessive BP reduction in dehydrated patients or those with heart conditions, such as coronary artery disease (CAD). Considering the increased prevalence of cardiovascular disease with age, anesthesiologists must be cautious about BP reduction during general anesthesia in older adults. In the present case, a 76-year-old male patient with undiagnosed CAD in a hypovolemic state experienced a significant drop in systolic BP to the fifties during propofol and sevoflurane anesthesia. Despite the use of vasopressors, excessive hypotension persisted, leading to anesthesia suspension. Subsequent cardiac examinations, including computed tomography heart angio and calcium score, and coronary angiogram, revealed a near total occlusion of the proximal left anterior descending coronary artery (pLAD) and the formation of collateral circulation. After 5 days of hydration and anticoagulation medications and confirmation of normovolemic state, general anesthesia was attempted again and successfully induced; a normal BP was maintained throughout the surgery. Thus, it is important to conduct a thorough cardiac evaluation and maintain normovolemia for general anesthesia in older adults.
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Affiliation(s)
- Jae Young Ji
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea; (J.Y.J.); (H.S.J.); (H.R.C.); (J.S.P.); (Y.J.P.); (Y.E.S.)
| | - Yong Han Seo
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea; (J.Y.J.); (H.S.J.); (H.R.C.); (J.S.P.); (Y.J.P.); (Y.E.S.)
| | - Ho Soon Jung
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea; (J.Y.J.); (H.S.J.); (H.R.C.); (J.S.P.); (Y.J.P.); (Y.E.S.)
| | - Hea Rim Chun
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea; (J.Y.J.); (H.S.J.); (H.R.C.); (J.S.P.); (Y.J.P.); (Y.E.S.)
| | - Jin Soo Park
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea; (J.Y.J.); (H.S.J.); (H.R.C.); (J.S.P.); (Y.J.P.); (Y.E.S.)
| | - Woo Jong Kim
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea;
| | - Jae Min Ahn
- Department of Neurosurgery, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea;
| | - Yu Jun Park
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea; (J.Y.J.); (H.S.J.); (H.R.C.); (J.S.P.); (Y.J.P.); (Y.E.S.)
| | - Ye Eun Shin
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea; (J.Y.J.); (H.S.J.); (H.R.C.); (J.S.P.); (Y.J.P.); (Y.E.S.)
| | - Chan Ho Park
- Department of Radiology, Soonchunhyang University Hospital Cheonan, 31, Sooncheonhyang 6-gil, Donam-gu, Cheonan 31151, Republic of Korea;
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Zhang M, Cairen Z, Liu X, Deng J, Mu X, Wang Y, Lu Z. Transcutaneous electric acupoint stimulation reduced consumption of profopol in patients undergoing laparoscopic surgery: A randomized clinical trial. Medicine (Baltimore) 2024; 103:e35730. [PMID: 38277549 PMCID: PMC10817147 DOI: 10.1097/md.0000000000035730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 09/29/2023] [Indexed: 01/28/2024] Open
Abstract
BACKGROUND Propofol is a common regimen for general anesthesia maintenance. But propofol can dose-dependently generate cardiopulmonary depression. Thus, any strategy to reduce propofol dosage during laparoscopic surgery may have underlying beneficial effect for patient prognosis. Previous studies indicated both analgesic and sedative effect of acupoint stimulation. However, its main sedative effect on patients under general anesthesia remains unclear. OBJECTIVE The aim of this study was to investigate the sedative effect of transcutaneous electrical acupoint stimulation (TEAS) on patients scheduled for laparoscopic surgery under general anesthesia. DESIGN, SETTING, PARTICIPANTS AND INTERVENTIONS In this randomized clinical trial, patients scheduled for laparoscopic surgery under general anesthesia in Xijing hospital were randomly assigned to 3 groups, receiving electrical stimulation at the Shenmen (HT7)/Ximen (PC4) (TEAS group), stimulation at the shoulder (non-acupoint group) or no stimulation (control group), respectively. MAIN OUTCOME MEASURES One hundred sixty-two patients completed the study. The primary outcome was the consumption of propofol, and secondary outcomes included features of recovery after surgery, major complications after surgery and by 1 year after surgery. RESULTS In patients undergoing laparoscopic surgery, the doses of propofol decreased significantly in the TEAS group compared (0.10 ± 0.02 mg·kg-1·min-1) with the other 2 groups (both 0.12 ± 0.02 mg·kg-1·min-1, P < .001). The mean differences (95% confidence interval) for non-acupoint versus TEAS and control versus TEAS were 0.021 (0.012, 0.030) and 0.024 (0.013, 0.034), respectively. Time to awake and to extubation were not significantly different among the groups. The incidences of major complications after surgery and by 1 year after surgery were not significantly different among the groups. CONCLUSION TEAS could induce additional sedative effect in patients during laparoscopic surgery and reduce propofol consumption.
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Affiliation(s)
- Minjuan Zhang
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Airforce Medical University, Xi’an, Shaanxi, China
| | - Zhuoma Cairen
- Department of Anesthesiology, Qinghai Provincial People’s Hospital, Xijing, Qinghai, China
| | - Xiaoyu Liu
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Airforce Medical University, Xi’an, Shaanxi, China
| | - Jiao Deng
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Airforce Medical University, Xi’an, Shaanxi, China
| | - Xiaoxiao Mu
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Airforce Medical University, Xi’an, Shaanxi, China
| | - Yun Wang
- Department of Anesthesiology, Qinghai Provincial People’s Hospital, Xijing, Qinghai, China
| | - Zhihong Lu
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Airforce Medical University, Xi’an, Shaanxi, China
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Lee J, Han DW, Kim NY, Kim KS, Yang Y, Yang J, Lee HS, Kim MH. Comparison of Remimazolam versus Sevoflurane on the Postoperative Quality of Recovery in Cervical Spine Surgery: A Prospective Randomized Controlled Double-Blind Trial. Drug Des Devel Ther 2024; 18:121-132. [PMID: 38283136 PMCID: PMC10821644 DOI: 10.2147/dddt.s441622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 01/18/2024] [Indexed: 01/30/2024] Open
Abstract
Purpose Remimazolam is a newly developed ultra-short-acting benzodiazepine. We compared overall functional recovery, including the postoperative Quality of Recovery-15 (QoR-15) questionnaire scores, between balanced inhalational anesthesia using sevoflurane and total intravenous anesthesia (TIVA) with remimazolam in patients undergoing anterior cervical discectomy and fusion (ACDF). Patients and Methods Seventy-two patients were randomized to the remimazolam (group R) or sevoflurane (group S) group. The primary outcome was the total QoR-15 score on postoperative day (POD) 1. We also assessed the total QoR-15 score on POD2, sub-scores of the QoR-15, perioperative parameters, and postoperative recovery profiles. Group-time interaction effects on the QoR-15 and its sub-scores were analyzed using a linear mixed model. Results The total QoR-15 score on POD1 (120.2 in group R vs 114.3 in group S, P=0.189) was not statistically different between the groups. There were no significant group-time interaction effects on total QoR-15 scores. Instead, patients in group R showed significantly better sub-scores in psychological and postoperative nausea and vomiting (PONV) items on POD1, as well as a lower degree of PONV, than those in group S. Among the five dimensions of the QoR-15, a significant group-time interaction effect was observed for psychological support. Group R showed significantly less changeability in blood pressure and heart rate with a lower dose of intraoperatively administered vasopressor than group S. Conclusion Considering QoR-15, including PONV reduction, and intraoperative hemodynamic stability, remimazolam can be used as the novel and safe anesthetic agent for maintaining general anesthesia instead of sevoflurane in patients undergoing ACDF.
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Affiliation(s)
- Jiwon Lee
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Republic of Korea
| | - Dong Woo Han
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Republic of Korea
| | - Na Young Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Keun-Su Kim
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Spine Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yunil Yang
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Republic of Korea
| | - Juyeon Yang
- Department of Research Affairs, Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hye Sun Lee
- Department of Research Affairs, Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Myoung Hwa Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Republic of Korea
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Sidhu R, Turnbull D, Haboubi H, Leeds JS, Healey C, Hebbar S, Collins P, Jones W, Peerally MF, Brogden S, Neilson LJ, Nayar M, Gath J, Foulkes G, Trudgill NJ, Penman I. British Society of Gastroenterology guidelines on sedation in gastrointestinal endoscopy. Gut 2024; 73:219-245. [PMID: 37816587 PMCID: PMC10850688 DOI: 10.1136/gutjnl-2023-330396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 09/06/2023] [Indexed: 10/12/2023]
Abstract
Over 2.5 million gastrointestinal endoscopic procedures are carried out in the United Kingdom (UK) every year. Procedures are carried out with local anaesthetic r with sedation. Sedation is commonly used for gastrointestinal endoscopy, but the type and amount of sedation administered is influenced by the complexity and nature of the procedure and patient factors. The elective and emergency nature of endoscopy procedures and local resources also have a significant impact on the delivery of sedation. In the UK, the vast majority of sedated procedures are carried out using benzodiazepines, with or without opiates, whereas deeper sedation using propofol or general anaesthetic requires the involvement of an anaesthetic team. Patients undergoing gastrointestinal endoscopy need to have good understanding of the options for sedation, including the option for no sedation and alternatives, balancing the intended aims of the procedure and reducing the risk of complications. These guidelines were commissioned by the British Society of Gastroenterology (BSG) Endoscopy Committee with input from major stakeholders, to provide a detailed update, incorporating recent advances in sedation for gastrointestinal endoscopy.This guideline covers aspects from pre-assessment of the elective 'well' patient to patients with significant comorbidity requiring emergency procedures. Types of sedation are discussed, procedure and room requirements and the recovery period, providing guidance to enhance safety and minimise complications. These guidelines are intended to inform practising clinicians and all staff involved in the delivery of gastrointestinal endoscopy with an expectation that this guideline will be revised in 5-years' time.
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Affiliation(s)
- Reena Sidhu
- Academic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
- Department of Infection, Immunity & Cardiovascular Disease, The University of Sheffield, Sheffield, UK
| | - David Turnbull
- Department of Anaesthetics, Royal Hallamshire Hospital, Sheffield, UK
| | - Hasan Haboubi
- Department of Gastroenterology, University Hospital Llandough, Llandough, South Glamorgan, UK
- Institute of Life Sciences, Swansea University, Swansea, UK
| | - John S Leeds
- Hepato-Pancreato-Biliary Unit, Freeman Hospital, Newcastle upon Tyne, UK
- Newcastle University Population Health Sciences Institute, Newcastle upon Tyne, UK
| | - Chris Healey
- Airedale NHS Foundation Trust, Keighley, West Yorkshire, UK
| | - Srisha Hebbar
- Department of Gastroenterology, University Hospital of North Midlands, Stoke-on-Trent, Staffordshire, UK
| | - Paul Collins
- Department of Gastroenterology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Wendy Jones
- Specialist Pharmacist Breastfeeding and Medication, Portsmouth, UK
| | - Mohammad Farhad Peerally
- Digestive Diseases Unit, Kettering General Hospital; Kettering, Kettering, Northamptonshire, UK
- Department of Population Health Sciences, College of Life Science, University of Leicester, Leicester, UK
| | - Sara Brogden
- Department of Gastroenterology, University College London, UK, London, London, UK
| | - Laura J Neilson
- Department of Gastroenterology, South Tyneside District Hospital, South Shields, Tyne and Wear, UK
| | - Manu Nayar
- Hepato-Pancreato-Biliary Unit, Freeman Hospital, Newcastle upon Tyne, UK
- Newcastle University Population Health Sciences Institute, Newcastle upon Tyne, UK
| | - Jacqui Gath
- Patient Representative on Guideline Development Group and member of Independent Cancer Patients' Voice, Sheffield, UK
| | - Graham Foulkes
- Patient Representative on Guideline Development Group, Manchester, UK
| | - Nigel J Trudgill
- Department of Gastroenterology, Sandwell General Hospital, West Bromwich, UK
| | - Ian Penman
- Centre for Liver and Digestive Disorders, Royal Infirmary Edinburgh, Edinburgh, Midlothian, UK
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Chiu WC, Wu ZF, Lee MS, Chen JYH, Huang YH, Tseng WC, Lai HC. Propofol-based total intravenous anesthesia is associated with less postoperative recurrence than desflurane anesthesia in thyroid cancer surgery. PLoS One 2024; 19:e0296169. [PMID: 38181006 PMCID: PMC10769032 DOI: 10.1371/journal.pone.0296169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 12/06/2023] [Indexed: 01/07/2024] Open
Abstract
BACKGROUND The effects of anesthesia in patients undergoing thyroid cancer surgery are still not known. We investigated the relationship between the type of anesthesia and patient outcomes following elective thyroid cancer surgery. METHODS This was a retrospective cohort study of patients who underwent elective surgical resection for papillary thyroid carcinoma between January 2009 and December 2019. Patients were grouped according to the type of anesthesia they received, desflurane or propofol. A Kaplan-Meier analysis was conducted, and survival/recurrence curves were presented from the date of surgery to death/recurrence. Univariable and multivariable Cox regression models were used to compare hazard ratios for recurrence after propensity matching. RESULTS A total of 621 patients (22 deaths, 3.5%) under desflurane anesthesia and 588 patients (32 deaths, 5.4%) under propofol anesthesia were included. Five hundred and eighty-eight patients remained in each group after propensity matching. Propofol anesthesia was not associated with better survival compared to desflurane anesthesia in the matched analysis (P = 0.086). However, propofol anesthesia was associated with less recurrence (hazard ratio, 0.38; 95% confidence interval, 0.25-0.56; P < 0.001) in the matched analysis. CONCLUSIONS Propofol anesthesia was associated with less recurrence, but not mortality, following surgery for papillary thyroid carcinoma than desflurane anesthesia. Further prospective investigation is needed to examine the influence of propofol anesthesia on patient outcomes following thyroid cancer surgery.
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Affiliation(s)
- Wei-Chieh Chiu
- Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Zhi-Fu Wu
- Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, Republic of China
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan, Republic of China
- Department of Anesthesiology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, Republic of China
- Center for Regional Anesthesia and Pain Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan, ROC
| | - Meei-Shyuan Lee
- School of Public Health, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Jamie Yu-Hsuan Chen
- School of Public Health, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Yi-Hsuan Huang
- Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Wei-Cheng Tseng
- Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Hou-Chuan Lai
- Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, Republic of China
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Lu C, Kang Y, Luo Q, Zhong F, Cai Y, Zhang G, Guo Z, Zhang S, Ma J, Shu H. Effectiveness of general anaesthesia with remimazolam tosilate on intraoperative haemodynamics and postoperative recovery: study protocol for a randomised, positive-controlled, pragmatic clinical trial (GARTH trial). BMJ Open 2024; 14:e073024. [PMID: 38176870 PMCID: PMC10773345 DOI: 10.1136/bmjopen-2023-073024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 10/23/2023] [Indexed: 01/06/2024] Open
Abstract
INTRODUCTION It is encouraged to estimate the effectiveness of components within the enhanced recovery after surgery (ERAS) protocol through patient-reported outcomes, alongside doctor-reported outcomes and length of hospital stay. At present, studies on the contributions of optimal anaesthetic drugs within the ERAS protocol to patient-reported and doctor-reported outcomes are limited. Therefore, this study aims to pragmatically evaluate the effectiveness and safety of general anaesthesia (GA) with remimazolam tosilate within the ERAS protocol on intraoperative haemodynamics and postoperative recovery in adults undergoing elective surgeries, compared with propofol. METHODS AND ANALYSIS This study is a single-centre, randomised, blinded, positive-controlled, pragmatic clinical trial. A total of 900 patients, aged ≥18 years old, scheduled for an elective surgical procedure under GA will be included. Patients will be randomised in a 1:1 ratio to the remimazolam group (the GA with remimazolam tosilate within the ERAS protocol group) or propofol group (the GA with propofol within the ERAS protocol group), stratified by general surgery, thoracic surgery and other surgeries (including urological surgery and otolaryngology surgery). The primary outcomes include the 24-hour postoperative quality of recovery-40 score and the rate of intraoperative hypotension. Secondary endpoints include the rate of sedative hypotension requiring treatment, the haemodynamic profiles, the 72-hour postoperative quality of recovery-40 score, the functional anaesthetic capability, adverse events and complications, quality of life within 3 months as well as economic health outcomes. ETHICS AND DISSEMINATION This study protocol has been approved by the ethics committee of Guangdong Provincial People's Hospital (KY-H-2022-005-03-08). Dissemination plans will be presented at scientific meetings and in scientific publications. TRIAL REGISTRATION NUMBER ChiCTR2200062520.
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Affiliation(s)
- Changyin Lu
- Department of Anesthesiology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
- Department of Anesthesiology, Shenzhen Traditional Chinese Medicine Hospital, The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, China
| | - Yin Kang
- Department of Anesthesiology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Quehua Luo
- Department of Anesthesiology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Fei Zhong
- Global Health Research Center, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yujing Cai
- Department of Anesthesiology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Guangyan Zhang
- Department of Anesthesiology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Zhimin Guo
- Department of Anesthesiology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Shaoting Zhang
- Department of Anesthesiology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
- Department of Anesthesiology, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Jue Ma
- Department of Anesthesiology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - HaiHua Shu
- Department of Anesthesiology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- School of Medicine, South China University of Technology, Guangzhou, China
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Zhang L, Liu C, Yan Q, Cai X. Impact of prognostic nutritional index change on prognosis after colorectal cancer surgery under propofol or sevoflurane anesthesia. BMC Anesthesiol 2024; 24:12. [PMID: 38172695 PMCID: PMC10763006 DOI: 10.1186/s12871-023-02308-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 10/09/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND The alteration of the prognostic nutritional index (PNI) or the utilization of distinct anesthesia strategies has been linked to the prognosis of various cancer types, but the existing evidence is limited and inconclusive, particularly for colorectal cancer (CRC). Our objective was to evaluate the association between PNI change and progression free survival (PFS) and overall survival (OS) in patients treated with CRC surgery after propofol-based or sevoflurane-based anesthesia. METHODS We conducted a retrospective analysis of 414 patients with CRC who underwent surgical resection. Among them, 165 patients received propofol-based total intravenous anesthesia (TIVA-P), while 249 patients received sevoflurane-based inhalation anesthesia (IA-S). The PNI change (ΔPNI) was calculated by subtracting the pre-surgery PNI from the post-surgery PNI, and patients were categorized into high (≥ -2.25) and low (< -2.25) ΔPNI groups. Univariate and multivariate analyses were employed to evaluate the effects of the two anesthesia methods, ΔPNI, and their potential interaction on PFS and OS. RESULTS The median duration of follow-up was 35.9 months (interquartile range: 18-60 months). The five-year OS rates were 63.0% in the TIVA-P group and 59.8% in the IA-S group (hazard ratio [HR]: 0.96; 95% confidence interval [CI]: 0.70-1.35; p = 0.864), while the five-year PFS rates were 55.8% and 51.0% (HR: 0.92; 95% CI: 0.68-1.26; p = 0.614), respectively. In comparison to patients in the low ΔPNI group, those in the high ΔPNI group exhibited a favorable association with both OS (HR: 0.57; 95% CI: 0.40-0.76; p < 0.001) and PFS (HR: 0.58; 95% CI: 0.43-0.79; p < 0.001). Stratified analysis based on ΔPNI revealed significant protective effects in the propofol-treated participants within the high ΔPNI group, whereas such effects were not observed in the low ΔPNI group, for both OS (p for interaction = 0.004) and PFS (p for interaction = 0.024). CONCLUSIONS Our data revealed that among patients who underwent CRC surgery, those treated with TIVA-P exhibited superior survival outcomes compared to those who received IA-S, particularly among individuals with a high degree of PNI change.
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Affiliation(s)
- Longtang Zhang
- Department of Anesthesiology, the Fifth Affiliated Hospital of Xinjiang Medical University, No. 118 Henan West Road, Xinshi District, Urumqi City, Xinjiang, China
| | - Chong Liu
- Department of Anesthesiology, the Fifth Affiliated Hospital of Xinjiang Medical University, No. 118 Henan West Road, Xinshi District, Urumqi City, Xinjiang, China
| | - Qiang Yan
- Department of Anesthesiology, Xinjiang Uygur Autonomous Region People's Hospital, No. 91 Tianchi Road, Tianshan District, Urumqi City, Xinjiang, China
| | - Xiaoli Cai
- Department of Anesthesiology, the Fifth Affiliated Hospital of Xinjiang Medical University, No. 118 Henan West Road, Xinshi District, Urumqi City, Xinjiang, China.
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Wu X, Liao M, Lin X, Hu J, Zhao T, Sun H. Effective doses of ciprofol combined with alfentanil in inhibiting responses to gastroscope insertion, a prospective, single-arm, single-center study. BMC Anesthesiol 2024; 24:2. [PMID: 38166724 PMCID: PMC10759617 DOI: 10.1186/s12871-023-02387-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 12/17/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Ciprofol is a novel intravenous sedative and anesthetic. Studies have shown that it features a rapid onset of action, a fast recovery time, slight inhibition of respiratory and cardiovascular functions, and a low incidence of adverse reactions. This study aims to explore the median effective dose (ED50) and the 95% effective dose (ED95) of ciprofol in inhibiting responses to gastroscope insertion when combined with a low dose of alfentanil, and to evaluate its safety, to provide a reference for the rational use of ciprofol in clinical practices. METHODS We included 25 patients aged 18-64 years of either sex who underwent gastroscopy under intravenous general anesthesia, with a Body Mass Index (BMI) 18-28 kg/m2, and an American Society of Anesthesiologists (ASA) grade I or II. In this study, the dose-finding strategy of ciprofol followed a modified Dixon's up-and-down method with an initial dose of 0.30 mg/kg and an increment of 0.02 mg/kg. Ciprofol was administered after intravenous injection of 7 µg/kg of alfentanil, and 2 min later a gastroscope was inserted. When the insertion response of one participant was positive (including body movement, coughing, and eye opening), an escalation of 0.02 mg/kg would be given to the next participant; otherwise, a de-escalation of 0.02 mg/kg would be administered. The study was terminated when negative response and positive response alternated 8 times. A Probit model was used to calculate the ED50 and ED95 of ciprofol in inhibiting responses to gastroscope insertion when combined with alfentanil. Patients' recovery time, discharge time, vital signs and occurrence of adverse reactions were recorded. RESULTS The ED50 of single-dose intravenous ciprofol injection with 7 µg/kg of alfentanil in inhibiting gastroscope insertion responses was 0.217 mg/kg, and the ED95 was 0.247 mg/kg. Patients' recovery time and discharge time were 11.04 ± 1.49 min and 9.64 ± 2.38 min, respectively. The overall incidence of adverse reactions was 12%. CONCLUSION The ED50 of ciprofol combined with 7 µg/kg of alfentanil in inhibiting gastroscope insertion responses was 0.217 mg/kg, and the ED95 was 0.247 mg/kg. Ciprofol showed a low incidence of anesthesia-related adverse events. TRIAL REGISTRATION http://www.chictr.org.cn (ChiCTR2200061727).
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Affiliation(s)
- Xiaoru Wu
- Department of Anesthesiology, The Second Affiliated Hospital of Hainan Medical University, Hai Kou, 570311, China
| | - Min Liao
- Department of Anesthesiology, The Second Affiliated Hospital of Hainan Medical University, Hai Kou, 570311, China
| | - Xingzhou Lin
- Department of Anesthesiology, The Second Affiliated Hospital of Hainan Medical University, Hai Kou, 570311, China
| | - Jianing Hu
- Department of Anesthesiology, The Second Affiliated Hospital of Hainan Medical University, Hai Kou, 570311, China
| | - Tangyuanmeng Zhao
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Hu Sun
- Department of Anesthesiology, The Second Affiliated Hospital of Hainan Medical University, Hai Kou, 570311, China.
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Abd Ellatif SE, Mowafy SMS, Shahin MA. Ketofol versus Dexmedetomidine for preventing postoperative delirium in elderly patients undergoing intestinal obstruction surgeries: a randomized controlled study. BMC Anesthesiol 2024; 24:1. [PMID: 38166598 PMCID: PMC10759539 DOI: 10.1186/s12871-023-02378-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 12/11/2023] [Indexed: 01/05/2024] Open
Abstract
PURPOSE Postoperative delirium (POD) is considered the most common postoperative neurological complication in elderly patients. The aim of this study was to evaluate the efficacy of the administration of ketofol versus dexmedetomidine (DEX) for minimizing POD in elderly patients undergoing urgent exploration for intestinal obstruction. METHODS This prospective double-blinded randomized clinical trial was conducted on 120 elderly patients undergoing urgent exploration for intestinal obstruction. Patients were randomly allocated to one of the three groups: Group C (control group) patients received normal saline 0.9%, group D received dexmedetomidine, and group K received ketofol (ketamine: propofol was 1:4). The primary outcome was the incidence of POD. Secondary outcomes were incidence of emergence agitation, postoperative pain, consumption of rescue opioids, hemodynamics, and any side effects. RESULTS The incidence of POD was statistically significantly lower in ketofol and DEX groups than in the control group at all postoperative time recordings. Additionally, VAS scores were statistically significantly decreased in the ketofol and DEX groups compared to the control group at all time recordings except at 48 and 72 h postoperatively, where the values of the three studied groups were comparable. The occurrence of emergence agitation and high-dose opioid consumption postoperatively were found to be significant predictors for the occurrence of POD at 2 h and on the evening of the 1st postoperative day. CONCLUSION The administration of ketofol provides a promising alternative option that is as effective as DEX in reducing the incidence of POD in elderly patients undergoing urgent exploration for intestinal obstruction. TRIAL REGISTRATION This clinical trial was approved by the Institutional Review Board (IRB) at Zagazig University (ZU-IRB# 6704// 3/03/2021) and ClinicalTrials.gov (NCT04816162, registration date 22/03/ 2021). The first research participant was enrolled on 25/03/2021).
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Affiliation(s)
- Shereen E Abd Ellatif
- Department of Anesthesia, Intensive Care, and Pain Management. Faculty of Medicine, Zagazig University, Zagazig, Egypt.
| | - Sherif M S Mowafy
- Department of Anesthesia, Intensive Care, and Pain Management. Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Mona A Shahin
- Department of Anesthesia, Intensive Care, and Pain Management. Faculty of Medicine, Zagazig University, Zagazig, Egypt
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Demir M, Balkiz Soyal Ö, Aytaç BG. Assessment of Optic Nerve Sheath Diameter in Patients Undergoing Endoscopic Retrograde Cholangiopancreatography: A Prospective, Randomized, Controlled Double-Blinded Comparison of Propofol and Ketofol Anesthesia. Niger J Clin Pract 2024; 27:22-28. [PMID: 38317031 DOI: 10.4103/njcp.njcp_876_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 12/17/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND ERCP is an endoscopic procedure for the diagnosis and treatment of biliopancreatic system diseases. An increase in intra-abdominal pressure due to the insufflation of air to the intestinal lumen may be transmitted to ICP through the course of ERCP. In this prospective, randomized, controlled double-blinded study, we aimed to assess the ICP change using ultrasonography measurement of ONSD in patients undergoing ERCP comparing the effects of propofol and ketofol anesthesia. MATERIAL/METHODS One hundred and nine patients undergoing ERCP under propofol or ketofol anesthesia were enrolled in the study. Ultrasonography measurement of ONSD was performed before (T0) and immediately after induction of anesthesia (T1), during sphincterotomy (T2), at the end of procedure (T3), and after the patient is fully awake (T4). RESULTS Comparison of ONSD values and ONSD alteration between groups showed no statistically significant difference (P > 0.05). Both groups showed significantly greater changes from T0 to T2 compared with values from T0 to T1, T3, and T4, respectively (P = 0,000). T0 to T3 alteration was also significantly greater than T0 to T1 and T4 change in both groups (P = 0,000). CONCLUSIONS ERCP procedure increases intracranial pressure most prominently during sphincterotomy both under propofol or ketofol anesthesia. Further studies are needed to investigate the impact of this phenomenon on adverse clinical outcomes.
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Affiliation(s)
- M Demir
- Anesthesiology Department, Kars Kağızman State Hospital, Kars, Turkey
| | - Ö Balkiz Soyal
- Anesthesiology Department, Ankara City Hospital, Anesthesiology and Reanimation Clinic, Ankara, Turkey
| | - B G Aytaç
- Anesthesiology Department, Ankara City Hospital, Anesthesiology and Reanimation Clinic, Ankara, Turkey
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Assadoon MS, Kovacevic MP, Dube KM, Szumita PM, Lupi KE, DeGrado JR. Evaluation of Atypical Antipsychotics for the Facilitation of Weaning Sedation in Mechanically Ventilated Critically Ill Patients. J Intensive Care Med 2024; 39:52-58. [PMID: 37431208 DOI: 10.1177/08850666231188029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2023]
Abstract
INTRODUCTION Sedatives and analgesics are commonly utilized as continuous infusions in the ICU but have complications, including an increase in mechanical ventilation days, ICU length of stay, and delirium. Atypical antipsychotics (AAPs) affect several receptors including muscarinic, histamine, and α-1 adrenergic receptors, which may allow them to act as adjunctive agents to facilitate weaning of continuous infusions. OBJECTIVE To determine if there is a decrease in sedatives/analgesics requirements with the use of quetiapine and olanzapine in mechanically ventilated critically ill patients. METHODS A single-center, retrospective study conducted at Brigham and Women's Hospital from 1/1/2018 to 12/31/2019. Patients were included if they were mechanically ventilated for at least 48 hours before and following AAP initiation, were receiving at least one sedative/analgesic by continuous infusion and received AAP for at least 48 hours. The major endpoint was the percentage of patients with ≥20% reduction in the cumulative dose (CD) of midazolam, propofol, or opioids using morphine mg equivalent (MME), 48 hours from AAP initiation. Minor endpoints included median changes in CD at 24 and 48 hours, and Richmond Agitation-Sedation Scale (RASS), and Critical Care Pain Observation Tool (CPOT) changes at 48 hours. RESULTS A total of 1177 encounters were screened and 107 were included. Within the 48 hours after AAP initiation, 77.6% had ≥20% reduction in the CD of a sedative/analgesic. There was a significant reduction in propofol, no change in MME, and significant increase in dexmedetomidine median CD at 48 hours from AAP start. No difference was found in pain scores, but patients had significantly lighter sedation scores in the 48 hours after AAP initiation. A multivariate analysis showed that earlier initiation of antipsychotics was associated with a higher likelihood of achieving a 20% reduction in a sedative/analgesic. CONCLUSION AAP use was associated with a significant reduction in sedatives/analgesics doses. Future studies are warranted to confirm the results.
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Affiliation(s)
- Maha S Assadoon
- Department of Pharmacy, King Abdul-Aziz Medical City, Riyadh, Saudi Arabia
| | - Mary P Kovacevic
- Department of Pharmacy, Brigham and Women's Hospital, Boston, USA
| | - Kevin M Dube
- Department of Pharmacy, Brigham and Women's Hospital, Boston, USA
| | - Paul M Szumita
- Department of Pharmacy, Brigham and Women's Hospital, Boston, USA
| | - Kenneth E Lupi
- Department of Pharmacy, Brigham and Women's Hospital, Boston, USA
| | - Jeremy R DeGrado
- Department of Pharmacy, Brigham and Women's Hospital, Boston, USA
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Dubowitz J, Riedel B, Blaas C, Hiller J, Braat S. On the horns of a dilemma: choosing total intravenous anaesthesia or volatile anaesthesia for cancer surgery, an enduring controversy. Br J Anaesth 2024; 132:5-9. [PMID: 37884407 DOI: 10.1016/j.bja.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 10/01/2023] [Indexed: 10/28/2023] Open
Abstract
Two methods for administering general anaesthesia are widely used: propofol-based total intravenous anaesthesia (propofol-TIVA) and inhalation volatile agent-based anaesthesia. Both modalities, which have been standards of care for several decades, boast a robust safety profile. Nevertheless, the potential differential effects of these anaesthetic techniques on immediate, intermediate, and extended postoperative outcomes remain a subject of inquiry. We discuss a recently published longitudinal analysis stemming from a multicentre randomised controlled trial comparing sevoflurane-based inhalation anaesthesia with propofol-TIVA in older patients with cancer, which showed a reduced incidence of emergence and postoperative delirium, comparable postoperative complication rates within 30 days after surgery, and comparable long-term survival rates. We undertake an assessment of the trial's methodological strengths and limitations, contextualise its results within the broader scientific evidence, and explore avenues for resolving the extant controversies in anaesthetic choice for cancer surgery. We aim to pave the way for the incorporation of precision medicine paradigms into the evolving landscape of perioperative care for patients with cancer.
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Affiliation(s)
- Julia Dubowitz
- Department of Anaesthesia, Perioperative Medicine, and Pain Medicine, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia.
| | - Bernhard Riedel
- Department of Anaesthesia, Perioperative Medicine, and Pain Medicine, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia
| | - Celia Blaas
- Department of Anaesthesia, Perioperative Medicine, and Pain Medicine, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Jonathan Hiller
- Department of Anaesthesia, Perioperative Medicine, and Pain Medicine, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Sabine Braat
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia; MISCH (Methods and Implementation Support for Clinical Health) Research Hub, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
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Egan TD. The story of propofol: an interview with John (Iain) B. Glen. Br J Anaesth 2024; 132:196. [PMID: 38016906 DOI: 10.1016/j.bja.2023.09.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 09/28/2023] [Indexed: 11/30/2023] Open
Affiliation(s)
- Talmage D Egan
- Department of Anesthesiology, University of Utah, Salt Lake City, UT, USA.
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Kawamura A, Tsuboi K, Oka A, Sakaguchi H, Suzuki Y. Anesthesia management in a child with mucopolysaccharidosis and toxic epidermal necrolysis: A case report. Paediatr Anaesth 2024; 34:89-91. [PMID: 37577929 DOI: 10.1111/pan.14746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 07/13/2023] [Accepted: 07/31/2023] [Indexed: 08/15/2023]
Abstract
Toxic epidermal necrolysis and mucopolysaccharidosis are both rare diseases that pose significant airway maintenance challenges to anesthesiologists. In this report, we describe the anesthesia management in a 4-year-old male with mucopolysaccharidosis type II who developed toxic epidermal necrolysis and presented for ophthalmic surgical procedures. Combined use of propofol and ketamine with the support of high-flow nasal oxygen enabled adequate analgesia and sedation while maintaining spontaneous ventilation and airway patency. The strategy presented in this report may contribute to enhancing the safety of sedation in spontaneously breathing children with abnormal airways.
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Affiliation(s)
- Akihisa Kawamura
- Department of Critical Care and Anesthesia, National Center for Child Health and Development, Tokyo, Japan
| | - Kaoru Tsuboi
- Department of Critical Care and Anesthesia, National Center for Child Health and Development, Tokyo, Japan
| | - Aiko Oka
- Department of Anesthesia, Tokyo Women's Medical University, Tokyo, Japan
| | - Hirotoshi Sakaguchi
- Division of Stem Cell Transplant and Cellular Therapy, National Center for Child Health and Development, Tokyo, Japan
| | - Yasuyuki Suzuki
- Department of Anesthesia, Tokyo Women's Medical University, Tokyo, Japan
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Minciullo A, Filomeno L. Nurse-Administered Propofol Sedation Training Curricula and Propofol Administration in Digestive Endoscopy Procedures: A Scoping Review of the Literature. Gastroenterol Nurs 2024; 47:33-40. [PMID: 37937982 DOI: 10.1097/sga.0000000000000780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 07/21/2023] [Indexed: 11/09/2023] Open
Abstract
Although efficacy and safety of nonanesthesiologist administration of propofol and nurse-administered propofol sedation practices have been amply demonstrated in patients at low American Society of Anesthesiologists physical status risk, they are still severely limited. To date, it is quite difficult to find a protocol or a shared training program. The aim of the study was to verify requirements, types of training, and operating methods described in the literature for the administration of propofol by a nurse. A scoping review of the literature was conducted in accordance with the PRISMA-ScR guidelines and in line with Arksey and O'Malley's framework, within four main databases of biomedical interest: MEDLINE, CINAHL, Scopus, and Web of Science. We selected studies published during the last 20 years, including only nurses not trained in anesthesia. Seventeen articles were eligible. Despite the differences between the training and administration methods, efficacy and safety of deep sedation managed by trained nurses were comparable, just like when sedation was administered by certified registered nurse anesthetists. Training programs have been investigated in detail by only a small number of studies, although its efficacy and safety have been widely demonstrated. It is important, then, to collect evidence that allows developing of unified international guidelines for training methods to offer safe and cost-effective quality sedation.
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Affiliation(s)
- Andrea Minciullo
- Andrea Minciullo, MSN, RN, is Head Nurse, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
- Lucia Filomeno, MSN, RN, is Research Fellow, Sapienza University of Rome, Rome, Italy
| | - Lucia Filomeno
- Andrea Minciullo, MSN, RN, is Head Nurse, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
- Lucia Filomeno, MSN, RN, is Research Fellow, Sapienza University of Rome, Rome, Italy
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Hailemariam T, Sisay S, Mebratu Y, Belay F, Getinet T, Solomon S, Belina M, Abebe A, Hilawi Tewodros B, Manyazewal T. Effects of sedatives on radiologic enema reduction in children with ileocolic intussusception: A systematic review and meta-analysis. Eur J Radiol 2024; 170:111237. [PMID: 38039783 DOI: 10.1016/j.ejrad.2023.111237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 11/05/2023] [Accepted: 11/25/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND In children with ileocolic intussusception, sedatives such as midazolam, ketamine and propofol may facilitate radiologic enema reduction, but studies on their separate and joint effects remain controversial. OBJECTIVES We aimed to systematically analyze studies for the effects of sedatives on the radiologic reduction of ileocolic intussusception in children. METHODS We searched PubMed, EMBASE, CINAHL, Scopus and Web of Science from database inception through March 2023 for articles that enrolled children with ileocolic intussusception who underwent non-operative pneumatic or hydrostatic enema reduction under ultrasound or fluoroscopic guidance with or without the use of sedatives. The primary and secondary outcomes were success rate in radiologic reduction of ileocolic intussusception and risk of perforation, respectively. Effect estimates from the individual studies were extracted and combined using the Hartung-Knapp-Sidik-Jonkman log-odds random-effects model. Heterogeneity between studies was checked using Cochran's Q test and the I2 statistic. RESULTS A total of 17 studies with 2094 participants were included in the final review, of which 15 were included in the meta-analysis. Nine studies reported on the success rate of radiologic reduction performed under sedation in all participants, while six studies compared the success rate in two patient groups undergoing the procedure with or without sedation. The pooled success rate of non-operative reduction under sedation was 87 % (95 % CI: 80-95 %), P = 0.000 with considerable heterogeneity (I2 = 85 %). A higher success rate of 94 % (95 % CI: 88-99 %) and homogeneity (I2 = 12 %) were found in studies with pneumatic enema reduction. Among comparative studies, the odds of success of non-operative reduction were increased when the procedure was performed under sedation, with a pooled odds ratio of 2.41 (95 % CI: 1.27-4.57), P = 0.010 and moderate heterogeneity (I2 = 60 %). In a sensitivity analysis, homogeneity was found between analyzed studies when two outliers were excluded (I2 = 0.73 %). The risk of perforation was not significantly different (OR 1.52, 95 % CI: 0.09-23.34), P = 0.764 indicating small study effects. No publication, bias was detected on visual inspection of the funnel plots or the Begg's and Egger's bias tests. Most studies were categorized as having a low risk of bias using Joanna Briggs Institute checklists. CONCLUSIONS In selected patient groups, sedation can increase the success rate of radiologic enema reduction in children with ileocolic intussusception without evidence of increased risk of perforation. Systematic review protocol registration: PROSPERO CRD42023404887.
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Affiliation(s)
- Tesfahunegn Hailemariam
- Addis Ababa University, College of Health Sciences, Department of Radiology, Addis Ababa, Ethiopia; Ababa University, College of Health Sciences, Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa, Ethiopia.
| | - Samuel Sisay
- Addis Ababa University, College of Health Sciences, Department of Radiology, Addis Ababa, Ethiopia.
| | - Yonas Mebratu
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Fekadu Belay
- Wachemo University, College of Medicine and Health Sciences, Department of Pediatrics and Child Health, Hossana, Ethiopia
| | - Tewodros Getinet
- St. Paul's Hospital Millennium Medical College, School of Public Health, Addis Ababa, Ethiopia
| | - Samrawit Solomon
- St. Paul's Hospital Millennium Medical College, School of Public Health, Addis Ababa, Ethiopia.
| | - Merga Belina
- Ababa University, College of Health Sciences, Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa, Ethiopia
| | - Abel Abebe
- Detroit Medical Center/Wayne State University, Sinai Grace Hospital, Detroit, MI, USA
| | | | - Tsegahun Manyazewal
- Ababa University, College of Health Sciences, Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa, Ethiopia
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Wahedi R, Willems S, Feldhege J, Jularic M, Hartmann J, Anwar O, Dickow J, Harloff T, Gessler N, Gunawardene MA. Pulsed-field versus cryoballoon ablation for atrial fibrillation-Impact of energy source on sedation and analgesia requirement. J Cardiovasc Electrophysiol 2024; 35:162-170. [PMID: 38009545 DOI: 10.1111/jce.16141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 11/07/2023] [Accepted: 11/12/2023] [Indexed: 11/29/2023]
Abstract
INTRODUCTION Pulsed field ablation (PFA) represents a novel, nonthermal energy modality that can be applied for single-shot pulmonary vein isolation (PVI) in atrial fibrillation (AF). Comparative data with regard to deep sedation to established single-shot modalities such as cryoballoon (CB) ablation are scarce. The aim of this study was to compare a deep sedation protocol in patients receiving PVI with either PFA or CB. METHODS Prospective, consecutive AF patients undergoing PVI with a pentaspline PFA catheter were compared to a retrospective CB-PVI cohort of the same timeframe. Study endpoints were the requirements of analgesics, cardiorespiratory stability, and sedation-associated complications. RESULTS A total of 100 PVI patients were included (PFA n = 50, CB n = 50, mean age 66 ± 10.6, 61% male patients, 65% paroxysmal AF). Requirement of propofol, midazolam, and sufentanyl was significantly higher in the PFA group compared to CB [propofol 0.14 ± 0.04 mg/kg/min in PFA vs. 0.11 ± 0.04 mg/kg/min in CB (p = .001); midazolam 0.00086 ± 0.0004 mg/kg/min in PFA vs. 0.0006295 ± 0.0003 mg/kg/min in CB (p = .002) and sufentanyl 0.0013 ± 0.0007 µg/kg/min in PFA vs. 0.0008 ± 0.0004 µg/kg/min in CB (p < .0001)]. Sedation-associated complications did not differ between both groups (PFA n = 1/50 mild aspiration pneumonia, CB n = 0/50, p > .99). Nonsedation-associated complications (PFA: n = 2/50, 4%, CB: n = 1/50, 2%, p > .99) and procedure times (PFA 75 ± 31, CB 84 ± 32 min, p = .18) did not differ between groups. CONCLUSIONS PFA is associated with higher sedation and especially analgesia requirements. However, the safety of deep sedation does not differ to CB ablation.
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Affiliation(s)
- Rahin Wahedi
- Department of Cardiology and Intensive Care Medicine, Asklepios Hospital St. Georg, Hamburg, Germany
- Semmelweis University, Budapest, Hungary
| | - Stephan Willems
- Department of Cardiology and Intensive Care Medicine, Asklepios Hospital St. Georg, Hamburg, Germany
- Semmelweis University, Budapest, Hungary
- DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Berlin, Germany
| | | | - Mario Jularic
- Department of Cardiology and Intensive Care Medicine, Asklepios Hospital St. Georg, Hamburg, Germany
- Semmelweis University, Budapest, Hungary
| | - Jens Hartmann
- Department of Cardiology and Intensive Care Medicine, Asklepios Hospital St. Georg, Hamburg, Germany
- Semmelweis University, Budapest, Hungary
| | - Omar Anwar
- Department of Cardiology and Intensive Care Medicine, Asklepios Hospital St. Georg, Hamburg, Germany
- Semmelweis University, Budapest, Hungary
| | - Jannis Dickow
- Department of Cardiology and Intensive Care Medicine, Asklepios Hospital St. Georg, Hamburg, Germany
- Semmelweis University, Budapest, Hungary
| | - Tim Harloff
- Department of Cardiology and Intensive Care Medicine, Asklepios Hospital St. Georg, Hamburg, Germany
- Semmelweis University, Budapest, Hungary
| | - Nele Gessler
- Department of Cardiology and Intensive Care Medicine, Asklepios Hospital St. Georg, Hamburg, Germany
- Semmelweis University, Budapest, Hungary
- DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Berlin, Germany
- Asklepios Proresearch, Hamburg, Germany
| | - Melanie A Gunawardene
- Department of Cardiology and Intensive Care Medicine, Asklepios Hospital St. Georg, Hamburg, Germany
- Semmelweis University, Budapest, Hungary
- DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Berlin, Germany
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Gomes VH, Peixoto AJ, EdosSL Fernandes M, de Souza Campos AC, Coelho CM, da Silva MF. Evaluation of lidocaine administration into the ovarian pedicle for the control of intraoperative and early postoperative pain during ovariohysterectomy in dogs. Vet Anaesth Analg 2024; 51:64-70. [PMID: 37919174 DOI: 10.1016/j.vaa.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 07/10/2023] [Accepted: 07/11/2023] [Indexed: 11/04/2023]
Abstract
OBJECTIVE To evaluate effects of lidocaine 2% administration into the ovarian pedicle on intraoperative nociception and early postoperative pain in dogs undergoing ovariohysterectomy. STUDY DESIGN Prospective, randomized, blinded clinical study. ANIMALS A total of 20 healthy adult female dogs of different breeds. METHODS Dogs were premedicated with acepromazine (0.02 mg kg-1) and morphine (0.5 mg kg-1) intramuscularly, anesthesia induced with propofol and maintained with isoflurane. Dogs were randomly assigned to be administered 2 mL of saline (group S) or lidocaine 2% (group L) into the mesovarium (1 mL each side). Heart rate (HR) and noninvasive systemic arterial pressure were recorded before surgery (T0), before (T1) and during ligation of the right ovarian pedicle (T2), before (T3) and during ligation of the left ovarian pedicle (T4). Rescue treatment (propofol) was administered if HR or systolic arterial pressure (SAP) increased by 20% compared with the previous time point. Pain, assessed with the Glasgow Composite Measure Pain Scale-Short Form (CMPS-SF) was recorded before premedication (baseline) and after extubation. Administration of postoperative rescue analgesia was recorded. RESULTS In group S, HR was higher at T2 than T1 (112 ± 18 versus 89 ± 21 beats minute-1, p = 0.001) There were no significant differences between treatments at any time. SAP was higher at T2 than T1 in group S (110 ± 12 versus 100 ± 10 mmHg, p = 0.031). SAP was higher in group S than group L at T3 (113 ± 12 and 91 ± 10 mmHg, respectively, p = 0.001). No dogs required propofol intraoperatively. All dogs required postoperative rescue analgesia. Compared with baseline, CMPS-SF increased 60 minutes after extubation (group S; p = 0.019, group L; p = 0.043). CONCLUSIONS AND CLINICAL RELEVANCE Administration of lidocaine 2% into the mesovarium did not reduce intraoperative nociception and did not improve postoperative analgesia.
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Affiliation(s)
- Viviane H Gomes
- Department of Veterinary Medicine and Surgery, Universidade Federal Rural do Rio de Janeiro, UFRRJ, Seropédica, RJ, Brazil.
| | - Anna Jr Peixoto
- Department of Veterinary Medicine and Surgery, Universidade Federal Rural do Rio de Janeiro, UFRRJ, Seropédica, RJ, Brazil
| | - Maria EdosSL Fernandes
- Department of Veterinary Medicine and Surgery, Universidade Federal Rural do Rio de Janeiro, UFRRJ, Seropédica, RJ, Brazil
| | - Ana Carolina de Souza Campos
- Department of Veterinary Medicine and Surgery, Universidade Federal Rural do Rio de Janeiro, UFRRJ, Seropédica, RJ, Brazil
| | - Cassia Mm Coelho
- Department of Veterinary Medicine and Surgery, Universidade Federal Rural do Rio de Janeiro, UFRRJ, Seropédica, RJ, Brazil
| | - Marta Fa da Silva
- Department of Veterinary Medicine and Surgery, Universidade Federal Rural do Rio de Janeiro, UFRRJ, Seropédica, RJ, Brazil
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O'Reilly D, Naughton R, Lavelle A. Delirium in older patients given propofol or sevoflurane anaesthesia for major cancer surgery: a multicentre randomised trial. Comment on Br J Anaesth 2023; 131: 253-65. Br J Anaesth 2024; 132:164-165. [PMID: 37866982 DOI: 10.1016/j.bja.2023.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/19/2023] [Accepted: 09/26/2023] [Indexed: 10/24/2023] Open
Affiliation(s)
- Darragh O'Reilly
- Department of Anaesthesiology, St. James's Hospital, Dublin, Ireland.
| | - Rory Naughton
- Department of Anaesthesiology, St. James's Hospital, Dublin, Ireland
| | - Aoife Lavelle
- Department of Anaesthesiology, St. James's Hospital, Dublin, Ireland
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Rossetti AO, Claassen J, Gaspard N. Status epilepticus in the ICU. Intensive Care Med 2024; 50:1-16. [PMID: 38117319 DOI: 10.1007/s00134-023-07263-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 10/26/2023] [Indexed: 12/21/2023]
Abstract
Status epilepticus (SE) is a common medical emergency associated with significant morbidity and mortality. Management that follows published guidelines is best suited to improve outcomes, with the most severe cases frequently being managed in the intensive care unit (ICU). Diagnosis of convulsive SE can be made without electroencephalography (EEG), but EEG is required to reliably diagnose nonconvulsive SE. Rapidly narrowing down underlying causes for SE is crucial, as this may guide additional management steps. Causes may range from underlying epilepsy to acute brain injuries such as trauma, cardiac arrest, stroke, and infections. Initial management consists of rapid administration of benzodiazepines and one of the following non-sedating intravenous antiseizure medications (ASM): (fos-)phenytoin, levetiracetam, or valproate; other ASM are increasingly used, such as lacosamide or brivaracetam. SE that continues despite these medications is called refractory, and most commonly treated with continuous infusions of midazolam or propofol. Alternatives include further non-sedating ASM and non-pharmacologic approaches. SE that reemerges after weaning or continues despite management with propofol or midazolam is labeled super-refractory SE. At this step, management may include non-sedating or sedating compounds including ketamine and barbiturates. Continuous video EEG is necessary for the management of refractory and super-refractory SE, as these are almost always nonconvulsive. If possible, management of the underlying cause of seizures is crucial particularly for patients with autoimmune encephalitis. Short-term mortality ranges from 10 to 15% after SE and is primarily related to increasing age, underlying etiology, and medical comorbidities. Refractoriness of treatment is clearly related to outcome with mortality rising from 10% in responsive cases, to 25% in refractory, and nearly 40% in super-refractory SE.
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Affiliation(s)
- Andrea O Rossetti
- Department of Neurology, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Jan Claassen
- Department of Neurology, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Nicolas Gaspard
- Service de Neurologie, Hôpital Universitaire de Bruxelles, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium.
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA.
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Jensen CB, Gromov K, Foss NB, Kehlet H, Pleckaitiene L, Varnum C, Troelsen A. Spinal anaesthesia versus general anaesthesia (SAGA) on recovery after hip and knee arthroplasty: A study protocol for three randomized, single-blinded, multi-centre, clinical trials. Acta Anaesthesiol Scand 2024; 68:137-143. [PMID: 37743099 DOI: 10.1111/aas.14331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 09/03/2023] [Indexed: 09/26/2023]
Abstract
Mobilisation difficulties, due to muscle weakness, and urinary retention are common reasons for prolonged admission following hip and knee arthroplasty procedures. Whether spinal anaesthesia is detrimental to early mobilisation is controversial. Previous studies have reported differences in post-operative recovery between spinal anaesthesia and general anaesthesia; however, up-to-date comparisons in fast-track setups are needed. Our randomized, single-blinded, multi-centre, clinical trials aim to compare the post-operative recovery after total hip (THA), total knee (TKA), and unicompartmental knee arthroplasties (UKA) respectively when using either spinal anaesthesia (SA) or general anaesthesia (GA) in a fast-track setup. Included patients (74 THA, 74 TKA, and 74 UKA patients) are randomized (1:1) to receive either SA (2 mL 0.5% Bupivacaine) or GA (Induction: Propofol 1.0-2.0 mg/kg iv with Remifentanil 3-5 mcg/kg iv. Infusion: Propofol 3-5 mg/kg/h and Remifentanil 0.5 mcg/kg/min iv). Patients undergo standard primary unilateral hip and knee arthroplasty procedures in an optimized fast-track setup with intraoperative local infiltrative analgesia in TKA and UKA, post-operative multimodal opioid sparing analgesia, immediate mobilisation with full weightbearing, no drains and in-hospital only thromboprophylaxis. Data will be collected on the day of surgery and until patients are discharged. The primary outcome is the ability to be safely mobilised during a 5-m walking test within 6 h of surgery. Secondary outcomes include fulfilment of discharge criteria, post-operative pain, dizziness, and nausea as well as patient reported recovery and opioid related side effects. Data will also be gathered on all hospital contacts within 30-days of surgery. This study will offer insights into advantages and disadvantages of anaesthetic methods used in fast-track arthroplasty surgery.
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Affiliation(s)
- Christian Bredgaard Jensen
- Department of Orthopaedic Surgery, Clinical Orthopaedic Surgery Hvidovre (CORH), Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Kirill Gromov
- Department of Orthopaedic Surgery, Clinical Orthopaedic Surgery Hvidovre (CORH), Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Nicolai Bang Foss
- Department of Anaesthesiology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Henrik Kehlet
- Section of Surgical Pathophysiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Lina Pleckaitiene
- Department of Anaesthesiology, Lillebaelt Hospital - Vejle, Vejle, Denmark
| | - Claus Varnum
- Department of Orthopaedic Surgery, Lillebaelt Hospital - Vejle, Vejle, Denmark
| | - Anders Troelsen
- Department of Orthopaedic Surgery, Clinical Orthopaedic Surgery Hvidovre (CORH), Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
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Zhang R, Zhao G, Yan Z, Xuan H, Chen Y. The effective dose of remimazolam in adult gastroscopy. Indian J Pharmacol 2024; 56:10-15. [PMID: 38454583 PMCID: PMC11001170 DOI: 10.4103/ijp.ijp_425_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/24/2023] [Accepted: 01/29/2024] [Indexed: 03/09/2024] Open
Abstract
OBJECTIVES The objectives of this study were to explore the median effective dose (ED50) and the dose required for successful anesthesia in 95% of the patients (ED95) of remimazolam for intravenous anesthesia in adult outpatients undergoing gastroscopy. METHODS This pilot study was conducted in patients scheduled to undergo painless gastroscopy at the authors' hospital between March 15, 2022 and March 25, 2022. The ED of remimazolam was determined using the modified Dixon sequential method, using an initial induction dose of 0.2 mg/kg. With successful or failed anesthesia, the remimazolam dose was decreased or increased by 0.05 mg/kg for the next patient, respectively. RESULTS Twenty-two patients (43.6 ± 10.5 years of age) were enrolled. During gastroscopy, the remimazolam induction dose was 19.93 ± 2.96 mg (0.2-0.45 mg/kg). Eighteen patients could complete anesthesia with remimazolam alone, and four patients needed propofol to complete anesthesia. The induction time after the injection of remimazolam was 20.8 ± 8.4 s, the gastroscopy time was 5.1 ± 1.3 min, and the anesthesia recovery time was 17.5 ± 5.6 min. The ED50 and the ED95 of remimazolam were 0.362 mg/kg (95% confidence interval [CI]: 0.313-0.455 mg/kg) and 0.464 mg/kg (95% CI: 0.403-2.242 mg/kg), respectively. The vital signs of all patients remained within the predefined acceptable limits. No patients required antagonist rescue. CONCLUSION The ED50 and ED95 of remimazolam for adult gastroscopy were 0.362 mg/kg and 0.464 mg/kg, respectively. Additional anesthetics might be required during gastroscopy in some patients. TRIAL REGISTRATION The trial was registered. The number is ChiCTR2200057446.
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Affiliation(s)
- Rongyan Zhang
- Department of Anesthesiology, Zhuji Central Hospital, Zhuji, Zhejiang, China
| | - Gang Zhao
- Department of Anesthesiology, Zhuji People’s Hospital, Zhuji, Zhejiang, China
| | - Zhangjun Yan
- Department of Anesthesiology, Zhuji People’s Hospital, Zhuji, Zhejiang, China
| | - Hongmei Xuan
- Department of Anesthesiology, Zhuji People’s Hospital, Zhuji, Zhejiang, China
| | - Yan Chen
- Department of Anesthesiology, Zhuji People’s Hospital, Zhuji, Zhejiang, China
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Iacopino S, Filannino P, Artale P, Petretta A, Colella J, Statuto G, Di Vilio A, Dini D, Mantovani L, Rago A, Sorrenti PF, Fabiano G, Campagna G, Fabiano E, Malacrida M, Cecchini F. Investigating Deep Sedation With Intravenous Ketamine in Spontaneous Respiration During Pulsed-Field Ablation. J Cardiothorac Vasc Anesth 2024; 38:148-154. [PMID: 37953172 DOI: 10.1053/j.jvca.2023.10.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 10/13/2023] [Accepted: 10/16/2023] [Indexed: 11/14/2023]
Abstract
OBJECTIVES The authors report their experience of a protocol for deep sedation with ketamine in spontaneous respiration during the pulsed-field ablation (PFA) of atrial fibrillation (AF). DESIGN Observational, prospective, nonrandomized fashion. SETTING Single-center hospitalized patients. PARTICIPANTS All consecutive patients undergoing PFA of AF. INTERVENTIONS Patients undergoing deep sedation with intravenous ketamine. MEASUREMENTS AND MAIN RESULTS The authors' sedation protocol involves the intravenous administration of fentanyl (1.5 µg/kg) and midazolam (2 mg) at low doses before local anesthesia with lidocaine. A ketamine adjunct (1 mg/kg) in 5-minute boluses was injected about 5 minutes before the first PFA delivery. The authors enrolled 117 patients (age = 59 ± 10 y, 74.4% males, body mass index = 27.6 ± 5 kg/m2, fluoroscopy time = 24 ± 14 minutes, skin-to-skin time = 80 ± 40 minutes and PFA LA dwell time = 24 ± 7 minutes). By the end of the procedure, pulmonary vein isolation had been achieved in all patients using PFA alone. The mean time under sedation was 54.9 ± 6 minutes, with 92 patients (79%) being sedated for <1 hour. A satisfactory Ramsay Sedation Scale level before ketamine administration was achieved in all patients, except one (80.3% of the patients with rank 3; 18.4% with rank 2). In all procedures, the satisfaction level was found acceptable by both the patient and the primary operator (satisfactory in 98.2% of cases). All patients achieved a Numeric Rating Scale for Pain ≤3 (none or mild). No major procedure or anesthesia-related complications were reported. CONCLUSION The authors' standardized sedation protocol with the administration of drugs with rapid onset and pharmacologic offset at low doses was safe and effective, with an optimal degree of patient and operator satisfaction.
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Trenholme HN, Sakai DM, Craig HA, Torpy FJ, Reed RA, Martin-Flores M. Evaluation of a rapid sequence induction technique in dogs with or without rocuronium. Vet Anaesth Analg 2024; 51:52-59. [PMID: 38071121 DOI: 10.1016/j.vaa.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 11/12/2023] [Accepted: 11/12/2023] [Indexed: 12/27/2023]
Abstract
OBJECTIVE To determine, using a rapid sequence induction (RSI) technique, whether rocuronium improves the quality and speed of endotracheal intubation in healthy dogs. STUDY DESIGN Randomized, crossover, experimental study. ANIMALS Six adult intact male Beagles (12.3 ± 0.4 kg). METHODS Dogs were premedicated with intravenous acepromazine (0.03 mg kg-1) and hydromorphone (0.1 mg kg-1). Ten minutes later, anesthesia was induced with intravenous propofol (2 mg kg-1 over 5 seconds), followed by saline (0.06 mL kg-1, CT group) or rocuronium (0.6 mg kg-1, RT group), with orotracheal intubation attempted after 45 seconds. Intubation time (IT) and conditions (IC) were assessed. PaO2, PaCO2, arterial blood pH and serum cortisol were obtained before and after RSI. After endotracheal intubation, saline (0.04 mL kg-1) or sugammadex (4 mg kg-1) were administered intravenously in CT or RT groups, respectively. Spontaneous ventilation restoration was noted. RESULTS The IT was 54.3 ± 6.9 (mean ± SD) and 57.8 ± 5.2 seconds for CT and RT, respectively (p = 0.385). All laryngoscopies indicated good IC in both treatment groups. Heart rate was lower in CT group than in RT group (66 ± 16 versus 103 ± 39 beats minute-1, p = 0.016). PaCO2, pH, PaO2 and cortisol did not differ between treatments. Compared with baseline, PaCO2 increased from 47.7 ± 6.2 to 58.8 ± 5.8 (p < 0.001) and pH decreased from 7.35 ± 0.04 to 7.28 ± 0.04 (p = 0.003), independent of treatment. Dogs in both treatment groups returned to spontaneous ventilation within 30 seconds of RSI. CONCLUSIONS AND CLINICAL RELEVANCE RSI resulted in respiratory acidosis without hypoxemia or increased cortisol. Rocuronium did not improve IT or IC. Spontaneous ventilation was observed immediately after administering saline or sugammadex. The co-administration of rocuronium showed no clinical benefits over propofol alone in RSI in healthy dogs.
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Affiliation(s)
- H Nicole Trenholme
- Department of Large Animal Medicine, College of Veterinary Medicine, University of Georgia, Athens, GA, USA
| | - Daniel M Sakai
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, GA, USA.
| | - Hannah A Craig
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, GA, USA
| | - Frederick J Torpy
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, GA, USA
| | - Rachel A Reed
- Department of Large Animal Medicine, College of Veterinary Medicine, University of Georgia, Athens, GA, USA
| | - Manuel Martin-Flores
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, USA
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Aggarwal S, Misquith JCR, Rao ST, Mahanta P. Comparison of three scoring criteria to assess recovery from general anesthesia in the postanesthesia care unit in the indian population. Ann Afr Med 2024; 23:82-86. [PMID: 38358176 PMCID: PMC10922174 DOI: 10.4103/aam.aam_165_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 11/08/2023] [Accepted: 11/28/2023] [Indexed: 02/16/2024] Open
Abstract
Background Different discharge criteria are available for shifting patients out from postanesthesia care room following surgery. This study was done to compare the three-scoring system namely traditional time-based criteria, Fast track criteria and modified Aldrete score, in Indian population patients who recover after general anesthesia in postanesthesia care unit (PACU). Materials and Methods Three hundred and seventy-five patients scheduled for general anesthesia were included in this study. Induction of anesthesia was done with intravenous (IV) propofol and maintained with sevoflurane inhalation with oxygen and nitrous oxide. Reversal of residual neuromuscular blockade was done with IV neostigmine and glycopyrrolate. Patients were shifted to PACU following tracheal extubation and recovery was assessed using the traditional time-based criteria, fast track criteria, and modified Aldrete score. Results As per modified Aldrete score, mean time of shift out is 19 min with median of 15 min and standard deviation of 21.7 min. As per fast-track score, mean time of shift out is 187 min with median of 30 min and standard deviation of 243.7 min. As per the time-based criteria, mean time of shift out is 222 min with median of 240 min and standard deviation of 136.8 min. While using modified Aldrete score, majority of patients had a shorter stay in PACU and faster time to shift out as compared to fast-track criteria and traditional time-based criteria. Conclusion Modified Aldrete score when compared to fast-track scoring and time-based criteria shows early recovery and reduces the length of stay in PACU.
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Affiliation(s)
- Shagun Aggarwal
- Department of Anaesthesiology, Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan, India
| | - Julie C R Misquith
- Department of Anaesthesiology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India
| | - Sumesh T. Rao
- Department of Anaesthesiology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India
| | - Priyanka Mahanta
- Department of Anaesthesiology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India
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Crimmins D, Ryan E, Shah D, Lwin TN, Ayotte S, Redmond K, Highton D. The Effect of Anesthetic Agent and Mean Arterial Pressure on Functional Outcome After General Anesthesia for Endovascular Thrombectomy. J Neurosurg Anesthesiol 2024; 36:29-36. [PMID: 36477404 DOI: 10.1097/ana.0000000000000897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 10/06/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND The optimal general anesthetic (GA) technique for stroke patients undergoing endovascular thrombectomy (ET) is unclear. We compared favorable outcomes and mortality in patients receiving propofol or volatile GA during ET and assessed associations between mean arterial pressure (MAP) and outcome. METHODS Ninety-three patients with anterior circulation stroke who received propofol or volatile GA during ET between February 2015 and February 2018 were included in this retrospective study. Ninety-day modified Rankin scores were compared and mortality was adjusted for intravenous thrombolysis and diabetes. We performed ordinal logistic regression analyses containing MAP time/exposure thresholds. RESULTS There was no difference in the rate of favorable outcome (modified Rankin scores 0-2) in the volatile and propofol groups (48.8% vs. 55.8%, respectively; P =0.5). Ninety-day mortality was lower in patients receiving propofol (11.5%) than in those receiving volatile GA (29.3%) (odds ratio, 0.32; 95% confidence interval, 0.11 to 0.94; P =0.03); this mortality benefit was greater in patients that did not receive intravenous thrombolysis before ET (odds ratio for survival, 6; 95% confidence interval, 1.13 to 31.74). There was no difference in MAP between groups and a (nonsignificant) trend towards the benefit of MAP <90 mm Hg but not <70 mm Hg. CONCLUSIONS Favorable outcome rates were similar in stroke patients receiving propofol or volatile GA during ET. Propofol was associated with lower mortality, an effect magnified in patients that did not receive intravenous thrombolysis. MAP time/exposure thresholds were associated with outcome but independent of the anesthetic agent. Our data suggest that a difference in outcome related to an anesthetic agent may exist; this hypothesis needs to be tested in a prospective study.
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Affiliation(s)
| | - Elizabeth Ryan
- Centre for Health Services Research, Faculty of Medicine
- QCIF Facility for Advanced Bioinformatics, Institute for Molecular Bioscience, The University of Queensland, Brisbane, Australia
| | | | | | - Steven Ayotte
- Princess Alexandra Hospital, Southside Clinical Unit
| | | | - David Highton
- Princess Alexandra Hospital, Southside Clinical Unit
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Vullo PA, Real Navacerrada MÍI, Navarro Suay R. Hemodynamic impact of increasing time between fentanyl and propofol administration during anesthesia induction: a randomised, clinical trial. Braz J Anesthesiol 2024; 74:744230. [PMID: 34324933 PMCID: PMC10877358 DOI: 10.1016/j.bjane.2021.07.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 06/25/2021] [Accepted: 07/10/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND OBJECTIVE Anesthesia induction can produce severe propofol dose-dependent hypotension. Fentanyl coadministration reduces the catecholaminergic response to orotracheal intubation allowing propofol dose reduction. The aim of this study is to determine whether the hemodynamic response is improved by increasing the time between fentanyl and propofol administration and reducing the dose of the latter without increasing the time to achieve optimal hypnosis. METHODS After approval by the Research Ethics Committee, patients undergoing non-cardiac surgery with endotracheal intubation were randomized by a computer-generated table into six time-dose groups (1 or 2...minutes/1, 1.5, or 2...mg.kg-1 of propofol). Patients with high bronchoaspiration risk, a difficult airway, hemodynamic instability, or anesthetic allergies were excluded. After giving intravenous fentanyl (2.....g.kg-1), each group received different doses of propofol after 1 or 2...minutes. Noninvasive blood pressure (BP) and heart rate (HR) were measured at pre-induction, pre-intubation, and post-intubation. Time to hypnosis (bispectral index < 60) was also recorded. RESULTS Of the 192 recruited patients, 186 completed the study (1...min group n...=...94; 2...min group n...=...92). It was observed that HR and BP decreased after propofol administration and increased after intubation in all groups (p...<...0.0001). In patients over 55 years, the 2 min ... 2 mg.kg-1 group showed the greatest systolic BP reduction (36........12%) at pre-intubation, while the 1...min.........1.5...mg.kg-1 group showed the least hemodynamic alteration between pre- and post-intubation (-4........13%). No significant differences were found in younger patients or in the time to reach hypnosis between the six groups. While no cases of severe bradycardia were recorded, 5,4% of the sample required vasopressors. CONCLUSION Increasing the time between the administration of fentanyl and propofol by up to two minutes results in greater hypotension in patients over 55 years.
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Affiliation(s)
- Paula A Vullo
- Hospital Central de la Defensa G..mez Ulla-IMIDEF, Critical Care and Pain Unit, Department of Anesthesia, Madrid, Spain.
| | - Mar Ía I Real Navacerrada
- Hospital Universitario 12 de Octubre, Critical Care and Pain Unit, Department of Anesthesia, Madrid, Spain
| | - Ricardo Navarro Suay
- Hospital Central de la Defensa G..mez Ulla-IMIDEF, Critical Care and Pain Unit, Department of Anesthesia, Madrid, Spain
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81
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吴 美, 杨 芳, 马 行, 蔡 宁. [Comparison of clinical effects and safety of remidazolam and esketamine for preoperative sedation in children]. Nan Fang Yi Ke Da Xue Xue Bao 2023; 43:2126-2131. [PMID: 38189400 PMCID: PMC10774111 DOI: 10.12122/j.issn.1673-4254.2023.12.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Indexed: 01/09/2024]
Abstract
OBJECTIVE To compare the clinical effects and safety of remiazolam and esketamine in preoperative sedation in children. METHODS This study was conducted among 61 children (1-4 years old) undergoing elective bilateral tonsillectomy with or without adenoidectomy under general anesthesia from January 2022 to March 2023. The children were randomized into two groups to receive preoperative sedation with intravenous administration of 0.2 mg/kg remidazolam (R group, 30 cases) or 0.5 mg/kg esketamine (S group, 31 cases). The two groups were compared for PSAS score, vital signs (MAP, SpO2, and HR), sedation score, mask acceptance score at induction, sedation onset time, postoperative recovery time, MAP and HR after induction, Ramsay sedation score after awakening, doses of propofol and remifentanil during anesthesia, emergence agitation (EA), postoperative adverse effects and negative postoperative behavioral changes (NPOBCs) on the 7th and 14th days after operation. RESULTS The PSAS score, sedation score, mask acceptance score at induction, MAP and HR after induction, Ramsay sedation score after awakening, propofol dose during anesthesia induction, and the incidence of EA and NPOBCs after operation were all similar between the two groups (P > 0.05). Compared with those in S group, the sedation onset time was slightly longer, the recovery time was shorter, and the doses of propofol and remifentanil for anesthesia maintenance was higher (P < 0.05) in R group. Sedation with remidazolam did not cause significant changes in MAP, SpO2 or HR (P > 0.05), while administration of esketamine significantly increased MAP and HR (P < 0.05) without obviously affecting SpO2 (P > 0.05). CONCLUSION In children aged 1-4 years, compared with 0.5 mg/kg esketamine, intravenous injection of 0.2 mg/kg remidazolam for preoperative sedation has a slightly longer onset time and is associated with a shorter recovery time and more stable hemodynamics, suggesting its good feasibility and safety.
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Affiliation(s)
- 美潮 吴
- />阜阳市人民医院麻醉科,安徽 阜阳 236000Department of Anesthesia, Fuyang People's Hospital, Fuyang 236000, China
| | - 芳芳 杨
- />阜阳市人民医院麻醉科,安徽 阜阳 236000Department of Anesthesia, Fuyang People's Hospital, Fuyang 236000, China
| | - 行军 马
- />阜阳市人民医院麻醉科,安徽 阜阳 236000Department of Anesthesia, Fuyang People's Hospital, Fuyang 236000, China
| | - 宁 蔡
- />阜阳市人民医院麻醉科,安徽 阜阳 236000Department of Anesthesia, Fuyang People's Hospital, Fuyang 236000, China
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82
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Li X, Wu J, Lan H, Shan W, Xu Q, Dong X, Duan G. Effect of Intraoperative Intravenous Lidocaine on Postoperative Delirium in Elderly Patients with Hip Fracture: A Prospective Randomized Controlled Trial. Drug Des Devel Ther 2023; 17:3749-3756. [PMID: 38125207 PMCID: PMC10730424 DOI: 10.2147/dddt.s437599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 12/11/2023] [Indexed: 12/23/2023] Open
Abstract
Purpose This study was performed to evaluate the effects of intraoperative intravenous lidocaine on postoperative delirium in elderly patients with hip fracture. Patients and methods In total, 100 elderly patients undergoing hip fracture surgery were randomized to the lidocaine group (Group L) or saline (control) group (Group C). Before anesthetic induction, Group L received lidocaine at 1 mg/kg for more than 10 minutes followed by continuous infusion at 1.5 mg/kg/h until the end of surgery. Group C received normal saline, and the injection methods were consistent with those in Group L. General anesthesia was induced with propofol, sufentanil, and cis-atracurium. Anesthesia was maintained by propofol and remifentanil. The primary outcome was the incidence of postoperative delirium in the first 7 postoperative days. The secondary outcomes included the severity of delirium, onset and duration of delirium, emergence agitation, adverse events, total propofol dose, intraoperative opioid dosage, length of post-anesthesia care unit stay, extubation time, and patient satisfaction with postoperative pain management. Results All 100 patients completed the study. The incidence of postoperative delirium was lower in Group L than in Group C (14% vs 36%, P = 0.011). The delirium severity scores were lower in Group L (3 [3-4]) than in Group C (4 [4-5]) (P = 0.017). In addition, the incidences of hypertension, tachycardia, and emergence agitation were significantly lower in Group L than in Group C. No cases of local anesthetic toxicity occurred in either group. Conclusion Patients received lidocaine at 1 mg/kg for more than 10 minutes followed by continuous infusion at 1.5 mg/kg/h until the end of surgery, which can reduce the incidence of postoperative delirium in elderly patients undergoing hip fracture. In addition, the used regimen of lidocaine would not increase the risk of local anesthetic toxicity.
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Affiliation(s)
- Xiaofen Li
- Nursing Department, Lishui People’s Hospital, The Sixth Affiliated Hospital of Wenzhou Medical University, Lishui, People’s Republic of China
| | - Jimin Wu
- Department of Anesthesiology, Lishui People’s Hospital, The Sixth Affiliated Hospital of Wenzhou Medical University, Lishui, People’s Republic of China
| | - Haiyan Lan
- Department of Anesthesiology, Lishui People’s Hospital, The Sixth Affiliated Hospital of Wenzhou Medical University, Lishui, People’s Republic of China
| | - Weifeng Shan
- Department of Anesthesiology, Lishui People’s Hospital, The Sixth Affiliated Hospital of Wenzhou Medical University, Lishui, People’s Republic of China
| | - Qiaomin Xu
- Department of Anesthesiology, Lishui People’s Hospital, The Sixth Affiliated Hospital of Wenzhou Medical University, Lishui, People’s Republic of China
| | - Xiaoli Dong
- Department of Anesthesiology, Lishui People’s Hospital, The Sixth Affiliated Hospital of Wenzhou Medical University, Lishui, People’s Republic of China
| | - Gongchen Duan
- Department of Anesthesiology, Lishui People’s Hospital, The Sixth Affiliated Hospital of Wenzhou Medical University, Lishui, People’s Republic of China
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Cui S, Huang P, Wei Z, Guo T, Zhang A, Huang L. Esketamine Combined with Propofol TCI versus Propofol TCI for Deep Sedation during Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration: A Prospective, Randomized, and Controlled Trial. Int J Clin Pract 2023; 2023:1155126. [PMID: 38115950 PMCID: PMC10728353 DOI: 10.1155/2023/1155126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 11/19/2023] [Accepted: 12/06/2023] [Indexed: 12/21/2023] Open
Abstract
Background Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is an invasive procedure that required deep sedation to suppress coughing and body movements. Deep sedation, on the other hand, has been shown to cause respiratory and circulatory depression, especially when the airway is shared with the endoscopist. Esketamine is a novel sedative and analgesic with little respiratory inhibition that appears to be an appropriate adjuvant in propofol sedation for EBUS-TBNA. We compared the efficacy and safety of esketamine combined with propofol target-controlled infusion (TCI) and propofol TCI for deep sedation in EBUS-TBNA. Methods The study included 135 patients with ASA II-III undergoing EBUS-TBNA. They were randomly divided into two groups (group E and group P). Both groups received midazolam (0.01-0.03 mg/kg) and oxycodone (0.07-0.08 mg/kg). Then, patients in group E received 0.3 mg/kg esketamine, propofol TCI, and 0.2 mg·kg-1·h-1 esketamine for sedative maintenance. Patients in group P received only propofol TCI. The primary outcome was the dose of 1% lidocaine administrated by the endoscopist and the times of lidocaine sprays. Secondary outcome indicators were cough score, propofol dosage, patient satisfaction, endoscopist satisfaction, the incidence of sedation-related adverse effects and side effects, and recovery time. Results Patients in group E were given significantly less lidocaine (4.36 ml/h (2.67-6.00) vs 6.00 ml/h (4.36-7.20), P < 0.001) and less spraying frequency (2.18 times/h (1.33-3.00) vs 3.00 times/h (2.18-3.60), P < 0.001) than group P. There was a statistically significant difference in cough score between the two groups (group E 2 (0-4) vs group P 3 (2-4), P=0.03). Also, mean arterial pressure (MAP) was higher in group E in the 30th min (T5, 84.10 ± 12.91 mmHg versus 79.04 ± 10.01 mmHg, P=0.012) and 40th min (T6, 87.72 ± 15.55 mmHg versus 82.14 ± 10.51 mmHg, P=0.026). There were no significant differences between the two groups in terms of sedation-related adverse events and side effects, recovery time, endoscopist satisfaction, and patient satisfaction. Conclusions In patients with ASA II-III, esketamine as an adjuvant in combination with propofol TCI deep sedation for EBUS-TBNA can improve the sedation effect, reduce coughing reaction during the procedure, and obtain more stable blood pressure. No reduction in the occurrence of sedation-related side effects was observed. This trial is registered with ChiCTR2200061124.
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Affiliation(s)
- Sichen Cui
- Department of Anesthesiology, The Second Hospital of Hebei Medical University, Shijiazhuang 050000, China
| | - Peiying Huang
- Department of Anesthesiology, The Second Hospital of Hebei Medical University, Shijiazhuang 050000, China
| | - Zhanxiong Wei
- Department of Anesthesiology, The Second Hospital of Hebei Medical University, Shijiazhuang 050000, China
| | - Ting Guo
- Department of Pneumology, The Second Hospital of Hebei Medical University, Shijiazhuang 050000, China
| | - Aiyan Zhang
- Department of Pneumology, The Second Hospital of Hebei Medical University, Shijiazhuang 050000, China
| | - Lining Huang
- Department of Anesthesiology, The Second Hospital of Hebei Medical University, Shijiazhuang 050000, China
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Xie P, Wu Z, Zha B, Xu L, Shen S, Zhuang H, Wei H. Risk factors for pharyngalgia and xerostomia undergoing supraglottic jet oxygenation and ventilation in gastrointestinal endoscopy: a retrospective study. Sci Rep 2023; 13:21949. [PMID: 38081892 PMCID: PMC10713572 DOI: 10.1038/s41598-023-49473-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 12/08/2023] [Indexed: 12/18/2023] Open
Abstract
Supraglottic jet oxygenation/ventilation (SJOV) can reduce hypoxemia in sedated endoscopy but may increase minor side effects like pharyngalgia and xerostomia. This study aimed to identify risk factors for pharyngalgia/xerostomia with SJOV during gastrointestinal endoscopy. From January 1 to December 31, 2021, 5313 patients with propofol sedation and SJOV underwent gastrointestinal endoscopy or removal of gastrointestinal polyps was analyzed retrospectively. Data included patient characteristics, operation details, postoperative adverse events, and potential risk factors for postoperative adverse events. Parameters considered as potential risk factors were identified based on study results published previously and based on the researcher's idea and clinical experience. The patient factors and the incidence of pharyngalgia/xerostomia at 30 min post-procedure were assessed. Descriptive statistics were calculated using SPSS software. Evaluation potential risk factors using univariate and multivariate logistic regression. Pharyngalgia/xerostomia occurred in 18.7% of patients at 30 min after procedure. A multivariable analysis showed that procedure time and pharyngalgia/xerostomia within 2 weeks were independent risk factors. Procedure time had the strongest association with postoperative pharyngalgia/xerostomia (OR, 8.09 [95% CI, 4.197-6.312]). No factors were significantly associated with hypoxemia risk (1.7% incidence). There were no barotrauma or other serious morbidity or mortality. Procedure duration and recent pharyngalgia/xerostomia increased risk of pharyngalgia/xerostomia with SJOV during endoscopy. Limiting SJOV duration may reduce side effects in susceptible patients. No predictors of hypoxemia were identified.
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Affiliation(s)
- Ping Xie
- Department of Anesthesiology, 910th Hospital of PLA, Quanzhou, 362000, China
| | - Zhiyun Wu
- Department of Anesthesiology, 910th Hospital of PLA, Quanzhou, 362000, China
| | - Benjun Zha
- Department of Anesthesiology, 910th Hospital of PLA, Quanzhou, 362000, China.
| | - Li Xu
- Department of Anesthesiology, 910th Hospital of PLA, Quanzhou, 362000, China
| | - Shanyi Shen
- Department of Anesthesiology, 910th Hospital of PLA, Quanzhou, 362000, China
| | - Haibin Zhuang
- Department of Anesthesiology, 910th Hospital of PLA, Quanzhou, 362000, China
| | - Huafeng Wei
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
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85
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Bilgen S, Erdogan D, Ökten SB. Infusion of propofol with bispectral index monitoring does not reduce the amount of propofol used during transvaginal oocyte retrieval procedure. Sci Rep 2023; 13:21561. [PMID: 38057377 PMCID: PMC10700325 DOI: 10.1038/s41598-023-48611-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 11/28/2023] [Indexed: 12/08/2023] Open
Abstract
In our study we aimed to investigate whether the use of bispectral index (BIS) monitoring would decrease total propofol consumption during the transvaginal oocyte retrieval procedure. This was a prospective, randomized, controlled, parallel-group clinical trial. The study was conducted in the operating room, and postoperative recovery room. One hundred and thirty, American Society of Anesthesiologists (ASA) I-II patients, over age 18, undergoing transvaginal oocyte retrieval were included in this study. All patients were administered 2 μg/kg fentanyl, and 2 mg/kg propofol for the induction of anesthesia. The patients were divided into two groups. Patients in the group bolus were given 0.5 mg/kg of propofol when necessary, according to the observer's range of motion. Patients in the group BIS were given 10 mg/kg/h propofol infusion adjusted to keep the BIS value between 40 and 60. The primary outcome was the total dose of propofol administered per patient. The secondary outcomes were the time to reach the value of 5 on the Modified Observer's Assessment of Alertness Sedation Scale (MOASs), the time to reach Post Anesthetic Discharge Scoring System (PADSS) ≥ 9 of the patients, satisfaction of the patient, and the gynecologist. The amount of total propofol was higher in the group BIS than in the group bolus administered according to the patient's clinic. There was no difference in the time to reach the value of 5 on the MOASs between the groups. The time to reach PADSS ≥ 9 was longer in the group BIS than in the group bolus. There was no difference between the two groups in terms of the satisfaction of the patient and the gynecologist. Administration of propofol as an infusion with BIS monitoring did not reduce the amount of propofol administered to patients during transvaginal oocyte retrieval.Clinical trial registration number: NCT05631925-30/11/2022.
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Affiliation(s)
- Sevgi Bilgen
- Department of Anesthesiology, Acibadem Kozyatagi Hospital, Ondokuz Mayıs Mah., Begonya Sokak., No:12 Kadıköy, Istanbul, Turkey.
| | - Dilek Erdogan
- Department of Anesthesiology, Acibadem Kozyatagi Hospital, Ondokuz Mayıs Mah., Begonya Sokak., No:12 Kadıköy, Istanbul, Turkey
| | - Sabri Berkem Ökten
- Department of Obstetrics and Gynecology, Acibadem Kozyatagi Hospital, Ondokuz Mayıs Mah., Begonya Sokak., No:12 Kadıköy, Istanbul, Turkey
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86
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Sun Z, Sui J. Delirium in older patients given propofol or sevoflurane anaesthesia for major cancer surgery: a multicentre randomised trial. Comment on Br J Anaesth 2023; 131: 253-65. Br J Anaesth 2023; 131:e185-e186. [PMID: 37793958 DOI: 10.1016/j.bja.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 09/05/2023] [Indexed: 10/06/2023] Open
Affiliation(s)
- Zhongpeng Sun
- Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Jinghu Sui
- Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China.
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Beilstein CM, Meyer A, Lehmann LE, Wuethrich PY. Comments on "Postanesthesia Recovery Unit Optimization for Patients With Postictal Agitation Secondary to Electroconvulsive Therapy" by Arora et al. J ECT 2023; 39:274-275. [PMID: 38009971 DOI: 10.1097/yct.0000000000000963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
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Smischney NJ, Stoltenberg AD, Schroeder DR, DeAngelis JL, Kaufman DA. Noninvasive Cardiac Output Monitoring (NICOM) in the Critically Ill Patient Undergoing Endotracheal Intubation: A Prospective Observational Study. J Intensive Care Med 2023; 38:1108-1120. [PMID: 37322892 DOI: 10.1177/08850666231183401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Background: Cardiovascular instability occurring during endotracheal intubation (ETI) in the critically ill is a commonly recognized phenomenon. However, this complication has not been evaluated in terms of the physiological cause (ie, decreased preload, contractility, or afterload) leading to the instability. Thus, the aim of the current investigation was to describe the hemodynamics occurring during ETI with noninvasive physiologic monitoring and to collect preliminary data on the hemodynamic effects of induction agents and positive pressure ventilation. Methods: A multicenter prospective study enrolling adult (≥18 years) critically ill patients undergoing ETI with noninvasive cardiac output monitoring in a medical/surgical intensive care unit from June 2018 to May 2019 was conducted. This study used the Cheetah Medical noninvasive cardiac output monitor to collect hemodynamic data during the peri-intubation period. Additional data collected included baseline characteristics such as illness severity, peri-intubation pharmacologic administration, and mechanical ventilation settings. Results: From the original 27 patients, only 19 (70%) patients had complete data and were included in the final analysis. Propofol was the most common sedative 8 (42%) followed by ketamine 6 (32%) and etomidate 5 (26%). Patients given propofol demonstrated a decrease in total peripheral resistance index (delta change [dynes × s/cm-5/m2]: -2.7 ± 778.2) but stabilization in cardiac index (delta change (L/min/m2]: 0.1 ± 1.5) while etomidate and ketamine demonstrated increases in total peripheral resistance index (etomidate delta change [dynes × s/cm-5/m2]: 302.1 ± 414.3; ketamine delta change [dynes × s/cm-5/m2]: 278.7 ± 418.9) but only etomidate resulted in a decrease in cardiac index (delta change [L/min/m2]: -0.3 ± 0.5). Positive pressure ventilation resulted in minimal changes to hemodynamics during ETI. Conclusions: The current study demonstrates that although propofol administration leads to a decrease in total peripheral resistance index, cardiac index is maintained while etomidate leads to a decrease in cardiac index with both etomidate and ketamine increasing total peripheral resistance index. These hemodynamic profiles are minimally affected by positive pressure ventilation. Study registration: ClinicalTrials.gov ID, NCT03525743.
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Affiliation(s)
- Nathan J Smischney
- Department of Anesthesiology and Perioperative Medicine, Division of Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
- HEModynamic and AIRway Management (HEMAIR) Study Group, Mayo Clinic, Rochester, MN, USA
| | - Anita D Stoltenberg
- Department of Anesthesiology and Perioperative Medicine, Division of Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | | | | | - David A Kaufman
- Division of Pulmonary, Critical Care, and Sleep Medicine, NYU Langone Health School of Medicine, New York, NY, USA
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Kang S, Hu L, Zhang B, Zhou HM. Efficacy, safety, and postoperative fatigue syndrome in combined alfentanil and propofol for patients with simple snoring undergoing gastroscopy with conscious or deep sedation levels. Asian J Surg 2023; 46:5605-5606. [PMID: 37597980 DOI: 10.1016/j.asjsur.2023.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 08/06/2023] [Indexed: 08/21/2023] Open
Affiliation(s)
- Shuai Kang
- Department of Anesthesiology, Second Affiliated Hospital of Jiaxing University, Jiaxing, 314000, Zhejiang Province, China
| | - Li Hu
- Department of Anesthesiology, Second Affiliated Hospital of Jiaxing University, Jiaxing, 314000, Zhejiang Province, China
| | - Bin Zhang
- Department of Anesthesiology, Second Affiliated Hospital of Jiaxing University, Jiaxing, 314000, Zhejiang Province, China.
| | - Hong-Mei Zhou
- Department of Anesthesiology, Second Affiliated Hospital of Jiaxing University, Jiaxing, 314000, Zhejiang Province, China
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90
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Huang YQ, Weiss S, Gros P, Wong E, Piché PP, Vyas MV, Tam AKH, Watt JA. Prevention and treatment of traumatic brain injury-related delirium: a systematic review. J Neurol 2023; 270:5966-5987. [PMID: 37634162 DOI: 10.1007/s00415-023-11889-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 07/15/2023] [Accepted: 07/17/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Our systematic review examines the effectiveness and safety of non-pharmacologic and pharmacologic interventions in preventing or treating traumatic brain injury (TBI)-related delirium in acute care. METHODS We searched four electronic databases (MEDLINE, EMBASE, CENTRAL/CDSR, and PsycINFO) to identify randomized controlled trials (RCTs), quasi-experimental, and observational studies. Eligible studies included adults with TBI, at least one comparator group, delirium as an outcome and took place in acute care. Two reviewers independently completed all study screening, data abstraction, and risk of bias assessment using the Cochrane risk of bias 2 tool for RCTs or risk of bias in non-randomized studies-of interventions tool for observational studies. We implemented the PROGRESS-Plus framework to describe social determinants of health (SDoH) reporting. RESULTS We identified 20,022 citations, reviewed 301 in full text, and included eight studies in the descriptive synthesis. The mean age of study participants ranged from 32 to 62 years. 12.5% of included studies reported SDoH. Included studies had moderate-to-high risk of bias. Studies compared reorientation programs and an intervention bundle to usual care, but these interventions were not better than usual care in treating TBI-related delirium. Individual studies found that rosuvastatin and aripiprazole were more efficacious than placebo, and dexmedetomidine was more efficacious than propofol and haloperidol for preventing TBI-related delirium. No studies reported safety as the primary outcome. CONCLUSIONS We identified efficacious pharmacologic interventions for preventing TBI-related delirium, but these studies were at moderate-to-high risk of bias, which limits our confidence in these findings. Future studies should incorporate safety outcomes, and a diverse study population, including older adults.
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Affiliation(s)
- Yu Qing Huang
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, 190 Elizabeth Street, R. Fraser Elliott Building, 3-805, Toronto, ON, M5G 2C4, Canada
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, ON, M5B 1W8, Canada
| | - Sophie Weiss
- Temerty Faculty of Medicine, University of Toronto, 6 Queen's Park Crescent West, Third Floor, Toronto, ON, M5S 3H2, Canada
| | - Priti Gros
- Division of Neurology, Department of Medicine, University of Toronto, 6th Floor, Stroke and Neurology Clinic, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - Edwin Wong
- Temerty Faculty of Medicine, University of Toronto, 6 Queen's Park Crescent West, Third Floor, Toronto, ON, M5S 3H2, Canada
| | - Pierre-Philippe Piché
- Division of Infectious Diseases, The Hospital for Sick Children, Toronto, ON, M5G 1X8, Canada
| | - Manav V Vyas
- Division of Neurology, Department of Medicine, University of Toronto, 6th Floor, Stroke and Neurology Clinic, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - Alan Ka Ho Tam
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, ON, M5G 2C4, Canada
| | - Jennifer Ann Watt
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, 190 Elizabeth Street, R. Fraser Elliott Building, 3-805, Toronto, ON, M5G 2C4, Canada.
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, ON, M5B 1W8, Canada.
- St. Michael's Hospital, 36 Queen St East, Toronto, ON, M5B 1W8, Canada.
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91
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Joe HB, Chae YJ, Song SH, Yi IK. Comparison of the effects of dexmedetomidine and propofol on the cardiovascular autonomic nervous system during spinal anesthesia: preliminary randomized controlled observational study. J Clin Monit Comput 2023; 37:1541-1551. [PMID: 37572236 PMCID: PMC10651711 DOI: 10.1007/s10877-023-01062-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 07/21/2023] [Indexed: 08/14/2023]
Abstract
Spinal anesthesia induces sympatholysis and is usually combined with dexmedetomidine or propofol which induce different hemodynamic changes. The purpose of this study was to compare the effect on autonomic nervous system between dexmedetomidine and propofol combined with spinal anesthesia. Patients aged 20-65 undergoing elective surgery under spinal anesthesia were randomly assigned to dexmedetomidine or propofol group. Heart rate variability (HRV) and hemodynamic variables were measured at four time points: T0, baseline; T1, 10 min after spinal anesthesia; T2, 10 min after sedative administration; and T3, 20 min after sedative administration. In 59 patients, dexmedetomidine and propofol groups had significantly different hemodynamic changes over time (time × group effect P < 0.001). The dexmedetomidine group had slower heart rate at T2 (P = 0.001) and higher blood pressures at T2 and T3 (P < 0.001) than the propofol group. Overall HRV dynamics showed a significant change over time from T0 to T3, but both groups exhibited similar trends. Compared to the baseline data within the group, the low frequency (LF) decreased in both groups but the decrease occurred at T2 in the propofol group and at T3 in the dexmedetomidine group. The high frequency (HF) increased at T2 and T3 only in the dexmedetomidine group. The LF/HF ratio decreased in the dexmedetomidine group at T3. Dexmedetomidine showed slower heart rate and higher blood pressure than propofol when combined with spinal anesthesia, however, dexmedetomidine and propofol exhibited similar trends in HRV dynamics. Compared with the baseline within each group, both agents decreased LF, but only dexmedetomidine increased HF and decreased in the LF/HF ratio significantly.
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Affiliation(s)
- Han Bum Joe
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, 164, World cup- ro, Yeongtong-gu, Suwon, 16499, Republic of Korea
| | - Yun Jeong Chae
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, 164, World cup- ro, Yeongtong-gu, Suwon, 16499, Republic of Korea
| | - Seung Ho Song
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, 164, World cup- ro, Yeongtong-gu, Suwon, 16499, Republic of Korea
| | - In Kyong Yi
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, 164, World cup- ro, Yeongtong-gu, Suwon, 16499, Republic of Korea.
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92
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Khurana N, Sünner T, Hubbard O, Imburgia CE, Yellepeddi V, Ghandehari H, Watt KM. Direct and continuous dosing of propofol can saturate Ex vivo ECMO circuit to improve propofol recovery. J Extra Corpor Technol 2023; 55:194-196. [PMID: 38099634 PMCID: PMC10723571 DOI: 10.1051/ject/2023036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 07/28/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is a cardiopulmonary bypass device that provides life-saving complete respiratory and cardiac support in patients with cardiorespiratory failure. The majority of drugs prescribed to patients on ECMO lack a dosing strategy optimized for ECMO patients. Several studies demonstrated that dosing is different in this population because the ECMO circuit components can adsorb drugs and affect drug exposure substantially. Saturation of ECMO circuit components by drug disposition has been posited but has not been proven. In this study, we have attempted to determine if propofol adsorption is saturable in ex vivo ECMO circuits. METHODS We injected ex vivo ECMO circuits with propofol, a drug that is highly adsorbed to the ECMO circuit components. Propofol was injected as a bolus dose (50 μg/mL) and a continuous infusion dose (6 mg/h) to investigate the saturation of the ECMO circuit. RESULTS After the bolus dose, only 27% of propofol was recovered after 30 minutes which is as expected. However, >80% propofol was recovered after the infusion dose which persisted even when the infusion dose was discontinued. CONCLUSION Our results suggest that if ECMO circuits are dosed directly with propofol, drug adsorption can be eliminated as a cause for altered drug exposure. Field of Research: Artificial Lung/ECMO.
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Affiliation(s)
- Nitish Khurana
- Utah Center for Nanomedicine, Department of Molecular Pharmaceutics, College of Pharmacy, University of Utah Salt Lake City Utah 84112 USA
| | - Till Sünner
- Philipps Universität Marburg, Institut für Pharmazeutische Technologie und Biopharmazie Robert-Koch-Straße 4 35037 Marburg Germany
| | - Oliver Hubbard
- Department of Biomedical Engineering, College of Engineering, University of Utah 36 S. Wasatch Salt Lake City Utah 84112 USA
| | - Carina E. Imburgia
- Division of Clinical Pharmacology, Department of Pediatrics, School of Medicine, University of Utah 295 Chipeta Way Salt Lake City Utah 84108 USA
| | - Venkata Yellepeddi
- Utah Center for Nanomedicine, Department of Molecular Pharmaceutics, College of Pharmacy, University of Utah Salt Lake City Utah 84112 USA
- Division of Clinical Pharmacology, Department of Pediatrics, School of Medicine, University of Utah 295 Chipeta Way Salt Lake City Utah 84108 USA
| | - Hamidreza Ghandehari
- Utah Center for Nanomedicine, Department of Molecular Pharmaceutics, College of Pharmacy, University of Utah Salt Lake City Utah 84112 USA
- Department of Biomedical Engineering, College of Engineering, University of Utah 36 S. Wasatch Salt Lake City Utah 84112 USA
| | - Kevin M. Watt
- Division of Clinical Pharmacology, Department of Pediatrics, School of Medicine, University of Utah 295 Chipeta Way Salt Lake City Utah 84108 USA
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93
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Ripperger D, Atte A, Ritto F. Cannabis Users Require More Anesthetic Agents for General Anesthesia in Ambulatory Oral and Maxillofacial Surgery Procedures. J Oral Maxillofac Surg 2023; 81:1460-1465. [PMID: 37783364 DOI: 10.1016/j.joms.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 09/10/2023] [Accepted: 09/10/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND The use of cannabis in the general population has steadily increased over recent years and there is limited literature regarding the anesthetic implications of chronic cannabis use, particularly in the setting of outpatient anesthesia. PURPOSE To determine whether chronic cannabis users undergoing deep sedation or general anesthesia during ambulatory procedures require more anesthetic agents than nonusers. STUDY DESIGN, SETTING, AND SAMPLE A retrospective cohort study of subjects undergoing deep sedation or general anesthesia at the Oklahoma University Oral and Maxillofacial Surgery Clinic from January to December 2022 was performed. The inclusion criteria were duration of anesthetic procedure between 15 to 40 minutes, use of propofol, fentanyl, ketamine, and midazolam, and extraction of at least 2 teeth. The exclusion criterion was patients undergoing adjunctive procedures other than extractions during sedation. PREDICTOR VARIABLE Cannabis use status was grouped as users and nonusers. A user was defined as a subject who self-reported any regular use of cannabis. OUTCOME VARIABLE The primary outcome variable was the amount of intravenous anesthetic agents administered. Secondary outcome variables included the length of the procedure and the number of teeth extracted. COVARIATES Age, sex, and the senior-most resident involved in the sedation. ANALYSES IBM SPSS was utilized to perform descriptive statistics, paired t-tests, ANOVA, and multivariate linear regression. A level of significance of 5% (P < .05) was used for all analyses. RESULTS Four hundred and ninety nine subjects were identified, 189 met the inclusion criteria, and 57 reported using cannabis. The mean age of nonusers was 28.2 ± 7.8 years and that of users was 26.6 ± 6.4 years (P = .09). Females represented 71.9% of nonusers and 72.7% of users. Cannabis users received significantly more propofol (117.5 mg ± 71.3 vs 152.5 mg ± 101.8; P = .004), midazolam (4.7 mg ± 1.0 vs 5.1 mg ± 1.5; P = .01), ketamine (40.2 mg ± 15.7 vs 46.1 mg ± 16.9; P = .01), and fentanyl (75.2 μg ± 26.3 vs 88.6 μg ± 32.8; P = .002) than nonusers, despite extracting a similar number of teeth (4.5 ± 3.1 vs 4.4 ± 3.5; P = .37) in a similar amount of time (25.5 ± 7.3 vs 27.3 ± 7.8; P = .06). CONCLUSION AND RELEVANCE Cannabis users required more propofol, midazolam, ketamine, and fentanyl than non-cannabis users during outpatient oral and maxillofacial surgery procedures.
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Affiliation(s)
- Daniel Ripperger
- Chief Resident, Department of Oral and Maxillofacial Surgery, University of Oklahoma, Oklahoma City, OK
| | - Antonio Atte
- Resident, Department of Oral and Maxillofacial Surgery, University of Oklahoma, Oklahoma City, OK
| | - Fabio Ritto
- Professor & Program Director, Department of Oral and Maxillofacial Surgery, University of Oklahoma, Oklahoma City, OK.
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94
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Okasaki FB, Duarte LGTA, Sabadini E. Increasing the aqueous solubility of the anesthetic propofol through wormlike micelle formation. Colloids Surf B Biointerfaces 2023; 232:113592. [PMID: 37857185 DOI: 10.1016/j.colsurfb.2023.113592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 09/28/2023] [Accepted: 10/11/2023] [Indexed: 10/21/2023]
Abstract
Propofol, a phenol derivative, is commonly employed as an intravenous anesthetic during clinical procedures, formulated as an oil/water emulsion due to its poor solubility in water. The stability limitations associated with emulsions have prompted research efforts towards developing aqueous formulations of propofol. In this work, we investigate the solubility enhancement of propofol in anionic and cationic surfactants. Our findings reveal that the solubility of propofol can increase significantly, up to 100-fold, depending on the nature of the micellar aggregate, as observed for alkylammonium halogenates CnTAB (for n = 12, 14 and 16), contrasting with the lower solubility with SDS. Interestingly, C14TAB and C16TAB demonstrate significantly higher solubility than C12TAB. This was attributed to the formation of wormlike micelles, in which the propofol molecules are positioned between the cationic heads of the surfactant molecules, changing the micellar curvature and the morphology of the aggregate. Therefore, the aromatic molecules in the micellar environment can be partitioned into the micellar cores and their palisades. Regarding C12TAB, the alkyl chain is too short to form wormlike micelles, thus, concentrating propofol molecules mainly into the micellar core, and consequently, leading to their aggregation. Solubility diagrams of propofol were constructed in conjunction with different surfactants. The systems exhibiting viscoelastic behavior, indicative of wormlike micelle formation, were further investigated using rheology. Additionally, the fluorescent properties of propofol enabled the examination of the anesthetic molecule within diverse micellar environments.
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Affiliation(s)
- Fernando B Okasaki
- Department of Physical Chemistry, Institute of Chemistry, University of Campinas, UNICAMP, P.O. Box 6154, Campinas 13084-862, SP, Brazil
| | - Luís G T A Duarte
- Department of Physical Chemistry, Institute of Chemistry, University of Campinas, UNICAMP, P.O. Box 6154, Campinas 13084-862, SP, Brazil
| | - Edvaldo Sabadini
- Department of Physical Chemistry, Institute of Chemistry, University of Campinas, UNICAMP, P.O. Box 6154, Campinas 13084-862, SP, Brazil.
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Dolmans RG, Nahed BV, Robertson FC, Peul WC, Rosenthal ES, Broekman ML. Practice-Pattern Variation in Sedation of Neurotrauma Patients in the Intensive Care Unit: An International Survey. J Intensive Care Med 2023; 38:1143-1150. [PMID: 37415510 PMCID: PMC10616999 DOI: 10.1177/08850666231186563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 06/21/2023] [Indexed: 07/08/2023]
Abstract
Background: Analgo-sedation plays an important role during intensive care management of traumatic brain injury (TBI) patients, however, limited evidence is available to guide practice. We sought to quantify practice-pattern variation in neurotrauma sedation management, surveying an international sample of providers. Methods: An electronic survey consisting of 56 questions was distributed internationally to neurocritical care providers utilizing the Research Electronic Data Capture platform. Descriptive statistics were used to quantitatively describe and summarize the responses. Results: Ninety-five providers from 37 countries responded. 56.8% were attending physicians with primary medical training most commonly in intensive care medicine (68.4%) and anesthesiology (26.3%). Institutional sedation guidelines for TBI patients were available in 43.2%. Most common sedative agents for induction and maintenance, respectively, were propofol (87.5% and 88.4%), opioids (60.2% and 70.5%), and benzodiazepines (53.4% and 68.4%). Induction and maintenance sedatives, respectively, are mostly chosen according to provider preference (68.2% and 58.9%) rather than institutional guidelines (26.1% and 35.8%). Sedation duration for patients with intracranial hypertension ranged from 24 h to 14 days. Neurological wake-up testing (NWT) was routinely performed in 70.5%. The most common NWT frequency was every 24 h (47.8%), although 20.8% performed NWT at least every 2 h. Richmond Agitation and Sedation Scale targets varied from deep sedation (34.7%) to alert and calm (17.9%). Conclusions: Among critically ill TBI patients, sedation management follows provider preference rather than institutional sedation guidelines. Wide practice-pattern variation exists for the type, duration, and target of sedative management and NWT performance. Future comparative effectiveness research investigating these differences may help optimize sedation strategies to promote recovery.
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Affiliation(s)
- Rianne G.F. Dolmans
- Department of Neurosurgery, Leiden University Medical Center, Leiden, the Netherlands
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Brian V. Nahed
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Faith C. Robertson
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Wilco C. Peul
- Department of Neurosurgery, Haaglanden Medical Centre, The Hague, the Netherlands
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Neurosurgery, Leiden, the Netherlands
| | - Eric S. Rosenthal
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Marike L.D. Broekman
- Department of Neurosurgery, Leiden University Medical Center, Leiden, the Netherlands
- Department of Neurosurgery, Haaglanden Medical Centre, The Hague, the Netherlands
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96
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Wang XD, Zhou Y, Guo ZJ, Jiao L, Han F, Yang XD. Efficacy of ultrasound guided superior laryngeal nerve block on sedation for delayed extubation in maxillofacial surgery with free flap reconstruction. J Stomatol Oral Maxillofac Surg 2023; 124:101589. [PMID: 37543208 DOI: 10.1016/j.jormas.2023.101589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 07/30/2023] [Accepted: 08/02/2023] [Indexed: 08/07/2023]
Abstract
OBJECTIVE Superior laryngeal nerve block (SLNB) is a regional anesthesia technique for addressing airway response. However, SLNB on the efficacy of sedation in patients with delayed extubation is unknown, particularly for maxillofacial surgery (MS). The aim of the study was to assess whether ultrasound guided (UG) SLNB reduces the incidence of moderate to severe cough for delayed extubation in MS with free flap reconstruction. METHODS 60 patients were randomly assigned to the GEA group (control group) and the SLNB group (UG-SLNB postoperatively, study group). During the initial two postoperative hours, the incidence of moderate and severe cough, agitation, and the number of patients requiring rescue propofol and flurbiprofen were recorded. Additionally, the time spent under the target level of sedation, postoperative hemodynamics, and the total does of propofol during the postoperative 24 h were recorded. RESULTS The data showed the SLNB group had a significantly lower incidence of moderate to severe cough and agitation (p < 0.05), and a longer sedation time (p < 0.05). The number of patients required rescue propofol and flurbiprofen, as well as the hemodynamic changes, were significantly different between the two groups (p < 0.05). CONCLUSION The use of UG-SLNB is associated with reduced incidence of postoperative cough. Moreover, SLNB can enhance the efficacy of postoperative sedation with need of fewer agents postoperatively. CLINICAL TRIAL REGISTRATION ChiCTR2000039982.
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Affiliation(s)
- Xiao-Dong Wang
- Department of Anesthesiology, Peking University School and Hospital of Stomatology, Beijing, PR China
| | - Yi Zhou
- Department of Anesthesiology, Peking University School and Hospital of Stomatology, Beijing, PR China
| | - Zi-Jian Guo
- Department of Anesthesiology, Peking University School and Hospital of Stomatology, Beijing, PR China
| | - Liang Jiao
- Department of Anesthesiology, Peking University School and Hospital of Stomatology, Beijing, PR China
| | - Fang Han
- Department of Anesthesiology, Peking University School and Hospital of Stomatology, Beijing, PR China
| | - Xu-Dong Yang
- Department of Anesthesiology, Peking University School and Hospital of Stomatology, Beijing, PR China.
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97
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Ulutas H, Ucar M, Celik MR, Agar M, Gulcek I. Sedation with Propofol and Propofol-Ketamine (Ketofol) in Flexible Bronchoscopy: A Randomized, Double-Blind, Prospective Study. Niger J Clin Pract 2023; 26:1817-1823. [PMID: 38158347 DOI: 10.4103/njcp.njcp_245_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 10/09/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND The flexible bronchoscopy procedure, which is performed in awake conditions or under local anesthesia, is a difficult and complicated procedure for patients and physicians. Propofol is a fast-acting sedative-hypnotic anesthetic with a rapid return. Ketamine hydrochloride is a fast-acting general anesthetic producing an anesthetic state characterized by deep analgesia, normal pharyngeal, and laryngeal reflexes. MATERIALS AND METHOD The study was planned in a randomized, prospective, and double-blind design. The drug(s) administered by the anesthesiologist was not known to the bronchoscopist and the patient. A total of 64 cases were included in the study (34/propofol, 30/ketamine-propofol (ketofol) group). Group propofol received 0.1 mL/kg propofol, and group ketofol received 0.1 mL/kg ketofol intravenously over approximately 30 seconds. Vital signs, non-invasive blood pressure, peripheral oxygen saturation, and pulse values of all cases were measured three times and were recorded just before the start of the procedure, after entering the trachea, and after the procedure was terminated. The Visual Analogue Scale (VAS) and The Ramsay scoring were additionally used in the present study. RESULTS Statistically significant differences were detected between the groups in terms of blood pressure and heart rates. Statistically significant differences were detected between the two groups according to The VAS scoring and additional dose requirement. CONCLUSION It must be noted that flexible bronchoscopy procedures, which are performed with local anesthesia by both the patient and the physician with a high degree of difficulty, especially combined drugs to be applied with anesthesia support, are more effective/comfortable/reliable, and have fewer complications and higher tolerability if there are no contraindications.
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Affiliation(s)
- H Ulutas
- Department of Thoracic Surgery, University of Inonu, School of Medicine, Malatya, Turkey
| | - M Ucar
- Department of Anesthesiology, University of Inonu, School of Medicine, Malatya, Turkey
| | - M R Celik
- Department of Thoracic Surgery, University of Atılım, School of Medicine, Ankara, Turkey
| | - M Agar
- Department of Thoracic Surgery, University of Inonu, School of Medicine, Malatya, Turkey
| | - I Gulcek
- Department of Thoracic Surgery, University of Inonu, School of Medicine, Malatya, Turkey
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Behrens A, Ell C. Safety of endoscopist-guided sedation in a low-risk collective. Z Gastroenterol 2023; 61:1593-1602. [PMID: 36630976 DOI: 10.1055/a-1957-7788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Worldwide, gastrointestinal endoscopies are predominantly performed under sedation. National and international guidelines and recommendations contain very different specifications for the use of sedation in gastrointestinal endoscopy. These differences come from specific requirements for staffing during endoscopy. AIM The aim of the study is to evaluate whether endoscopist-guided sedation without additional sedation assistance is not inferior to endoscopist-guided sedation with additional sedation assistance with respect to the rate of sedation-associated complications in a defined low-risk population (low-risk procedure and low-risk patient). METHODS Prospective, multicenter, randomized study. RESULTS 27 German study centers participated in the study. A total of 30 569 endoscopies were recorded during the study period from 1.8.2015 to 10.3.2020. The final data analysis included 28 673 examinations (64.1 % esophagosgastroduodenoscopies and 35.9 % colonoscopies). In 307 (1.1 %) examinations, 322 sedation-associated complications occurred. Of these, 321 (1.1 %) were minor complications and one (0.003 %) was a major complication. There was no statistically significant difference in the frequency of sedation-associated complications between endoscopist-guided sedation with versus without additional sedation assistance. Within the legal framework, a "shadow" sedation assistant was present in the study group without sedation assistance. This assistant intervened because of sedation-associated complications in 101 (0.7 %) of the endoscopies. CONCLUSION The study documents the safety of propofol-based endoscopist-guided sedation in a low-risk population. In 98.9 % of all endoscopies, no sedation-associated complication occurred or it was so minimal that no intervention (e. g., increase of oxygen supply) was necessary. The study cannot answer to what extent a serious complication was avoided by the active intervention of the "shadow" sedation assistance in the group without sedation assistance.The study proves in a randomized, prospective design that sedation in low-risk endoscopy (low-risk patient, low-risk procedure) can be performed as endoscopist-guided sedation without additional sedation assistance, without demonstrably accepting a reduction in safety.
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Affiliation(s)
- Angelika Behrens
- Klinik für Innere Medizin mit den Schwerpunkten Gastroenterologie und Pneumologie, Evangelische Elisabeth Klinik Krankenhausbetriebs gGmbH, Berlin, Germany
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Yoon S, Jung SY, Kim MS, Yoon D, Cho Y, Jeon Y. Impact of Propofol-based Total Intravenous Anesthesia Versus Inhalation Anesthesia on Long-term Survival After Cancer Surgery in a Nationwide Cohort. Ann Surg 2023; 278:1024-1031. [PMID: 35837948 DOI: 10.1097/sla.0000000000005568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare the impact of propofol-based total intravenous anesthesia (TIVA) versus inhalational anesthesia (IA) on the overall survival following cancer surgery. BACKGROUND The association between intraoperative anesthetics and patients' long-term outcomes following cancer surgery remains controversial. METHODS This retrospective cohort study used nationwide data from the Korean National Health Insurance Service. Adult patients who underwent cancer resection surgery (breast, gastric, lung, liver, kidney, colorectal, pancreatic, esophageal, and bladder cancer) under general anesthesia between January 2007 and December 2016 were included. Patients were divided into propofol-based TIVA or IA groups according to the type of anesthesia received. A total of 312,985 patients (37,063 in the propofol-based TIVA group and 275,922 patients in the IA group) were eligible for analysis. The primary outcome was the comparison of overall survival following surgery between the groups in each cancer type. We compared the all-cause mortality between the 2 groups, stratified by cancer type using time-dependent Cox regression after propensity score-based inverse probability of treatment weighting. We further examined the comparison of overall survival in a meta-analysis using data from our study and previously published data comparing propofol-based TIVA with IA after cancer surgery. RESULTS The number of deaths in the propofol-based TIVA and IA groups was 5037 (13.6%) and 45,904 (16.6%), respectively; the median (interquartile range) follow-up duration was 1192 (637-2011) days. Multivariable Cox proportional hazards regression analysis revealed no significant association between the type of general anesthesia and overall survival after cancer surgery in the weighted cohort for each cancer type (all P >0.05) and for total population [adjusted hazard ratio (HR): 0.98, 95% confidence interval (CI): 0.93-1.04]. In a meta-analysis, single-center studies showed higher overall survival in the TIVA group than in the IA group (pooled adjusted HR: 0.65, 95% CI: 0.47-0.91, P =0.01), while multicenter studies showed insignificant pooled adjusted HRs (pooled adjusted HR: 1.05, 95% CI: 0.82-1.33, P =0.71). CONCLUSIONS There is no association between the type of general anesthesia used during cancer surgery and postoperative overall, 1-, and 5-year survival.
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Affiliation(s)
- Susie Yoon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sun-Young Jung
- College of Pharmacy, Chung-Ang University, Seoul, Republic of Korea
- Department of Global Innovative Drugs, Graduate School of Chung-Ang University, Seoul, Republic of Korea
| | - Myo-Song Kim
- Department of Global Innovative Drugs, Graduate School of Chung-Ang University, Seoul, Republic of Korea
| | - Danbi Yoon
- College of Statistics, Sungkyunkwan University, Seoul, Republic of Korea
| | - Younghae Cho
- College of Statistics, Sungkyunkwan University, Seoul, Republic of Korea
| | - Yunseok Jeon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
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Bracht H, Meiser A, Wallenborn J, Guenther U, Kogelmann KM, Faltlhauser A, Schwarzkopf K, Soukup J, Becher T, Kellner P, Knafelj R, Sackey P, Bellgardt M. ICU- and ventilator-free days with isoflurane or propofol as a primary sedative - A post- hoc analysis of a randomized controlled trial. J Crit Care 2023; 78:154350. [PMID: 37327507 DOI: 10.1016/j.jcrc.2023.154350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 05/19/2023] [Accepted: 05/26/2023] [Indexed: 06/18/2023]
Abstract
PURPOSE To compare ICU-free (ICU-FD) and ventilator-free days (VFD) in the 30 days after randomization in patients that received isoflurane or propofol without receiving the other sedative. MATERIALS AND METHODS A recent randomized controlled trial (RCT) compared inhaled isoflurane via the Sedaconda® anaesthetic conserving device (ACD) with intravenous propofol for up to 54 h (Meiser et al. 2021). After end of study treatment, continued sedation was locally determined. Patients were eligible for this post-hoc analysis only if they had available 30-day follow-up data and never converted to the other drug in the 30 days from randomization. Data on ventilator use, ICU stay, concomitant sedative use, renal replacement therapy (RRT) and mortality were collected. RESULTS Sixty-nine of 150 patients randomized to isoflurane and 109 of 151 patients randomized to propofol were eligible. After adjusting for potential confounders, the isoflurane group had more ICU-FD than the propofol group (17.3 vs 13.8 days, p = 0.028). VFD for the isoflurane and propofol groups were 19.8 and 18.5 respectively (p = 0.454). Other sedatives were used more frequently (p < 0.0001) and RRT started in a greater proportion of patients in the propofol group (p = 0.011). CONCLUSIONS Isoflurane via the ACD was not associated with more VFD but with more ICU-FD and less concomitant sedative use.
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Affiliation(s)
- Hendrik Bracht
- University Hospital Bielefeld Bethel, Campus Bielefeld-Bethel, Department of Anesthesiology, Intensive Care, Emergency and Transfusion Medicine and Pain Therapy, Bielefeld, Germany.
| | - Andreas Meiser
- University Hospital Homburg/Saar, Department of Anaesthesiology, Homburg, Germany
| | - Jan Wallenborn
- HELIOS Klinikum Aue, Department of Anaesthesiology, AUE, Germany
| | - Ulf Guenther
- University Clinic of Anaesthesiology, Klinikum Oldenburg, Oldenburg Research Network Emergency- and Intensive Care Medicine (OFNI), Faculty VI - Medicine and Health Sciences, Carl v. Ossietzky University Oldenburg, Oldenburg, Germany
| | | | - Andreas Faltlhauser
- Central Emergency Care Unit and Admission HDU, Wels General Hospital, Wels, Austria
| | - Konrad Schwarzkopf
- Department of Anesthesia and Intensive Care, Klinikum Saarbruecken, Saarbruecken, Germany
| | - Jens Soukup
- Department of Anaesthesiology, Intensive Care Medicine and Palliative Care Medicine, Carl-Thiem-Hospital, Cottbus, Germany
| | - Tobias Becher
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Patrick Kellner
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Luebeck, Germany
| | - Rihard Knafelj
- University Medical Center Ljubljana, Klinični oddelek za interno Intenzivno Medicine, KOIIM, Ljubljana, Slovenia
| | - Peter Sackey
- Department of Physiology and Pharmacology, Unit of Anaesthesiology and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Martin Bellgardt
- Department of Anaesthesiology and intensive Care Medicine, St. Josef-Hospital, University Hospital of Ruhr-University of Bochum, Germany
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