Hypertriglyceridemia: a potential side effect of propofol sedation in critical illness

Why sedative hypnotics often fail in development

PURPOSE OF REVIEW

Drug development to support anaesthesia and sedation has been slow with few candidates emerging from preclinical discovery and limited innovation beyond attempted reformulation of existing compounds.

RECENT FINDINGS

The market is well supported by low-cost generic products and development compounds have not been shown to improve patient outcomes or possess other distinctive characteristics to justify the cost of development.

SUMMARY

To make progress in a large-volume, low margin and highly competitive environment requires meaningful advances in relevant basic science. Opportunities exist, but probably require bolder initiatives than further attempts at reformulation or fiddling with the structure of propofol. Extending development ambitions to include nonanaesthesiologist providers challenges professional boundaries but may facilitate cost-effective changes in patterns of care.

Nutrition considerations for patients with persistent critical illness: A narrative review

Critically ill patients experience high rates of malnutrition and significant muscle loss during their intensive care unit (ICU) admission, impacting recovery. Nutrition is likely to play an important role in mitigating the development and progression of malnutrition and muscle loss observed in ICU, yet definitive clinical trials of nutrition interventions in ICU have failed to show benefit. As improvements in the quality of medical care mean that sicker patients are able to survive the initial insult, combined with an aging and increasingly comorbid population, it is anticipated that ICU length of stay will continue to increase. This review aims to discuss nutrition considerations unique to critically ill patients who have persistent critical illness, defined as an ICU stay of >10 days. A discussion of nutrition concepts relevant to patients with persistent critical illness will include energy and protein metabolism, prescription, and delivery; monitoring of nutrition at the bedside; and the role of the healthcare team in optimizing nutrition support.

Impact of Pharmacist Monitoring of Serum Triglycerides for Critically Ill Patients Receiving Propofol

Background: Elevated serum triglycerides due to the use of propofol for sedation in the ICU is associated with adverse effects and serum triglyceride monitoring may be improved by pharmacists. Objective: To determine if there was improvement in serum triglyceride monitoring in ICU patients receiving propofol for sedation after implementation of a pharmacist-driven triglyceride monitoring protocol. Methods: This was a single-center pre-post-intervention retrospective cohort study. The protocol was implemented on January 10 2019. Data were collected over 1 year, and patients were divided between those started on propofol before and after protocol implementation. Results: There were 412 patients included in the final analysis with no significant differences between groups. There was a significant increase in the number of patients who had a triglyceride concentration obtained after protocol implementation (31.1% pre-vs 64.0% post-protocol; P < .001). For patients on propofol greater than 24 h, there was a significant increase in baseline triglyceride concentration obtained (7.6% pre-vs 15.1% post-protocol; P = .043). More instances of elevated triglyceride concentrations were identified by pharmacists than other providers (9 vs 5; P < .001). Time between propofol being ordered and first triglyceride concentration ordered was shorter (.86 days pre-protocol vs .71 days post-protocol; P = .064), but not statistically significant. Conclusion: Implementation of a pharmacist-driven protocol in the ICU increased the number of serum triglyceride levels obtained for patients receiving propofol for sedation. Pharmacists can improve triglyceride monitoring in patients receiving propofol and future studies should investigate the impact on outcomes.

Incidence of Hypertriglyceridemia in Patients on Propofol, Clevidipine, or Both

BACKGROUND

Propofol and clevidipine (PC) are commonly used in the treatment of critically ill patients. While both medications are lipid emulsions, there is limited evidence concerning the incidence of hypertriglyceridemia (HTG) when these agents are used individually or concurrently.

OBJECTIVE

The objective of this study is to determine the effects of propofol, clevidipine, or concurrent PC on triglycerides (TGs) and related outcomes in critically ill adults.

METHODS

This was a retrospective cohort study conducted at an academic medical center. Patients were included if they received ≥24 hours of continuous propofol and/or clevidipine. Excluded were those without TG levels after ≥24 hours of infusion, baseline HTG, acute pancreatitis at admission, or receiving total parenteral nutrition with lipids. The primary outcome was incidence of HTG (defined as a TG level >400 mg/dL). Secondary outcomes included median and peak TG levels, hospital length of stay, intensive care unit length of stay, total lipid infused, time to peak TG level, peak lipase level, and development of pancreatitis.

RESULTS

In total, 190 patients were studied: 109 in the propofol group, 50 in the clevidipine group, and 31 in the PC group. Incidence of HTG was similar (19 [17.4%] vs 6 [12%] vs 4 [12.9%] patients, P = 0.6246). Peak and median TG levels were similar for propofol, clevidipine, and PC groups (216 mg/dL vs 189.5 mg/dL vs 205 mg/dL, P = 0.7069; 177 mg/dL vs 185.5 mg/dL vs 177 mg/dL, P = 0.6791).

CONCLUSIONS AND RELEVANCE

There was a similar incidence of HTG in all groups. The results of this study suggest that the concurrent use of PC should not modify the frequency of TG level monitoring.

[Laboratory and calorimetric monitoring of medical nutrition therapy in intensive and intermediate care units : Second position paper of the Section Metabolism and Nutrition of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI)]

This second position paper of the Section Metabolism and Nutrition of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI) provides recommendations on the laboratory monitoring of macro- and micronutrient intake as well as the use of indirect calorimetry in the context of medical nutrition therapy of critically ill adult patients. In addition, recommendations are given for disease-related or individual (level determination) substitution and (high-dose) pharmacotherapy of vitamins and trace elements.

Impact of critical illness on cholesterol and fatty acids: insights into pathophysiology and therapeutic targets

Critical illness is characterized by a hypercatabolic response encompassing endocrine and metabolic alterations. Not only the uptake, synthesis and metabolism of glucose and amino acids is majorly affected, but also the homeostasis of lipids and cholesterol is altered during acute and prolonged critical illness. Patients who suffer from critically ill conditions such as sepsis, major trauma, surgery or burn wounds display an immediate and sustained reduction in low plasma LDL-, HDL- and total cholesterol concentrations, together with a, less pronounced, increase in plasma free fatty acids. The severity of these alterations is associated with severity of illness, but the underlying pathophysiological mechanisms are multifactorial and only partly clarified. This narrative review aims to provide an overview of the current knowledge of how lipid and cholesterol uptake, synthesis and metabolism is affected during critical illness. Reduced nutritional uptake, increased scavenging of lipoproteins as well as an increased conversion to cortisol or other cholesterol-derived metabolites might all play a role in the decrease in plasma cholesterol. The acute stress response to critical illness creates a lipolytic cocktail, which might explain the increase in plasma free fatty acids, although reduced uptake and oxidation, but also increased lipogenesis, especially in prolonged critical illness, will also affect the circulating levels. Whether a disturbed lipid homeostasis warrants intervention or should primarily be interpreted as a signal of severity of illness requires further research.

Nutritional support and prevention of post-intensive care syndrome: the Italian SIAARTI survey

BACKGROUND

Malnutrition and muscle wasting are common in ICU patients and predict adverse patient-centered outcomes. The Italian Society of Anesthesia Analgesia Resuscitation and Intensive Care (SIAARTI) conducted a nationwide survey to identify the nutritional practices in the Italian ICUs and to plan future, training interventions to improve the national clinical practice.

METHODS

Nationwide online survey, involving Italian ICUs, developed by experts affiliated with SIAARTI. Invitations to participate were distributed through emails and social networks. Data were collected over a period of three months (October 1 to December 31, 2022) during 2022.

RESULTS

One hundred full responses from participating ICUs were collected. The number of beds is < 10 in most ICUs and > 20 in 11 ICUs. Most ICUs (87%) are mixed, cardiac (5%), neurosurgical (4%), or pediatric ICUs (1%). Although the nutritional program is widely prescribed based on the patients' general evaluation, 52 ICUs (52%) do not perform nutritional risk evaluation at admission in case of > 24-h stay. Daily caloric intake is mainly based on the 25 kcal/kg equation; otherwise, the Harris-Benedict formula is mostly used, whereas indirect calorimetry is less used. Most clinicians apply a personalized nutritional approach to organ failure. Most ICUs have a nutritional management protocol, and enteral nutrition (EN) is frequently started within 2 days from admission, while supplemental parenteral nutrition is used when EN is insufficient by most clinicians. The EN administered seems to correspond to that prescribed, but it is stopped if the gastric residual gastric is > 300-500 ml in most ICUs.

CONCLUSION

Prescription, route, and mode of administration of nutritional support seem to be in line with international recommendations, while suggestions on the tools for assessing the nutritional risk and monitoring efficacy and complications seem far less followed. Future national clinical studies are necessary to investigate the optimal nutritional and metabolic management of critically ill patients and the correspondence with the results of this survey on actual practices.

Efficacy and Safety of Ciprofol Sedation in ICU Patients Undergoing Mechanical Ventilation: A Multicenter, Single-Blind, Randomized, Noninferiority Trial

OBJECTIVES

To determine the effectiveness and safety of ciprofol for sedating patients in ICUs who required mechanical ventilation (MV).

DESIGN

A multicenter, single-blind, randomized, noninferiority trial.

SETTING

Twenty-one centers across China from December 2020 to June 2021.

PATIENTS

A total of 135 ICU patients 18 to 80 years old with endotracheal intubation and undergoing MV, who were expected to require sedation for 6-24 hours.

INTERVENTIONS

One hundred thirty-five ICU patients were randomly allocated into ciprofol ( n = 90) and propofol ( n = 45) groups in a 2:1 ratio. Ciprofol or propofol were IV infused at loading doses of 0.1 mg/kg or 0.5 mg/kg, respectively, over 4 minutes ± 30 seconds depending on the physical condition of each patient. Ciprofol or propofol were then immediately administered at an initial maintenance dose of 0.3 mg/kg/hr or 1.5 mg/kg/hr, to achieve the target sedation range of Richmond Agitation-Sedation Scale (+1 to -2). Besides, continuous IV remifentanil analgesia was administered (loading dose: 0.5-1 μg/kg, maintenance dose: 0.02-0.15 μg/kg/min).

MEASUREMENTS AND MAIN RESULTS

Of the 135 patients enrolled, 129 completed the study. The primary endpoint-sedation success rates of ciprofol and propofol groups were 97.7% versus 97.8% in the full analysis set (FAS) and were both 100% in per-protocol set (PPS). The noninferiority margin was set as 8% and confirmed with a lower limit of two-sided 95% CI for the inter-group difference of -5.98% and -4.32% in the FAS and PPS groups. Patients who received ciprofol had a longer recovery time ( p = 0.003), but there were no differences in the remaining secondary endpoints (all p > 0.05). The occurrence rates of treatment-emergent adverse events (TEAEs) or drug-related TEAEs were not significantly different between the groups (all p > 0.05).

CONCLUSIONS

Ciprofol was well tolerated, with a noninferior sedation profile to propofol in Chinese ICU patients undergoing MV for a period of 6-24 hours.

Propofol-Associated Hypertriglyceridemia in Adults With Acute Respiratory Distress Syndrome on Extracorporeal Membrane Oxygenation

The incidence and risk factors for propofol-associated hypertriglyceridemia (HTG) in patients receiving extracorporeal membrane oxygenation (ECMO) have not been evaluated. The purpose of this study was to determine the incidence and risk factors for propofol-associated HTG in patients with acute respiratory distress syndrome (ARDS) on ECMO. This retrospective, cohort study included 167 adults admitted to a medical intensive care unit (ICU) from July 1, 2013 to September 1, 2021, who received 24 hours of concurrent propofol and ECMO therapy. The primary outcome was the incidence of propofol-associated HTG. Secondary outcomes included HTG risk factors, time to development and resolution of HTG, and incidence of pancreatitis. HTG occurred in 58 (34.7%) patients. Patients with HTG had longer durations of ECMO (19 vs. 13 days, p < 0.001), longer ICU length of stay (26.5 vs. 23 days, p = 0.002), and higher in-hospital mortality (51.7 vs. 34.9%, p = 0.047). Baseline sequential organ failure assessment score was associated with an increased risk of developing HTG (hazard ratio [HR] = 1.19, 95% confidence interval [CI] = 1.09-1.30; p < 0.001). Propofol-associated HTG occurred in one-third of patients receiving ECMO for ARDS. Higher baseline illness severity and ECMO duration were associated with an increased risk of propofol-associated HTG.

Ciprofol: A Novel Alternative to Propofol in Clinical Intravenous Anesthesia?

Ciprofol is a novel compound that was independently developed in China. According to the Chinese product instructions approved by the China National Medical Products Administration and the information of official website, indications for ciprofol include sedation and anesthesia during the surgical/procedure of nontracheal intubation, induction and maintenance of general anesthesia, and sedation during intensive care. Ciprofol is a short-acting intravenous sedative based on the structural modification of propofol. Ciprofol has high efficacy, good selectivity, and fewer adverse reactions, indicating good clinical application potential. A series of clinical studies have been conducted to evaluate the sedative effect of ciprofol in various procedures and settings, including gastroscopy and colonoscopy, fiber-optic bronchoscopy, general anesthesia in elective surgeries, and mechanical ventilation in intensive care units. This review summarizes the chemical structure, pharmacodynamics, and pharmacokinetic properties of ciprofol. We also assessed the efficacy and safety of ciprofol by synthesizing the relevant clinical trial data.

Triglyceride Concentrations and Their Relationship to Sedation Choice and Outcomes in Mechanically Ventilated Patients Receiving Propofol

Rationale: Propofol is a first-line sedative agent in the intensive care unit (ICU) but may be associated with hypertriglyceridemia and pancreatitis. To date, the relationship between propofol-induced hypertriglyceridemia and pancreatitis, as well as clinician responses to propofol-induced hypertriglyceridemia, have not been comprehensively studied. Objectives: To assess the incidence of hypertriglyceridemia and pancreatitis in patients receiving continuous propofol infusions in the ICU and to describe the association between hypertriglyceridemia and the use of nonpropofol continuous sedative infusions. Methods: This was a retrospective observational cohort study conducted at three urban academic hospitals within a single health system. Findings were additionally validated using the Medical Information Mart for Intensive Care-IV (MIMIC-IV) database containing data from a separate tertiary care hospital. Mechanically ventilated adult patients who received a continuous propofol infusion between 2016 and 2021 were included. The primary exposure was serum triglyceride concentration, and hypertriglyceridemia was defined as a triglyceride concentration greater than 400 mg/dl. Outcomes included new-onset pancreatitis as well as receipt of midazolam, dexmedetomidine, or ketamine after the triglyceride measurement. The incidence of pancreatitis was compared between groups using a Fisher's Exact test. Multivariable logistic regression was used to assess the association between dichotomized triglyceride concentration and alternative sedative use. Results: In the primary cohort of 7,037 patients, 1,724 (24.5%) had one or more triglyceride concentration measured. Of these, 1,365 (79.2%) had a maximum concentration of less than 400 mg/dl, and 359 (20.8%) had a maximum concentration of greater than 400 mg/dl. Compared with patients with low triglyceride concentrations, patients with high triglyceride concentrations were more likely to receive a continuous infusion of midazolam (37.0% vs. 16.4%; adjusted odds ratio [aOR], 3.1; 95% confidence interval [CI], 2.2-4.4; P < 0.01), ketamine (22.8% vs. 6.9%; aOR, 3.5; 95% CI, 2.3-5.3; P < 0.01), and dexmedetomidine (57.7% vs. 46.6%; aOR, 1.5; 95% CI, 1.1-2.0; P < 0.01). Rates of midazolam infusion increased as triglyceride concentrations exceeded 500 mg/dl. Forty-four (0.6%) patients developed pancreatitis after propofol initiation, of which 4 (9.1%) were considered related to propofol-associated hypertriglyceridemia. Findings were similar in the MIMIC-IV cohort. Conclusions: Propofol-associated hypertriglyceridemia is relatively common in mechanically ventilated ICU patients who have triglycerides measured. Pancreatitis related to propofol-associated hypertriglyceridemia is rare. Patients who develop hypertriglyceridemia while receiving propofol are more likely to receive continuous infusions of other sedatives.

[Parenteral nutrition-associated complications in patients with SARS-CoV-2 infection]

BACKGROUND

it is unknown whether patients with acute respiratory distress syndrome (ARDS) secondary to COVID-19 are at greater risk of developing complications associated with parenteral nutrition (PN).

AIM

to describe the incidence, risk factors, and clinical impact of complications in patients with ARDS-COVID-19 receiving PN.

METHODS

a prospective cohort study of 87 patients with ARDS-COVID-19 infection. The incidence of complications and odds ratios of risk factors were analysed.

RESULTS

age ≥ 65 years (OR, 2.52, 95 % CI: 1.16 to 5.46), obesity (OR, 3.34, 95 % CI: 2.35 to 4.33) and treatment with propofol (OR, 2.45, 95 % CI: 1.55 to 3.35) or lopinavir/ritonavir (OR, 4.98, 95 % CI: 3.60 to 6.29) were risk factors for hipertriglyceridemia. Obesity (OR, 3.11, 95 % CI: 1.10 to 8.75), dyslipidemia (OR, 3.22, 95 % CI: 1.23 to 8.40) or treatment with propofol (OR, 5.47, 95 % CI: 1.97 to 15.1) were risk factors for intravascular catheter-related infection. No risk factors were described for hiperglycemia. Mortality was higher in patients with intravascular catheter-related infection (46.7 % vs 10.8 %, p = 0.014). Mortality risk was higher in older patients (OR, 2.74, 95 % CI: 1.08 to 6.95) or patients with intravascular catheter-related infection (OR, 3.22, 95 % CI: 1.23 to 8.40).

CONCLUSIONS

the incidence of complications associated with PN in patients with COVID-19-related ARDS is frequent. The mortality risk is higher in older patients or those with catheter-related infection.

Efficacy and Safety of HSK3486 for Anesthesia/Sedation in Patients Undergoing Fiberoptic Bronchoscopy: A Multicenter, Double-Blind, Propofol-Controlled, Randomized, Phase 3 Study

BACKGROUND

Fiberoptic bronchoscopy is a complex procedure with the need for sufficient patient anesthesia/sedation while maintaining safety. This trial aimed to evaluate the efficacy, safety, and pharmacokinetics of HSK3486 during fiberoptic bronchoscopy.

METHODS

This multicenter, double-blind, randomized, non-inferiority, parallel-group phase 3 trial was conducted in patients who underwent fiberoptic bronchoscopy. Patients randomly received HSK3486 0.4 mg/kg (N = 134) or propofol 2.0 mg/kg (N = 133). The primary efficacy endpoint was the successful rate of fiberoptic bronchoscopy, and secondary efficacy endpoints included successful induction of anesthesia/sedation, duration, time to being fully alert, and time to patient discharge. Safety assessments and drug concentrations were also measured.

RESULTS

A total of 267 patients completed fiberoptic bronchoscopy, with a success rate of 100% and a 95% confidence interval of - 2.8 to 2.8% for the difference between the groups, which met the predesigned criteria of > - 8%, confirming the non-inferiority of anesthesia/sedation produced by HSK3486 compared to propofol. Among the secondary efficacy endpoints, only time to full alertness (median 8.50 vs. 6.00 min, P = 0.012) and time to discharge (median 13.00 vs. 9.87 min, P = 0.002) were slightly longer in the HSK3486 group. The incidence of adverse events was significant lower in the HSK3486 group (52.6 vs. 76.5%, P < 0.001) mainly because of less pain on injection (4.4 vs. 39.4%, P < 0.001) compared to the propofol group. HSK3486 had a similar terminal elimination half-life as propofol.

CONCLUSIONS

HSK3486 exhibited non-inferiority anesthesia/sedation compared to propofol in patients undergoing fiberoptic bronchoscopy, and had a good safety profile with a lower incidence of pain on injection.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT04111159, registered on 1 October 2019.

Safety and efficacy of ciprofol vs propofol for sedation in intensive care unit patients with mechanical ventilation: a multi-center, open label, randomized, phase 2 trial

Background:

Ciprofol (HSK3486; Haisco Pharmaceutical Group Co., Ltd., Chengdu, China), developed as a novel 2,6-disubstituted phenol derivative showed similar tolerability and efficacy characteristics as propofol when applicated as continuous intravenous infusion for 12 h maintenance sedation in a previous phase 1 trial. The phase 2 trial was designed to investigate the safety, efficacy, and pharmacokinetic characteristics of ciprofol for sedation of patients undergoing mechanical ventilation.

Methods:

In this multicenter, open label, randomized, propofol positive-controlled, phase 2 trial, 39 Chinese intensive care unit patients receiving mechanical ventilation were enrolled and randomly assigned to a ciprofol or propofol group in a 2:1 ratio. The ciprofol infusion was started with a loading infusion of 0.1–0.2 mg/kg for 0.5–5.0 min, followed by an initial maintenance infusion rate of 0.30 mg·kg⁻¹·h⁻¹, which could be adjusted to an infusion rate of 0.06 to 0.80 mg·kg⁻¹·h⁻¹, whereas for propofol the loading infusion dose was 0.5–1.0 mg/kg for 0.5–5.0 min, followed by an initial maintenance infusion rate of 1.50 mg·kg⁻¹·h⁻¹, which could be adjusted to 0.30–4.00 mg·kg⁻¹·h⁻¹ to achieve −2 to +1 Richmond Agitation-Sedation Scale sedation within 6–24 h of drug administration.

Results:

Of the 39 enrolled patients, 36 completed the trial. The median (min, max) of the average time to sedation compliance values for ciprofol and propofol were 60.0 (52.6, 60.0) min and 60.0 (55.2, 60.0) min, with median difference of 0.00 (95% confidence interval: 0.00, 0.00). In total, 29 (74.4%) patients comprising 18 (69.2%) in the ciprofol and 11 (84.6%) in the propofol group experienced 86 treatment emergent adverse events (TEAEs), the majority being of severity grade 1 or 2. Drug- and sedation-related TEAEs were hypotension (7.7% vs. 23.1%, P = 0.310) and sinus bradycardia (3.8% vs. 7.7%, P = 1.000) in the ciprofol and propofol groups, respectively. The plasma concentration-time curves for ciprofol and propofol were similar.

Conclusions:

ciprofol is comparable to propofol with good tolerance and efficacy for sedation of Chinese intensive care unit patients undergoing mechanical ventilation in the present study setting.

Trial registration:

ClinicalTrials.gov, NCT04147416.

Effects of dexmedetomidine, propofol, sevoflurane and S-ketamine on the human metabolome: A randomised trial using nuclear magnetic resonance spectroscopy

BACKGROUND

Pharmacometabolomics uses large-scale data capturing methods to uncover drug-induced shifts in the metabolic profile. The specific effects of anaesthetics on the human metabolome are largely unknown.

OBJECTIVE

We aimed to discover whether exposure to routinely used anaesthetics have an acute effect on the human metabolic profile.

DESIGN

Randomised, open-label, controlled, parallel group, phase IV clinical drug trial.

SETTING

The study was conducted at Turku PET Centre, University of Turku, Finland, 2016 to 2017.

PARTICIPANTS

One hundred and sixty healthy male volunteers were recruited. The metabolomic data of 159 were evaluable.

INTERVENTIONS

Volunteers were randomised to receive a 1-h exposure to equipotent doses (EC50 for verbal command) of dexmedetomidine (1.5 ng ml-1; n = 40), propofol (1.7 μg ml-1; n = 40), sevoflurane (0.9% end-tidal; n = 39), S-ketamine (0.75 μg ml-1; n = 20) or placebo (n = 20).

MAIN OUTCOME MEASURES

Metabolite subgroups of apolipoproteins and lipoproteins, cholesterol, glycerides and phospholipids, fatty acids, glycolysis, amino acids, ketone bodies, creatinine and albumin and the inflammatory marker GlycA, were analysed with nuclear magnetic resonance spectroscopy from arterial blood samples collected at baseline, after anaesthetic administration and 70 min postanaesthesia.

RESULTS

All metabolite subgroups were affected. Statistically significant changes vs. placebo were observed in 11.0, 41.3, 0.65 and 3.9% of the 155 analytes in the dexmedetomidine, propofol, sevoflurane and S-ketamine groups, respectively. Dexmedetomidine increased glucose, decreased ketone bodies and affected lipoproteins and apolipoproteins. Propofol altered lipoproteins, fatty acids, glycerides and phospholipids and slightly increased inflammatory marker glycoprotein acetylation. Sevoflurane was relatively inert. S-ketamine increased glucose and lactate, whereas branched chain amino acids and tyrosine decreased.

CONCLUSION

A 1-h exposure to moderate doses of routinely used anaesthetics led to significant and characteristic alterations in the metabolic profile. Dexmedetomidine-induced alterations mirror α2-adrenoceptor agonism. Propofol emulsion altered the lipid profile. The inertness of sevoflurane might prove useful in vulnerable patients. S-ketamine induced amino acid alterations might be linked to its suggested antidepressive properties.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02624401. URL: https://clinicaltrials.gov/ct2/show/NCT02624401.

Hypertriglyceridemia in Critically Ill Patients With SARS-CoV-2 Infection

BACKGROUND

Patients with SARS-CoV-2 infection could develop severe disease requiring critical care admission. Case reports indicated high incidence of hypertriglyceridemia (HTG) in critically ill patients infected with SARS-CoV-2, which might be related to the drugs.

OBJECTIVE

We sought to determine the risk factors associated with HTG in this population and to investigate the relationship between HTG and lipase.

METHODS

A retrospective observational study was conducted at our hospital between March 1 and June 30, 2020. Patients were included if they were ≥18 years old, admitted to the intensive care unit (ICU), tested positive for SARS-CoV-2, and had triglycerides (TG) checked during their hospital stay.

RESULTS

Of the 111 critically ill patients, 103 patients were included. Males comprised 88.3% of the sample. The median TG at baseline was 197.4 (IQR: 139.8-283) mg/dL. The lipase median level at baseline was 23.00 (IQR: 0.00-69.50) IU/L. The results of the mixed-effects logistic regression analysis indicated that patient-level variables, favipiravir use, blood glucose level, and propofol use were significantly associated with HTG. There was no relationship between lipase and TG levels over time. Furthermore, TG concentrations over time showed a similar trend to inflammatory markers.

CONCLUSION AND RELEVANCE

The incidence of clinically significant HTG was high and was associated with propofol and favipiravir use. HTG might reflect the high inflammatory state in these patients. Clinicians should look at the full picture before changing therapies based only on HTG. Our findings need to be replicated in a larger prospective study.

High-Loading Self-Assembling Peptide Nanoparticles as a Lipid-Free Carrier for Hydrophobic General Anesthetics

Purpose

Typical hydrophobic amino acids (HAAs) are important motifs for self-assembling peptides (SAPs), but they lead to low water-solubility or compact packing of peptides, limiting their capacity for encapsulating hydrophobic drugs. As an alternative, we designed a peptide GQY based on atypical HAAs, which could encapsulate hydrophobic drugs more efficiently. Although hydrophobic general anesthetics (GAs) have been formulated as lipid emulsions, their lipid-free formulations have been pursued because of some side effects inherent to lipids. Using GAs as targets, potential application of GQY as a carrier for hydrophobic drugs was evaluated.

Methods

Thioflavin-T (ThT) binding test, dynamic light scattering (DLS) and transmission electron microscopy (TEM) were used to examine the self-assembling ability of GQY. Pyrene and 8-Anilino-1-naphthalenesulfonic acid (ANS) were used to confirm formation of hydrophobic domain in GQY nanoparticles. Using pyrene as a model, GQY’s capacity to encapsulate hydrophobic drugs was evaluated. GAs including propofol, etomidate and ET26 were encapsulated by GQY. Loss of righting reflex (LORR) test was conducted to assess the anesthetic efficacy of these lipid-free formulations. Paw-licking test was used to evaluate pain-on-injection of propofol-GQY (PROP-GQY) formulation. Hemolytic and cytotoxicity assay were used to evaluate biocompatibility of GQY.

Results

Stable nanoparticles containing plenty of hydrophobic cavities could be formed by GQY, which could encapsulate hydrophobic drugs at very high concentration and form stable suspensions. Propofol, etomidate and ET26 formulated by GQY showed anesthetic efficacy comparable to their currently available formulations. Unlike clinic lipid emulsion, PROP-GQY formulation did not cause pain-on-injection in rats. Neither obvious cytotoxicity nor hemolytic activity of GQY was observed.

Conclusion

GQY could encapsulate GAs to obtain stable and effective formulations. As a lipid-free carrier, GQY exhibited considerable biocompatibility and other side benefits such as reducing pain-on-injection. More SAPs based on atypical HAAs could be designed as promising carriers for hydrophobic drugs.

Acute Hypertriglyceridemia in Patients with COVID-19 Receiving Parenteral Nutrition

Hypertriglyceridemia is a metabolic complication associated with parenteral nutrition (PN). It is unknown if patients with acute respiratory distress syndrome (ARDS) secondary to COVID-19 are more at risk. Our aim was to describe the incidence, risk factors and clinical impact of hypertriglyceridemia in critically ill patients with ARDS-COVID-19 receiving PN. We designed a cohort study of patients with ARDS-COVID-19 infection that required admission to critical care units and nutritional support with PN. Individual PN prescriptions for macronutrients and insulin were provided. Lipid emulsion contained fish oil (SMOFlipid® or Lipoplus®). Hypertriglyceridemia was defined as plasma levels above 400 mg/dL. Eighty-seven patients, 66.6% men, 60.1 ± 10.8 years old, BMI 29.1 ± 5.6 kg/m2, 71% of whom received lopinavir/ritonavir, 56% received Propofol and 55% received Tocilizumab were included. The incidence of hypertriglyceridemia was 37 × 100 patient-days with PN. This complication was more frequent in obese patients (OR 3.34; 95% CI, 2.35-4.33) and in those treated with lopinavir/ritonavir (OR 4.98; 95% CI, 3.60-6.29) or Propofol (OR 2.45; 95% CI, 1.55-3.35). Total mortality was 33.3%, similar between the type of lipid emulsion (p = 0.478). On average, patients with hypertriglyceridemia had a longer requirement of PN compared to the group without elevated triglycerides (TG), probably because of their longer survival (p = 0.001). TG higher than 400 mg/dL was not a protective factor for mortality (OR 0.31; 95% CI, 0.01-1.30). In conclusion, the incidence of hypertriglyceridemia was 37 × 100 patient-days with PN. The risk of this complication is associated with obesity and the use of lopinavir/ritonavir or Propofol.

Butorphanol versus Propofol in Patients Undergoing Noninvasive Ventilation: A Prospective Observational Study

Background

The present study aimed to explore sedation management in agitated patients who suffered from acute respiratory failure (ARF) and were treated with noninvasive ventilation (NIV).

Patients and Methods

We divided 118 patients undergoing NIV treatment with butorphanol or propofol into two groups: group B (n = 57, butorphanol was initiated at the rate of 0.12 µg/kg/min as a continuous intravenous infusion and then titrated by 0.06 µg/kg/min every half an hour, group P (n = 61, propofol was initiated at the rate of 5 µg/kg/min as a continuous intravenous infusion and then titrated by 1.5 µg/kg/min every half an hour). Score of Sedation Agitation Scale (SAS) in the two groups was maintained between 3 and 4. Medications including sedative, analgesic, and antipsychotic, NIV intolerance score, SAS score, visual analog scale (VAS), medication use and adverse events were recorded repeatedly.

Results

Patients receiving butorphanol required significantly less total amount of fentanyl than patients receiving propofol during NIV to maintain the target VAS [0 (0–0) µg vs 150 (50–200) µg, P< 0.005]. Hemodynamic stability during NIV showed it was better kept in patients treated with butorphanol.

Conclusion

Butorphanol not only decreased the requirements of fentanyl but also enhanced hemodynamic stability in agitated patients suffering from ARF receiving NIV.

Trial Registration

Registered at http://www.chictr.org.cn/ (ChiCTR1800015534).

Optimization of propofol loaded niosomal gel for transdermal delivery

Propofol is an oily liquid widely used for rapid onset of anaesthesia via intravenous route, which shows major limitations of hypersensitivity, anaphylactic reactions and pain. The aim of the present work was to bypass the above issues by formulating tailored niosomal gel to deliver propofol via non-invasive transdermal route. The niosomes were prepared by film hydration method and sonication using cholesterol and Span 80. The Box Behnken design (BBD) was applied to optimize the size (93.5 nm) and the entrapment efficacy (81.5%) of the niosomes by selecting cholesterol at 139 mg, Span 80 at 0.525% and sonication time at 5.13 min. The scanning electron microscopy image showed spherical shape niosomes with smooth surface without aggregation. The ex vivo release data showed significant improvement in the propofol release (92.2% after 10 h) using niosomes in comparison to the control propofol gel (with 30% methanol) without niosomes (25.3% after 10 h). The in vivo pharmacokinetic parameters in the rat model confirmed the improvement in the relative bioavailability with optimized niosomal gel (relative bioavailability = 12.12) in comparison to the control propofol gel. In conclusion, the niosomal gel offered a potential alternative non-invasive route to deliver propofol for procedural sedation especially in pediatric population.

TICACOS international: A multi-center, randomized, prospective controlled study comparing tight calorie control versus Liberal calorie administration study

Since the first TICACOS study, 3 additional studies have been published comparing a medical nutrition therapy guided by indirect calorimetry to a regimen prescribed on the basis of predictive equations. A recent guidelines document included a meta-analysis including these 4 papers and found a trend for improvement (OR 0.98-1.48) in favor of medical nutrition therapy guided by indirect calorimetry in terms of survival. The aim of our study was to perform a multicenter prospective, randomized, controlled non blinded study in critically patients to assess the added value for measuring daily resting energy expenditure as a guide for nutritional support. The primary objective was to decrease infectious rate of these critically ill patients.

MATERIAL AND METHODS

This phase III, multi-center, randomized, controlled non blinded study was planned to include 580 newly-admitted, adult ventilated ICU patients that were planned to stay more than 48 h in the ICU departments. The nutritional support was aimed to meet 80-100% of energy requirement measured by indirect calorimetry. The calorie needs were determined by IC in the Study group and by an equation (20-25 kcal/kg ideal body weight/day) in the Control Group. The ICU staff was trained to strive to supply 80-100% of a patient's energy requirements through artificial nutrition, preferably enteral feeding. Primary endpoint was infection rate and secondary endpoints included other morbidities and mortality during ICU, at 90 and 180 days. Comparison between the study and the control group was performed using T test for equality of means (independent samples test). Correlations were performed using the Pearson correlation test. A p level of 0.05 or below was considered as significant. Cross tabs procedure used Chi-square test for testing differences in complication rates, length of stay and length of ventilation. Correlations between energy balances and complications was also be tested using one way analysis as well as ANOVA analysis between groups and within groups. Kaplan Meir curves assessed the proportion of surviving patients in the 2 groups.

RESULTS

Seven centers with a calorimeter available participated to the study. Due to slow inclusion rate, the study was stopped after 6 years and after inclusion of 417 patients only. From the 417 intended to treat patients, 339 followed the protocol. There was no differences between control and study groups in terms of age, sex BMI, SOFA (7.1 ± 3.1 vs 7.4 ± 3.3) and APACHE II scores (22.4 ± 7.9 vs 22.2 ± 7.4). The rate of infection (40 vs 31), including pneumonia rate, need for surgery, dialysis requirement, length of ventilation, ICU length of stay, and hospital length of stay were not different between groups. Mortality (30 in the control vs 21 in the study group) was not significantly different between groups. The decreased mortality observed in the study group when added to previous studies may have a positive effect on the meta-analysis previously published.

CONCLUSION

Tight Calorie Control guided by indirect calorimetry decreased the rate of infection and mortality but not significantly. This may be explained by the not relatively small sample size. There results together with the previous 4 prospective randomized studies, may improve the results of the meta-analysis exploring the effects of IC guided nutrition on mortality.

Evaluation of Hypertriglyceridemia in Critically Ill Patients With Coronavirus Disease 2019 Receiving Propofol

Objectives

To report the prevalence of, and evaluate risk factors for, the development of hypertriglyceridemia (defined as a serum triglyceride level of > 400 mg/dL) in patients with coronavirus disease 2019 who received propofol.

Design

Single-center, retrospective, observational analysis.

Setting

Brigham and Women's Hospital, a tertiary academic medical center in Boston, MA.

Patients

All ICU patients who with coronavirus disease 19 who received propofol between March 1, 2020, and April 20, 2020.

Interventions

None.

Measurements and Main Results

The major outcome of this analysis was to report the prevalence of, and risk factors for, the development of hypertriglyceridemia in patients with coronavirus disease 19 who received propofol. Minor outcomes included the development of acute pancreatitis and description of propofol metrics. Of the 106 patients that were included, 60 (56.6%) developed hypertriglyceridemia, with a median time to development of 46 hours. A total of five patients had clinical suspicion of acute pancreatitis, with one patient having confirmatory imaging. There was no difference in the dose or duration of propofol in patients who developed hypertriglyceridemia compared with those who did not. In the patients who developed hypertriglyceridemia, 35 patients (58.5%) continued receiving propofol for a median duration of 105 hours. Patients who developed hypertriglyceridemia had elevated levels of inflammatory markers.

Conclusions

Hypertriglyceridemia was commonly observed in critically ill patients with coronavirus disease 2019 who received propofol. Neither the cumulative dose nor duration of propofol were identified as a risk factor for the development of hypertriglyceridemia. Due to the incidence of hypertriglyceridemia in this patient population, monitoring of serum triglyceride levels should be done frequently in patients who require more than 24 hours of propofol. Many patients who developed hypertriglyceridemia were able to continue propofol in our analysis after reducing the dose.

Propofol-Associated Hypertriglyceridemia in Coronavirus Disease 2019 Versus Noncoronavirus Disease 2019 Acute Respiratory Distress Syndrome

Supplemental Digital Content is available in the text.

Objectives:

To characterize the incidence and characteristics of propofol-associated hypertriglyceridemia in coronavirus disease 2019 versus noncoronavirus disease 2019 acute respiratory distress syndrome.

Design:

Single-center prospective, observational cohort study.

Setting:

Medical ICU and regional infectious containment unit.

Patients:

Patients with acute respiratory distress syndrome admitted from April 7, 2020, to May 15, 2020, requiring continuous propofol administration.

Interventions:

None.

Measurements and Main Results:

Of 50 patients enrolled, 54% had coronavirus disease 2019 acute respiratory distress syndrome. Median Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores were 35.5 (interquartile range, 30.2–41) and 8 (interquartile range, 6–9). Pao₂/Fio₂ ratio was 130.5 (interquartile range, 94.5–193.8). Patients with coronavirus disease 2019-associated acute respiratory distress syndrome experienced a higher rate of hypertriglyceridemia (triglyceride ≥ 500 mg/dL) than noncoronavirus disease 2019-associated acute respiratory distress syndrome (9 [33.3%] vs 1 [4.3%]; p = 0.014). Those with coronavirus disease 2019, compared with those without, received more propofol prior to becoming hypertriglyceridemic (median, 5,436.0 mg [interquartile range, 3,405.5–6,845.5 mg] vs 4,229.0 mg [interquartile range, 2,083.4–4,972.1 mg]; p = 0.027). After adjustment for propofol dose with logistic regression (odds ratio, 5.97; 95% CI, 1.16–59.57; p = 0.031) and propensity score matching (odds ratio, 8.64; 95% CI, 1.27–149.12; p = 0.025), there remained a significant difference in the development of hypertriglyceridemia between coronavirus disease 2019-associated acute respiratory distress syndrome and noncoronavirus disease 2019-associated acute respiratory distress syndrome. There was no difference between groups in time to hypertriglyceridemia (p = 0.063). Serum lipase was not different between those who did or did not develop hypertriglyceridemia (p = 0.545). No patients experienced signs or symptoms of pancreatitis.

Conclusions:

Patients with coronavirus disease 2019 acute respiratory distress syndrome experienced a higher rate of propofol-associated hypertriglyceridemia than noncoronavirus disease 2019 acute respiratory distress syndrome patients, even after accounting for differences in propofol administration.

The Incidence of Propofol-Induced Hypertriglyceridemia and Identification of Associated Risk Factors

Supplemental Digital Content is available in the text.

Objectives:

The objective of this study was to describe the incidence of propofol-induced hypertriglyceridemia and the risk factors associated with hypertriglyceridemia in mechanically ventilated ICU patients while receiving propofol.

Design:

This was a single-center case-control study.

Setting:

Brigham and Women’s Hospital, a tertiary academic medical center in Boston, MA.

Subjects:

Adult ICU patients who received continuous infusion propofol for at least 24 hours from May 1, 2019, to December 31, 2019, were included. Patients were excluded if they were diagnosed with acute pancreatitis upon admission or did not have any serum triglyceride levels evaluated during propofol administration.

Interventions:

None.

Measurements and Main Results:

The major outcome was the incidence and risk factors associated with the development of propofol-induced hypertriglyceridemia, defined as triglyceride level greater than or equal to 400 mg/dL. Minor outcomes included the prevalence of acute pancreatitis. A hybrid multivariate logistic regression analysis was used to evaluate the relation between individual risk factors and the dependent variable of hypertriglyceridemia. During the study period, 552 patients were evaluated for inclusion, of which 136 were included in the final analysis. A total of 38 patients (27.9%) developed hypertriglyceridemia with a median time to hypertriglyceridemia of 47 hours. The only significant independent risk factor for development of hypertriglyceridemia identified was the cumulative propofol dose (odds ratio, 1.04; 95% CI, 1.01–1.08; p = 0.016). Two of the 38 hypertriglyceridemia patients (5.3%) were diagnosed with acute pancreatitis.

Conclusions:

In our analysis, approximately one third of patients developed hypertriglyceridemia with cumulative propofol dose identified as a significant predictor of the development of hypertriglyceridemia. Despite a high incidence of hypertriglyceridemia, a significant number of patients continued propofol therapy, and a relatively low prevalence of pancreatitis was observed. Future analyses are warranted to further investigate these results.

Acute Hypertriglyceridaemia Caused by Tocilizumab in a Patient with Severe COVID-19

Treatment with tocilizumab (TCZ) to block interleukin-6 (IL-6) signalling is predicted to mitigate cytokine release syndrome (CRS) caused by coronavirus disease 2019 (COVID-19). However, the adverse effects of TCZ on patients with COVID-19 remain unclear. We herein report a patient with COVID-19 treated with TCZ who developed acute hypertriglyceridaemia. Despite favipiravir treatment, acute respiratory distress syndrome developed in a 45-year-old patient with COVID-19; thus, TCZ was initiated. The triglyceride levels greatly increased after TCZ administration. Physicians should consider the negative impact of TCZ on the lipid profile in patients with COVID-19, although COVID-19-induced CRS itself may be an aggravating factor.

Different Cases of SARS-CoV-2 Infection and Its Impact on Health and Economy with Special Emphasis on Antiviral Drug Targets

COVID-19 caused by SARS-CoV-2 has not only issued a pandemic situation but also lead to economic disaster and unprecedented health emergency. Being a close relative of Bat corona-virus, SARS and MERS it’s structural and sequence similarity has abled scientists for repurposing of popular drugs like hydroxychloroquine, cloroquine and also scavenging for lead molecules by in-silico and in-vivo or in-vitro approach. The potent drug targets are ACE2; spike protein binding receptor to host cell surface, Mpro; proteo-lytic polyprotein processing enzymes needed for virion maturation and RdRp; RNA dependent RNA polymerase needed for RNA replication. The recent trend focuses on the fact that cocktail of anti-corona virus treatment will be available soon by broad spectrum antiviral compounds. It takes time to develop such drug targets till then social distancing and following of hygiene are the only way to thrive well. This article incorporates the present World scenario related to COVID infection, focuses on its origin and also future possibilities for a COVID free future.

Feeding should be individualized in the critically ill patients

PURPOSE OF REVIEW

Any critical care therapy requires individual adaptation, despite standardization of the concepts supporting them. Among these therapies, nutrition care has been repeatedly shown to influence clinical outcome. Individualized feeding is the next needed step towards optimal global critical care.

RECENT FINDINGS

Both underfeeding and overfeeding generate complications and should be prevented. The long forgotten endogenous energy production, maximal during the first 3 to 4 days, should be integrated in the nutrition plan, through a slow progression of feeding, as full feeding may result in early overfeeding. Accurate and repeated indirect calorimetry is becoming possible thanks to the recent development of a reliable, easy to use and affordable indirect calorimeter. The optimal timing of the prescription of the measured energy expenditure values as goal remains to be determined. Optimal protein prescription remains difficult as no clinically available tool has yet been identified reflecting the body needs.

SUMMARY

Although energy expenditure can now be measured, we miss indicators of early endogenous energy production and of protein needs. A pragmatic ramping up of extrinsic energy provision by nutrition support reduces the risk of overfeeding-related adverse effects.

A Comprehensive Update on the Chylomicronemia Syndrome

The chylomicronemia syndrome is characterized by severe hypertriglyceridemia and fasting chylomicronemia and predisposes affected individuals to acute pancreatitis. When due to very rare monogenic mutations in the genes encoding the enzyme, lipoprotein lipase, or its regulators, APOC2, APOA5, GPIHBP1, and LMF1, it is referred to as the familial chylomicronemia syndrome. Much more frequently, the chylomicronemia syndrome results from a cluster of minor genetic variants causing polygenic hypertriglyceridemia, which is exacerbated by conditions or medications which increase triglyceride levels beyond the saturation point of triglyceride removal systems. This situation is termed the multifactorial chylomicronemia syndrome. These aggravating factors include common conditions such as uncontrolled diabetes, overweight and obesity, alcohol excess, chronic kidney disease and pregnancy and several medications, including diuretics, non-selective beta blockers, estrogenic compounds, corticosteroids, protease inhibitors, immunosuppressives, antipsychotics, antidepressants, retinoids, L-asparaginase, and propofol. A third uncommon cause of the chylomicronemia syndrome is familial forms of partial lipodystrophy. Development of pancreatitis is the most feared complication of the chylomicronemia syndrome, but the risk of cardiovascular disease as well as non-alcoholic steatohepatitis is also increased. Treatment consists of dietary fat restriction and weight reduction combined with the use of triglyceride lowering medications such as fibrates, omega 3 fatty acids and niacin. Effective management of aggravating factors such as improving diabetes control, discontinuing alcohol and replacing or reducing the dose of medications that raise triglyceride levels is essential. Importantly, many if not most cases of the chylomicronemia syndrome can be prevented by effective identification of polygenic hypertriglyceridemia in people with conditions that increase its likelihood or before starting medications that may increase triglyceride levels. Several new pharmacotherapeutic agents are being tested that are likely to considerably improve treatment of hypertriglyceridemia in people at risk.

Nutritrauma: A Key Concept for Minimising the Harmful Effects of the Administration of Medical Nutrition Therapy

Critically ill patients often require life support measures such as mechanical ventilation or haemodialysis. Despite the essential role of nutrition in patients’ recovery, the inappropriate use of medical nutrition therapy can have deleterious effects, as is the case with the use of respiratory, circulatory, or renal support. To increase awareness and to monitor the effects of inappropriate medical nutrition therapy, we propose to introduce the concept of nutritrauma in clinical practice, defined as metabolic adverse events related to the inappropriate administration of medical nutrition therapy or inadequate nutritional monitoring.

Elevated triglycerides level in hospital stay as a risk factor of mortality in patients with severe acute pancreatitis

Hypertriglyceridaemia is one of the most common causes of severe acute pancreatitis (SAP). However, the association between elevated triglycerides (TG) level in hospital stay and outcome in SAP patients with normal TG level at admission has not been clearly demonstrated. This retrospective study assessed the serum TG levels of patients with SAP admitted to the intensive care unit (ICU) in 2017. Variables with a statistically significant association with the incidence of in-hospital TG elevation, as determined by univariate analysis, were analysed using a logistic regression model to predictors. Of the 99 patients included in the study, TG levels were within the normal range in 59 (59.59%) patients at admission. Among patients with normal TG level when admitted to ICU, 28 (47.46%) experienced at least one episode of TG level elevation during their ICU stay. Elevated TG level in hospitalization is associated with an increased length of ICU stay, as well as increased mortality. In addition to other factors, propofol usage was independently associated with the occurrence of in-hospital-TG elevation. To conclude, we retrospectively investigated the incidence, outcome, and risk factors for in-hospital TG elevation events in SAP patients admitted to the ICU. We found a high incidence of both preexisting and in-hospital-acquired TG elevation in SAP patients admitted to the ICU. The TG elevation that occurred during the ICU stay was associated with worse outcomes and long-term hospitalization of the ICU. Propofol usage was independently associated with the TG elevation occurrence in the ICU.

ESPEN guideline on clinical nutrition in the intensive care unit

Following the new ESPEN Standard Operating Procedures, the previous guidelines to provide best medical nutritional therapy to critically ill patients have been updated. These guidelines define who are the patients at risk, how to assess nutritional status of an ICU patient, how to define the amount of energy to provide, the route to choose and how to adapt according to various clinical conditions. When to start and how to progress in the administration of adequate provision of nutrients is also described. The best determination of amount and nature of carbohydrates, fat and protein are suggested. Special attention is given to glutamine and omega-3 fatty acids. Particular conditions frequently observed in intensive care such as patients with dysphagia, frail patients, multiple trauma patients, abdominal surgery, sepsis, and obesity are discussed to guide the practitioner toward the best evidence based therapy. Monitoring of this nutritional therapy is discussed in a separate document.

Propofol and Clevidipine-induced Hypertriglyceridemia

Hypertriglyceridemia and related pancreatitis due to the use of lipid emulsions such as propofol has been documented, but less is known about the additive adverse effects of propofol and clevidipine lipid emulsions in the literature. We report an unusual case, highlighting the trend of serum triglyceride and pancreatic enzymes (amylase/lipase) with the administration of propofol and clevidipine for a prolonged period in the neurocritical care setting. We present a case of a 27-year-old male who was admitted to the neuroscience intensive care unit (NSICU) for management of severe subarachnoid hemorrhage (SAH) with six-millimeter (mm) midline shift to the left from the rupture of anterior communicating artery aneurysm. The patient was given propofol infusion to maintain sedation and manage intracranial pressures, and clevidipine was chosen over other antihypertensive class for blood pressure management secondary to renal impairment. To focus on the risk of hypertriglyceridemia and associated pancreatitis with the combined use of lipid emulsions we quantified the effect of lipid emulsions on serum triglycerides. We calculated the total calorie and fat content the patient received from the propofol and clevidipine along with the calorie intake from enteral nutrition (Fibersource® tube feed). The patient received a total propofol infusion of 44,391.2 milligrams (mg) over 16 days which accounts for 4,882.99 kilocalories (kcal) and 443.91 grams of fat. He received a total clevidipine infusion of 297 mg over the 48-hour period which contributes 594 kcal and 59.4 grams of fat. The required daily calorie intake through enteral nutrition of Fibresource® was titrated to a goal of 80 mL/hour which provided 2,304 kcal and 76.8 grams of fat each day. We also graphically depicted the rise in the serum triglyceride level after continuous infusion of propofol and clevidipine and subsequent improvement in the amylase and lipase level after the propofol was discontinued. Hence we conclude, careful and periodic monitoring of the serum triglyceride levels and limitation on the total calories from other fat sources such as enteral nutrition can help to mitigate the drug-induced effects.

Does Propofol Sedation Contribute to Overall Energy Provision in Mechanically Ventilated Critically Ill Adults? A Retrospective Observational Study

BACKGROUND

Propofol sedation is common in critically ill patients, providing energy of 1.1 kcal/mL when administered as a 1% solution. We aimed to determine the proportion of energy administered as propofol on days 1-5 in the intensive care unit (ICU) and any association with outcomes.

METHODS

Retrospective observational study in a quaternary ICU from January-December 2012. Inclusion criteria were length of stay (LOS) ≥5 days, age ≥18 years, and provision of mechanical ventilation (MV) for ≥5 days. Outcome measures included proportion of total daily energy provided as propofol, overall energy balance, hospital mortality, duration of MV, and ICU LOS.

RESULTS

Data from 370 patients were analyzed, 87.8% (n = 325) of whom received propofol during days 1-5 in ICU. A median [interquartile range (IQR)] of 119 [50-730] kcal was provided as propofol per patient-day. Proportion of energy provided by propofol as a percentage of total energy delivered was 55.4%, 15.4%, 9.3%, 7.9%, and 9.9% days 1-5, respectively. Patients administered propofol received a greater proportion of their total daily energy prescription compared with those who were not (P < .01). Proportion of energy provided as propofol was not significantly different based on hospital mortality (P = .62), duration of MV (P = .50), or ICU LOS (P = .15).

CONCLUSION

Propofol contributes to overall energy intake on days 1-5 of ICU admission. Energy balance was higher in those receiving propofol. No association was found between the proportion of energy delivered as propofol and outcomes.

Propofol sedation substantially increases the caloric and lipid intake in critically ill patients

OBJECTIVE

The amount of lipid delivered to patients varies considerably depending on the non-nutritional intake from sedation, and on the feeding solution. The aim of this study was to quantify the magnitude and proportion of lipids and energy provided from propofol sedation in intensive care unit (ICU) patients.

METHODS

This was a retrospective analysis of prospectively collected data in consecutive patients admitted to the ICUs of two university hospitals. Inclusion criterion included an ICU stay >5 d. Data were collected for a maximum of 10 d. Propofol sedation using 1% or 2% propofol solutions was defined as >100 mg/d. Nutritional management was per protocol in both centers, recommending enteral feeding. Data are shown as means ± standard deviation.

RESULTS

In all, 701 admissions (687 patients, ages 59 ± 16 y, SAPS II 51 ± 17) and 6485 d, including 3484 propofol sedation days were analyzed. Energy targets were 1987 ± 411 kcal/d; mean energy delivery was 1362 ± 811 kcal/d (70% ± 38% of prescription) including propofol and dextrose. Enteral feeding dominated (75% of days) and progressed similarly in both ICUs. Mean propofol sedation dose was 2045 ± 1650 mg/d, resulting in 146 ± 117 kcal/d. Fat from propofol constituted 17% of total energy (up to 100% during the first days). Fat delivery (40 ± 23 g/d: maximum 310 g/d) was significantly increased by the combination of propofol sedation, the 1% solution, and high-fat-containing feeds. In survivors, high-fat proportion was associated with prolonged ventilation time (P < 0.0001).

CONCLUSION

Propofol sedation resulted in large doses of lipids being delivered to patients, some receiving pure lipids during the first days. As the metabolic effects of high proportions of fat are unknown, further research is warranted.

Does the type of parenteral lipids matter? A clinical hint in critical illness

BACKGROUND & AIMS

An altered lipid profile is common among intensive care unit (ICU) patients, but evidence regarding the impact of different fatty acid (FA) emulsions administered to patients requiring parenteral nutrition (PN) is scarce. This study aimed to compare the plasma triglycerides (TG) response to two types of commercial lipid emulsions: a structured mixture of long- and medium-chain triglycerides (LCT/MCT) or LCTs with n-9 FA (LCT+) in ICU patients.

METHODS

In this retrospective observational study conducted in a multidisciplinary ICU: two groups were defined by the type of emulsion used. Inclusion criteria were: consecutive patients on PN staying ≥4 days with one TG determination before commencing PN and at least one during PN. Recorded variables included energy intake, amount and type of nutritional lipids, propofol dose, glucose and protein intake, laboratory parameters, and all drugs received. Hypertriglyceridemia (hyperTG) was defined as TG >2 mmol/L.

RESULTS

The dynamic impact of the emulsion was analyzed in 187/757 patients completing the inclusion criteria (112 LCT/MCT and 75 LCT+). The demographic variables, severity indices, diagnostic categories, and outcomes did not differ between the two groups. Seventy-seven patients (41%) presented hyperTG. Both groups received similar daily energy (1604 versus 1511 kcal/day), lipids (60 versus 61 g/day), and glucose intake (233 versus 197 g/day). There was no increase of TG concentration in those receiving the LCT/MCT emulsion compared to those receiving the LCT+ emulsion (0 and 0.2 mmol/L, respectively, p < 0.05).

CONCLUSION

LCT/MCT emulsions are associated with a less pronounced increase of plasma TG levels than LCT+ emulsions.

A Phase 1c Trial Comparing the Efficacy and Safety of a New Aqueous Formulation of Alphaxalone with Propofol

BACKGROUND:

Phaxan™ (PHAX, Chemic Labs, Canton, MA) is an aqueous solution of 10 mg/mL alphaxalone and 13% 7-sulfobutylether β-cyclodextrin (betadex). In preclinical studies, PHAX is a fast onset–offset IV anesthetic like propofol, but causes less cardiovascular depression. This first-in-man study was designed to find the anesthetic dose of PHAX and to compare it with an equivalent dose of propofol for safety, efficacy, and quality of recovery from anesthesia and sedation.

METHODS:

The study adhered to compliance with Good Clinical Practices regulations (clinical trials registry number, ACTRN12611000343909). This randomized, double-blind study compared PHAX and propofol using a Bayesian algorithm to determine dose equivalence for effects on the bispectral index (BIS). Male volunteers, ASA physical status I, gave written informed consent (n = 12 per group; PHAX or propofol). Parameters assessed for 80 minutes after drug injection (single bolus dose) were pain on injection, involuntary movement, BIS, blood pressure, need for airway support, and, as measures of recovery from sedation, the Richmond Agitation and Sedation Scale and the Digit Symbol Substitution Test. Arterial blood was withdrawn for biochemistry, hematology, and complement levels.

RESULTS:

No subject complained of pain on injection with PHAX, whereas 8 of the 12 subjects given propofol did. Nine PHAX and 8 propofol subjects reached BIS values of ≤50: median (interquartile range [IQR]) mg/kg dose = 0.5 (0.5–0.6) for PHAX and 2.9 (2.4–3.0) for propofol. The lowest median BIS reached was 27 to 28 for both agents with no significant differences between them for timing of onset and recovery of BIS. The concomitant median changes in systolic and diastolic blood pressures were −11% vs −19% for systolic and −25% vs −37% for diastolic in PHAX- and propofol-treated subjects, respectively. Nine of the 12 propofol-treated subjects and none of 12 PHAX-treated subjects required airway support. For subjects reaching an equivalent BIS of ≤50: a Richmond Agitation and Sedation Scale score of 0 was reached at a median of 5 (IQR, 5–10) and 15 (IQR, 10–20) minutes after PHAX and propofol, respectively; BIS returned to 90 at a mean of 21 (SD, 10.1) and 21 (SD, 9.2) minutes after PHAX and propofol, respectively; and Digit Symbol Substitution Test scores returned to predrug injection values at median of 50 (IQR, 35–72.5) and 42.5 (IQR, 35–76.3) minutes after PHAX and propofol, respectively. There was no increase in C3 and C4 complement fractions after either drug.

CONCLUSIONS:

PHAX causes fast-onset, short-duration anesthesia with fast cognitive recovery similar to propofol, but with less cardiovascular depression, or airway obstruction and no pain on injection.

Published ahead of print July 29, 2015

Unexplained hemolysis in patients undergoing ECMO: beware of hypertriglyceridemia

Hemolysis is a common complication of extracorporeal membrane oxygenation (ECMO) support and is associated with increased mortality. Frequent monitoring of markers of hemolysis is performed at ECMO centers. We report two cases of spurious hemolysis caused by hypertriglyceridemia in patients undergoing ECMO support. Critically ill patients, including those receiving ECMO, may be at risk of developing medication-induced hypertriglyceridemia. The interference of lipids with the measurement of plasma free hemoglobin, a marker of hemolysis, should be recognized. Our cases highlight the importance of investigating hypertriglyceridemia as part of the assessment of unexplained hemolysis in patients supported with ECMO.

Relationship Between Triglyceride Tolerance, Body Mass Index, and Fat Depots in Hospitalized Patients Receiving Parenteral Nutrition

BACKGROUND

Hypertriglyceridemia has been associated with adverse outcomes in patients receiving intravenous fat emulsions (IVFEs), but little is known about its prevalence and causes.

MATERIALS AND METHODS

The study investigated whether a relationship exists between body mass index (BMI) and triglyceride tolerance in parenterally fed patients. We conducted a retrospective analysis of 287 adults receiving parenteral nutrition to determine whether patients with very low BMI (VLBMI, <16 kg/m(2)) tolerate IVFEs better than do patients with low BMI (LBMI, 16-18.4 kg/m(2)), normal-weight patients (NBMI, 18.5-24.9 kg/m(2)), and overweight/obese patients (HBMI, ≥25 kg/m(2)).

RESULTS

The median triglyceride concentration during IVFE was significantly lower in VLBMI patients at 107 mg/dL compared with 124 mg/dL in non-VLBMI patients (P = .016), despite higher lipid infusion rates in the VLBMI group. There was a significant association between triglycerides and BMI in the aggregate cohort (R = 0.2375, P < .0001), with the highest frequency of hypertriglyceridemia occurring in HBMI patients despite relatively lower lipid and energy supply. In a subset of VLBMI patients (n = 36) who had an abdominal computed tomography scan, there was 25- to 100-fold variability in the size of the abdominal adipose tissue depots. In this subgroup, triglyceride concentrations correlated with visceral fat but not subcutaneous abdominal fat.

CONCLUSIONS

In summary, patients with VLBMI have lower triglyceride concentrations during IVFEs than do other individuals, but there is considerable variability in triglycerides and body fat in this group. Caution should be employed with the use of IVFEs, especially in HBMI patients.