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Demoule A, Decavele M, Antonelli M, Camporota L, Abroug F, Adler D, Azoulay E, Basoglu M, Campbell M, Grasselli G, Herridge M, Johnson MJ, Naccache L, Navalesi P, Pelosi P, Schwartzstein R, Williams C, Windisch W, Heunks L, Similowski T. Dyspnoea in acutely ill mechanically ventilated adult patients: an ERS/ESICM statement. Eur Respir J 2024; 63:2300347. [PMID: 38387998 DOI: 10.1183/13993003.00347-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 09/16/2023] [Indexed: 02/24/2024]
Abstract
This statement outlines a review of the literature and current practice concerning the prevalence, clinical significance, diagnosis and management of dyspnoea in critically ill, mechanically ventilated adult patients. It covers the definition, pathophysiology, epidemiology, short- and middle-term impact, detection and quantification, and prevention and treatment of dyspnoea. It represents a collaboration of the European Respiratory Society and the European Society of Intensive Care Medicine. Dyspnoea ranks among the most distressing experiences that human beings can endure. Approximately 40% of patients undergoing invasive mechanical ventilation in the intensive care unit (ICU) report dyspnoea, with an average intensity of 45 mm on a visual analogue scale from 0 to 100 mm. Although it shares many similarities with pain, dyspnoea can be far worse than pain in that it summons a primal fear response. As such, it merits universal and specific consideration. Dyspnoea must be identified, prevented and relieved in every patient. In the ICU, mechanically ventilated patients are at high risk of experiencing breathing difficulties because of their physiological status and, in some instances, because of mechanical ventilation itself. At the same time, mechanically ventilated patients have barriers to signalling their distress. Addressing this major clinical challenge mandates teaching and training, and involves ICU caregivers and patients. This is even more important because, as opposed to pain which has become a universal healthcare concern, very little attention has been paid to the identification and management of respiratory suffering in mechanically ventilated ICU patients.
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Affiliation(s)
- Alexandre Demoule
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Médecine Intensive - Réanimation, Département R3S, F-75013 Paris, France
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005 Paris, France
| | - Maxens Decavele
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Médecine Intensive - Réanimation, Département R3S, F-75013 Paris, France
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005 Paris, France
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Luigi Camporota
- Department of Adult Critical Care, Health Centre for Human and Applied Physiological Sciences, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Fekri Abroug
- ICU and Research Lab (LR12SP15), Fattouma Bourguiba Teaching Hospital, Monastir, Tunisia
| | - Dan Adler
- Division of Pulmonary Diseases, Hôpital de la Tour, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Elie Azoulay
- Medical Intensive Care Unit, APHP Hôpital Saint-Louis, Paris, France
| | - Metin Basoglu
- Istanbul Center for Behaviorial Sciences (DABATEM), Istanbul, Turkey
| | | | - Giacomo Grasselli
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Anesthesia, Critical Care and Emergency, Milan, Italy
- University of Milan, Department of Pathophysiology and Transplantation, Milan, Italy
| | - Margaret Herridge
- Toronto General Research Institute, University Health Network, Toronto, ON, Canada
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Lionel Naccache
- Département de Neurophysiologie, Sorbonne Université, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
- Institut du Cerveau et de la Moelle Épinière, ICM, PICNIC Lab, Paris, France
| | - Paolo Navalesi
- Department of Medicine, University of Padua, Padua, Italy
- Institute of Anesthesia and Intensive Care, Padua University Hospital, Padua, Italy
| | - Paolo Pelosi
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Richard Schwartzstein
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Wolfram Windisch
- Department of Pneumology, Cologne Merheim Hospital, Kliniken der Stadt Köln, Witten/Herdecke University, Cologne, Germany
| | - Leo Heunks
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
- L. Heunks and T. Similowski contributed equally to the manuscript
| | - Thomas Similowski
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005 Paris, France
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Département R3S, F-75013 Paris, France
- L. Heunks and T. Similowski contributed equally to the manuscript
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Demoule A, Decavele M, Antonelli M, Camporota L, Abroug F, Adler D, Azoulay E, Basoglu M, Campbell M, Grasselli G, Herridge M, Johnson MJ, Naccache L, Navalesi P, Pelosi P, Schwartzstein R, Williams C, Windisch W, Heunks L, Similowski T. Dyspnoea in acutely ill mechanically ventilated adult patients: an ERS/ESICM statement. Intensive Care Med 2024; 50:159-180. [PMID: 38388984 DOI: 10.1007/s00134-023-07246-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 09/16/2023] [Indexed: 02/24/2024]
Abstract
This statement outlines a review of the literature and current practice concerning the prevalence, clinical significance, diagnosis and management of dyspnoea in critically ill, mechanically ventilated adult patients. It covers the definition, pathophysiology, epidemiology, short- and middle-term impact, detection and quantification, and prevention and treatment of dyspnoea. It represents a collaboration of the European Respiratory Society (ERS) and the European Society of Intensive Care Medicine (ESICM). Dyspnoea ranks among the most distressing experiences that human beings can endure. Approximately 40% of patients undergoing invasive mechanical ventilation in the intensive care unit (ICU) report dyspnoea, with an average intensity of 45 mm on a visual analogue scale from 0 to 100 mm. Although it shares many similarities with pain, dyspnoea can be far worse than pain in that it summons a primal fear response. As such, it merits universal and specific consideration. Dyspnoea must be identified, prevented and relieved in every patient. In the ICU, mechanically ventilated patients are at high risk of experiencing breathing difficulties because of their physiological status and, in some instances, because of mechanical ventilation itself. At the same time, mechanically ventilated patients have barriers to signalling their distress. Addressing this major clinical challenge mandates teaching and training, and involves ICU caregivers and patients. This is even more important because, as opposed to pain which has become a universal healthcare concern, very little attention has been paid to the identification and management of respiratory suffering in mechanically ventilated ICU patients.
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Affiliation(s)
- Alexandre Demoule
- Service de Médecine Intensive-Réanimation, Département R3S, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, 75013, Paris, France.
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, 75005, Paris, France.
| | - Maxens Decavele
- Service de Médecine Intensive-Réanimation, Département R3S, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, 75013, Paris, France
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, 75005, Paris, France
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Luigi Camporota
- Department of Adult Critical Care, Health Centre for Human and Applied Physiological Sciences, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Fekri Abroug
- ICU and Research Lab (LR12SP15), Fattouma Bourguiba Teaching Hospital, Monastir, Tunisia
| | - Dan Adler
- Division of Pulmonary Diseases, Hôpital de la Tour, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Elie Azoulay
- Medical Intensive Care Unit, APHP Hôpital Saint-Louis, Paris, France
| | - Metin Basoglu
- Istanbul Center for Behavioral Sciences (DABATEM), Istanbul, Turkey
| | | | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Margaret Herridge
- Toronto General Research Institute, University Health Network, Toronto, ON, Canada
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Lionel Naccache
- Département de Neurophysiologie, Sorbonne Université, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, Paris, France
- Institut du Cerveau et de la Moelle Épinière, ICM, PICNIC Lab, Paris, France
| | - Paolo Navalesi
- Department of Medicine, University of Padua, Padua, Italy
- Institute of Anesthesia and Intensive Care, Padua University Hospital, Padua, Italy
| | - Paolo Pelosi
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Richard Schwartzstein
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Wolfram Windisch
- Department of Pneumology, Cologne Merheim Hospital, Kliniken der Stadt Köln, Witten/Herdecke University, Cologne, Germany
| | - Leo Heunks
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Thomas Similowski
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, 75005, Paris, France
- Département R3S, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, 75013, Paris, France
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Guo NN, Wang HL, Zhao MY, Li JG, Liu HT, Zhang TX, Zhang XY, Chu YJ, Yu KJ, Wang CS. Management of procedural pain in the intensive care unit. World J Clin Cases 2022; 10:1473-1484. [PMID: 35211585 PMCID: PMC8855268 DOI: 10.12998/wjcc.v10.i5.1473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 07/22/2021] [Accepted: 01/20/2022] [Indexed: 02/06/2023] Open
Abstract
Pain is a common experience for inpatients, and intensive care unit (ICU) patients undergo more pain than other departmental patients, with an incidence of 50% at rest and up to 80% during common care procedures. At present, the management of persistent pain in ICU patients has attracted considerable attention, and there are many related clinical studies and guidelines. However, the management of transient pain caused by certain ICU procedures has not received sufficient attention. We reviewed the different management strategies for procedural pain in the ICU and reached a conclusion. Pain management is a process of continuous quality improvement that requires multidisciplinary team cooperation, pain-related training of all relevant personnel, effective relief of all kinds of pain, and improvement of patients' quality of life. In clinical work, which involves complex and diverse patients, we should pay attention to the following points for procedural pain: (1) Consider not only the patient's persistent pain but also his or her procedural pain; (2) Conduct multimodal pain management; (3) Provide combined sedation on the basis of pain management; and (4) Perform individualized pain management. Until now, the pain management of procedural pain in the ICU has not attracted extensive attention. Therefore, we expect additional studies to solve the existing problems of procedural pain management in the ICU.
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Affiliation(s)
- Na-Na Guo
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, Harbin 150081, Heilongjiang Province, China
| | - Hong-Liang Wang
- Department of Critical Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin 150081, Heilongjiang Province, China
| | - Ming-Yan Zhao
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin 150081, Heilongjiang Province, China
| | - Jian-Guo Li
- Department of Intensive Care Unit, Zhongnan Hospital of Wuhan University, Wuhan 430000, Hubei Province, China
| | - Hai-Tao Liu
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, Harbin 150081, Heilongjiang Province, China
| | - Ting-Xin Zhang
- Department of Orthopedics, The Second Affiliated Hospital of Harbin Medical University, Harbin 150081, Heilongjiang Province, China
| | - Xin-Yu Zhang
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, Harbin 150081, Heilongjiang Province, China
| | - Yi-Jun Chu
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, Harbin 150081, Heilongjiang Province, China
| | - Kai-Jiang Yu
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin 150081, Heilongjiang Province, China
| | - Chang-Song Wang
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, Harbin 150081, Heilongjiang Province, China
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Caron M, Parrot A, Elabbadi A, Dupeyrat S, Turpin M, Baury T, Rozencwajg S, Blayau C, Fulgencio JP, Gibelin A, Blanchard PY, Rodriguez S, Daigné D, Allain MC, Fartoukh M, Pham T. Pain and dyspnea control during awake fiberoptic bronchoscopy in critically ill patients: safety and efficacy of remifentanil target-controlled infusion. Ann Intensive Care 2021; 11:48. [PMID: 33725225 PMCID: PMC7966657 DOI: 10.1186/s13613-021-00832-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 03/02/2021] [Indexed: 12/13/2022] Open
Abstract
Purpose Flexible fiberoptic bronchoscopy is frequently used in intensive care unit, but is a source of discomfort, dyspnea and anxiety for patients. Our objective was to assess the feasibility and tolerance of a sedation using remifentanil target-controlled infusion, to perform fiberoptic bronchoscopy in awake ICU patients. Materials, patients and methods This monocentric, prospective observational study was conducted in awake patients requiring fiberoptic bronchoscopy. In accordance with usual practices in our center, remifentanil target-controlled infusion was used under close monitoring and adapted to the patient’s reactions. The primary objective was the rate of successful procedures without additional analgesia or anesthesia. The secondary objectives were clinical tolerance and the comfort of patients (graded from “very uncomfortable” to “very comfortable”) and operators (numeric scale from 0 to 10) during the procedure. Results From May 2014 to December 2015, 72 patients were included. Most of them (69%) were hypoxemic and admitted for acute respiratory failure. No additional medication was needed in 96% of the patients. No severe side-effects occurred. Seventy-eight percent of patients described the procedure as “comfortable or very comfortable”. Physicians rated their comfort with a median [IQR] score of 9 [8–10]. Conclusion Remifentanil target-controlled infusion administered to perform awake fiberoptic bronchoscopy in critically ill patients is feasible without requirement of additional analgesics or sedative drugs. Clinical tolerance as well as patients’ and operators’ comfort were good to excellent. This technique could benefit patients’ experience. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-021-00832-6.
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Affiliation(s)
- Margot Caron
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris, Service de médecine intensive réanimation, Hôpital Tenon, Paris, France
| | - Antoine Parrot
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris, Service de médecine intensive réanimation, Hôpital Tenon, Paris, France
| | - Alexandre Elabbadi
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris, Service de médecine intensive réanimation, Hôpital Tenon, Paris, France
| | - Sophie Dupeyrat
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris, Service de médecine intensive réanimation, Hôpital Tenon, Paris, France
| | - Matthieu Turpin
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris, Service de médecine intensive réanimation, Hôpital Tenon, Paris, France
| | - Thomas Baury
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris, Service de médecine intensive réanimation, Hôpital Tenon, Paris, France
| | - Sacha Rozencwajg
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris, Service de médecine intensive réanimation, Hôpital Tenon, Paris, France
| | - Clarisse Blayau
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris, Service de médecine intensive réanimation, Hôpital Tenon, Paris, France
| | - Jean-Pierre Fulgencio
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris, Service de médecine intensive réanimation, Hôpital Tenon, Paris, France
| | - Aude Gibelin
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris, Service de médecine intensive réanimation, Hôpital Tenon, Paris, France
| | - Pierre-Yves Blanchard
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris, Service de médecine intensive réanimation, Hôpital Tenon, Paris, France
| | - Séverine Rodriguez
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris, Service de médecine intensive réanimation, Hôpital Tenon, Paris, France
| | - Daisy Daigné
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris, Service de médecine intensive réanimation, Hôpital Tenon, Paris, France
| | - Marie-Cécile Allain
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris, Service de médecine intensive réanimation, Hôpital Tenon, Paris, France
| | - Muriel Fartoukh
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris, Service de médecine intensive réanimation, Hôpital Tenon, Paris, France.,Groupe de Recherche Clinique GRC05 CARMAS, Institut Mondor de recherche biomédicale, INSERM, Créteil, France
| | - Tài Pham
- Université Paris-Saclay, AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, DMU CORREVE, FHU SEPSIS, Groupe de recherche clinique CARMAS, Le Kremlin-Bicêtre, France.
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Scarlata S, Costa F, Pascarella G, Strumia A, Antonelli Incalzi R, Agrò FE. Remifentanil Target-Controlled Infusion for Conscious Sedation in Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration (EBUS-TBNA): A Case Series. Clin Drug Investig 2020; 40:985-988. [PMID: 32767252 DOI: 10.1007/s40261-020-00960-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Simone Scarlata
- Geriatrics, Unit of Respiratory Pathophysiology, Campus Bio Medico University and Teaching Hospital, Via Alvaro del Portillo 200, 00128, Rome, Italy.
| | - Fabio Costa
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Campus Bio Medico University and Teaching Hospital, Via Álvaro del Portillo 200, 00128, Rome, Italy
| | - Giuseppe Pascarella
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Campus Bio Medico University and Teaching Hospital, Via Álvaro del Portillo 200, 00128, Rome, Italy
| | - Alessandro Strumia
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Campus Bio Medico University and Teaching Hospital, Via Álvaro del Portillo 200, 00128, Rome, Italy
| | - Raffaele Antonelli Incalzi
- Geriatrics, Unit of Respiratory Pathophysiology, Campus Bio Medico University and Teaching Hospital, Via Alvaro del Portillo 200, 00128, Rome, Italy
| | - Felice E Agrò
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Campus Bio Medico University and Teaching Hospital, Via Álvaro del Portillo 200, 00128, Rome, Italy
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Analgosedation during flexible fiberoptic bronchoscopy: comparing the clinical effectiveness and safety of remifentanil versus midazolam/propofol. BMC Pulm Med 2019; 19:240. [PMID: 31818268 PMCID: PMC6902590 DOI: 10.1186/s12890-019-1004-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 11/21/2019] [Indexed: 11/24/2022] Open
Abstract
Background There are limited data regarding the efficacy and safety of remifentanil sedation for diagnostic bronchoscopy. The aim of this study was to evaluate the clinical efficacy and safety of remifentanil by comparing it with those of conventional drugs, midazolam and propofol. Methods A retrospective study of 186 patients who underwent diagnostic bronchoscopy at Chonbuk National University Hospital was performed. Patients were classified into the remifentanil group and midazolam/propofol group according to the drugs used during bronchoscopy. Results Of the 186 patients, 111 patients received remifentanil and 75 received midazolam/propofol during the bronchoscopy. The proportion of patients who required bronchoscopy for endobronchial inspection alone was significantly higher in the midazolam/propofol group than in the remifentanil group (93.3% vs. 73.0%; p < 0.001). In contrast, the proportion of patients who required more invasive procedures, such as bronchoscopic biopsy, bronchoalveolar lavage, or transbronchial lung biopsy, was significantly higher in the remifentanil group than in the midazolam/propofol group (27.0% vs. 6.7%; p < 0.001). The recovery time was significantly shorter in the remifentanil group than in the midazolam/propofol group (mean 6.4 min vs. 11.6 min, p < 0.001). There were no significant differences between the groups with regard to safety events including desaturation, hypotension, and arrhythmia. Conclusions Despite the higher proportion of patients who underwent more invasive procedures in the remifentanil group than in the midazolam/propofol group, there was no significant difference in safety events between the groups. Those in the remifentanil group also demonstrated a faster recovery time than those in the midazolam/propofol group.
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Target Controlled Infusion in the ICU: An Opportunity to Optimize Antibiotic Therapy. ANNUAL UPDATE IN INTENSIVE CARE AND EMERGENCY MEDICINE 2019 2019. [DOI: 10.1007/978-3-030-06067-1_38] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Ergan B, Nava S. The use of bronchoscopy in critically ill patients: considerations and complications. Expert Rev Respir Med 2018; 12:651-663. [PMID: 29958019 DOI: 10.1080/17476348.2018.1494576] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Flexible bronchoscopy has been well established for diagnostic and therapeutic purposes in critically ill patients. Areas covered: This review outlines the clinical evidence of the utility and safety of flexible bronchoscopy in the intensive care unit, as well as specific considerations, including practical points and potential complications, in critically ill patients. Expert commentary: Its ease to learn and perform and its capacity for bedside application with relatively few complications make flexible bronchoscopy an indispensable tool in the intensive care unit setting. The main indications for flexible bronchoscopy in the intensive care unit are the visualization of the airways, sampling for diagnostic purposes and management of the artificial airways. The decision to perform flexible bronchoscopy can only be made by trade-offs between potential risks and benefits because of the fragile nature of the critically ill. Flexible bronchoscopy-associated serious adverse events are inevitable in cases of a lack of expertise or appropriate precautions.
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Affiliation(s)
- Begum Ergan
- a Department of Pulmonary and Critical Care , School of Medicine, Dokuz Eylul University , Izmir , Turkey
| | - Stefano Nava
- b Department of Clinical , Integrated and Experimental Medicine (DIMES), Respiratory and Critical Care Unit, S. Orsola-Malpighi Hospital, Alma Mater University , Bologna , Italy
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Gao Y, Kang K, Liu H, Jia L, Tang R, Zhang X, Wang H, Yu K. Effect of dexmedetomidine and midazolam for flexible fiberoptic bronchoscopy in intensive care unit patients: A retrospective study. Medicine (Baltimore) 2017; 96:e7090. [PMID: 28640084 PMCID: PMC5484192 DOI: 10.1097/md.0000000000007090] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
This study aimed to investigate the clinical effectiveness of dexmedetomidine and midazolam for sedation of intensive care unit (ICU) patients requiring flexible fiberoptic bronchoscopy (FFB).This retrospective cohort study included 148 patients from the third ICU ward of the Second Affiliated Hospital of Harbin Medical University (Harbin, China) who received simultaneous invasive mechanical ventilation and FFB between March 2012 and December 2014. Patients were divided into dexmedetomidine (n = 72) and midazolam (n = 76) groups according to sedative mode. The sedative effects, incidence of adverse events, and bronchoscopist satisfaction scores were compared between groups.During FFB, total sedation time and total time of FFB were significantly shorter in the midazolam group (P < .001, respectively), with a lower percentage of these patients requiring propofol for remedial sedation (P < .001). The incidence of FFB-related adverse events (including bronchospasm, cough, and decreased oxygen saturation) was significantly higher in dexmedetomidine group compared with midazolam group (P = .007, .014 and .008, respectively). However, the incidence of other adverse events was not significantly different between groups. In addition, bronchoscopist satisfaction scores were significantly higher in the midazolam compared with dexmedetomidine group (7.72 ± 1.65 vs 7.08 ± 1.77; P = .030).For sedation of ICU patients during FFB, combination of midazolam and dexmedetomidine demonstrated an enhanced sedative effect, lower incidence of adverse events, and higher bronchoscopist satisfaction score compared with dexmedetomidine alone, thus represents a suitable alternative sedative for FFB patients.
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Affiliation(s)
- Yang Gao
- Department of Critical Care Medicine, the Second Affiliated Hospital of Harbin Medical University
| | - Kai Kang
- Department of Critical Care Medicine, the First Affiliated Hospital of Harbin Medical University
| | - Haitao Liu
- Department of Critical Care Medicine, the Cancer Hospital of Harbin Medical University
| | - Liu Jia
- Department of Critical Care Medicine, the Second Affiliated Hospital of Harbin Medical University
| | - Rong Tang
- Department of Critical Care Medicine, the Second Affiliated Hospital of Harbin Medical University
| | - Xing Zhang
- Department of Critical Care Medicine, the Second Affiliated Hospital of Harbin Medical University
| | - Hongliang Wang
- Department of Critical Care Medicine, the Second Affiliated Hospital of Harbin Medical University
| | - Kaijiang Yu
- Department of Critical Care Medicine, the Cancer Hospital of Harbin Medical University
- Institute of Critical Care Medicine in Sino Russian Medical Research Center of Harbin Medical University, Harbin, China
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Rezaiguia-Delclaux S, Laverdure F, Kortchinsky T, Lemasle L, Imbert A, Stéphan F. Fiber optic bronchoscopy and remifentanil target-controlled infusion in critically ill patients with acute hypoxaemic respiratory failure: A descriptive study. Anaesth Crit Care Pain Med 2016; 36:273-277. [PMID: 27867133 DOI: 10.1016/j.accpm.2016.07.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Revised: 06/07/2016] [Accepted: 07/11/2016] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Sedation optimizes patient comfort and ease of execution during fiber optic bronchoscopy (FOB). Our objective was to describe the safety and efficacy of remifentanil-TCI during FOB in non-intubated, hypoxaemic, thoracic surgery ICU patients. METHODS Consecutive spontaneously breathing adults requiring FOB after thoracic surgery were included if they had hypoxaemia (PaO2/FiO2<300mmHg or need for non-invasive ventilation [NIV]) and prior FOB failure under topical anaesthesia. The remifentanil initial target was chosen at 1ng/mL brain effect-site concentration (Cet), then titrated to 0.5ng/mL Cet increments according to patient comfort and coughing. Outcomes were patient-reported pain and discomfort (Visual Analogue Scale scores), ventilatory support intensification within 24hours after bronchoscopy, and ease of FOB execution. RESULTS Thirty-nine patients were included; all had a successful FOB. Their median PO2/FiO2 before starting FOB was 187±84mmHg and 24 patients received NIV. Median [interquartile range] pain scores were not different before and after FOB (1.0 [0.0-3.0] and 0.0 [0.0-2.0], respectively). Discomfort was reported as absent or minimal by 27 patients (69%; 95% confidence interval [95% CI], 54-81%) and as bothersome but tolerable by 12 patients (31%; 95% CI, 19-46%). Mean FiO2 returned to baseline within 2hours after FOB in 30 patients; the remaining 9 patients (23%; 95% CI, 13-38%) received ventilatory support intensification. Ease of execution was good or very good in 34 patients (87%; 95% CI, 73-94%), acceptable in 4 patients, and poor in 1 patient (persistent cough). CONCLUSION Sedation with remifentanil-TCI during FOB with prior failure under topical anaesthesia alone was effective and acceptably safe in non-intubated hypoxaemic thoracic surgery patients.
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Affiliation(s)
- Saïda Rezaiguia-Delclaux
- Cardiothoracic Intensive Care Unit, hôpital Marie-Lannelongue, 133, avenue de la Résistance, 92350 Le Plessis-Robinson, France; Université Paris Sud, Paris, France.
| | - Florent Laverdure
- Cardiothoracic Intensive Care Unit, hôpital Marie-Lannelongue, 133, avenue de la Résistance, 92350 Le Plessis-Robinson, France; Université Paris Sud, Paris, France
| | - Talna Kortchinsky
- Cardiothoracic Intensive Care Unit, hôpital Marie-Lannelongue, 133, avenue de la Résistance, 92350 Le Plessis-Robinson, France; Université Paris Sud, Paris, France
| | - Léa Lemasle
- Cardiothoracic Intensive Care Unit, hôpital Marie-Lannelongue, 133, avenue de la Résistance, 92350 Le Plessis-Robinson, France; Université Paris Sud, Paris, France
| | - Audrey Imbert
- Cardiothoracic Intensive Care Unit, hôpital Marie-Lannelongue, 133, avenue de la Résistance, 92350 Le Plessis-Robinson, France; Université Paris Sud, Paris, France
| | - François Stéphan
- Cardiothoracic Intensive Care Unit, hôpital Marie-Lannelongue, 133, avenue de la Résistance, 92350 Le Plessis-Robinson, France; Université Paris Sud, Paris, France
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Abstract
Noninvasive ventilation (NIV) has assumed a prominent role in the treatment of patients with both hypoxemic and hypercapnic acute respiratory failure (ARF). The main theoretic advantages of NIV include avoiding side effects and complications associated with endotracheal intubation, improving patient comfort, and preserving airway defense mechanisms. Factors that affect the success of NIV in patients with ARF are clinicians' expertise, selection of patient, choice of interface, selection of ventilator setting, proper monitoring, and patient motivation. Advances in the understanding of the physiologic aspects of using NIV through different interfaces and ventilator modalities have improved patient-machine interaction, thus enhancing favorable NIV outcome.
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Affiliation(s)
- Giuseppe Bello
- Department of Anesthesia and Intensive Care, Agostino Gemelli Hospital, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, Rome 00168, Italy
| | - Gennaro De Pascale
- Department of Anesthesia and Intensive Care, Agostino Gemelli Hospital, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, Rome 00168, Italy
| | - Massimo Antonelli
- Department of Anesthesia and Intensive Care, Agostino Gemelli Hospital, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, Rome 00168, Italy.
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Remifentanil target-controlled infusion for fiberoptic bronchoscopy in the ICU: feasability, safety and tolerance evaluation. Intensive Care Med Exp 2015. [PMCID: PMC4798556 DOI: 10.1186/2197-425x-3-s1-a325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Anesthesia for Advanced Bronchoscopic Procedures: State-of-the-Art Review. Lung 2015; 193:453-65. [PMID: 25921014 DOI: 10.1007/s00408-015-9733-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 04/17/2015] [Indexed: 12/19/2022]
Abstract
The bronchoscopic procedures have seen a remarkable increase in both numbers and complexity. Although many anesthesia providers have kept pace with the challenge, the practice is varied and frequently suboptimal. Shared airway during bronchoscopy poses unique challenges. The available reviews have tried to address this lacuna; however, these have frequently dealt with the technical aspects of bronchoscopy than anesthetic challenges. The present review provides evidence-based management insights into anesthesia for bronchoscopy-both flexible and rigid. A systematic approach toward pre-procedural evaluation and risk stratification is presented. The possible anatomical and physiological factors that can influence the outcomes are discussed. Pharmacological principles guiding sedation levels and appropriate selection of sedatives form the crux of safe anesthetic management. The newer and safer drugs that can have potential role in anesthesia for bronchoscopy in the near future are discussed. Ventilatory strategies during bronchoscopy for prevention of hypoxia and hypercarbia are emphasized.
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Management of anesthetic emergencies and complications outside the operating room. Curr Opin Anaesthesiol 2015; 27:437-41. [PMID: 24762955 DOI: 10.1097/aco.0000000000000088] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
PURPOSE OF REVIEW Anesthesia outside the operating room is commonly uncomfortable and risky. In this setting, anesthetic emergencies or complications may occur. This review aims to report the most recent updates regarding the management of prehospital anesthesia, anesthesia in the trauma and emergency rooms, and anesthesia for endoscopy and interventional radiology. RECENT FINDINGS After tracheal intubation failure, airway control of outpatients could be achieved by pharmacologically assisted laryngeal mask insertion. Management of traumatic injured patients is best guided in the frame of checklists. Monitoring sedation in this setting is challenging notably because of the threat of haemodynamic instability. Unfortunately, BIS monitoring cannot be recommended to guide sedation in this setting. Ketamine can be used to prevent hypotension during prehospital anesthesia or procedural sedation, especially as its neuroprotective effects have been recently best understood. Target-controlled infusion propofol administration with small concentration increments is adapted to prevent hypotension and hypoxaemia during sedation for gastrointestinal endoscopy and interventional radiology. Target-controlled infusion remifentanil administration is also adapted to many procedures. SUMMARY Anesthesia outside the operating room requires careful monitoring to avoid side-effects and education of nonanaesthetists when they are involved. A useful tool is to continuously improve the protocols and checklists to make anesthesia in this setting safer.
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Goudra BG, Singh PM, Manjunath AK, Reihmer JW, Haas AR, Lanfranco AR, Sinha AC, Harris K. Effectiveness of high dose remifentanil in preventing coughing and laryngospasm in non-paralyzed patients for advanced bronchoscopic procedures. Ann Thorac Med 2014; 9:23-8. [PMID: 24551014 PMCID: PMC3912682 DOI: 10.4103/1817-1737.124437] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Accepted: 09/18/2013] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND: Anesthesia for bronchoscopy presents unique challenges, as constant stimulus due to bronchoscope needs to be obtunded using drugs with a minimal post-procedure residual effect. Remifentanil for maintenance is an ideal choice, but optimal doses are yet to be determined. MATERIALS AND METHODS: Bronchoscopic procedures were prospectively evaluated for 4 months studying the frequency of complications and anesthesia techniques. Anesthesia was maintained on remifentanil/propofol infusion avoiding neuromuscular blockers. Laryngeal mask airway was used for the controlled ventilation (with high oxygen concentration) that also served as a conduit for bronchoscope insertions. Anesthesiologists were blinded to the study (avoiding performance bias) and the Pulmonologist was blinded to the anesthesia technique (to document unbiased procedural satisfaction scores). Procedures were divided into 2 groups based on the dose of remifentanil used for maintenance: Group-H (high dose −0.26 to 0.5 μg/kg/min and Group-NH (non-high dose ≤0.25 μg/kg/min). RESULTS: Observed 75 procedures were divided into Group-H (42) and Group-NH (33). Number of statistical difference was found in demography, procedural profile, hemodynamic parameters and total phenylephrine used. Chi-square test showed Group-NH had significantly higher frequency of laryngospasm (P = 0.047) and coughing (P = 0.002). The likelihood ratio of patient coughing and developing laryngospasm in Group-NH was found to be 4.56 and 10.97 times respectively. Minimum pulse-oximeter saturation was statistically higher in Group-H (98.80% vs. 96.50% P = 0.009). Pulmonologist satisfaction scores were significantly better in Group-H. CONCLUSIONS: High dose of remifentanil infusion is associated with a lower incidence of coughing and laryngospasms during bronchoscopy. Simultaneously, it improves Pulmonologist's satisfaction and procedural conditions.
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Affiliation(s)
- Basavana Gouda Goudra
- Department of Anesthesia, Hospital of the University of Pennsylvania, Philadelphia, USA
| | | | - Amit K Manjunath
- Department of Anesthesia, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Joel W Reihmer
- Department of Anesthesia, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Andrew R Haas
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Anthony R Lanfranco
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Ashish C Sinha
- Department of Anesthesiology and Perioperative Medicine, Drexel University College of Medicine, Philadelphia, USA
| | - Kassem Harris
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, USA
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Year in review in Intensive Care Medicine 2013: II. Sedation, invasive and noninvasive ventilation, airways, ARDS, ECMO, family satisfaction, end-of-life care, organ donation, informed consent, safety, hematological issues in critically ill patients. Intensive Care Med 2014; 40:305-19. [PMID: 24458282 DOI: 10.1007/s00134-014-3217-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Accepted: 01/11/2014] [Indexed: 01/02/2023]
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Khan ZH. Pain management in intensive care unit patients: the role of ultra-short acting opioid: remifentanil. Anesth Pain Med 2013; 3:188-90. [PMID: 24223360 PMCID: PMC3821149 DOI: 10.5812/aapm.10299] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Accepted: 02/20/2013] [Indexed: 11/30/2022] Open
Affiliation(s)
- Zahid Hussain Khan
- Department of Anesthesiology and Intensive Care, Imam Khomeini Medical Center, Tehran University of Medical Sciences (TUMS), Tehran, Iran
- Corresponding author: Zahid Hussain Khan, Department of Anesthesiology and Intensive Care, Imam Khomeini Medical Center, Keshavarz Blvd., Tehran University of Medical Sciences (TUMS), 1419733141 Tehran, Iran. Tel: +98-2161192828, Fax: +98-2166581537, E-mail:
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Lin TY, Lo YL, Hsieh CH, Ni YL, Wang TY, Lin HC, Wang CH, Yu CT, Kuo HP. The potential regimen of target-controlled infusion of propofol in flexible bronchoscopy sedation: a randomized controlled trial. PLoS One 2013; 8:e62744. [PMID: 23638141 PMCID: PMC3634750 DOI: 10.1371/journal.pone.0062744] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2012] [Accepted: 03/14/2013] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES Target-controlled infusion (TCI) provides precise pharmacokinetic control of propofol concentration in the effect-site (Ce), eg. brain. This pilot study aims to evaluate the feasibility and optimal TCI regimen for flexible bronchoscopy (FB) sedation. METHODS After alfentanil bolus, initial induction Ce of propofol was targeted at 2 μg/ml. Patients were randomized into three titration groups (i.e., by 0.5, 0.2 and 0.1 μg/ml, respectively) to maintain stable sedation levels and vital signs. Adverse events, frequency of adjustments, drug doses, and induction and recovery times were recorded. RESULTS The study was closed early due to significantly severe hypoxemia events (oxyhemoglobin saturation <70%) in the group titrated at 0.5 μg/ml. Forty-nine, 49 and 46 patients were enrolled into the 3 respective groups before study closure. The proportion of patients with hypoxemia events differed significantly between groups (67.3 vs. 46.9 vs. 41.3%, p = 0.027). Hypotension events, induction and recovery time and propofol doses were not different. The Ce of induction differed significantly between groups (2.4±0.5 vs. 2.1±0.4 vs. 2.1±0.3 μg/ml, p = 0.005) and the Ce of procedures was higher at 0.5 μg/ml titration (2.4±0.5 vs. 2.1±0.4 vs. 2.2±0.3 μg/ml, p = 0.006). The adjustment frequency tended to be higher for titration at 0.1 μg/ml but was not statistically significant (2 (0∼6) vs. 3 (0∼6) vs. 3 (0∼11)). Subgroup analysis revealed 14% of all patients required no further adjustment during the whole sedation. Comparing patients requiring at least one adjustment with those who did not, they were observed to have a shorter induction time (87.6±34.9 vs. 226.9±147.9 sec, p<0.001), a smaller induction dose and Ce (32.5±4.1 vs. 56.8±22.7 mg, p<0.001; 1.76±0.17 vs. 2.28 ±0.41, p<0.001, respectively), and less hypoxemia and hypotension (15.8 vs.56.9%, p = 0.001; 0 vs. 24.1%, p = 0.008, respectively). CONCLUSION Titration at 0.5 μg/ml is risky for FB sedation. A subgroup of patients required no more TCI adjustment with fewer complications. Further studies are warranted to determine the optimal regimen of TCI for FB sedation. TRIAL REGISTRATION ClinicalTrials.gov NCT01101477.
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Affiliation(s)
- Ting-Yu Lin
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taipei, Taiwan
| | - Yu-Lun Lo
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taipei, Taiwan
| | - Chung-Hsing Hsieh
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taipei, Taiwan
| | - Yung-Lun Ni
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taipei, Taiwan
| | - Tsai-Yu Wang
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taipei, Taiwan
| | - Horng-Chyuan Lin
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taipei, Taiwan
| | - Chun-Hua Wang
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taipei, Taiwan
| | - Chih-Teng Yu
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taipei, Taiwan
| | - Han-Pin Kuo
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taipei, Taiwan
- * E-mail:
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Muñoz L, Arévalo JJ, Reyes LE, Balaguera CE. Remifentanilo versus propofol con infusión controlada a objetivo en sitio efecto para la sedación de pacientes durante procedimientos endoscópicos gastrointestinales: ensayo clínico controlado aleatorizado. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2013. [DOI: 10.1016/j.rca.2012.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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