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Macpherson D, Hutchinson A, Bloomer MJ. Factors that influence critical care nurses' management of sedation for ventilated patients in critical care: A qualitative study. Intensive Crit Care Nurs 2024; 83:103685. [PMID: 38493573 DOI: 10.1016/j.iccn.2024.103685] [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: 12/02/2023] [Revised: 03/05/2024] [Accepted: 03/11/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND Optimising sedation use is key to timely extubation. Whilst sedation protocols may be used to guide critical care nurses' management of sedation, sedation management and decision-making is complex, influenced by multiple factors related to patients' circumstances, intensive care unit design and the workforce. AIM To explore (i) critical care nurses' experiences managing sedation in mechanically ventilated patients and (ii) the factors that influence their sedation-related decision-making. DESIGN Qualitative descriptive study using semi-structured interviews. Data were analysed using Braun and Clarke's six-step thematic analysis. SETTING AND PARTICIPANTS This study was conducted in a 26-bed level 3 accredited ICU, in a private hospital in Melbourne, Australia. The majority of patients are admitted following elective surgery. Critical care nurses, who were permanently employed as a registered nurse, worked at least 16 h per week, and cared for ventilated patients, were invited to participate. FINDINGS Thirteen critical care nurses participated. Initially, participants suggested their experiences managing sedation were linked to local unit policy and learning. Further exploration revealed that experiences were synonymous with descriptors of factors influencing sedation decision-making according to three themes: (i) Learning from past experiences, (ii) Situational awareness and (iii) Prioritising safety. Nurses relied on their cumulative knowledge from prior experiences to guide decision-making. Situational awareness about other emergent priorities in the unit, staffing and skill-mix were important factors in guiding sedation decision-making. Safety of patients and staff was essential, at times overriding goals to reduce sedation. CONCLUSION Sedation decision making cannot be considered in isolation. Rather, sedation decision making must take into account outcomes of patient assessment, emergent priorities, unit and staffing factors and safety concerns. IMPLICATIONS FOR CLINICAL PRACTICE Opportunities for ongoing education are essential to promote nurses' situational awareness of other emergent unit priorities, staffing and skill-mix, in addition to evidence-based sedation management and decision making.
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Affiliation(s)
- Danielle Macpherson
- Intensive Care Unit, Epworth HealthCare Richmond, Victoria, Australia; School of Nursing and Midwifery, Deakin University, Geelong, Victoria, Australia
| | - Anastasia Hutchinson
- School of Nursing and Midwifery, Deakin University, Geelong, Victoria, Australia; Centre for Quality and Patient Safety Research in the Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia; Centre for Quality and Patient Safety Research - Epworth HealthCare Partnership, Richmond, Victoria, Australia
| | - Melissa J Bloomer
- School of Nursing and Midwifery, Griffith University, Nathan, Queensland, Australia; Intensive Care Unit, Princess Alexandra Hospital, Queensland Health, Woolloongabba, Queensland, Australia.
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Rixecker TM, Ast V, Rodriguez E, Mazuru V, Wagenpfeil G, Mang S, Muellenbach RM, Nobile L, Ajouri J, Bals R, Seiler F, Taccone FS, Lepper PM. Carbon Dioxide Targets in Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome. ASAIO J 2024:00002480-990000000-00509. [PMID: 38905594 DOI: 10.1097/mat.0000000000002255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/23/2024] Open
Abstract
Target values for arterial carbon dioxide tension (PaCO2) in extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome (ARDS) are unknown. We hypothesized that lower PaCO2 values on ECMO would be associated with lighter sedation. We used data from two independent patient cohorts with ARDS spending 1,177 days (discovery cohort, 69 patients) and 516 days (validation cohort, 70 patients) on ECMO and evaluated the associations between daily PaCO2, pH, and bicarbonate (HCO3) with sedation. Median PaCO2 was 41 (interquartile range [IQR] = 37-46) mm Hg and 41 (IQR = 37-45) mm Hg in the discovery and the validation cohort, respectively. Lower PaCO2 and higher pH but not bicarbonate (HCO3) served as significant predictors for reaching a Richmond Agitation Sedation Scale (RASS) target range of -2 to +1 (lightly sedated to restless). After multivariable adjustment for mortality, tracheostomy, prone positioning, vasoactive inotropic score, Simplified Acute Physiology Score (SAPS) II or Sequential Organ Failure Assessment (SOFA) Score and day on ECMO, only PaCO2 remained significantly associated with the RASS target range (adjusted odds ratio 1.1 [95% confidence interval (CI) = 1.01-1.21], p = 0.032 and 1.29 [95% CI = 1.1-1.51], p = 0.001 per mm Hg decrease in PaCO2 for the discovery and the validation cohort, respectively). A PaCO2 ≤40 mm Hg, as determined by the concordance probability method, was associated with a significantly increased probability of a sedation level within the RASS target range in both patient cohorts (adjusted odds ratio = 2.92 [95% CI = 1.17-7.24], p = 0.021 and 6.82 [95% CI = 1.50-31.0], p = 0.013 for the discovery and the validation cohort, respectively).
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Affiliation(s)
- Torben M Rixecker
- From the Department of Internal Medicine V (Pneumology, Allergology and Intensive Care Medicine), University Medical Center and Saarland University, Germany
| | - Vanessa Ast
- From the Department of Internal Medicine V (Pneumology, Allergology and Intensive Care Medicine), University Medical Center and Saarland University, Germany
| | - Elianna Rodriguez
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Vitalie Mazuru
- From the Department of Internal Medicine V (Pneumology, Allergology and Intensive Care Medicine), University Medical Center and Saarland University, Germany
| | - Gudrun Wagenpfeil
- Department of Medical Biometry, Epidemiology and Medical Informatics, Saarland University, Homburg, Germany
| | - Sebastian Mang
- From the Department of Internal Medicine V (Pneumology, Allergology and Intensive Care Medicine), University Medical Center and Saarland University, Germany
| | - Ralf M Muellenbach
- Department of Anesthesiology and Critical Care Medicine, Campus Kassel of the University of Southampton, Kassel, Germany
| | - Leda Nobile
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Jonas Ajouri
- Department of Anesthesiology and Critical Care Medicine, Campus Kassel of the University of Southampton, Kassel, Germany
| | - Robert Bals
- From the Department of Internal Medicine V (Pneumology, Allergology and Intensive Care Medicine), University Medical Center and Saarland University, Germany
| | - Frederik Seiler
- From the Department of Internal Medicine V (Pneumology, Allergology and Intensive Care Medicine), University Medical Center and Saarland University, Germany
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Philipp M Lepper
- From the Department of Internal Medicine V (Pneumology, Allergology and Intensive Care Medicine), University Medical Center and Saarland University, Germany
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Teixeira C, Rosa RG. Unmasking the hidden aftermath: postintensive care unit sequelae, discharge preparedness, and long-term follow-up. CRITICAL CARE SCIENCE 2024; 36:e20240265en. [PMID: 38896724 PMCID: PMC11152445 DOI: 10.62675/2965-2774.20240265-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 01/03/2024] [Indexed: 06/21/2024]
Abstract
A significant portion of individuals who have experienced critical illness encounter new or exacerbated impairments in their physical, cognitive, or mental health, commonly referred to as postintensive care syndrome. Moreover, those who survive critical illness often face an increased risk of adverse consequences, including infections, major cardiovascular events, readmissions, and elevated mortality rates, during the months following hospitalization. These findings emphasize the critical necessity for effective prevention and management of long-term health deterioration in the critical care environment. Although conclusive evidence from well-designed randomized clinical trials is somewhat limited, potential interventions include strategies such as limiting sedation, early mobilization, maintaining family presence during the intensive care unit stay, implementing multicomponent transition programs (from intensive care unit to ward and from hospital to home), and offering specialized posthospital discharge follow-up. This review seeks to provide a concise summary of recent medical literature concerning long-term outcomes following critical illness and highlight potential approaches for preventing and addressing health decline in critical care survivors.
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Affiliation(s)
- Cassiano Teixeira
- Department of Internal MedicineUniversidade Federal de Ciências da Saúde de Porto AlegrePorto AlegreRSBrazilDepartment of Internal Medicine, Universidade Federal de Ciências da Saúde de Porto Alegre - Porto Alegre (RS), Brazil.
| | - Regis Goulart Rosa
- Department of Internal MedicineHospital Moinhos de VentoPorto AlegreRSBrazilDepartment of Internal Medicine, Hospital Moinhos de Vento - Porto Alegre (RS), Brazil.
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Bhattacharyya A, Laycock H, Brett SJ, Beatty F, Kemp HI. Health care professionals' experiences of pain management in the intensive care unit: a qualitative study. Anaesthesia 2024; 79:611-626. [PMID: 38153304 DOI: 10.1111/anae.16209] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2023] [Indexed: 12/29/2023]
Abstract
Despite the existence of evidence-based guidelines for the assessment and management of pain in the critical care setting, the prevalence of acute pain remains high. Inadequate pain management is associated with longer duration of mechanical ventilation, reduced capacity for rehabilitation and long-term psychological sequelae. This study aimed to describe the experiences of pain management from healthcare professionals working in intensive care units. Healthcare professionals were recruited from intensive care units in London, UK using a purposive sampling technique. Semi-structured interviews were transcribed verbatim. Transcripts were analysed using an inductive thematic analysis technique. Thirty participants were recruited from eight diverse intensive care units. Five themes were identified. First, there was a lack of consensus in pain assessment in the ICU where nursing staff described more knowledge and confidence of validated pain measures than physicians, and concerns over validity and usability were raised. Second, there was a universal perception of resource availability impacting the quality of pain management including high clinical workload, staff turnover and availability of certain pain management techniques. Third, acknowledgement of the importance of pain management was highest in those with experience of interacting with critical care survivors. Fourth, participants described their own emotional reaction to managing those in pain which influenced their learning. Finally, there was a perception that, due to the complexity of the intensive care unit population, pain was de-prioritised and there were conflicting views as to whether standardised analgosedation algorithms were useful. This study provides evidence to suggest interdisciplinary training, collaboratively designed decision-making tools, prioritisation initiatives and research priorities are areas that could be targeted to improve pain management in critical care.
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Affiliation(s)
| | - H Laycock
- Department of Anaesthesia, Great Ormond Street Hospital, London, UK
| | - S J Brett
- Division of Anaesthesia, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, UK
- Directorate of Critical Care, Imperial College Healthcare NHS Trust, London, UK
| | - F Beatty
- Guy's and St Thomas' NHS Trust, London, UK
| | - H I Kemp
- The Pain Research Group, Imperial College London, London, UK
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5
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Vollmer NJ, Wieruszewski ED, Nei AM, Mara KC, Rabinstein AA, Brown CS. Impact of Continuous Infusion Ketamine Compared to Continuous Infusion Benzodiazepines on Delirium in the Intensive Care Unit. J Intensive Care Med 2024:8850666241253541. [PMID: 38778678 DOI: 10.1177/08850666241253541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
Purpose: The purpose of this study was to evaluate rates of delirium or coma-free days between continuous infusion sedative-dose ketamine and continuous infusion benzodiazepines in critically ill patients. Materials and Methods: In this single-center, retrospective cohort adult patients were screened for inclusion if they received continuous infusions of either sedative-dose ketamine or benzodiazepines (lorazepam or midazolam) for at least 24 h, were mechanically ventilated for at least 48 h and admitted to the intensive care unit of a large quaternary academic center between 5/5/2018 and 12/1/2021. Results: A total of 165 patients were included with 64 patients in the ketamine group and 101 patients in the benzodiazepine group (lorazepam n = 35, midazolam n = 78). The primary outcome of median (IQR) delirium or coma-free days within the first 28 days of hospitalization was 1.2 (0.0, 3.7) for ketamine and 1.8 (0.7, 4.6) for benzodiazepines (p = 0.13). Patients in the ketamine arm spent a significantly lower proportion of time with RASS -3 to +4, received significantly higher doses and longer durations of propofol and fentanyl infusions, and had a significantly longer intensive care unit length of stay. Conclusions: The use of sedative-dose ketamine had no difference in delirium or coma-free days compared to benzodiazepines.
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Affiliation(s)
| | - Erin D Wieruszewski
- Department of Pharmacy, Mayo Clinic Hospital, Rochester, MN, USA
- Department of Emergency Medicine, Mayo Clinic Hospital, Rochester, MN, USA
| | - Andrea M Nei
- Department of Pharmacy, Mayo Clinic Hospital, Rochester, MN, USA
| | - Kristin C Mara
- Department of Quantitative Health Sciences, Mayo Clinic Hospital, Rochester, MN, USA
| | | | - Caitlin S Brown
- Department of Pharmacy, Mayo Clinic Hospital, Rochester, MN, USA
- Department of Emergency Medicine, Mayo Clinic Hospital, Rochester, MN, USA
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Jansen G, Latka E, Bernhard M, Deicke M, Fischer D, Hoyer A, Keller Y, Kobiella A, Strickmann B, Strototte LM, Thies KC, Johanning K. Prehospital anesthesia in postcardiac arrest patients: a multicenter retrospective cohort study. Eur J Med Res 2024; 29:263. [PMID: 38698492 PMCID: PMC11067130 DOI: 10.1186/s40001-024-01864-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 04/24/2024] [Indexed: 05/05/2024] Open
Abstract
BACKGROUND Currently, the data regarding the impact of prehospital postcardiac arrest anesthesia on target hemodynamic and ventilatory parameters of early postresuscitation care and recommendations on its implementation are rare. The present study examines the incidence and impact of prehospital postcardiac arrest anesthesia on hemodynamic and ventilatory target parameters of postresuscitation care. METHODS In this multicentre observational study between 2019 and 2021 unconscious adult patients after out-of-hospital-cardiac arrest with the presence of a return-of-spontaneous circulation until hospital admission were included. Primary endpoint was the application of postarrest anesthesia. Secondary endpoints included the medication group used, predisposing factors to its implementation, and its influence on achieving target parameters of postresuscitation care (systolic blood pressure: ≥ 100 mmHg, etCO2:35-45 mmHg, SpO2: 94-98%) at hospital handover. RESULTS During the study period 2,335 out-of-hospital resuscitations out of 391,305 prehospital emergency operations (incidence: 0.58%; 95% CI 0.54-0.63) were observed with a return of spontaneous circulation to hospital admission in 706 patients (30.7%; 95% CI 28.8-32.6; female: 34.3%; age:68.3 ± 14.2 years). Postcardiac arrest anesthesia was performed in 482 patients (68.3%; 95% CI 64.7-71.7) with application of hypnotics in 93.4% (n = 451), analgesics in 53.7% (n = 259) and relaxants in 45.6% (n = 220). Factors influencing postcardiac arrest sedation were emergency care by an anesthetist (odds ratio: 2.10; 95% CI 1.34-3.30; P < 0.001) and treatment-free interval ≤ 5 min (odds ratio: 1.59; 95% CI 1.01-2.49; P = 0.04). Although there was no evidence of the impact of performing postcardiac arrest anesthesia on achieving a systolic blood pressure ≥ 100 mmHg at the end of operation (odds ratio: 1.14; 95% CI 0.78-1.68; P = 0.48), patients with postcardiac arrest anesthesia were significantly more likely to achieve the recommended ventilation (odds ratio: 1.59; 95% CI 1.06-2.40; P = 0.02) and oxygenation (odds ratio:1.56; 95% CI 1.04-2.35; P = 0.03) targets. Comparing the substance groups, the use of hypnotics significantly more often enabled the target values for etCO2 to be reached alone (odds ratio:2.79; 95% CI 1.04-7.50; P = 0.04) as well as in combination with a systolic blood pressure ≥ 100 mmHg (odds ratio:4.42; 95% CI 1.03-19.01; P = 0.04). CONCLUSIONS Postcardiac arrest anesthesia in out-of-hospital cardiac arrest is associated with early achievement of respiratory target parameters in prehospital postresuscitation care without evidence of more frequent hemodynamic complications.
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Affiliation(s)
- Gerrit Jansen
- University Department of Anesthesiology, Intensive Care Medicine and Emergency Medicine, Johannes Wesling Klinikum Minden, Ruhr University Bochum, Hans-Nolte-Straße 1, 32429, Minden, Germany.
- Medical School OWL, Bielefeld University, Universitätsstraße 25, 33615, Bielefeld, Germany.
- Department of Medical and Emergency Services, Study Institute Westfalen-Lippe, Remterweg 44, 33617, Bielefeld, Germany.
| | - Eugen Latka
- Department of Medical and Emergency Services, Study Institute Westfalen-Lippe, Remterweg 44, 33617, Bielefeld, Germany
| | - Michael Bernhard
- Central Emergency Department, University Hospital of Düsseldorf, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Martin Deicke
- Emergency Medical Service, Countryside of Osnabrueck, Am Schölerberg 1, 49082, Osnabrueck, Germany
- Department of Anesthesiology and Operative Intensive Care Medicine, Hospital of Osnabrueck, Am Finkenhügel 1, 49076, Osnabrueck, Germany
| | - Daniel Fischer
- Emergency Medical Service, City and District of Lippe-Detmold, Röntgenstraße 18, 32756, Detmold, Germany
| | - Annika Hoyer
- Biostatistics and Medical Biometry, Medical School OWL, Bielefeld University, Universitätsstraße 25, 33615, Bielefeld, Germany
| | - Yacin Keller
- Department of Public Order and Security, Fire and Disaster Control Office, Integrated Regional Control Centre, Scharfenberger Straße 47, 01139, Dresden, Germany
- Departement for Anesthesiology and Intensive Care Medicine, Emergency Medicine and Pain Therapy, Municipal Hospital Dresden - Friedrichstadt, Friedrichstraße 41, 01067, Dresden, Germany
| | - André Kobiella
- Emergency Medical Service, City and District of Guetersloh, Herzebrocker Strasse 140, 33324, Guetersloh, Germany
| | - Bernd Strickmann
- Emergency Medical Service, City and District of Guetersloh, Herzebrocker Strasse 140, 33324, Guetersloh, Germany
| | - Lisa Marie Strototte
- Department of Anesthesiology, Intensive Care, Emergency Medicine, Transfusion Medicine, and Pain Therapy, Protestant Hospital of the Bethel Foundation, Medical School OWL, Bielefeld University, Burgsteig 13, 33617, Bielefeld, Germany
| | - Karl-Christian Thies
- Department of Anesthesiology, Intensive Care, Emergency Medicine, Transfusion Medicine, and Pain Therapy, Protestant Hospital of the Bethel Foundation, Medical School OWL, Bielefeld University, Burgsteig 13, 33617, Bielefeld, Germany
| | - Kai Johanning
- Department of Anesthesiology, Operative Intensive Care Medicine, Emergency Medicine and Pain Therapy, Bielefeld Municipal Hospital, Medical School OWL, Bielefeld University, Campus Klinikum Bielefeld, Teutoburger Straße 50, 33604, Bielefeld, Germany
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Yu J, Yang Z, Sun S, Sun K, Chen W, Zhang L, Xu J, Xu Q, Liu Z, Ke J, Zhang L, Zhu Y. The effect of weighted blankets on sleep and related disorders: a brief review. Front Psychiatry 2024; 15:1333015. [PMID: 38686123 PMCID: PMC11056563 DOI: 10.3389/fpsyt.2024.1333015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 03/27/2024] [Indexed: 05/02/2024] Open
Abstract
Background Sleep disorders such as insomnia can lead to a range of health problems. The high risk of side effects and drug abuse of traditional pharmacotherapy calls for a safer non-pharmacotherapy. Aims To examine the use and efficacy of weighted blankets in improving sleep and related disorders in different populations and explore the possible mechanisms. Methods A literature search was conducted using PubMed, Embase, Web of Science, MEDLINE, Cochrane Library and CNKI databases. Eligible studies included an intervention with weighted blankets and outcomes covering sleep and/or related disorders (behavioral disturbance, negative emotions and daytime symptoms). Studies using other deep pressure, compression, or exercise-related interventions were excluded. Conclusions Most of the included studies showed that weighted blankets could effectively improve sleep quality and alleviate negative emotions and daytime symptoms in patients with sleep disorders, attention deficit hyperactivity disorder, autism spectrum disorder, and other related disorders, with a possible mechanism of deep pressure touch. Recommendations Weighted blankets might be a promising tool for sleep interventions among individuals with sleep disorders in clinical settings. More high-quality and large-scale randomized controlled trials are needed to further validate the safety and efficacy of weighted blankets and explore precise mechanisms.
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Affiliation(s)
- Jie Yu
- Center for Clinical Big Data and Analytics of the Second Affiliated Hospital, and Department of Big Data in Health Science School of Public Health, The Key Laboratory of Intelligent Preventive Medicine of Zhejiang Province, Zhejiang University School of Medicine, Hangzhou, China
| | - Zhenqing Yang
- Center for Clinical Big Data and Analytics of the Second Affiliated Hospital, and Department of Big Data in Health Science School of Public Health, The Key Laboratory of Intelligent Preventive Medicine of Zhejiang Province, Zhejiang University School of Medicine, Hangzhou, China
| | - Sudan Sun
- Center for Clinical Big Data and Analytics of the Second Affiliated Hospital, and Department of Big Data in Health Science School of Public Health, The Key Laboratory of Intelligent Preventive Medicine of Zhejiang Province, Zhejiang University School of Medicine, Hangzhou, China
| | - Kaili Sun
- Center for Clinical Big Data and Analytics of the Second Affiliated Hospital, and Department of Big Data in Health Science School of Public Health, The Key Laboratory of Intelligent Preventive Medicine of Zhejiang Province, Zhejiang University School of Medicine, Hangzhou, China
| | - Weiran Chen
- Center for Clinical Big Data and Analytics of the Second Affiliated Hospital, and Department of Big Data in Health Science School of Public Health, The Key Laboratory of Intelligent Preventive Medicine of Zhejiang Province, Zhejiang University School of Medicine, Hangzhou, China
| | - Liming Zhang
- Center for Clinical Big Data and Analytics of the Second Affiliated Hospital, and Department of Big Data in Health Science School of Public Health, The Key Laboratory of Intelligent Preventive Medicine of Zhejiang Province, Zhejiang University School of Medicine, Hangzhou, China
| | - Jiahui Xu
- Department of Neurology/Center for Sleep Medicine, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Qinglin Xu
- Department of Neurology/Center for Sleep Medicine, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Zuyun Liu
- Center for Clinical Big Data and Analytics of the Second Affiliated Hospital, and Department of Big Data in Health Science School of Public Health, The Key Laboratory of Intelligent Preventive Medicine of Zhejiang Province, Zhejiang University School of Medicine, Hangzhou, China
| | - Juan Ke
- Department of Internal Medicine of Traditional Chinese Medicine, Shaoxing Hospital of Traditional Chinese Medicine, Shaoxing, China
| | - Lisan Zhang
- Department of Neurology/Center for Sleep Medicine, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yubo Zhu
- Department of Neurology, Affiliated Hospital of Shaoxing University, Shaoxing, China
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Hauser CD, Bell CM, Zamora RA, Mazur J, Neyens RR. Characterization of Opioid Use in the Intensive Care Unit and Its Impact Across Care Transitions: A Prospective Study. J Pharm Pract 2024; 37:343-350. [PMID: 36259532 DOI: 10.1177/08971900221134553] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Purpose: The objective of this study is to characterize opioid intensity in the intensive care unit (ICU) and its association with opioid utilization across care transitions. Methods: This is a prospective cohort study. Medically ill ICU patients with complete medication histories who survived to discharge were included. Opioid intensity was characterized based on IV morphine milligram equivalents (IV MME). Primary outcomes were opioid prescribing upon ICU and hospital discharge. Results: Opioids were prescribed to 34.1% and 31.1% of patients upon ICU and hospital discharge. Within the ≥50 mean IV MME/ICU day cohort, 64.7% of patients received opioids after ICU discharge compared to 45.8% and 13.6% in the 1-49 mean IV MME/ICU day and no opioid groups (P < .05). Within the ≥50 mean IV MME/ICU day cohort, 70.6% of patients were prescribed opioids after hospitalization compared to 37.3% and 13.6% of patients who received less or no opioids. (P < .05). Within the ≥50 mean IV MME/ICU day cohort, 29.4% of patients were opioid naïve and discharged with an opioid, which is over double compared to patients with lower opioid requirements (P < .05). Conclusion: Patients with higher mean daily ICU opioid requirements had increased opioid prescribing across care transitions despite preadmission opioid use.
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Affiliation(s)
- Christian D Hauser
- Critical Care and Emergency Medicine Clinical Pharmacy Specialist, Department of Pharmacy, Indiana University Health Methodist Hospital, Indianapolis, IN, USA
| | - Carolyn M Bell
- Department of Pharmacy, Medical University of South Carolina
| | | | - Joseph Mazur
- Department of Pharmacy, Medical University of South Carolina
| | - Ron R Neyens
- Department of Pharmacy, Medical University of South Carolina
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9
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Armstrong-Hough M, Lin P, Venkatesh S, Ghous M, Hough CL, Cook SH, Iwashyna TJ, Valley TS. Ethnic Disparities in Deep Sedation of Patients with Acute Respiratory Distress Syndrome in the United States: Secondary Analysis of a Multicenter Randomized Trial. Ann Am Thorac Soc 2024; 21:620-626. [PMID: 38324712 PMCID: PMC10995555 DOI: 10.1513/annalsats.202307-600oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 02/05/2024] [Indexed: 02/09/2024] Open
Abstract
Rationale: Patients identified as Hispanic, the largest minority group in the United States, are more likely to die from acute respiratory distress syndrome (ARDS) than non-Hispanic patients. Mechanisms to explain this disparity remain unidentified. However, Hispanic patients may be at risk of overexposure to deep sedation because of language differences between patients and clinicians, and deep sedation is associated with higher ARDS mortality.Objective: We examined associations between Hispanic ethnicity and exposure to deep sedation among patients with ARDS.Methods: A secondary analysis was conducted of patients enrolled in the control arm of a randomized trial of neuromuscular blockade for ARDS across 48 U.S. hospitals. Exposure to deep sedation was measured over the first 5 days that a patient was alive and received mechanical ventilation. Multilevel mixed-effects models were used to evaluate associations between Hispanic ethnicity and exposure to deep sedation, controlling for patient characteristics.Results: Patients identified as Hispanic had approximately five times the odds of deep sedation (odds ratio, 4.98; 95% confidence interval, 2.02-12.28; P < 0.0001) on a given day, compared with non-Hispanic White patients. Hospitals with at least one enrolled Hispanic patient kept all enrolled patients deeply sedated longer than hospitals without any enrolled Hispanic patients (85.8% of ventilator-days vs. 65.5%; P < 0.001).Conclusions: Hispanic patients are at higher risk of exposure to deep sedation than non-Hispanic White patients. There is an urgent need to understand and address disparities in sedation delivery.
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Affiliation(s)
- Mari Armstrong-Hough
- Department of Epidemiology and
- Department of Social and Behavioral Sciences, New York University School of Global Public Health, New York, New York
| | - Paul Lin
- Institute for Healthcare Policy and Innovation
| | | | - Muhammad Ghous
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, and
| | - Catherine L. Hough
- Division of Pulmonary and Critical Care, Oregon Health and Science University, Portland, Oregon
| | - Stephanie H. Cook
- Department of Social and Behavioral Sciences, New York University School of Global Public Health, New York, New York
| | - Theodore J. Iwashyna
- Department of Medicine and Department of Health Policy and Management, Johns Hopkins University, Baltimore, Maryland; and
| | - Thomas S. Valley
- Institute for Healthcare Policy and Innovation
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, and
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, Michigan
- VA Center for Clinical Management Research, Ann Arbor, Michigan
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Parrilla-Gómez FJ, Marin-Corral J, Castellví-Font A, Pérez-Terán P, Picazo L, Ravelo-Barba J, Campano-García M, Festa O, Restrepo M, Masclans JR. Switches in non-invasive respiratory support strategies during acute hypoxemic respiratory failure: Need to monitoring from a retrospective observational study. Med Intensiva 2024; 48:200-210. [PMID: 37985338 DOI: 10.1016/j.medine.2023.11.006] [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: 08/11/2023] [Revised: 10/02/2023] [Accepted: 10/17/2023] [Indexed: 11/22/2023]
Abstract
OBJECTIVE To explore combined non-invasive-respiratory-support (NIRS) patterns, reasons for NIRS switching, and their potential impact on clinical outcomes in acute-hypoxemic-respiratory-failure (AHRF) patients. DESIGN Retrospective, single-center observational study. SETTING Intensive Care Medicine. PATIENTS AHRF patients (cardiac origin and respiratory acidosis excluded) underwent combined NIRS therapies such as non-invasive-ventilation (NIV) and High-Flow-Nasal-Cannula (HFNC). INTERVENTIONS Patients were classified based on the first NIRS switch performed (HFNC-to-NIV or NIV-to-HFNC), and further specific NIRS switching strategies (NIV trial-like vs. Non-NIV trial-like and single vs. multiples switches) were independently evaluated. MAIN VARIABLES OF INTEREST Reasons for switching, NIRS failure and mortality rates. RESULTS A total of 63 patients with AHRF were included, receiving combined NIRS, 58.7% classified in the HFNC-to-NIV group and 41.3% in the NIV-to-HFNC group. Reason for switching from HFNC to NIV was AHRF worsening (100%), while from NIV to HFNC was respiratory improvement (76.9%). NIRS failure rates were higher in the HFNC-to-NIV than in NIV-to-HFNC group (81% vs. 35%, p < 0.001). Among HFNC-to-NIV patients, there was no difference in the failure rate between the NIV trial-like and non-NIV trial-like groups (86% vs. 78%, p = 0.575) but the mortality rate was significantly lower in NIV trial-like group (14% vs. 52%, p = 0.02). Among NIV to HFNC patients, NIV failure was lower in the single switch group compared to the multiple switches group (15% vs. 53%, p = 0.039), with a shorter length of stay (5 [2-8] vs. 12 [8-30] days, p = 0.001). CONCLUSIONS NIRS combination is used in real life and both switches' strategies, HFNC to NIV and NIV to HFNC, are common in AHRF management. Transitioning from HFNC to NIV is suggested as a therapeutic escalation and in this context performance of a NIV-trial could be beneficial. Conversely, switching from NIV to HFNC is suggested as a de-escalation strategy that is deemed safe if there is no NIRS failure.
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Affiliation(s)
- Francisco José Parrilla-Gómez
- Critical Care Department, Hospital del Mar de Barcelona. Critical illness research group (GREPAC), Hospital del Mar Research Institute (IMIM); Department of Medicine and Life Sciences (MELIS), UPF, Barcelona, Spain.
| | - Judith Marin-Corral
- Critical Care Department, Hospital del Mar de Barcelona. Critical illness research group (GREPAC), Hospital del Mar Research Institute (IMIM); Division of Pulmonary & Critical Care Medicine, University of Texas Health San Antonio, San Antonio, San Antonio, TX, USA
| | - Andrea Castellví-Font
- Critical Care Department, Hospital del Mar de Barcelona. Critical illness research group (GREPAC), Hospital del Mar Research Institute (IMIM)
| | - Purificación Pérez-Terán
- Critical Care Department, Hospital del Mar de Barcelona. Critical illness research group (GREPAC), Hospital del Mar Research Institute (IMIM); Department of Medicine and Life Sciences (MELIS), UPF, Barcelona, Spain
| | - Lucía Picazo
- Critical Care Department, Hospital del Mar de Barcelona. Critical illness research group (GREPAC), Hospital del Mar Research Institute (IMIM)
| | - Jorge Ravelo-Barba
- Critical Care Department, Hospital del Mar de Barcelona. Critical illness research group (GREPAC), Hospital del Mar Research Institute (IMIM)
| | - Marta Campano-García
- Critical Care Department, Hospital del Mar de Barcelona. Critical illness research group (GREPAC), Hospital del Mar Research Institute (IMIM)
| | - Olimpia Festa
- Anaesthesia and Reanimation Department, Hospital General de Sant Boi, Barcelona, Spain
| | - Marcos Restrepo
- Division of Pulmonary & Critical Care Medicine, University of Texas Health San Antonio, San Antonio, San Antonio, TX, USA; Division of Pulmonary Diseases & Critical Care Medicine, South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Joan Ramón Masclans
- Critical Care Department, Hospital del Mar de Barcelona. Critical illness research group (GREPAC), Hospital del Mar Research Institute (IMIM); Department of Medicine and Life Sciences (MELIS), UPF, Barcelona, Spain
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Lapinsky SE, Vasquez DN. Acute Respiratory Failure in Pregnancy. Crit Care Clin 2024; 40:353-366. [PMID: 38432700 DOI: 10.1016/j.ccc.2024.01.005] [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] [Indexed: 03/05/2024]
Abstract
Respiratory failure may affect up to 1 in 500 pregnancies, due to pregnancy-specific conditions, conditions aggravated by the pregnant state, or other causes. Management during pregnancy is influenced by altered maternal physiology, and the presence of a fetus influencing imaging, and drug therapy choices. Few studies have addressed the approach to invasive mechanical ventilatory management in pregnancy. Hypoxemia is likely harmful to the fetus, but precise targets are unknown. Hypocapnia reduces uteroplacental circulation, and some degree of hypercapnia may be tolerated in pregnancy. Delivery of the fetus may be considered to improve maternal respiratory status but improvement does not always occur.
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Affiliation(s)
- Stephen E Lapinsky
- Mount Sinai Hospital, Toronto, Interdepartmental Division of Critical Care Medicine, University of Toronto, 600 University Avenue, Toronto M5G1X5, Canada.
| | - Daniela N Vasquez
- ICU Head of Department, Sanatorio Anchorena, Tomás M. de Anchorena 1872, City of Buenos Aires, Argentina
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Romagnoli S, Lobo FA, Picetti E, Rasulo FA, Robba C, Matta B. Non-invasive technology for brain monitoring: definition and meaning of the principal parameters for the International PRactice On TEChnology neuro-moniToring group (I-PROTECT). J Clin Monit Comput 2024:10.1007/s10877-024-01146-1. [PMID: 38512360 DOI: 10.1007/s10877-024-01146-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 02/26/2024] [Indexed: 03/23/2024]
Abstract
Technologies for monitoring organ function are rapidly advancing, aiding physicians in the care of patients in both operating rooms (ORs) and intensive care units (ICUs). Some of these emerging, minimally or non-invasive technologies focus on monitoring brain function and ensuring the integrity of its physiology. Generally, the central nervous system is the least monitored system compared to others, such as the respiratory, cardiovascular, and renal systems, even though it is a primary target in most therapeutic strategies. Frequently, the effects of sedatives, hypnotics, and analgesics are entirely unpredictable, especially in critically ill patients with multiple organ failure. This unpredictability exposes them to the risks of inadequate or excessive sedation/hypnosis, potentially leading to complications and long-term negative outcomes. The International PRactice On TEChnology neuro-moniToring group (I-PROTECT), comprised of experts from various fields of clinical neuromonitoring, presents this document with the aim of reviewing and standardizing the primary non-invasive tools for brain monitoring in anesthesia and intensive care practices. The focus is particularly on standardizing the nomenclature of different parameters generated by these tools. The document addresses processed electroencephalography, continuous/quantitative electroencephalography, brain oxygenation through near-infrared spectroscopy, transcranial Doppler, and automated pupillometry. The clinical utility of the key parameters available in each of these tools is summarized and explained. This comprehensive review was conducted by a panel of experts who deliberated on the included topics until a consensus was reached. Images and tables are utilized to clarify and enhance the understanding of the clinical significance of non-invasive neuromonitoring devices within these medical settings.
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Affiliation(s)
- Stefano Romagnoli
- Department of Health Science, Section of Anesthesia and Critical Care, Department of Anesthesia and Critical Care, University of Florence, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| | - Francisco A Lobo
- Anesthesiology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Edoardo Picetti, Parma University Hospital, Parma, Italy
| | - Frank A Rasulo
- Neuroanesthesia and Neurocritical Care Unit, Spedali Civili University affiliated hospital of Brescia, Brescia, Italy
| | - Chiara Robba
- IRCCS Policlinico San Martino, Genova, Italy
- Dipartimento di Scienze Chirurgiche Diagnostiche ed Integrate, Università di Genova, Genova, Italy
| | - Basil Matta
- Consultant in Anaesthesia, Trauma and Critical Care, Cambridge University Hospitals, Cambridge, England
- Assistant Professor - University of Cambridge, Cambridge, England
- Global Senior Medical Director - Masimo International Irvine, Irvine, CA, United States
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13
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Quickfall D, Sklar MC, Tomlinson G, Orchanian-Cheff A, Goligher EC. The influence of drugs used for sedation during mechanical ventilation on respiratory pattern during unassisted breathing and assisted mechanical ventilation: a physiological systematic review and meta-analysis. EClinicalMedicine 2024; 68:102417. [PMID: 38235422 PMCID: PMC10789641 DOI: 10.1016/j.eclinm.2023.102417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 12/20/2023] [Accepted: 12/20/2023] [Indexed: 01/19/2024] Open
Abstract
Background Sedation management has a major impact on outcomes in mechanically ventilated patients, but sedation strategies do not generally consider the differential effects of different sedatives on respiration and respiratory pattern. A systematic review was undertaken to quantitatively summarize the known effects of different classes of drugs used for sedation on respiratory pattern during both spontaneous breathing and assisted mechanical ventilation. Methods This was a systematic review and meta-analysis conducted using Ovid MEDLINE, Embase, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials up to June 2020 to retrieve studies that measured respiratory parameters before and after the administration of opioids, benzodiazepines, intravenous and inhaled anaesthetic agents, and other hypnotic agents (PROSPERO #CRD42020190017). A random-effects meta-analytic model was employed to estimate the mean percentage change in each of the respiratory indices according to medication exposure with and without mechanical ventilation. Risk of bias was assessed using the Cochrane risk of bias assessment tools. Findings Fifty-one studies were included in the analysis. Risk of bias was generally deemed to be low for most studies. Respiratory rate decreased with the administration of opioids in both non-ventilated patients (18% decrease, 95% CI 12-24%) and ventilated patients (26% decrease, 95% CI 15-37%) and increased with inhaled anaesthetics in non-ventilated patients (83% increase, 95% CI 49-118%) and ventilated patients (50% increase, 28-72%). In non-ventilated patients, tidal volume decreased following administration of inhaled aesthetics (55% decrease, 95% CI 25-86%), propofol (36% decrease, 95% CI 20-52%), and benzodiazepines (28% decrease, 95% CI 17-40%); in patients receiving assisted mechanical ventilation, tidal volume was not significantly affected by sedation. Administration of other hypnotic agents was not associated with changes in respiratory rate or tidal volume. Interpretation Different classes of drugs used for sedation exert differential effects on respiratory pattern, and this may influence weaning and outcomes in mechanically ventilated patients. Funding This study did not receive any funding support.
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Affiliation(s)
- Danica Quickfall
- Department of Critical Care Medicine, University of Calgary, Calgary, Canada
| | - Michael C. Sklar
- Unity Health, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - George Tomlinson
- Department of Medicine, University Health Network, Toronto, Canada
| | - Ani Orchanian-Cheff
- Library and Information Services, University Health Network, Toronto, Canada
| | - Ewan C. Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Department of Medicine, University Health Network, Toronto, Canada
- Toronto General Hospital Research Institute, Toronto, Canada
- Department of Physiology, University of Toronto, Toronto, Canada
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14
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García-Montoto F, Paz-Martín D, Pestaña D, Soro M, Marcos Vidal JM, Badenes R, Suárez de la Rica A, Bardi T, Pérez-Carbonell A, García C, Cervantes JA, Martínez MP, Guerrero JL, Lorente JV, Veganzones J, Murcia M, Belda FJ. Guidelines for inhaled sedation in the ICU. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024; 71:90-111. [PMID: 38309642 DOI: 10.1016/j.redare.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 07/29/2023] [Indexed: 02/05/2024]
Abstract
INTRODUCTION AND OBJECTIVES Sedation is used in intensive care units (ICU) to improve comfort and tolerance during mechanical ventilation, invasive interventions, and nursing care. In recent years, the use of inhalation anaesthetics for this purpose has increased. Our objective was to obtain and summarise the best evidence on inhaled sedation in adult patients in the ICU, and use this to help physicians choose the most appropriate approach in terms of the impact of sedation on clinical outcomes and the risk-benefit of the chosen strategy. METHODOLOGY Given the overall lack of literature and scientific evidence on various aspects of inhaled sedation in the ICU, we decided to use a Delphi method to achieve consensus among a group of 17 expert panellists. The processes was conducted over a 12-month period between 2022 and 2023, and followed the recommendations of the CREDES guidelines. RESULTS The results of the Delphi survey form the basis of these 39 recommendations - 23 with a strong consensus and 15 with a weak consensus. CONCLUSION The use of inhaled sedation in the ICU is a reliable and appropriate option in a wide variety of clinical scenarios. However, there are numerous aspects of the technique that require further study.
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Affiliation(s)
- F García-Montoto
- UCI de Anestesia, Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de Cáceres, Cáceres, Spain.
| | - D Paz-Martín
- UCI, Departamento de Anestesia y Cuidados Intensivos, Clínica Universidad de Navarra, Pamplona, Navarra, Spain
| | - D Pestaña
- UCI de Anestesia, Servicio de Anestesiología y Reanimación, Hospital Universitario Ramon y Cajal, Madrid, Spain; Universidad de Alcalá de Henares, Alcalá de Henares, Madrid, Spain
| | - M Soro
- UCI, Servicio de Anestesiología y Cuidados Intensivos, Hospital IMED, Valencia, Spain
| | - J M Marcos Vidal
- Unidad de Reanimación, Servicio de Anestesiología y Reanimación, Complejo Asistencial Universitario de León, León, Spain
| | - R Badenes
- Departamento Cirugía, Facultad de Medicina, Universidad de Valencia, Valencia, Spain; UCI de Anestesia, Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Clínico Universitario de Valencia, Valencia, Spain; INCLIVA Instituto de Investigación Sanitaria, Valencia, Spain
| | - A Suárez de la Rica
- Unidad de Reanimación, Servicio de Anestesiología y Reanimación, Hospital Universitario de La Princesa, Madrid, Spain
| | - T Bardi
- UCI de Anestesia, Servicio de Anestesiología y Reanimación, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - A Pérez-Carbonell
- UCI Quirúrgica, Servicio de Anestesiología, UCI Quirúrgica y Unidad del Dolor, Hospital General Universitario de Elche, Elche, Alicante, Spain
| | - C García
- UCI Quirúrgica, Servicio de Anestesiología y Reanimación, Hospital General Universitario Dr. Balmis, Alicante, Spain
| | - J A Cervantes
- Unidad de Reanimación, Servicio de Anestesiología y Reanimación, Hospital Universitario Torrecárdenas, Almería, Spain
| | - M P Martínez
- Unidad de Reanimación, Servicio de Anestesiología y Reanimación, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - J L Guerrero
- Unidad de Reanimación, Servicio de Anestesiología y Reanimación, Hospital Universitario Virgen de la Victoria, Málaga, Spain; Universidad de Málaga, Málaga, Spain; Instituto Biomédico de Málaga, Málaga, Spain
| | - J V Lorente
- Unidad de Reanimación, Servicio de Anestesiología y Reanimación, Hospital Juan Ramón Jiménez, Huelva, Spain
| | - J Veganzones
- Unidad de Reanimación, Servicio de Anestesiología y Reanimación, Hospital Universitario La Paz, Madrid, Spain
| | - M Murcia
- UCI, Servicio de Anestesiología y Cuidados Intensivos, Hospital IMED, Valencia, Spain
| | - F J Belda
- Departamento Cirugía, Facultad de Medicina, Universidad de Valencia, Valencia, Spain
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15
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De Tymowski C, Dépret F, Dudoignon E, Moreno N, Zagdanski AM, Hodjat K, Deniau B, Mebazaa A, Legrand M, Mallet V. Ketamine restriction correlates with reduced cholestatic liver injury and improved outcomes in critically ill patients with burn injury. JHEP Rep 2024; 6:100950. [PMID: 38304235 PMCID: PMC10832380 DOI: 10.1016/j.jhepr.2023.100950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 09/29/2023] [Indexed: 02/03/2024] Open
Abstract
Background & Aims Ketamine-associated cholestatic liver injury is reported in patients with severe burn injury, but its association with patient outcome is unclear. We investigated the relationship between ketamine exposure, cholestatic liver injury, and outcome of critically ill patients with burn injury. Methods In a retrospective study, patients with severe burn injury were analysed across two periods: unrestricted ketamine prescription (ketamine-liberal) and capped ketamine dosage (ketamine-restricted). The primary endpoint was cholestatic liver injury, and the secondary endpoint was 3-month mortality. Binary logistic regression models and the revised electronic causality assessment method were used to measure the strength of associations and causality assessment, respectively. Results Of 279 patients (median age 51 [IQR 31-67] years; 63.1% men; burned surface area 28.5%, IQR 20-45%), 155 (56%) were in the ketamine-liberal group, and 124 (44%) were in the ketamine-restricted group, with comparable clinical characteristics, except for ketamine exposure (median doses 265.0 [IQR 0-8,021] mg and 20 [IQR 0-105] mg, respectively; p <0.001). A dose- and time-dependent relationship was observed between ketamine exposure and cholestatic liver injury. Ketamine restriction was associated with a reduced risk of cholestatic liver injury (adjusted odds ratio 0.16, 95% CI 0.04-0.50; p = 0.003) and with a higher probability of 3-month survival (p = 0.035). The revised electronic causality assessment method indicated that ketamine was probably and possibly the cause of cholestatic liver injury for 14 and 10 patients, respectively. Cholangitis was not observed in the ketamine-restricted group. In propensity-matched patients, the risk of 3-month mortality was higher (adjusted odds ratio 9.92, 95% CI 2.76-39.05; p = 0.001) in patients with cholestatic liver injury and ketamine exposure ≥10,000 mg. Other sedative drugs were not associated with liver and patient outcome. Conclusions In this cohort, ketamine restriction was associated with less cholestatic liver injury and reduced 3-month mortality. Impact and implications In a cohort of 279 critically ill patients with burn injury, ketamine was associated with a risk of liver bile duct toxicity. The risk was found to be dependent on both the dosage and duration of ketamine use. A restriction policy of ketamine prescription was associated with a risk reduction of liver injury and 3-month mortality. These findings have implications for the analgesia and sedation of critically ill patients with ketamine, with higher doses raising safety concerns.
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Affiliation(s)
- Christian De Tymowski
- Université Paris Cité, Paris, France
- Department of Anaesthesiology and Surgical Intensive Care Unit, Groupe Hospitalier Bichat Claude Bernard, DMU PARABOL, Assistance Publique–Hôpitaux de Paris, Paris, France
- Department of Anaesthesiology, Hôpital Louis Mourier, DMU PARABOL, Assistance Publique–Hôpitaux de Paris, Paris, France
- AP-HP.Nord, Groupe Hospitalier Saint Louis Lariboisière, DMU PARABOL, Département d’anesthésie réanimation et centre de traitement des brûlés, Paris, France
- Université Paris Cité, Centre de Recherche sur l’Inflammation, INSERM UMR 1149, CNRS ERL8252, Paris, France
| | - François Dépret
- Université Paris Cité, Paris, France
- AP-HP.Nord, Groupe Hospitalier Saint Louis Lariboisière, DMU PARABOL, Département d’anesthésie réanimation et centre de traitement des brûlés, Paris, France
- Institut National de la Santé et de la Recherche Médicale (INSERM), INSERM UMR-S 942 Mascot, Lariboisière Hospital, Paris, France
- INI-CRCT Network, Nancy, France
- FHU PROMICE, Paris, France
| | - Emmanuel Dudoignon
- Université Paris Cité, Paris, France
- AP-HP.Nord, Groupe Hospitalier Saint Louis Lariboisière, DMU PARABOL, Département d’anesthésie réanimation et centre de traitement des brûlés, Paris, France
- FHU PROMICE, Paris, France
| | - Nabila Moreno
- AP-HP.Nord, Groupe Hospitalier Saint Louis Lariboisière, Laboratoire de Biochimie, Paris, France
| | - Anne-Marie Zagdanski
- AP-HP.Nord, Groupe Hospitalier Saint Louis Lariboisière, Département de radiologie, Paris, France
| | - Kyann Hodjat
- AP-HP.Nord, Groupe Hospitalier Saint Louis Lariboisière, DMU PARABOL, Département d’anesthésie réanimation et centre de traitement des brûlés, Paris, France
| | - Benjamin Deniau
- Université Paris Cité, Paris, France
- AP-HP.Nord, Groupe Hospitalier Saint Louis Lariboisière, DMU PARABOL, Département d’anesthésie réanimation et centre de traitement des brûlés, Paris, France
- Institut National de la Santé et de la Recherche Médicale (INSERM), INSERM UMR-S 942 Mascot, Lariboisière Hospital, Paris, France
- FHU PROMICE, Paris, France
| | - Alexandre Mebazaa
- Université Paris Cité, Paris, France
- AP-HP.Nord, Groupe Hospitalier Saint Louis Lariboisière, DMU PARABOL, Département d’anesthésie réanimation et centre de traitement des brûlés, Paris, France
- Institut National de la Santé et de la Recherche Médicale (INSERM), INSERM UMR-S 942 Mascot, Lariboisière Hospital, Paris, France
- FHU PROMICE, Paris, France
| | - Matthieu Legrand
- INI-CRCT Network, Nancy, France
- Department of Anesthesia and Peri-operative Care, Division of Critical Care Medicine, University of California, San Francisco, CA, USA
| | - Vincent Mallet
- Université Paris Cité, Paris, France
- AP-HP.Nord, Groupe Hospitalier Saint Louis Lariboisière, DMU PARABOL, Département d’anesthésie réanimation et centre de traitement des brûlés, Paris, France
- Assistance Publique–Hôpitaux de Paris (AP-HP), Groupe Hospitalier Cochin Port Royal, DMU Cancérologie et spécialités médico-chirurgicales, Service de Maladie du Foie, Paris, France
| | - for the Keta-Cov research group
- Université Paris Cité, Paris, France
- Department of Anaesthesiology and Surgical Intensive Care Unit, Groupe Hospitalier Bichat Claude Bernard, DMU PARABOL, Assistance Publique–Hôpitaux de Paris, Paris, France
- Department of Anaesthesiology, Hôpital Louis Mourier, DMU PARABOL, Assistance Publique–Hôpitaux de Paris, Paris, France
- AP-HP.Nord, Groupe Hospitalier Saint Louis Lariboisière, DMU PARABOL, Département d’anesthésie réanimation et centre de traitement des brûlés, Paris, France
- Université Paris Cité, Centre de Recherche sur l’Inflammation, INSERM UMR 1149, CNRS ERL8252, Paris, France
- Institut National de la Santé et de la Recherche Médicale (INSERM), INSERM UMR-S 942 Mascot, Lariboisière Hospital, Paris, France
- INI-CRCT Network, Nancy, France
- FHU PROMICE, Paris, France
- AP-HP.Nord, Groupe Hospitalier Saint Louis Lariboisière, Laboratoire de Biochimie, Paris, France
- AP-HP.Nord, Groupe Hospitalier Saint Louis Lariboisière, Département de radiologie, Paris, France
- Department of Anesthesia and Peri-operative Care, Division of Critical Care Medicine, University of California, San Francisco, CA, USA
- Assistance Publique–Hôpitaux de Paris (AP-HP), Groupe Hospitalier Cochin Port Royal, DMU Cancérologie et spécialités médico-chirurgicales, Service de Maladie du Foie, Paris, France
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Roche M, Rousseleau D, Danel C, Henry H, Lebuffe G, Odou P, Lannoy D, Simon N. Combination of a propofol emulsion with alpha-2 adrenergic receptor agonists used for multimodal analgesia or sedation in intensive care units: a physicochemical stability study. Eur J Hosp Pharm 2024:ejhpharm-2023-004027. [PMID: 38290833 DOI: 10.1136/ejhpharm-2023-004027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 01/15/2024] [Indexed: 02/01/2024] Open
Abstract
OBJECTIVES To assess the physicochemical stability of the combination of a propofol emulsion with an alpha-2 (α2) adrenergic receptor agonist (α2A; clonidine or dexmedetomidine) under conditions mimicking routine practice in an intensive care unit or in multimodal analgesia procedures. METHODS We developed and validated three stability-indicating methods based on high-performance liquid chromatography with ultraviolet (HPLC-UV) detection. Eight different conditions per combination were evaluated in triplicate, with variations in the simulated, bodyweight-adjusted dose level and the drugs' flow rate. The drugs were mixed in clinically relevant concentrations and proportions and then stored unprotected from light, in clear glass vials at room temperature for 96 hours. At each sampling point, we assessed the chemical stability (the HPLC-UV drug level, pH, and osmolality) and physical compatibility (visual aspect, zeta potential (ZP), mean droplet diameter (MDD, Z-average) and polydispersity index (PDI)). We validated our stability findings in positive and negative control experiments. RESULTS Over the 96-hour test, the concentrations of propofol, clonidine and dexmedetomidine did not fall below 90% of the initial value, and the pH and osmolality were stable. The visual aspect of the mixed propofol emulsions did not change. The MDD remained below 500 nm (range 165-195 nm). The PDI was always below 0.4; 78.7% of the measurements were below 0.1 and 21.3% were between 0.1 and 0.4. The ZP measurements (-31.3 to -42.9 mV) suggested that the emulsion was stable. The MDD and PDI increased slightly at 96 hours under some conditions, which might indicate early destabilisation of the emulsion. Given that the MDD remained below 500 nm, these emulsions are compatible with intravenous administration. CONCLUSIONS Our results demonstrate the chemical and physical compatibility of propofol-α2 agonist mixtures at concentrations and in proportions representative of standard protocols when stored unprotected from light at room temperature for 96 hours.
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Affiliation(s)
- Marine Roche
- Pharmacy, Lille University Hospital, Lille, Nord, France
- ULR 7365-GRITA-Groupe de Recherche sur les formes Injectables et les Technologies Associées, Lille University, Lille, France
| | - Damien Rousseleau
- ULR 7365-GRITA-Groupe de Recherche sur les formes Injectables et les Technologies Associées, Lille University, Lille, France
- Anaesthesia and Intensive Care Department, Hospital Claude Huriez, Lille University Hospital, Lille, France
| | - Cécile Danel
- Pharmacy, Lille University Hospital, Lille, Nord, France
- ULR 7365-GRITA-Groupe de Recherche sur les formes Injectables et les Technologies Associées, Lille University, Lille, France
| | - Héloïse Henry
- Pharmacy, Lille University Hospital, Lille, Nord, France
- ULR 7365-GRITA-Groupe de Recherche sur les formes Injectables et les Technologies Associées, Lille University, Lille, France
| | - Gilles Lebuffe
- ULR 7365-GRITA-Groupe de Recherche sur les formes Injectables et les Technologies Associées, Lille University, Lille, France
- Anaesthesia and Intensive Care Department, Hospital Claude Huriez, Lille University Hospital, Lille, France
| | - Pascal Odou
- Pharmacy, Lille University Hospital, Lille, Nord, France
- ULR 7365-GRITA-Groupe de Recherche sur les formes Injectables et les Technologies Associées, Lille University, Lille, France
| | - Damien Lannoy
- Pharmacy, Lille University Hospital, Lille, Nord, France
- ULR 7365-GRITA-Groupe de Recherche sur les formes Injectables et les Technologies Associées, Lille University, Lille, France
| | - Nicolas Simon
- Pharmacy, Lille University Hospital, Lille, Nord, France
- ULR 7365-GRITA-Groupe de Recherche sur les formes Injectables et les Technologies Associées, Lille University, Lille, France
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Pellet PL, Stevic N, Degivry F, Louis B, Argaud L, Guérin C, Cour M. Effects on mechanical power of different devices used for inhaled sedation in a bench model of protective ventilation in ICU. Ann Intensive Care 2024; 14:18. [PMID: 38285231 PMCID: PMC10825094 DOI: 10.1186/s13613-024-01245-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 01/06/2024] [Indexed: 01/30/2024] Open
Abstract
BACKGROUND Inhaled sedation during invasive mechanical ventilation in patients with acute respiratory distress syndrome (ARDS) has received increasing attention. However, inhaled sedation devices increase dead-space ventilation and an undesirable effect is the increase in minute ventilation needed to maintain CO2 removal. A consequence of raising minute ventilation is an increase in mechanical power (MP) that can promote lung injury. However, the effect of inhaled sedation devices on MP remains unknown. METHODS We conducted a bench study to assess and compare the effects of three devices delivering inhaled sevoflurane currently available in ICU (AnaConDa-50 mL (ANA-50), AnaConDa-100 mL (ANA-100), and MIRUS) on MP by using a test lung model set with three compliances (20, 40, and 60 mL/cmH2O). We simulated lung-protective ventilation using a low tidal volume and two levels of positive end-expiratory pressure (5 and 15 cmH2O) under ambient temperature and dry conditions. Following the insertion of the devices, either the respiratory rate or tidal volume was increased in 15%-steps until end-tidal CO2 (EtCO2) returned to the baseline value. MP was calculated at baseline and after EtCO2 correction using a simplified equation. RESULTS Following device insertion, the EtCO2 increase was significantly greater with MIRUS (+ 78 ± 13%) and ANA-100 (+ 100 ± 11%) than with ANA-50 (+ 49 ± 7%). After normalizing EtCO2 by adjusting minute ventilation, MP significantly increased by more than 50% with all inhaled sedation devices compared to controls. The lowest increase in MP was observed with ANA-50 (p < 0.05 versus ANA-100 and MIRUS). The Costa index, another parameter assessing the mechanical energy delivered to the lungs, calculated as driving pressure × 4 + respiratory rate, significantly increased by more than 20% in all experimental conditions. Additional experiments performed under body temperature, ambient pressure, and gas saturated with water vapor conditions, confirmed the main results with an increase in MP > 50% with all devices after normalizing EtCO2 by adjusting minute ventilation. CONCLUSION Inhaled sedation devices substantially increased MP in this bench model of protective ventilation, which might limit their benefits in ARDS.
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Affiliation(s)
- Pierre-Louis Pellet
- Hospices Civils de Lyon, Service de Médecine Intensive -Réanimation, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69437, Lyon Cedex 03, France
- Université de Lyon, Université Claude Bernard Lyon 1, Faculté de Médecine Lyon-Est, 69373, Lyon, France
| | - Neven Stevic
- Hospices Civils de Lyon, Service de Médecine Intensive -Réanimation, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69437, Lyon Cedex 03, France
- Université de Lyon, Université Claude Bernard Lyon 1, Faculté de Médecine Lyon-Est, 69373, Lyon, France
| | - Florian Degivry
- Hospices Civils de Lyon, Service de Médecine Intensive -Réanimation, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69437, Lyon Cedex 03, France
| | - Bruno Louis
- Institut Mondor de Recherches Biomédicales INSERM 955 CNRS 7000, Créteil, France
| | - Laurent Argaud
- Hospices Civils de Lyon, Service de Médecine Intensive -Réanimation, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69437, Lyon Cedex 03, France
| | - Claude Guérin
- Hospices Civils de Lyon, Service de Médecine Intensive -Réanimation, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69437, Lyon Cedex 03, France
- Université de Lyon, Université Claude Bernard Lyon 1, Faculté de Médecine Lyon-Est, 69373, Lyon, France
| | - Martin Cour
- Hospices Civils de Lyon, Service de Médecine Intensive -Réanimation, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69437, Lyon Cedex 03, France.
- Université de Lyon, Université Claude Bernard Lyon 1, Faculté de Médecine Lyon-Est, 69373, Lyon, France.
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Li S, Su L, Lou R, Liu Y, Zhang H, Jiang L. Blended teaching mode based on small private online course and case-based learning in analgesia and sedation education in China: a comparison with an offline mode. BMC MEDICAL EDUCATION 2024; 24:28. [PMID: 38178081 PMCID: PMC10768422 DOI: 10.1186/s12909-023-04839-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 11/02/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Standardized training for pain, agitation-sedation, and delirium (PAD) management is urgently needed for Chinese intensivists' continuing education. Since 2020, because of the COVID-19 pandemic, the Chinese Analgesia and Sedation Education and Research (CASER) group has used an online blended teaching mode based on a small private online course (SPOC) and case-based learning (CBL). This study evaluated whether an online blended teaching mode has similar effects on PAD management training when an offline mode cannot be used. MATERIALS AND METHODS Since 2020, the CASER group has provided offline training and online SPOC&CBL training three times each, targeting intensivists and ICU nurses in China. All participants were divided into an offline group and SPOC&CBL group. A final examination was offered in each training session to assess the students' mastery of professional knowledge. Teachers' and students' perceptions regarding the online SPOC&CBL mode were evaluated through questionnaires. RESULTS Of all participants (n = 117), 106 completed all examinations and questionnaires. Most participants were aged 31-40 years (53, 50.0%), had an academic degree (60, 56.6%), and worked in a tertiary hospital (100, 94.34%). We assessed the learning effect on participants from two aspects: theory and clinical practice. There was no significant difference between the SPOC&CBL and offline groups in terms of theoretical, case analysis, and total scores (p > 0.05). In terms of the participants' perceptions regarding the SPOC&CBL mode, 91.5% considered the online mode to be a useful and accessible alternative to improve knowledge and skills. A total of 95.7% of the participants believed that they could interact well with group members, and 87.2% believed that they had a good degree of participation. Of these participants, 76.6% believed that they had received valuable learning resources. All instructors believed that the SPOC&CBL mode was more flexible than the offline mode in terms of teaching time and location, and they were all willing to carry out training with the SPOC&CBL mode. CONCLUSION Compared to the offline mode, the SPOC&CBL mode can also enhance participants' knowledge and skills and meets their expectations. Therefore, an online mode can be considered a potential method in PAD management education in China.
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Affiliation(s)
- Shu Li
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, China
| | - Longxiang Su
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Ran Lou
- Department of Critical Care Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ying Liu
- Department of Critical Care Medicine, Affiliated Hospital of Guizhou Medical University, Guizhou, China
| | - Hua Zhang
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, China
| | - Li Jiang
- Department of Critical Care Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China.
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Zhang R, Zhai K, Huang J, Wei S, Yang J, Zhang Y, Wu X, Li Y, Gao B. Sevoflurane alleviates lung injury and inflammatory response compared with propofol in a rat model of VV ECMO. Perfusion 2024; 39:142-150. [PMID: 36206156 DOI: 10.1177/02676591221131217] [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] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Although venovenous extracorporeal membrane oxygenation (VV ECMO) is a reasonable salvage treatment for acute respiratory distress syndrome (ARDS), it requires sedating the patient. Sevoflurane and propofol have pulmonary protective and immunomodulatory properties. This study aimed to compare the effectiveness of sevoflurane and propofol on rats with induced ARDS undergoing VV ECMO. METHODS Fifteen sprague-dawley (SD) rats were randomly divided into three groups: Con group, sevoflurane (Sevo) group and propofol (Pro) group. Arterial blood gas tests were performed at time pointsT0 (baseline), T1 (the time to ARDS), and T2 (weaning from ECMO). Oxygenation index (PaO2/FiO2) was calculated, and lung edema assessed by determining the lung wet:dry ratio. The protein concentration in bronchial alveolar lavage fluid (BALF) was determined by using bicinchoninic acid assay. Haematoxylin and eosin staining was used to evaluate the lung pathological scores in each group. IL-1β and TNF-α were also measured in the BALF, serum and lung. RESULTS Oxygenation index showed improvement in the Sevo group versus Pro group. The wet:dry ratio was reduced in the Sevo group compared with propofol-treated rats. Lung pathological scores were substantially lower in the Sevo group versus the Pro group. Protein concentrations in the BALF and levels of IL-1β and TNF-α in the Sevo group were substantially lower versus Pro group. CONCLUSION This study demonstrates that compared with propofol, sevoflurane was more efficacious in improving oxygenation and decreasing inflammatory response in rat models with ARDS subject to VV ECMO treatment.
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Affiliation(s)
- Rongzhi Zhang
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou, China
- Department of Anesthesiology, Lanzhou University Second Hospital, Lanzhou, China
| | - Kerong Zhai
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou, China
| | - Jian Huang
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou, China
| | - Shilin Wei
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou, China
| | - Jianbao Yang
- Department of Thoracic Surgery, Lanzhou University Second Hospital, Lanzhou, China
| | - Yanchun Zhang
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou, China
| | - Xiangyang Wu
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou, China
| | - Yongnan Li
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou, China
- Laboratory of Extracorporeal Life Support, Lanzhou University Second Hospital, Lanzhou, China
| | - Bingren Gao
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou, China
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Favre E, Rahmaty Z, Ben-Hamouda N, Miroz JP, Abed-Maillard S, Rusca M, Oddo M, Ramelet AS. Nociception assessment with videopupillometry in deeply sedated intensive care patients: Discriminative and criterion validations. Aust Crit Care 2024; 37:84-90. [PMID: 37684156 DOI: 10.1016/j.aucc.2023.07.038] [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: 03/20/2023] [Revised: 07/17/2023] [Accepted: 07/25/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Nociceptive assessment in deeply sedated patients is challenging. Validated instruments are lacking for this unresponsive population. Videopupillometry is a promising tool but has not been established in intensive care settings. AIM/OBJECTIVE To test the discriminate validity of pupillary dilation reflex (PDR) between non-noxious and noxious procedures for assessing nociception in non-neurological intensive care unit (ICU) patients and to test the criterion validity of pupil dilation using recommended PDR cut-off points to determine nociception. METHODS A single-centre prospective observational study was conducted in medical-surgical ICU patients. Two independent investigators performed videopupillometer measurements during a non-noxious and a noxious procedure, once a day (up to 7 days), when the patient remained deeply sedated (Richmond Agitation-Sedation Scale score: -5 or -4). The non-noxious procedures consisted of a gentle touch on each shoulder and the noxious procedures were endotracheal suctioning or turning onto the side. Bivariable and multivariable general linear mixed models were used to account for multiple measurements in same patients. Sensitivity and specificity, and areas under the curve of the receiver operating characteristic curve were calculated. RESULTS Sixty patients were included, and 305 sets of 3 measurements (before, during, and after), were performed. PDR was higher during noxious procedures than before (mean difference between noxious and non-noxious procedures = 31.66%). After testing all variables of patient and stimulation characteristics in bivariable models, age and noxious procedures were kept in the multivariable model. Adjusting for age, noxious procedures (coefficient = -15.14 (95% confidence interval = -20.17 to -15.52, p < 0.001) remained the only predictive factor for higher pupil change. Testing recommended cut-offs, a PDR of >12% showed a sensitivity of 65%, and a specificity of 94% for nociception prediction, with an area under the receiver operating curve of 0.828 (95% confidence interval = 0.779-0.877). CONCLUSIONS In conclusion, PDR is a potentially appropriate measure to assess nociception in deeply sedated ICU patients, and we suggest considering its utility in daily practices. REGISTRATION This study was not preregistered in a clinical registry. TWEETABLE ABSTRACT Pupillometry may help clinicians to assess nociception in deeply sedated ICU patients.
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Affiliation(s)
- Eva Favre
- Department of Intensive Care, Lausanne University Hospital and Lausanne University, Switzerland; Institute of Higher Education and Research in Healthcare, University of Lausanne and Lausanne University Hospital, Switzerland
| | - Zahra Rahmaty
- Institute of Higher Education and Research in Healthcare, University of Lausanne and Lausanne University Hospital, Switzerland
| | - Nawfel Ben-Hamouda
- Department of Intensive Care, Lausanne University Hospital and Lausanne University, Switzerland
| | - John-Paul Miroz
- Department of Intensive Care, Lausanne University Hospital and Lausanne University, Switzerland
| | - Samia Abed-Maillard
- Department of Intensive Care, Lausanne University Hospital and Lausanne University, Switzerland
| | - Marco Rusca
- Department of Intensive Care, Lausanne University Hospital and Lausanne University, Switzerland
| | - Mauro Oddo
- Department of Intensive Care, Lausanne University Hospital and Lausanne University, Switzerland; Medical Directorate for Research, Education and Innovation, Lausanne University Hospital and University of Lausanne, Switzerland
| | - Anne-Sylvie Ramelet
- Institute of Higher Education and Research in Healthcare, University of Lausanne and Lausanne University Hospital, Switzerland.
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Wang WZ, Ying LJ, Liu WD, Zhang P, Li SF. Findings of ventilator-measured P0.1 in assessing respiratory drive in patients with severe ARDS. Technol Health Care 2024; 32:719-726. [PMID: 37393453 DOI: 10.3233/thc-230096] [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] [Indexed: 07/03/2023]
Abstract
BACKGROUND Providers should adjust the depth of sedation to promote lung-protective ventilation in patients with severe ARDS. This recommendation was based on the assumption that the depth of sedation could be used to assess respiratory drive. OBJECTIVE To assess the association between respiratory drive and sedation in patients with severe ARDS by using ventilator-measured P0.1 and RASS score. METHODS Loss of spontaneous breathing was observed within 48 h of mechanical ventilation in patients with severe ARDS, and spontaneous breathing returned after 48 hours. P0.1 was measured by ventilator every 12 ± 2 hours, and the RASS score was measured synchronously. RESULTS The RASS score was moderately correlated with P0.1 (R𝑆𝑝𝑒𝑎𝑟𝑚𝑎𝑛, 0.570; 95% CI, 0.475 to 0.637; p= 0.00). However, only patients with a RASS score of -5 were considered to have no excessive respiratory drive, but there was a risk for loss of spontaneous breathing. A P0.1 exceeding 3.5 cm H2O in patients with other RASS scores indicated an increase in respiratory drive. CONCLUSION RASS score has little clinical significance in evaluating respiratory drive in severe ARDS. P0.1 should be evaluated by ventilator when adjusting the depth of sedation to promote lung-protective ventilation.
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Wu F, Zhan L, Xu W, Bian J. Effect of intravenous lidocaine on outcomes in patients receiving propofol for gastrointestinal endoscopic procedures: an updated systematic review and meta-analysis. Eur J Clin Pharmacol 2024; 80:39-52. [PMID: 37962581 DOI: 10.1007/s00228-023-03589-y] [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: 07/07/2023] [Accepted: 10/25/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Gastrointestinal endoscopic procedures (GEPs) are frequently employed for the diagnosis and treatment of various gastrointestinal ailments. While propofol sedation is widely used during these procedures, there is a concern regarding its potential negative effects. Intravenous (IV) lidocaine has been suggested as an add-on to propofol sedation for GEPs, but current evidence on its efficiency and safety is limited. This systematic review and meta-analysis aimed to assess the impact of IV lidocaine on outcomes in patients receiving propofol during GEPs. METHODS Electronic databases were screened for randomized controlled trials (RCTs), published up to 31 March 2023, investigating the effectiveness of intravenous lidocaine addition to propofol sedation during GEPs. RESULTS A total of 12 RCTs involving 712 patients that received IV lidocaine and propofol for GEF and 719 patients that received propofol were analyzed. Adding IV lidocaine to propofol sedation led to significant reduction in pain after the procedure (standardized mean difference (SMD) = - 0.91, 95% confidence interval [CI]; - 1.51 to - 0.32), decreased propofol usage (SMD = - 0.89; 95% CI, - 1.31 to - 0.48), lower recovery time (SMD = - 0.95 min; 95% CI, - 1.48 to - 0.43), and decreased pain score (SMD = - 0.91; 95% CI, - 1.51 to - 0.32). The overall rate of adverse events was markedly less in the lidocaine group than in the control group (RR = 0.74; 95% CI, 0.56 to 0.99). CONCLUSION Our results show that IV lidocaine improves patient outcomes by reducing post-procedural pain, decreasing propofol usage, shortening recovery time, and lowering pain scores. This study provides compelling evidence supporting the use of intravenous lidocaine as an adjunct to propofol sedation for gastrointestinal endoscopic procedures. However, further research is necessary to optimize the use of lidocaine and fully understand its long-term effects.
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Affiliation(s)
- Fangpu Wu
- Department of Anesthesiology, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People's Hospital, Quzhou, China
| | - Linsen Zhan
- Department of Anesthesiology, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People's Hospital, Quzhou, China
| | - Wei Xu
- Department of Gastroenterology, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People's Hospital, No.100, Minjiang Avenue, Kecheng District, Quzhou, China
| | - Jun Bian
- Department of Gastroenterology, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People's Hospital, No.100, Minjiang Avenue, Kecheng District, Quzhou, China.
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Tang Y, Gao X, Xu J, Ren L, Qi H, Li R, Shu H, Zou X, Yuan S, Yang X, Shang Y. Remimazolam besylate versus propofol for deep sedation in critically ill patients: a randomized pilot study. Crit Care 2023; 27:474. [PMID: 38049909 PMCID: PMC10694930 DOI: 10.1186/s13054-023-04760-8] [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: 08/17/2023] [Accepted: 11/27/2023] [Indexed: 12/06/2023] Open
Abstract
OBJECTIVE To compare the efficacy and safety of remimazolam besylate and propofol for deep sedation in critically ill patients. METHODS In this single-center, prospective, randomized, controlled pilot study, patients in the intensive care unit (ICU) requiring deep sedation were randomized to receive remimazolam besylate or propofol intravenously. Deep sedation was defined as a Richmond Agitation and Sedation Scale (RASS) score of - 4 or - 5. Sedation depth was monitored using RASS and Narcotrend Index (NI). The primary outcome was the percentage of time within the target sedation range without rescue sedation. The secondary outcomes included ventilator-free hours within 7 days, successful extubation, length of ICU stay, and 28-day mortality. Adverse events during the interventional period were also recorded. RESULTS Thirty patients were assigned to each group. The median (IQR) RASS score was - 5.0 (- 5.0, - 4.0), and the median (IQR) NI value was 29.0 (21.0, 37.0) during the intervention period. Target RASS was reached a median of 100% of the sedation time in the two groups. No significant differences were observed in ventilator-free hours within 7 days, successful extubation, length of ICU stay, or 28-day mortality among groups. Hypotension occurred in 16 (53.3%) patients of remimazolam group and 18 (60.0%) patients of propofol group (p > 0.05). No patient experienced bradycardia. CONCLUSIONS Remimazolam besylate appears to be an effective and safe agent for short-term deep sedation in critically ill patients. Our findings warrant large sample-sized randomized clinical trials.
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Affiliation(s)
- Yun Tang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xuehui Gao
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jiqian Xu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lehao Ren
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hong Qi
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ruiting Li
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Huaqing Shu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaojing Zou
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shiying Yuan
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaobo Yang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - You Shang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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Umbrello M, Venco R, Palandri C, Racagni M, Muttini S. Peripherally-active mu-opioid receptor antagonists for constipation in critically ill patients receiving opioids: A case-series and a systematic review and meta-analysis of the literature. Neurogastroenterol Motil 2023; 35:e14694. [PMID: 37869768 DOI: 10.1111/nmo.14694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 09/15/2023] [Accepted: 10/09/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND Constipation is frequent in critically ill patients, and potentially related to adverse outcomes. Peripherally-active mu-opioid receptor antagonists (PAMORAs) are approved for opioid-induced constipation, but information on their efficacy and safety in critically ill patients is limited. We present a single-center, retrospective, case-series of the use of naldemedine for opioid-associated constipation, and we systematically reviewed the use of PAMORAs in critically ill patients. METHODS Case-series included consecutive mechanically-ventilated patients; constipation was defined as absence of bowel movements for >3 days. Naldemedine was administered after failure of the local laxation protocol. Systematic review: PubMed was searched for studies of PAMORAs to treat opioid-induced constipation in adult critically ill patients. PRIMARY OUTCOMES time to laxation, and number of patients laxating at the shortest follow-up. SECONDARY OUTCOMES gastric residual volumes and adverse events. KEY RESULTS A total of 13 patients were included in the case-series; the most common diagnosis was COVID-19 ARDS. Patients had their first bowel movement 1 [0;2] day after naldemedine. Daily gastric residual volume was 725 [405;1805] before vs. 250 [45;1090] mL after naldemedine, p = 0.0078. Systematic review identified nine studies (two RCTs, one prospective case-series, three retrospective case-series and three case-reports). Outcomes were similar between groups, with a trend toward a lower gastric residual volume in PAMORAs group. CONCLUSIONS & INFERENCES In a highly-selected case-series of patients with refractory, opioid-associated constipation, naldemedine was safe and associated to reduced gastric residuals and promoting laxation. In the systematic review and meta-analysis, the use of PAMORAs (mainly methylnaltrexone) was safe and associated with a reduced intolerance to enteral feeding but no difference in the time to laxation.
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Affiliation(s)
- Michele Umbrello
- SC Rianimazione e Anestesia, Ospedale Nuovo di Legnano, ASST Ovest Milanese, Legnano, Italy
| | - Roberto Venco
- SC Anestesia e Rianimazione II, Ospedale San Carlo Borromeo, ASST Santi Paolo e Carlo, Milano, Italy
| | - Chiara Palandri
- SC Anestesia e Rianimazione II, Ospedale San Carlo Borromeo, ASST Santi Paolo e Carlo, Milano, Italy
| | - Milena Racagni
- SC Anestesia e Rianimazione II, Ospedale San Carlo Borromeo, ASST Santi Paolo e Carlo, Milano, Italy
| | - Stefano Muttini
- SC Anestesia e Rianimazione II, Ospedale San Carlo Borromeo, ASST Santi Paolo e Carlo, Milano, Italy
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25
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McKenzie C, Skrobik Y, Devlin JW. Scheduled intravenous opioids. Intensive Care Med 2023; 49:1541-1543. [PMID: 37922011 PMCID: PMC10709215 DOI: 10.1007/s00134-023-07254-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 10/10/2023] [Indexed: 11/05/2023]
Affiliation(s)
- Cathrine McKenzie
- National Institute of Health and Social Care Research (NIHR) Biomedical Research Centre, School of Medicine, Perioperative and Critical Care Theme and NIHR Applied Research Collaborative (ARC), University of Southampton, Wessex, Southampton, UK
- Pharmacy and Critical Care, University Hospital, Southampton NHS Foundation Trust, Southampton, UK
- Institute of Pharmaceutical Sciences, School of Cancer and Pharmacy, King's College London, London, UK
| | - Yoanna Skrobik
- Department of Medicine, McGill University, Montreal, QC, Canada
- Department of Medicine, Cambridge University, Cambridge, UK
| | - John W Devlin
- School of Pharmacy and Pharmaceutical Sciences, Bouve College of Health Sciences, Northeastern University, Boston, MA, USA.
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA.
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Marcos-Vidal JM, González R, Merino M, Higuera E, García C. Sedation for Patients with Sepsis: Towards a Personalised Approach. J Pers Med 2023; 13:1641. [PMID: 38138868 PMCID: PMC10744994 DOI: 10.3390/jpm13121641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 11/17/2023] [Accepted: 11/21/2023] [Indexed: 12/24/2023] Open
Abstract
This article looks at the challenges of sedoanalgesia for sepsis patients, and argues for a personalised approach. Sedation is a necessary part of treatment for patients in intensive care to reduce stress and anxiety and improve long-term prognoses. Sepsis patients present particular difficulties as they are at increased risk of a wide range of complications, such as multiple organ failure, neurological dysfunction, septic shock, ARDS, abdominal compartment syndrome, vasoplegic syndrome, and myocardial dysfunction. The development of any one of these complications can cause the patient's rapid deterioration, and each has distinct implications in terms of appropriate and safe forms of sedation. In this way, the present article reviews the sedative and analgesic drugs commonly used in the ICU and, placing special emphasis on their strategic administration in sepsis patients, develops a set of proposals for sedoanalgesia aimed at improving outcomes for this group of patients. These proposals represent a move away from simplistic approaches like avoiding benzodiazepines to more "objective-guided sedation" that accounts for a patient's principal pathology, as well as any comorbidities, and takes full advantage of the therapeutic arsenal currently available to achieve personalised, patient-centred treatment goals.
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Affiliation(s)
- José Miguel Marcos-Vidal
- Department of Anesthesiology and Critical Care, Universitary Hospital of Leon, 24071 Leon, Spain; (R.G.); (M.M.); (E.H.); (C.G.)
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Favre E, Bernini A, Miroz JP, Abed-Maillard S, Ramelet AS, Oddo M. Early processed electroencephalography for the monitoring of deeply sedated mechanically ventilated critically ill patients. Nurs Crit Care 2023. [PMID: 37997530 DOI: 10.1111/nicc.13009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 10/22/2023] [Accepted: 11/01/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND Deep sedation may be indicated in the intensive care unit (ICU) for the management of acute organ failure, but leads to sedative-induced delirium. Whether processed electroencephalography (p-EEG) is useful in this setting is unclear. METHODS We conducted a single-centre observational study of non-neurological ICU patients sedated according to a standardized guideline of deep sedation (Richmond Agitation Sedation Scale [RASS] between -5 and -4) during the acute phase of respiratory and/or cardio-circulatory failure. The SedLine (Masimo Incorporated, Irvine, California) was used to monitor the Patient State Index (PSI) (ranging from 0 to 100, <25 = very deep sedation and >50 = light sedation to full awareness) during the first 72 h of care. Delirium was assessed with the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). RESULTS The median duration of PSI monitoring was 43 h. Patients spent 49% in median of the total PSI monitoring duration with a PSI <25. Patients with delirium (n = 41/97, 42%) spent a higher percentage of total monitored time with PSI <25 (median 67% [19-91] vs. 47% [12.2-78.9]) in non-delirious patients (p .047). After adjusting for the cumulative dose of analgesia and sedation, increased time spent with PSI <25 was associated with higher delirium (odds ratio 1.014; 95% CI 1.001-1.027, p = .036). CONCLUSIONS A clinical protocol of deep sedation targeted to RASS at the acute ICU phase may be associated with prolonged EEG suppression and increased delirium. Whether PSI-targeted sedation may help reducing sedative dose and delirium deserves further clinical investigation. RELEVANCE TO CLINICAL PRACTICE Patients requiring deep sedation are at high risk of being over-sedated and developing delirium despite the application of an evidence-based sedation guideline. Development of early objective measures are essential to improve sedation management in these critically ill patients.
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Affiliation(s)
- Eva Favre
- Department of Intensive Care, Centre Hospitalier Universitaire Vaudois (CHUV)-Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Institute of Higher Education and Research in Healthcare, CHUV-Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Adriano Bernini
- Department of Intensive Care, Centre Hospitalier Universitaire Vaudois (CHUV)-Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - John-Paul Miroz
- Department of Intensive Care, Centre Hospitalier Universitaire Vaudois (CHUV)-Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Samia Abed-Maillard
- Department of Intensive Care, Centre Hospitalier Universitaire Vaudois (CHUV)-Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Anne-Sylvie Ramelet
- Institute of Higher Education and Research in Healthcare, CHUV-Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Mauro Oddo
- Medical Directorate for Research, Education and Innovation, CHUV-Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Wen J, Ding X, Liu C, Jiang W, Xu Y, Wei X, Liu X. A comparation of dexmedetomidine and midazolam for sedation in patients with mechanical ventilation in ICU: A systematic review and meta-analysis. PLoS One 2023; 18:e0294292. [PMID: 37963140 PMCID: PMC10645332 DOI: 10.1371/journal.pone.0294292] [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: 05/26/2023] [Accepted: 10/28/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND The use of dexmedetomidine rather than midazolam may improve ICU outcomes. We summarized the available recent evidence to further verify this conclusion. METHODS An electronic search of PubMed, Medline, Embase, Cochrane Library, and Web of Science was conducted. Risk ratios (RR) were used for binary categorical variables, and for continuous variables, weighted mean differences (WMD) were calculated, the effect sizes are expressed as 95% confidence intervals (CI), and trial sequential analysis was performed. RESULTS 16 randomized controlled trials were enrolled 2035 patients in the study. Dexmedetomidine as opposed to midazolam achieved a shorter length of stay in ICU (MD = -2.25, 95%CI = -2.94, -1.57, p<0.0001), lower risk of delirium (RR = 0.63, 95%CI = 0.50, 0.81, p = 0.0002), and shorter duration of mechanical ventilation (MD = -0.83, 95%CI = -1.24, -0.43, p<0.0001). The association between dexmedetomidine and bradycardia was also found to be significant (RR 2.21, 95%CI 1.31, 3.73, p = 0.003). We found no difference in hypotension (RR = 1.44, 95%CI = 0.87, 2.38, P = 0.16), mortality (RR = 1.02, 95%CI = 0.83, 1.25, P = 0.87), neither in terms of adverse effects requiring intervention, hospital length of stay, or sedation effects. CONCLUSIONS Combined with recent evidence, compared with midazolam, dexmedetomidine decreased the risk of delirium, mechanical ventilation, length of stay in the ICU, as well as reduced patient costs. But dexmedetomidine could not reduce mortality and increased the risk of bradycardia.
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Affiliation(s)
- Jiaxuan Wen
- School of Nursing, Weifang Medical University, Weifang, P. R. China
| | - Xueying Ding
- School of Nursing, Weifang Medical University, Weifang, P. R. China
| | - Chen Liu
- School of Nursing, Weifang Medical University, Weifang, P. R. China
| | - Wenyu Jiang
- School of Public Health, Weifang Medical University, Weifang, P. R. China
| | - Yingrui Xu
- School of Nursing, Weifang Medical University, Weifang, P. R. China
| | - Xiuhong Wei
- School of Nursing, Weifang Medical University, Weifang, P. R. China
| | - Xin Liu
- Department of Neonatology, Weifang People’s Hospital, P. R. China
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Smeets TJL, de Geus HRH, Valkenburg AJ, Baidjoe L, Gommers DAMPJ, Koch BCP, Hunfeld NGM, Endeman H. The Clearance of Midazolam and Metabolites during Continuous Renal Replacement Therapy in Critically Ill Patients with COVID-19. Blood Purif 2023; 53:107-113. [PMID: 37926072 PMCID: PMC10836747 DOI: 10.1159/000534538] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 09/29/2023] [Indexed: 11/07/2023]
Abstract
INTRODUCTION Midazolam-based continuous intravenous sedation in patients admitted to the intensive care unit (ICU) was a necessity during the COVID-19 pandemic. However, benzodiazepine-based sedation is associated with a high incidence of benzodiazepine-related delirium and additional days on mechanical ventilation. Due to the requirement of high midazolam doses in combination with the impaired renal clearance (CL) of the pharmacological active metabolite 1-OH-midazolam-glucuronide (10% compared to midazolam), ICU patients with COVID-19 and continuous renal replacement therapy (CRRT) were at risk of unintended prolonged sedation. Several CRRT-related factors may have influenced the delivered CL of midazolam and its metabolites. Therefore, the aim of the study was to identify and describe these CRRT-related factors. METHODS Pre-filter blood samples and ultrafiltrate samples were collected simultaneously. Midazolam, 1-OH-midazolam, and 1-OH-midazolam-glucuronide plasma samples were analyzed using an UPLC-MS/MS method. The prescribed CRRT dose was corrected for downtime and filter integrity using the urea ratio (urea concentration in effluent/urea concentration plasma). CL of midazolam and its metabolites were calculated with the delivered CRRT dose (corrected for downtime and saturation coefficient [SD]). RESULTS Three patients on continuous venovenous hemodialysis (CVVHD) and 2 patients on continuous venovenous hemodiafiltration (CVVHDF) were included. Midazolam, 1-OH-midazolam, and 1-OH-midazolam-glucuronide concentrations were 2,849 (0-6,700) μg/L, 153 (0-295) μg/L, and 27,297 (1,727-39,000) μg/L, respectively. The SD was 0.03 (0.02-0.03) for midazolam, 0.05 (0.05-0.06) for 1-OH-midazolam, and 0.33 (0.23-0.43) for 1-OH-midazolam-glucuronide. The delivered CRRT CL was 1.4 (0-1.7) mL/min for midazolam, 2.7 (0-3.5) mL/min for 1-OH-midazolam, and 15.7 (4.0-27.7) mL/min for 1-OH-midazolam-glucuronide. CONCLUSIONS Midazolam and 1-OH-midazolam were not removed during CVVHD and CVVHDF. However, 1-OH-midazolam-glucuronide was removed reasonably, approximately up to 43%. CRRT modality, filter integrity, and downtime affect this removal. These data imply a personalized titration of midazolam in critically ill patients with renal failure and awareness for the additional sedative effects of its active metabolites.
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Affiliation(s)
- Tim J L Smeets
- Department of Hospital Pharmacy, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Hilde R H de Geus
- Department of Intensive Care Adults, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Abraham J Valkenburg
- Department of Anesthesiology and Intensive Care, Isala Hospital, Zwolle, The Netherlands
| | - Lauren Baidjoe
- Department of Hospital Pharmacy, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Diederik A M P J Gommers
- Department of Intensive Care Adults, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Nicole G M Hunfeld
- Department of Hospital Pharmacy, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Intensive Care Adults, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Henrik Endeman
- Department of Intensive Care Adults, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
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Zheng CZ, Cortes-Puentes GA. Airway Versus Transpulmonary Driving Pressures During Pressure Support Ventilation in ARDS. Respir Care 2023; 68:1606-1608. [PMID: 37863827 PMCID: PMC10589109 DOI: 10.4187/respcare.11428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2023]
Affiliation(s)
- Christopher Z Zheng
- Department of Pulmonary and Critical Care Medicine Mayo Clinic Rochester, Minnesota
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Kobayashi N, Watanabe K, Murakami H, Yamauchi M. Continuous visualization and validation of pain in critically ill patients using artificial intelligence: a retrospective observational study. Sci Rep 2023; 13:17479. [PMID: 37838818 PMCID: PMC10576770 DOI: 10.1038/s41598-023-44970-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 10/13/2023] [Indexed: 10/16/2023] Open
Abstract
Machine learning tools have demonstrated viability in visualizing pain accurately using vital sign data; however, it remains uncertain whether incorporating individual patient baselines could enhance accuracy. This study aimed to investigate improving the accuracy by incorporating deviations from baseline patient vital signs and the concurrence of the predicted artificial intelligence values with the probability of critical care pain observation tool (CPOT) ≥ 3 after fentanyl administration. The study included adult patients in intensive care who underwent multiple pain-related assessments. We employed a random forest model, utilizing arterial pressure, heart rate, respiratory rate, gender, age, and Richmond Agitation-Sedation Scale score as explanatory variables. Pain was measured as the probability of CPOT scores of ≥ 3, and subsequently adjusted based on each patient's baseline. The study included 10,299 patients with 117,190 CPOT assessments. Of these, 3.3% had CPOT scores of ≥ 3. The random forest model demonstrated strong accuracy with an area under the receiver operating characteristic curve of 0.903. Patients treated with fentanyl were grouped based on CPOT score improvement. Those with ≥ 1-h of improvement after fentanyl administration had a significantly lower pain index (P = 0.020). Therefore, incorporating deviations from baseline patient vital signs improved the accuracy of pain visualization using machine learning techniques.
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Affiliation(s)
- Naoya Kobayashi
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan.
| | | | | | - Masanori Yamauchi
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
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Al Aseri Z, Alansari MA, Al-Shami SA, Alaskar B, Aljumaiah D, Elhazmi A. The advantages of inhalational sedation using an anesthetic-conserving device versus intravenous sedatives in an intensive care unit setting: A systematic review. Ann Thorac Med 2023; 18:182-189. [PMID: 38058786 PMCID: PMC10697299 DOI: 10.4103/atm.atm_89_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 05/10/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND Sedation is fundamental to the management of patients in the intensive care unit (ICU). Its indications in the ICU are vast, including the facilitating of mechanical ventilation, permitting invasive procedures, and managing anxiety and agitation. Inhaled sedation with halogenated agents, such as isoflurane or sevoflurane, is now feasible in ICU patients using dedicated devices/systems. Its use may reduce adverse events and improve ICU outcomes compared to conventional intravenous (IV) sedation in the ICU. This review examined the effectiveness of inhalational sedation using the anesthetic conserving device (ACD) compared to standard IV sedation for adult patients in ICU and highlights the technical aspects of its functioning. METHODS We searched the PubMed, Cochrane Central Register of Controlled Trials, The Cochrane Library, MEDLINE, Web of Science, and Sage Journals databases using the terms "anesthetic conserving device," "Anaconda," "sedation" and "intensive care unit" in randomized clinical studies that were performed between 2012 and 2022 and compared volatile sedation using an ACD with IV sedation in terms of time to extubation, duration of mechanical ventilation, and lengths of ICU and hospital stay. RESULTS Nine trials were included. Volatile sedation (sevoflurane or isoflurane) administered through an ACD shortened the awakening time compared to IV sedation (midazolam or propofol). CONCLUSION Compared to IV sedation, volatile sedation administered through an ACD in the ICU shortened the awakening and extubation times, ICU length of stay, and duration of mechanical ventilation. More clinical trials that assess additional clinical outcomes on a large scale are needed.
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Affiliation(s)
- Zohair Al Aseri
- Department Emergency Medicine and Critical Care, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Department of Clinical Sciences, College of Medicine and Riyadh Hospital, Dar Al Uloom University, Riyadh, Saudi Arabia
- Emergency and Critical Care Development Program, Therapeutic Deputyship, Ministry of Health, Riyadh, Saudi Arabia
| | - Mariam Ali Alansari
- Department of Adult Critical Care, King Fahad Hospital, Al-Ahsa Health Cluster, Al-Hafouf, Saudi Arabia
| | - Sara Ali Al-Shami
- Department of Clinical Sciences, College of Medicine and Riyadh Hospital, Dar Al Uloom University, Riyadh, Saudi Arabia
| | - Bayan Alaskar
- Department of Clinical Sciences, College of Medicine and Riyadh Hospital, Dar Al Uloom University, Riyadh, Saudi Arabia
| | - Dhuha Aljumaiah
- Department of Clinical Sciences, College of Medicine and Riyadh Hospital, Dar Al Uloom University, Riyadh, Saudi Arabia
| | - Alyaa Elhazmi
- Department of Internal Medicine, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
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Stallworth S, Ohman K, Schultheis J, Parish A, Erkanli A, Kim H, Rackley CR. Propofol-Associated Hypertriglyceridemia in Adults With Acute Respiratory Distress Syndrome on Extracorporeal Membrane Oxygenation. ASAIO J 2023; 69:856-862. [PMID: 37172007 DOI: 10.1097/mat.0000000000001978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023] Open
Abstract
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.
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Affiliation(s)
| | - Kelsey Ohman
- From the Duke University Hospital, Durham, North Carolina
| | | | - Alice Parish
- From the Duke University Hospital, Durham, North Carolina
| | | | - Heewon Kim
- From the Duke University Hospital, Durham, North Carolina
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Geller BJ, Maciel CB, May TL, Jentzer JC. Sedation and shivering management after cardiac arrest. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:518-524. [PMID: 37479475 DOI: 10.1093/ehjacc/zuad087] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/17/2023] [Accepted: 07/19/2023] [Indexed: 07/23/2023]
Abstract
Management of sedation and shivering during targeted temperature management (TTM) after cardiac arrest is limited by a dearth of high-quality evidence to guide clinicians. Data from general intensive care unit (ICU) populations can likely be extrapolated to post-cardiac arrest patients, but clinicians should be mindful of key differences that exist between these populations. Most importantly, the goals of sedation after cardiac arrest are distinct from other ICU patients and may also involve suppression of shivering during TTM. Drug metabolism and clearance are altered considerably during TTM when a low goal temperature is used, which can delay accurate neuroprognostication. When neuromuscular blockade is used to prevent shivering, sedation should be deep enough to prevent awareness and providers should be aware that this can mask clinical manifestations of seizures. However, excessively deep or prolonged sedation is associated with complications including delirium, infections, increased duration of ventilatory support, prolonged ICU length of stay, and delays in neuroprognostication. In this manuscript, we review sedation and shivering management best practices in the post-cardiac arrest patient population.
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Affiliation(s)
- Bram J Geller
- Department of Cardiovascular Medicine and Cardiovascular Critical Care Services, Maine Medical Center, Portland, ME, USA
| | - Carolina B Maciel
- Department of Neurology and Neurosurgery and Neurocritical Care, University of Florida, Gainesville, FL, USA
| | - Teresa L May
- Department of Critical Care Medicine, Maine Medical Center, Portland, ME, USA
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
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Chen H, Liang M, He Y, Teboul JL, Sun Q, Xie J, Yang Y, Qiu H, Liu L. Inspiratory effort impacts the accuracy of pulse pressure variations for fluid responsiveness prediction in mechanically ventilated patients with spontaneous breathing activity: a prospective cohort study. Ann Intensive Care 2023; 13:72. [PMID: 37592166 PMCID: PMC10435426 DOI: 10.1186/s13613-023-01167-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 08/01/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND Pulse pressure variation (PPV) is unreliable in predicting fluid responsiveness (FR) in patients receiving mechanical ventilation with spontaneous breathing activity. Whether PPV can be valuable for predicting FR in patients with low inspiratory effort is unknown. We aimed to investigate whether PPV can be valuable in patients with low inspiratory effort. METHODS This prospective study was conducted in an intensive care unit at a university hospital and included acute circulatory failure patients receiving volume-controlled ventilation with spontaneous breathing activity. Hemodynamic measurements were collected before and after a fluid challenge. The degree of inspiratory effort was assessed using airway occlusion pressure (P0.1) and airway pressure swing during a whole breath occlusion (ΔPocc) before fluid challenge. Patients were classified as fluid responders if their cardiac output increased by ≥ 10%. Areas under receiver operating characteristic (AUROC) curves and gray zone approach were used to assess the predictive performance of PPV. RESULTS Among the 189 included patients, 53 (28.0%) were defined as responders. A PPV > 9.5% enabled to predict FR with an AUROC of 0.79 (0.67-0.83) in the whole population. The predictive performance of PPV differed significantly in groups stratified by the median value of P0.1 (P0.1 < 1.5 cmH2O and P0.1 ≥ 1.5 cmH2O), but not in groups stratified by the median value of ΔPocc (ΔPocc < - 9.8 cmH2O and ΔPocc ≥ - 9.8 cmH2O). Specifically, in patients with P0.1 < 1.5 cmH2O, PPV was associated with an AUROC of 0.90 (0.82-0.99) compared with 0.68 (0.57-0.79) otherwise (p = 0.0016). The cut-off values of PPV were 10.5% and 9.5%, respectively. Besides, patients with P0.1 < 1.5 cmH2O had a narrow gray zone (10.5-11.5%) compared to patients with P0.1 ≥ 1.5 cmH2O (8.5-16.5%). CONCLUSIONS PPV is reliable in predicting FR in patients who received controlled ventilation with low spontaneous effort, defined as P0.1 < 1.5 cmH2O. Trial registration NCT04802668. Registered 6 February 2021, https://clinicaltrials.gov/ct2/show/record/NCT04802668.
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Affiliation(s)
- Hui Chen
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing, 210009 People’s Republic of China
- Department of Critical Care Medicine, The First Affiliated Hospital of Soochow University, Soochow University, No. 899 Pinghai Road, Suzhou, 215000 People’s Republic of China
| | - Meihao Liang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing, 210009 People’s Republic of China
- Department of Critical Care Medicine, Changsha central hospital, University of South China, No. 161, South Shaoshan Road, Changsha, 410000 Hunan People’s Republic of China
| | - Yuanchao He
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing, 210009 People’s Republic of China
- Department of Critical Care Medicine, Wuhan first hospital of Hubei Province, No 215 Zhongshan Avenue, Qiaokou District, Wuhan, 430000 People’s Republic of China
| | - Jean-Louis Teboul
- Service de médecine intensive-réanimation, Hôpital de Bicêtre, Université Paris-Saclay, AP-HP, Inserm UMR S_999, Le Kremlin-Bicêtre, France
| | - Qin Sun
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing, 210009 People’s Republic of China
| | - Jianfen Xie
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing, 210009 People’s Republic of China
| | - Yi Yang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing, 210009 People’s Republic of China
| | - Haibo Qiu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing, 210009 People’s Republic of China
| | - Ling Liu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing, 210009 People’s Republic of China
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Gutowski M, Klimkiewicz J, Michałowski A, Ordak M, Możański M, Lubas A. ICU Delirium Is Associated with Cardiovascular Burden and Higher Mortality in Patients with Severe COVID-19 Pneumonia. J Clin Med 2023; 12:5049. [PMID: 37568451 PMCID: PMC10420272 DOI: 10.3390/jcm12155049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 07/13/2023] [Accepted: 07/28/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND COVID-19 can lead to functional disorders and complications, e.g., pulmonary, thromboembolic, and neurological. The neuro-invasive potential of SARS-CoV-2 may result in acute brain malfunction, which manifests as delirium as a symptom. Delirium is a risk factor for death among patients hospitalized due to critical illness. Taking the above into consideration, the authors investigated risk factors for delirium in COVID-19 patients and its influence on outcomes. METHODS A total of 335 patients hospitalized due to severe forms of COVID-19 were enrolled in the study. Data were collected from medical charts. RESULTS Delirium occurred among 21.5% of patients. In the delirium group, mortality was significantly higher compared to non-delirium patients (59.7% vs. 28.5%; p < 0.001). Delirium increased the risk of death, with an OR of 3.71 (95% CI 2.16-6.89; p < 0.001). Age, chronic atrial fibrillation, elevated INR, urea, and procalcitonin, as well as decreased phosphates, appeared to be the independent risk factors for delirium occurrence. CONCLUSIONS Delirium occurrence in patients with severe COVID-19 significantly increases the risk of death and is associated with a cardiovascular burden. Hypophosphatemia is a promising reversible factor to reduce mortality in this group of patients. However, larger studies are essential in this area.
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Affiliation(s)
- Mateusz Gutowski
- Department of Anesthesiology and Intensive Care, Military Institute of Medicine—National Research Institute, 04-141 Warsaw, Poland; (J.K.); (A.M.); (M.M.)
| | - Jakub Klimkiewicz
- Department of Anesthesiology and Intensive Care, Military Institute of Medicine—National Research Institute, 04-141 Warsaw, Poland; (J.K.); (A.M.); (M.M.)
| | - Andrzej Michałowski
- Department of Anesthesiology and Intensive Care, Military Institute of Medicine—National Research Institute, 04-141 Warsaw, Poland; (J.K.); (A.M.); (M.M.)
| | - Michal Ordak
- Department of Pharmacotherapy and Pharmaceutical Care, Faculty of Pharmacy, Medical University of Warsaw, 02-097 Warsaw, Poland;
| | - Marcin Możański
- Department of Anesthesiology and Intensive Care, Military Institute of Medicine—National Research Institute, 04-141 Warsaw, Poland; (J.K.); (A.M.); (M.M.)
| | - Arkadiusz Lubas
- Department of Internal Diseases Nephrology and Dialysis, Military Institute of Medicine—National Research Institute, 04-141 Warsaw, Poland;
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Cutuli SL, Grieco DL, Michi T, Cesarano M, Rosà T, Pintaudi G, Menga LS, Ruggiero E, Giammatteo V, Bello G, De Pascale G, Antonelli M. Personalized Respiratory Support in ARDS: A Physiology-to-Bedside Review. J Clin Med 2023; 12:4176. [PMID: 37445211 DOI: 10.3390/jcm12134176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/19/2023] [Accepted: 06/19/2023] [Indexed: 07/15/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a leading cause of disability and mortality worldwide, and while no specific etiologic interventions have been shown to improve outcomes, noninvasive and invasive respiratory support strategies are life-saving interventions that allow time for lung recovery. However, the inappropriate management of these strategies, which neglects the unique features of respiratory, lung, and chest wall mechanics may result in disease progression, such as patient self-inflicted lung injury during spontaneous breathing or by ventilator-induced lung injury during invasive mechanical ventilation. ARDS characteristics are highly heterogeneous; therefore, a physiology-based approach is strongly advocated to titrate the delivery and management of respiratory support strategies to match patient characteristics and needs to limit ARDS progression. Several tools have been implemented in clinical practice to aid the clinician in identifying the ARDS sub-phenotypes based on physiological peculiarities (inspiratory effort, respiratory mechanics, and recruitability), thus allowing for the appropriate application of personalized supportive care. In this narrative review, we provide an overview of noninvasive and invasive respiratory support strategies, as well as discuss how identifying ARDS sub-phenotypes in daily practice can help clinicians to deliver personalized respiratory support and potentially improve patient outcomes.
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Affiliation(s)
- Salvatore Lucio Cutuli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Domenico Luca Grieco
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Teresa Michi
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Melania Cesarano
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Tommaso Rosà
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Gabriele Pintaudi
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Luca Salvatore Menga
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Ersilia Ruggiero
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Valentina Giammatteo
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Giuseppe Bello
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Gennaro De Pascale
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Massimo Antonelli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
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Zhai R, Lenga Ma Bonda W, Leclaire C, Saint-Béat C, Theilliere C, Belville C, Coupet R, Blondonnet R, Bouvier D, Blanchon L, Sapin V, Jabaudon M. Effects of sevoflurane on lung epithelial permeability in experimental models of acute respiratory distress syndrome. J Transl Med 2023; 21:397. [PMID: 37331963 DOI: 10.1186/s12967-023-04253-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 06/08/2023] [Indexed: 06/20/2023] Open
Abstract
BACKGROUND Preclinical studies in acute respiratory distress syndrome (ARDS) have suggested that inhaled sevoflurane may have lung-protective effects and clinical trials are ongoing to assess its impact on major clinical outcomes in patients with ARDS. However, the underlying mechanisms of these potential benefits are largely unknown. This investigation focused on the effects of sevoflurane on lung permeability changes after sterile injury and the possible associated mechanisms. METHODS To investigate whether sevoflurane could decrease lung alveolar epithelial permeability through the Ras homolog family member A (RhoA)/phospho-Myosin Light Chain 2 (Ser19) (pMLC)/filamentous (F)-actin pathway and whether the receptor for advanced glycation end-products (RAGE) may mediate these effects. Lung permeability was assessed in RAGE-/- and littermate wild-type C57BL/6JRj mice on days 0, 1, 2, and 4 after acid injury, alone or followed by exposure at 1% sevoflurane. Cell permeability of mouse lung epithelial cells was assessed after treatment with cytomix (a mixture of TNFɑ, IL-1β, and IFNγ) and/or RAGE antagonist peptide (RAP), alone or followed by exposure at 1% sevoflurane. Levels of zonula occludens-1, E-cadherin, and pMLC were quantified, along with F-actin immunostaining, in both models. RhoA activity was assessed in vitro. RESULTS In mice after acid injury, sevoflurane was associated with better arterial oxygenation, decreased alveolar inflammation and histological damage, and non-significantly attenuated the increase in lung permeability. Preserved protein expression of zonula occludens-1 and less increase of pMLC and actin cytoskeletal rearrangement were observed in injured mice treated with sevoflurane. In vitro, sevoflurane markedly decreased electrical resistance and cytokine release of MLE-12 cells, which was associated with higher protein expression of zonula occludens-1. Improved oxygenation levels and attenuated increase in lung permeability and inflammatory response were observed in RAGE-/- mice compared to wild-type mice, but RAGE deletion did not influence the effects of sevoflurane on permeability indices after injury. However, the beneficial effect of sevoflurane previously observed in wild-type mice on day 1 after injury in terms of higher PaO2/FiO2 and decreased alveolar levels of cytokines was not found in RAGE-/- mice. In vitro, RAP alleviated some of the beneficial effects of sevoflurane on electrical resistance and cytoskeletal rearrangement, which was associated with decreased cytomix-induced RhoA activity. CONCLUSIONS Sevoflurane decreased injury and restored epithelial barrier function in two in vivo and in vitro models of sterile lung injury, which was associated with increased expression of junction proteins and decreased actin cytoskeletal rearrangement. In vitro findings suggest that sevoflurane may decrease lung epithelial permeability through the RhoA/pMLC/F-actin pathway.
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Affiliation(s)
- Ruoyang Zhai
- iGReD, UFR de Médecine et des Professions Paramédicales, Place Henri Dunant, CNRS, INSERM, Université Clermont Auvergne, 63000, Clermont-Ferrand, France
| | - Woodys Lenga Ma Bonda
- iGReD, UFR de Médecine et des Professions Paramédicales, Place Henri Dunant, CNRS, INSERM, Université Clermont Auvergne, 63000, Clermont-Ferrand, France
| | - Charlotte Leclaire
- iGReD, UFR de Médecine et des Professions Paramédicales, Place Henri Dunant, CNRS, INSERM, Université Clermont Auvergne, 63000, Clermont-Ferrand, France
| | - Cécile Saint-Béat
- iGReD, UFR de Médecine et des Professions Paramédicales, Place Henri Dunant, CNRS, INSERM, Université Clermont Auvergne, 63000, Clermont-Ferrand, France
| | - Camille Theilliere
- iGReD, UFR de Médecine et des Professions Paramédicales, Place Henri Dunant, CNRS, INSERM, Université Clermont Auvergne, 63000, Clermont-Ferrand, France
| | - Corinne Belville
- iGReD, UFR de Médecine et des Professions Paramédicales, Place Henri Dunant, CNRS, INSERM, Université Clermont Auvergne, 63000, Clermont-Ferrand, France
| | - Randy Coupet
- iGReD, UFR de Médecine et des Professions Paramédicales, Place Henri Dunant, CNRS, INSERM, Université Clermont Auvergne, 63000, Clermont-Ferrand, France
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Raiko Blondonnet
- iGReD, UFR de Médecine et des Professions Paramédicales, Place Henri Dunant, CNRS, INSERM, Université Clermont Auvergne, 63000, Clermont-Ferrand, France
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Damien Bouvier
- iGReD, UFR de Médecine et des Professions Paramédicales, Place Henri Dunant, CNRS, INSERM, Université Clermont Auvergne, 63000, Clermont-Ferrand, France
- Department of Medical Biochemistry and Molecular Genetics, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Loic Blanchon
- iGReD, UFR de Médecine et des Professions Paramédicales, Place Henri Dunant, CNRS, INSERM, Université Clermont Auvergne, 63000, Clermont-Ferrand, France
| | - Vincent Sapin
- iGReD, UFR de Médecine et des Professions Paramédicales, Place Henri Dunant, CNRS, INSERM, Université Clermont Auvergne, 63000, Clermont-Ferrand, France
- Department of Medical Biochemistry and Molecular Genetics, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Matthieu Jabaudon
- iGReD, UFR de Médecine et des Professions Paramédicales, Place Henri Dunant, CNRS, INSERM, Université Clermont Auvergne, 63000, Clermont-Ferrand, France.
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France.
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Lassola S, Miori S, Sanna A, Menegoni I, De Rosa S, Bellani G, Umbrello M. Assessment of Inspiratory Effort in Spontaneously Breathing COVID-19 ARDS Patients Undergoing Helmet CPAP: A Comparison between Esophageal, Transdiaphragmatic and Central Venous Pressure Swing. Diagnostics (Basel) 2023; 13:diagnostics13111965. [PMID: 37296817 DOI: 10.3390/diagnostics13111965] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 04/28/2023] [Accepted: 05/29/2023] [Indexed: 06/12/2023] Open
Abstract
INTRODUCTION The clinical features of COVID-19 are highly variable. It has been speculated that the progression across COVID-19 may be triggered by excessive inspiratory drive activation. The aim of the present study was to assess whether the tidal swing in central venous pressure (ΔCVP) is a reliable estimate of inspiratory effort. METHODS Thirty critically ill patients with COVID-19 ARDS underwent a PEEP trial (0-5-10 cmH2O) during helmet CPAP. Esophageal (ΔPes) and transdiaphragmatic (ΔPdi) pressure swings were measured as indices of inspiratory effort. ΔCVP was assessed via a standard venous catheter. A low and a high inspiratory effort were defined as ΔPes ≤ 10 and >15 cmH2O, respectively. RESULTS During the PEEP trial, no significant changes in ΔPes (11 [6-16] vs. 11 [7-15] vs. 12 [8-16] cmH2O, p = 0.652) and in ΔCVP (12 [7-17] vs. 11.5 [7-16] vs. 11.5 [8-15] cmH2O, p = 0.918) were detected. ΔCVP was significantly associated with ΔPes (marginal R2 0.87, p < 0.001). ΔCVP recognized both low (AUC-ROC curve 0.89 [0.84-0.96]) and high inspiratory efforts (AUC-ROC curve 0.98 [0.96-1]). CONCLUSIONS ΔCVP is an easily available a reliable surrogate of ΔPes and can detect a low or a high inspiratory effort. This study provides a useful bedside tool to monitor the inspiratory effort of spontaneously breathing COVID-19 patients.
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Affiliation(s)
- Sergio Lassola
- Anesthesia and Intensive Care 1, Santa Chiara Hospital, APSS Trento, 38122 Trento, Italy
| | - Sara Miori
- Anesthesia and Intensive Care 1, Santa Chiara Hospital, APSS Trento, 38122 Trento, Italy
| | - Andrea Sanna
- Anesthesia and Intensive Care 1, Santa Chiara Hospital, APSS Trento, 38122 Trento, Italy
| | - Ilaria Menegoni
- Anesthesia and Intensive Care 1, Santa Chiara Hospital, APSS Trento, 38122 Trento, Italy
| | - Silvia De Rosa
- Anesthesia and Intensive Care 1, Santa Chiara Hospital, APSS Trento, 38122 Trento, Italy
- Centre for Medical Sciences-CISMed, University of Trento, Via S. Maria Maddalena 1, 38122 Trento, Italy
| | - Giacomo Bellani
- Anesthesia and Intensive Care 1, Santa Chiara Hospital, APSS Trento, 38122 Trento, Italy
- Centre for Medical Sciences-CISMed, University of Trento, Via S. Maria Maddalena 1, 38122 Trento, Italy
| | - Michele Umbrello
- Anesthesia and Intensive Care 2, San Carlo Borromeo Hospital, ASST Santi Paolo e Carlo-Polo Universitario, 20148 Milano, Italy
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Wong IMJ, Ferguson ND, Urner M. Invasive mechanical ventilation. Intensive Care Med 2023; 49:669-672. [PMID: 37115258 DOI: 10.1007/s00134-023-07079-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 04/13/2023] [Indexed: 04/29/2023]
Affiliation(s)
- Irene M J Wong
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.
- Departments of Medicine and Physiology, University of Toronto, Toronto, Canada.
- Division of Respirology and Critical Care Medicine, Department of Medicine, University Health Network, Toronto, Canada.
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada.
- Toronto General Research Institute, Toronto, Canada.
- Toronto General Hospital, 585 University Avenue, MaRS-9012, Toronto, ON, M5G 2N2, Canada.
| | - Martin Urner
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada
- Department of Anesthesia and Pain Management, University Health Network, Toronto, Canada
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Martínez-Castro S, Monleón B, Puig J, Ferrer Gomez C, Quesada M, Pestaña D, Balvis A, Maseda E, de la Rica AS, Feijoo AM, Badenes R. Sedation with Sevoflurane versus Propofol in COVID-19 Patients with Acute Respiratory Distress Syndrome: Results from a Randomized Clinical Trial. J Pers Med 2023; 13:925. [PMID: 37373914 DOI: 10.3390/jpm13060925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/08/2023] [Accepted: 05/25/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Acute respiratory distress syndrome (ARDS) related to COVID-19 (coronavirus disease 2019) led to intensive care units (ICUs) collapse. Amalgams of sedative agents (including volatile anesthetics) were used due to the clinical shortage of intravenous drugs (mainly propofol and midazolam). METHODS A multicenter, randomized 1:1, controlled clinical trial was designed to compare sedation using propofol and sevoflurane in patients with ARDS associated with COVID-19 infection in terms of oxygenation and mortality. RESULTS Data from a total of 17 patients (10 in the propofol arm and 7 in the sevoflurane arm) showed a trend toward PaO2/FiO2 improvement and the sevoflurane arm's superiority in decreasing the likelihood of death (no statistical significance was found). CONCLUSIONS Intravenous agents are the most-used sedative agents in Spain, even though volatile anesthetics, such as sevoflurane and isoflurane, have shown beneficial effects in many clinical conditions. Growing evidence demonstrates the safety and potential benefits of using volatile anesthetics in critical situations.
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Affiliation(s)
- Sara Martínez-Castro
- Department Anesthesiology, Surgical-Trauma Intensive Care and Pain Clinic, Hospital Clínic Universitari, University of Valencia, 46010 Valencia, Spain
| | - Berta Monleón
- Department Anesthesiology, Surgical-Trauma Intensive Care and Pain Clinic, Hospital Clínic Universitari, University of Valencia, 46010 Valencia, Spain
| | - Jaume Puig
- Anesthesiology and Intensive Care Department, Consorcio Hospital General Universitario, 46014 Valencia, Spain
| | - Carolina Ferrer Gomez
- Anesthesiology and Intensive Care Department, Consorcio Hospital General Universitario, 46014 Valencia, Spain
| | - Marta Quesada
- Anesthesiology and Intensive Care Department, Consorcio Hospital General Universitario, 46014 Valencia, Spain
| | - David Pestaña
- Anesthesiology and Intensive Care Department, Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain
| | - Alberto Balvis
- Anesthesiology and Intensive Care Department, Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain
| | - Emilio Maseda
- Surgical Critical Care Department, Hospital Universitario La Paz, 28046 Madrid, Spain
| | - Alejandro Suárez de la Rica
- Anesthesiology and Surgical Critical Care Department, Hospital Universitario De La Princesa, 28006 Madrid, Spain
| | - Ana Monero Feijoo
- Surgical Critical Care Department, Hospital Universitario La Paz, 28046 Madrid, Spain
| | - Rafael Badenes
- Department Anesthesiology, Surgical-Trauma Intensive Care and Pain Clinic, Hospital Clínic Universitari, University of Valencia, 46010 Valencia, Spain
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Paparoupa M, Fischer M, Pinnschmidt HO, Grensemann J, Roedl K, Kluge S, Jarczak D. Impact of COVID-19 on Sedation Requirements during Veno-Venous Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome. J Clin Med 2023; 12:jcm12103515. [PMID: 37240620 DOI: 10.3390/jcm12103515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 05/11/2023] [Accepted: 05/13/2023] [Indexed: 05/28/2023] Open
Abstract
COVID-19-associated ARDS (C-ARDS) is mentioned to express higher analgosedation needs, in comparison to ARDS of other etiologies. The objective of this monocentric retrospective cohort study was to compare the analgosedation needs between C-ARDS and non-COVID-19 ARDS (non-C-ARDS) on veno-venous extracorporeal membrane oxygenation (VV-ECMO). Data were collected from the electronic medical records of all adult patients treated with C-ARDS in our Department of Intensive Care Medicine between March 2020 and April 2022. The control group included patients treated with non-C-ARDS between the years 2009 and 2020. A sedation sum score was created in order to describe the overall analgosedation needs. A total of 115 (31.5%) patients with C-ARDS and 250 (68.5%) with non-C-ARDS requiring VV-ECMO therapy were included in the study. The sedation sum score was significantly higher in the C-ARDS group (p < 0.001). COVID-19 was significantly associated with analgosedation in the univariable analysis. By contrast, the multivariable model did not show a significant association between COVID-19 and the sum score. The year of VV-ECMO support, BMI, SAPS II and prone positioning were significantly associated with sedation needs. The potential impact of COVID-19 remains unclear, and further studies are warranted in order to evaluate specific disease characteristics linked with analgesia and sedation.
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Affiliation(s)
- Maria Paparoupa
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany
| | - Marlene Fischer
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany
| | - Hans O Pinnschmidt
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany
| | - Jörn Grensemann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany
| | - Kevin Roedl
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany
| | - Dominik Jarczak
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany
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Eikermann M, Needham DM, Devlin JW. Multimodal, patient-centred symptom control: a strategy to replace sedation in the ICU. THE LANCET. RESPIRATORY MEDICINE 2023:S2213-2600(23)00141-8. [PMID: 37187192 DOI: 10.1016/s2213-2600(23)00141-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 03/27/2023] [Accepted: 04/04/2023] [Indexed: 05/17/2023]
Affiliation(s)
- Matthias Eikermann
- Department of Anesthesiology, Montefiore Medical Center and Albert Einstein College of Medicine, New York, NY 10467, USA; Klinik fuer Anästhesiologie und Intensivmedizin, Universitaet Duisburg-Essen, Essen, Germany.
| | - Dale M Needham
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - John W Devlin
- School of Pharmacy, Northeastern University, Boston, MA, USA; Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
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Alabsi H, Emerson K, Lin DJ. Neurorecovery after Critical COVID-19 Illness. Semin Neurol 2023. [PMID: 37168008 DOI: 10.1055/s-0043-1768714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
With the hundreds of millions of people worldwide who have been, and continue to be, affected by pandemic coronavirus disease (COVID-19) and its chronic sequelae, strategies to improve recovery and rehabilitation from COVID-19 are critical global public health priorities. Neurologic complications have been associated with acute COVID-19 infection, usually in the setting of critical COVID-19 illness. Neurologic complications are also a core feature of the symptom constellation of long COVID and portend poor outcomes. In this article, we review neurologic complications and their mechanisms in critical COVID-19 illness and long COVID. We focus on parallels with neurologic disease associated with non-COVID critical systemic illness. We conclude with a discussion of how recent findings can guide both neurologists working in post-acute neurologic rehabilitation facilities and policy makers who influence neurologic resource allocation.
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Affiliation(s)
- Haitham Alabsi
- Division of Neurocritical Care, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Kristi Emerson
- Division of Neurocritical Care, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - David J Lin
- Division of Neurocritical Care, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Boselli E, Fatah A, Ledochowski S, Allaouchiche B. Variations of qCON and qNOX during tracheal suction in ICU patients on sedation and curarization for SARS-CoV2 pneumonia: a retrospective study. J Clin Monit Comput 2023:10.1007/s10877-023-00998-3. [PMID: 37004662 PMCID: PMC10067008 DOI: 10.1007/s10877-023-00998-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 03/15/2023] [Indexed: 04/04/2023]
Affiliation(s)
- Emmanuel Boselli
- Department of Anesthesiology, Centre Hospitalier Pierre Oudot, Bourgoin-Jallieu, France.
- University of Lyon, University Lyon I Claude Bernard, APCSe VetAgro Sup UP, 2021.A10, Marcy L'Étoile, France.
| | - Abdelhamid Fatah
- Department of Intensive Care, Centre Hospitalier Pierre Oudot, Bourgoin-Jallieu, France
| | - Stanislas Ledochowski
- Department of Intensive Care, Centre Hospitalier Pierre Oudot, Bourgoin-Jallieu, France
| | - Bernard Allaouchiche
- University of Lyon, University Lyon I Claude Bernard, APCSe VetAgro Sup UP, 2021.A10, Marcy L'Étoile, France
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Li J, Li Y. Extracorporeal Membrane Oxygenation and New Mental Health Diagnoses in Adult Survivors of Critical Illness. JAMA 2023; 329:844. [PMID: 36917059 DOI: 10.1001/jama.2022.24707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Affiliation(s)
- Jian Li
- Second Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Yongnan Li
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou, China
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Gómez Duque M, Medina R, Enciso C, Beltran E, Hernandez K, Molano Franco D, Masclans JR. Usefulness of Inhaled Sedation in Patients With Severe ARDS Due to COVID-19. Respir Care 2023; 68:293-299. [PMID: 36414277 PMCID: PMC10027142 DOI: 10.4187/respcare.10371] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Sedation in intensive care is fundamental for optimizing clinical outcomes. For many years the world has been facing high rates of opioid use, and to combat the increasing opioid addiction plans at both national and international level have been implemented.1 The COVID-19 pandemic posed a major challenge for health systems and also increased the use of sedatives and opioid analgesia for prolonged periods of time, and at high doses, in a significant proportion of patients. In our institutions, the shortage of many drugs for intravenous (IV) analgosedation forces us to alternatives to replace out-of-stock drugs or to seek sedation goals, which are difficult to obtain with traditional drugs at high doses.2 METHODS: This was an analytical retrospective cohort study evaluating the follow-up of subjects with inclusion criteria from ICU admission to discharge (alive or dead). Five end points were measured: need for high-dose opioids (≥ 200 µg/h), comparison of inhaled versus IV sedation of opioid analgesic doses, midazolam dose, need for muscle relaxant, and risk of delirium. RESULTS A total of 283 subjects were included in the study, of whom 230 were administered IV sedation and 53 inhaled sedation. In the inhaled sedation group, the relative risks (RRs) were 0.5 (95% CI 0.4-0.8, P = .045) for need of high-dose fentanyl, 0.3 (95% CI 0.20-0.45, P < .001) for need of muscle relaxant, and 0.8 (95% CI 0.61-1.15, P = .25) for risk of delirium. The median difference of fentanyl dose between the inhaled sedation and IV sedation groups was 61 µg/h or 1,200 µg/d (2.2 ampules/d, P < .001), and that of midazolam dose was 5.7 mg/h. CONCLUSIONS Inhaled sedation was associated with lower doses of opioids, benzodiazepines, and muscle relaxants compared to IV sedation. This therapy should be considered as an alternative in critically ill patients requiring prolonged ventilatory support and where IV sedation is not possible, always under adequate supervision of ICU staff.
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Affiliation(s)
- Mario Gómez Duque
- Service of Intensive Care Medicine, Hospital de San José, Fundación Universitaria de Ciencias de la Salud, Research Group CIMCA, Bogota, Colombia
| | - Ronald Medina
- Service of Intensive Care Medicine, Hospital de San José, Fundación Universitaria de Ciencias de la Salud, Research Group CIMCA, Bogota, Colombia
| | - Cesar Enciso
- Service of Intensive Care Medicine, Hospital de San José, Fundación Universitaria de Ciencias de la Salud, Research Group CIMCA, Bogota, Colombia
| | - Edgar Beltran
- Service of Intensive Care Medicine, Hospital de San José, Fundación Universitaria de Ciencias de la Salud, Research Group CIMCA, Bogota, Colombia
| | - Kevin Hernandez
- Service of Intensive Care Medicine, Hospital de San José, Fundación Universitaria de Ciencias de la Salud, Research Group CIMCA, Bogota, Colombia
| | - Daniel Molano Franco
- Service of Intensive Care Medicine, Hospital de San José, Los Cobos Medical Center, Research Group GRIBOS, Bogotá, Colombia.
| | - Joan R Masclans
- Service of Intensive Care Medicine, Hospital del Mar de Barcelona, IMIM (GREPAC), Department of Medicine (MELIS), Universitat Pompeu Fabra, Barcelona, Spain
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Henrie J, Gerard L, Declerfayt C, Lejeune A, Baldin P, Robert A, Laterre PF, Hantson P. Profile of liver cholestatic biomarkers following prolonged ketamine administration in patients with COVID-19. BMC Anesthesiol 2023; 23:44. [PMID: 36750971 PMCID: PMC9902832 DOI: 10.1186/s12871-023-02006-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 02/02/2023] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND To investigate the possible influence of prolonged ketamine (K) or esketamine (ESK) infusion on the profile of liver cholestatic biomarkers in patients with COVID-19 infection. METHODS A retrospective analysis was performed on 135 patients with COVID-19 related ARDS who received prolonged K or ESK infusion. They were compared to 15 COVID-19 ICU patients who did not receive K/ESK while being mechanically ventilated and 108 COVID-19 patients who did not receive mechanical ventilation nor K/ESK. The profile of the liver function tests was analysed in the groups. RESULTS Peak values of ALP, GGT and bilirubin were higher in the K/ESK group, but not for AST and ALT. Peak values of ALP were significantly higher among patients who underwent mechanical ventilation and who received K/ESK, compared with mechanically ventilated patients who did not receive K/ESK. There was a correlation between these peak values and the cumulative dose and duration of K/ESK therapy. CONCLUSIONS Based on the observations of biliary anomalies in chronic ketamine abusers, prolonged exposure to ketamine sedation during mechanical ventilation may also be involved, in addition to viral infection causing secondary sclerosing cholangitis. The safety of prolonged ketamine sedation on the biliary tract requires further investigations.
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Affiliation(s)
- Julie Henrie
- grid.7942.80000 0001 2294 713XDepartment of Intensive Care, Cliniques St-Luc, Université Catholique de Louvain, Avenue Hippocrate, 10, 1200 Brussels, Belgium
| | - Ludovic Gerard
- grid.7942.80000 0001 2294 713XDepartment of Intensive Care, Cliniques St-Luc, Université Catholique de Louvain, Avenue Hippocrate, 10, 1200 Brussels, Belgium
| | - Caroline Declerfayt
- grid.7942.80000 0001 2294 713XDepartment of Intensive Care, Cliniques St-Luc, Université Catholique de Louvain, Avenue Hippocrate, 10, 1200 Brussels, Belgium
| | - Adrienne Lejeune
- grid.7942.80000 0001 2294 713XDepartment of Intensive Care, Cliniques St-Luc, Université Catholique de Louvain, Avenue Hippocrate, 10, 1200 Brussels, Belgium
| | - Pamela Baldin
- grid.7942.80000 0001 2294 713XDepartment of Pathology, Cliniques St-Luc, Université Catholique de Louvain, 1200 Brussels, Belgium
| | - Arnaud Robert
- grid.7942.80000 0001 2294 713XDepartment of Intensive Care, Cliniques St-Luc, Université Catholique de Louvain, Avenue Hippocrate, 10, 1200 Brussels, Belgium
| | - Pierre-François Laterre
- grid.7942.80000 0001 2294 713XDepartment of Intensive Care, Cliniques St-Luc, Université Catholique de Louvain, Avenue Hippocrate, 10, 1200 Brussels, Belgium
| | - Philippe Hantson
- Department of Intensive Care, Cliniques St-Luc, Université Catholique de Louvain, Avenue Hippocrate, 10, 1200, Brussels, Belgium. .,Louvain Centre for Toxicology and Applied Pharmacology (LTAP), Université Catholique de Louvain, 1200, Brussels, Belgium.
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Zhou Y, Chi Y, He H, Cui N, Wang X, Long Y. High respiratory effort decreases splanchnic and peripheral perfusion in patients with respiratory failure during mechanical ventilation. J Crit Care 2023; 75:154263. [PMID: 36738632 DOI: 10.1016/j.jcrc.2023.154263] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 01/23/2023] [Accepted: 01/26/2023] [Indexed: 02/05/2023]
Abstract
PURPOSE This study aimed to evaluate the effects of high respiratory effort(HRE) on spleen, kidney, intestine, and peripheral perfusion in patients with respiratory failure during mechanical ventilation. METHODS HRE was defined as a pressure muscle index (PMI) > 6 cmH2O and airway pressure swing during occlusion (ΔPOCC) > 10 cmH2O. Capillary refill time(CRT) and peripheral perfusion index (PPI) were determined when HRE occurred. The resistance indices of the snuffbox, intestine, spleen, and kidney were measured using Doppler ultrasonography simultaneously. These parameters were re-measured when the patients had normal respiratory effort (NRE) following sedation and analgesia. RESULTS A total of 33 critically ill patients were enrolled in this prospective observational study. There was a significant increase in CRT (p = 0.0345) and PPI (p < 0.0001) from HRE to NRE; meanwhile, the resistance index of the snuffbox artery decreased (p < 0.0001). Regarding splanchnic perfusion indicators, all resistance indices of the superior mesenteric artery (p = 0.0002), spleen (p < 0.0001), and kidney (p < 0.0001) decreased significantly when the patient changed from HRE status to NRE. CONCLUSIONS HRE could decrease perfusion of peripheral tissues and splanchnic organs. The status of HRE should be avoided to protect splanchnic and peripheral organs in mechanically ventilated patients.
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Affiliation(s)
- Yuankai Zhou
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Yi Chi
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Huaiwu He
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Na Cui
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Xiaoting Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Yun Long
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Beijing, China.
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Mechanical Ventilation in Patients with Traumatic Brain Injury: Is it so Different? Neurocrit Care 2023; 38:178-191. [PMID: 36071333 DOI: 10.1007/s12028-022-01593-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 08/16/2022] [Indexed: 10/14/2022]
Abstract
Patients with traumatic brain injury (TBI) frequently require invasive mechanical ventilation and admission to an intensive care unit. Ventilation of patients with TBI poses unique clinical challenges, and careful attention is required to ensure that the ventilatory strategy (including selection of appropriate tidal volume, plateau pressure, and positive end-expiratory pressure) does not cause significant additional injury to the brain and lungs. Selection of ventilatory targets may be guided by principles of lung protection but with careful attention to relevant intracranial effects. In patients with TBI and concomitant acute respiratory distress syndrome (ARDS), adjunctive strategies include sedation optimization, neuromuscular blockade, recruitment maneuvers, prone positioning, and extracorporeal life support. However, these approaches have been largely extrapolated from studies in patients with ARDS and without brain injury, with limited data in patients with TBI. This narrative review will summarize the existing evidence for mechanical ventilation in patients with TBI. Relevant literature in patients with ARDS will be summarized, and where available, direct data in the TBI population will be reviewed. Next, practical strategies to optimize the delivery of mechanical ventilation and determine readiness for extubation will be reviewed. Finally, future directions for research in this evolving clinical domain will be presented, with considerations for the design of studies to address relevant knowledge gaps.
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