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O'Gara B, Boncyk C, Meiser A, Jerath A, Bellgardt M, Jabaudon M, Beitler JR, Hughes CG. Volatile Anesthetic Sedation for Critically Ill Patients. Anesthesiology 2024; 141:163-174. [PMID: 38860793 DOI: 10.1097/aln.0000000000004994] [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: 06/12/2024]
Abstract
Volatile anesthetics have multiple properties that make them useful for sedation in the intensive care unit. The team-based approach to volatile anesthetic sedation leverages these properties to provide a safe and effective alternative to intravenous sedatives.
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Affiliation(s)
- Brian O'Gara
- Beth Israel Deaconess Medical Center, Department of Anaesthesia, Critical Care, and Pain Medicine, Harvard Medical School, Boston, Massachusetts
| | - Christina Boncyk
- Vanderbilt University Medical Center, Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Andreas Meiser
- Saarland University Hospital, Privatdozent Medical Faculty of Saarland University, Homburg, Germany
| | - Angela Jerath
- Sunnybrook Research Institute, Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Martin Bellgardt
- St. Josef-Hospital, University Hospital of Ruhr-University of Bochum, Bochum, Germany
| | - Matthieu Jabaudon
- University Hospital Center Clermont-Ferrand, Department of Perioperative Medicine, Clermont Auvergne University, Institute of Genetics, Reproduction, and Development, National Center for Scientific Research, National Institute of Health and Medical Research, Clermont-Ferrand, France
| | - Jeremy R Beitler
- New York Presbyterian/Columbia University Medical Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Christopher G Hughes
- Vanderbilt University Medical Center, Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee
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Contreras S, Giménez-Esparza Vich C, Caballero J. Practical approach to inhaled sedation in the critically ill patient. Sedation, analgesia and Delirium Working Group (GTSAD) of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC). Med Intensiva 2024:S2173-5727(24)00134-6. [PMID: 38862301 DOI: 10.1016/j.medine.2024.05.011] [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: 11/22/2023] [Accepted: 04/16/2024] [Indexed: 06/13/2024]
Abstract
The use of sedatives in Intensive Care Units (ICU) is essential for relieving anxiety and stress in mechanically ventilated patients, and it is related to clinical outcomes, duration of mechanical ventilation, and length of stay in the ICU. Inhaled sedatives offer benefits such as faster awakening and extubation, decreased total opioid and neuromuscular blocking agents (NMB) doses, as well as bronchodilator, anticonvulsant, and cardiopulmonary and neurological protective effects. Inhaled sedation is administered using a specific vaporizer. Isoflurane is the recommended agent due to its efficacy and safety profile. Inhaled sedation is recommended for moderate and deep sedation, prolonged sedation, difficult sedation, patients with acute respiratory distress syndrome (ARDS), status asthmaticus, and super-refractory status epilepticus. By offering these significant advantages, the use of inhaled sedatives allows for a personalized and controlled approach to optimize sedation in the ICU.
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Affiliation(s)
- Sofía Contreras
- Servicio de Medicina Intensiva, Hospital Universitario Vall d'Hebron, Barcelona, Spain.
| | | | - Jesús Caballero
- Servicio de Medicina Intensiva, Hospital Universitari Arnau de Vilanova, Institut de Recerca Biomèdica de Lleida (IRBLleida), Lleida, Spain
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Wieruszewski ED, ElSaban M, Wieruszewski PM, Smischney NJ. Inhaled volatile anesthetics in the intensive care unit. World J Crit Care Med 2024; 13:90746. [PMID: 38633473 PMCID: PMC11019627 DOI: 10.5492/wjccm.v13.i1.90746] [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: 12/13/2023] [Revised: 01/19/2024] [Accepted: 02/20/2024] [Indexed: 03/05/2024] Open
Abstract
The discovery and utilization of volatile anesthetics has significantly transformed surgical practices since their inception in the mid-19th century. Recently, a paradigm shift is observed as volatile anesthetics extend beyond traditional confines of the operating theatres, finding diverse applications in intensive care settings. In the dynamic landscape of intensive care, volatile anesthetics emerge as a promising avenue for addressing complex sedation requirements, managing refractory lung pathologies including acute respiratory distress syndrome and status asthmaticus, conditions of high sedative requirements including burns, high opioid or alcohol use and neurological conditions such as status epilepticus. Volatile anesthetics can be administered through either inhaled route via anesthetic machines/devices or through extracorporeal membrane oxygenation circuitry, providing intensivists with multiple options to tailor therapy. Furthermore, their unique pharmacokinetic profiles render them titratable and empower clinicians to individualize management with heightened accuracy, mitigating risks associated with conventional sedation modalities. Despite the amounting enthusiasm for the use of these therapies, barriers to widespread utilization include expanding equipment availability, staff familiarity and training of safe use. This article delves into the realm of applying inhaled volatile anesthetics in the intensive care unit through discussing their pharmacology, administration considerations in intensive care settings, complication considerations, and listing indications and evidence of the use of volatile anesthetics in the critically ill patient population.
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Affiliation(s)
| | - Mariam ElSaban
- Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN 55905, United States
| | | | - Nathan J Smischney
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, MN 55905, United States
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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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Taylor B, Scott TE, Shaw J, Chockalingam N. Renal safety of critical care sedation with sevoflurane: a systematic review and meta-analysis. J Anesth 2023; 37:794-805. [PMID: 37498387 DOI: 10.1007/s00540-023-03227-y] [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: 01/24/2023] [Accepted: 07/11/2023] [Indexed: 07/28/2023]
Abstract
Volatile anesthetic agents are increasingly widely used for critical care sedation. There are concerns that sevoflurane presents a risk of renal injury when used in this role. RCTs comparing the use of critical care sevoflurane sedation with any control in humans were systematically identified using MEDLINE, Cochrane CENTRAL, web of Science, and CINAHL (until May 2022), if they presented comparative data on renal function or serum inorganic fluoride levels. Pooled SMDs (95% CI) were calculated where possible after assessment of quality with GRADE and risk of bias with ROB-2. Eight studies analyzing 793 patients were included. The median duration of use of critical care sevoflurane sedation was 4.8 [IQR 3.5-9.2] hours; however, most trials also included a period of prior intraoperative use. No significant difference was found in serum creatinine at 1 day (SMD 0.05, 95% CI - 0.12 to 0.21), 48 h (SMD = - 0.04; 95% Cl - 0.25 to 0.17), 72 h (SMD = - 0.15; 95% CI - 0.45 to 0.15), and at discharge (SMD = - 0.1; 95% CI - 0.3 to 0.13) between the sevoflurane group and the control groups. Creatinine clearance was measured in two studies at 48 h with no significant difference (SMD = - 0.13; 95% Cl - 0.38 to 0.11). Levels of serum inorganic fluoride were significantly elevated in patients where sevoflurane was used. Sevoflurane was not associated with renal failure when used for critical care sedation of fewer than 72-h duration, despite the elevation of serum fluoride. Longer-term studies are currently inadequate, including in patients with compromised renal function, to further evaluate the role of sevoflurane in this setting.Trial registration PROSPERO (CRD42022333099).
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Affiliation(s)
- Ben Taylor
- Department of Anaesthesia and Critical Care, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK.
- Academic Department of Military Anaesthesia and Critical Care, Birmingham, UK.
- Centre for Biomechanics and Rehabilitation Technologies, Staffordshire University, Stoke-on-Trent, UK.
| | - Timothy E Scott
- Department of Anaesthesia and Critical Care, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
- Academic Department of Military Anaesthesia and Critical Care, Birmingham, UK
- Centre for Biomechanics and Rehabilitation Technologies, Staffordshire University, Stoke-on-Trent, UK
| | - James Shaw
- Academic Department of Military Anaesthesia and Critical Care, Birmingham, UK
- Emergency Medical Retrieval and Transport Service Cymru, Llanelli, UK
| | - Nachiappan Chockalingam
- Centre for Biomechanics and Rehabilitation Technologies, Staffordshire University, Stoke-on-Trent, UK
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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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Paramythiotis D, Karlafti E, Veroplidou K, Fafouti M, Kaiafa G, Netta S, Michalopoulos A, Savopoulos C. Drug-Induced Acute Pancreatitis in Hospitalized COVID-19 Patients. Diagnostics (Basel) 2023; 13:diagnostics13081398. [PMID: 37189499 DOI: 10.3390/diagnostics13081398] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/28/2023] [Accepted: 03/29/2023] [Indexed: 05/17/2023] Open
Abstract
Coronavirus disease-19 (COVID-19), caused by SARS-CoV-2, is a systemic disease that affects not only the respiratory system, but also other systems, including gastrointestinal. A great number of different drugs have been used on hospitalized patients for the management of COVID-19, and acute pancreatitis (AP) has been reported as a complication or side effect of these drugs. The development of drug-induced acute pancreatitis (DIAP) follows a complex of pathophysiological mechanisms, and particular risk factors play a key role. Diagnosis of DIAP depends on specific criteria, and based on these, a drug may be characterized as having a definite, probable or possible connection with AP. The aim of this review is to present the medications that are used for COVID-19 management and are associated with AP in hospitalized patients. The list of these drugs mainly includes corticosteroids, glucocorticoids, non-steroidal anti-inflammatory drugs (NSAIDs), antiviral agents, antibiotics, monoclonal antibodies, estrogens and anesthetic agents. Moreover, the prevention of the development of DIAP is vital, especially for critically ill patients who may receive multiple drugs. DIAP management is mainly non-invasive and the first step concerns the exception of the suspicious drug from patients therapy.
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Affiliation(s)
- Daniel Paramythiotis
- First Propaedeutic Department of Surgery, AHEPA University General Hospital, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
| | - Eleni Karlafti
- Emergency Department, AHEPA University General Hospital, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
- First Propaedeutic Department of Internal Medicine, AHEPA University General Hospital, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
| | - Kalliopi Veroplidou
- First Propaedeutic Department of Surgery, AHEPA University General Hospital, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
| | - Maria Fafouti
- First Propaedeutic Department of Surgery, AHEPA University General Hospital, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
| | - Georgia Kaiafa
- First Propaedeutic Department of Internal Medicine, AHEPA University General Hospital, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
| | - Smaro Netta
- First Propaedeutic Department of Surgery, AHEPA University General Hospital, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
| | - Antonios Michalopoulos
- First Propaedeutic Department of Surgery, AHEPA University General Hospital, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
| | - Christos Savopoulos
- First Propaedeutic Department of Internal Medicine, AHEPA University General Hospital, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
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Ju LS, Zhu J, Brant JO, Morey TE, Gravenstein N, Seubert CN, Vasilopoulos T, Setlow B, Martynyuk AE. Intergenerational Perioperative Neurocognitive Disorder in Young Adult Male Rats with Traumatic Brain Injury. Anesthesiology 2023; 138:388-402. [PMID: 36637480 PMCID: PMC10411496 DOI: 10.1097/aln.0000000000004496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND The authors tested the hypothesis that the effects of traumatic brain injury, surgery, and sevoflurane interact to induce neurobehavioral abnormalities in adult male rats and in their offspring (an animal model of intergenerational perioperative neurocognitive disorder). METHODS Sprague-Dawley male rats (assigned generation F0) underwent a traumatic brain injury on postnatal day 60 that involved craniectomy (surgery) under 3% sevoflurane for 40 min followed by 2.1% sevoflurane for 3 h on postnatal days 62, 64, and 66 (injury group). The surgery group had craniectomy without traumatic brain injury, whereas the sevoflurane group had sevoflurane only. On postnatal day 90, F0 males and control females were mated to generate offspring (assigned generation F1). RESULTS Acutely, F0 injury rats exhibited the greatest increases in serum corticosterone and interleukin-1β and -6, and activation of the hippocampal microglia. Long-term, compared to controls, F0 injury rats had the most exacerbated corticosterone levels at rest (mean ± SD, 2.21 ± 0.64 vs. 7.28 ± 1.95 ng/ml, n = 7 - 8; P < 0.001) and 10 min after restraint (133.12 ± 33.98 vs. 232.83 ± 40.71 ng/ml, n = 7 - 8; P < 0.001), increased interleukin-1β and -6, and reduced expression of hippocampal glucocorticoid receptor (Nr3c1; 0.53 ± 0.08 fold change relative to control, P < 0.001, n = 6) and brain-derived neurotrophic factor genes. They also exhibited greater behavioral deficiencies. Similar abnormalities were evident in their male offspring, whereas F1 females were not affected. The reduced Nr3c1 expression in F1 male, but not female, hippocampus was accompanied by corresponding Nr3c1 promoter hypermethylated CpG sites in F0 spermatozoa and F1 male, but not female, hippocampus. CONCLUSIONS These findings in rats suggest that young adult males with traumatic brain injury are at an increased risk of developing perioperative neurocognitive disorder, as are their unexposed male but not female offspring. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Ling-Sha Ju
- Department of Anesthesiology, University of Florida, College of Medicine, Gainesville, Florida
| | - Jiepei Zhu
- Department of Anesthesiology, University of Florida, College of Medicine, Gainesville, Florida
| | - Jason O Brant
- Department of Biostatistics, University of Florida, College of Medicine, Gainesville, Florida
| | - Timothy E Morey
- Department of Anesthesiology, University of Florida, College of Medicine, Gainesville, Florida
| | - Nikolaus Gravenstein
- Department of Anesthesiology, University of Florida, College of Medicine, Gainesville, Florida
| | - Christoph N Seubert
- Department of Anesthesiology, University of Florida, College of Medicine, Gainesville, Florida
| | - Terrie Vasilopoulos
- Departments of Anesthesiology, Orthopedic Surgery and Sports Medicine, University of Florida, College of Medicine, Gainesville, Florida
| | - Barry Setlow
- Department of Psychiatry and the McKnight Brain Institute, University of Florida, College of Medicine, Gainesville, Florida
| | - Anatoly E Martynyuk
- Department of Anesthesiology and the McKnight Brain Institute, University of Florida, College of Medicine, Gainesville, Florida
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Soukup J, Michel P, Christel A, Schittek GA, Wagner NM, Kellner P. Prolonged sedation with sevoflurane in comparison to intravenous sedation in critically ill patients - A randomized controlled trial. J Crit Care 2023; 74:154251. [PMID: 36640476 DOI: 10.1016/j.jcrc.2022.154251] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 12/29/2022] [Accepted: 12/30/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND Volatile anesthetics are used more commonly for sedation in the intensive-care-unit (ICU). However, evidence for long-term use remains low. We therefore conducted a randomized-controlled trial comparing sevoflurane with intravenous sedation with particular focus on efficacy and safety. METHODS In this prospective, randomized-controlled phase-IIb monocentric clinical-trial ICU patients requiring at least 48 h of sedation were randomized to receive sevoflurane (S) or propofol/midazolam (P). Sedation quality was monitored using the Richmond-Agitation-Sedation-Scale. Following termination of sedation, the time to spontaneous breathing and extubation, opioid consumption, hemodynamics, ICU and hospital length of stay (LOS) and adverse events were recorded. RESULTS 79 patients were eligible to randomization. Sedation quality was comparable between sevoflurane (n = 39) and propofol (n = 40). However, the use of sevoflurane lead to a reduction in time to spontaneous breathing (26 min vs. 375 min, P < 0.001). Patients sedated with propofol had lower opioid requirements (remifentanil:400 μg/h vs. 500 μg/h, P = 0.007; sufentanil:40 μg/h vs. 30 μg/h, P = 0.007) while hemodynamics, LOS or the occurrence of adverse events did not differ. CONCLUSION ICU patients sedated with sevoflurane >48 h may return to spontaneous breathing faster, while the quality of sedation is comparable to a propofol-based sedation regime. Sevoflurane might be considered to be safe for long-term sedation in this patient population, while being non-inferior compared to propofol.
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Affiliation(s)
- Jens Soukup
- Department of Anesthesiology, Intensive Care Medicine and Palliative Care Medicine, Carl-Thiem-Hospital, Cottbus, Germany; Department of Anesthesiology and Surgical Intensive Care, University Hospital Halle (Saale), Halle (Saale), Germany
| | - Peter Michel
- Department of Anesthesiology and Surgical Intensive Care, University Hospital Halle (Saale), Halle (Saale), Germany
| | - Annett Christel
- Department of Anesthesiology and Surgical Intensive Care, University Hospital Halle (Saale), Halle (Saale), Germany
| | - Gregor Alexander Schittek
- Department of Anesthesiology and Intensive Care Medicine, Division of Special Anesthesiology, Pain and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Nana-Maria Wagner
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Münster, Münster, Germany
| | - Patrick Kellner
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Lübeck, Lübeck, Germany.
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Inhaled Sedation with Volatile Anesthetics for Mechanically Ventilated Patients in Intensive Care Units: A Narrative Review. J Clin Med 2023; 12:jcm12031069. [PMID: 36769718 PMCID: PMC9918250 DOI: 10.3390/jcm12031069] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 01/23/2023] [Accepted: 01/26/2023] [Indexed: 01/31/2023] Open
Abstract
Inhaled sedation was recently approved in Europe as an alternative to intravenous sedative drugs for intensive care unit (ICU) sedation. The aim of this narrative review was to summarize the available data from the literature published between 2005 and 2023 in terms of the efficacy, safety, and potential clinical benefits of inhaled sedation for ICU mechanically ventilated patients. The results indicated that inhaled sedation reduces the time to extubation and weaning from mechanical ventilation and reduces opioid and muscle relaxant consumption, thereby possibly enhancing recovery. Several researchers have reported its potential cardio-protective, anti-inflammatory or bronchodilator properties, alongside its minimal metabolism by the liver and kidney. The reflection devices used with inhaled sedation may increase the instrumental dead space volume and could lead to hypercapnia if the ventilator settings are not optimal and the end tidal carbon dioxide is not monitored. The risk of air pollution can be prevented by the adequate scavenging of the expired gases. Minimizing atmospheric pollution can be achieved through the judicious use of the inhalation sedation for selected groups of ICU patients, where the benefits are maximized compared to intravenous sedation. Very rarely, inhaled sedation can induce malignant hyperthermia, which prompts urgent diagnosis and treatment by the ICU staff. Overall, there is growing evidence to support the benefits of inhaled sedation as an alternative for intravenous sedation in ICU mechanically ventilated patients. The indication and management of any side effects should be clearly set and protocolized by each ICU. More randomized controlled trials (RCTs) are still required to investigate whether inhaled sedation should be prioritized over the current practice of intravenous sedation.
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Meiser A, Meis PLF, O’Gara B, Volk T, Kermad A. Increasing the reflection efficiency of the Sedaconda ACD-S by heating and cooling the anaesthetic reflector: a bench study using a test lung. J Clin Monit Comput 2023; 37:919-924. [PMID: 36625981 PMCID: PMC9830614 DOI: 10.1007/s10877-022-00967-2] [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: 04/19/2022] [Accepted: 12/21/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND As volatile anaesthetic gases contribute to global warming, improving the efficiency of their delivery can reduce their environmental impact. This can be achieved by rebreathing from a circle system, but also by anaesthetic reflection with an open intensive care ventilator. We investigated whether the efficiency of such a reflection system could be increased by warming the reflector during inspiration and cooling it during expiration (thermocycling). METHODS The Sedaconda-ACD-S (Sedana Medical, Danderyd, Sweden) was connected between an intensive care ventilator and a test lung. Liquid isoflurane was infused into the device at 0.5, 1.0, 2.0 and 5.0 mL/h; ventilator settings were 500 mL tidal volume, 12 bpm, 21% oxygen. Isoflurane concentrations were measured inside the test lung after equilibration. Thermocycling was achieved by heating the breathing gas in the inspiratory hose to 37 °C via a heated humidifier without water. Breathing gas expired from the test lung was cooled to 14 °C before reaching the ACD-S. In the test lung, body temperature pressure saturated conditions prevailed. Isoflurane concentrations and reflective efficiency were compared between thermocycling and control conditions. RESULTS With thermocycling higher isoflurane concentrations in the test lung were measured for all infusion rates studied. Interpolation of data showed that for achieving 0.4 (0.6) Vol% isoflurane, the infusion rate can be reduced from 1.2 to 0.7 (2.0 to 1.2) mL/h or else to 56% (58%) of control. CONCLUSION Thermocycling of the anaesthetic gas considerably increases the efficiency of the anaesthetic reflector and reduces anaesthetic consumption by almost half in a test lung model. Given that cooling can be miniaturized, this method carries a potential for further saving anaesthetics in clinical practice in the operating theatre as well as for inhaled sedation in the ICU.
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Affiliation(s)
- Andreas Meiser
- grid.411937.9Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, Saarland University Hospital Medical Center, Homburg, Saarland Germany
| | - Pierre Louis Fernando Meis
- grid.411937.9Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, Saarland University Hospital Medical Center, Homburg, Saarland Germany
| | - Brian O’Gara
- grid.239395.70000 0000 9011 8547Department of Anaesthesiology, Beth Israel Deaconess Medical Center, Boston, MA USA
| | - Thomas Volk
- grid.411937.9Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, Saarland University Hospital Medical Center, Homburg, Saarland Germany
| | - Azzeddine Kermad
- grid.411937.9Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, Saarland University Hospital Medical Center, Homburg, Saarland Germany ,Department of Cardiac Anesthesiology and Intensive Care Medicine, German Heart Center Charité, Berlin, Germany
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12
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Blondonnet R, Balde A, Zhai R, Pereira B, Futier E, Bazin JE, Godet T, Constantin JM, Lambert C, Jabaudon M. Use of volatile anesthetics for sedation in the ICU during the COVID-19 pandemic: A national survey in France (VOL'ICU 2 study). PLoS One 2022; 17:e0278090. [PMID: 36580451 PMCID: PMC9799316 DOI: 10.1371/journal.pone.0278090] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 11/09/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The COVID-19 pandemic has increased the number of patients in ICUs leading to a worldwide shortage of the intravenous sedative agents obligating physicians to find alternatives including inhaled sedation. Inhaled sedation in French ICU has been previously explored in 2019 (VOL'ICU study). This survey was designed to explore the use of inhaled sedation two years after our first survey and to evaluate how the COVID-19 pandemic has impacted the use of inhaled sedation. METHODS We designed a national survey, contacting medical directors of French ICUs between June and October 2021. Over a 50-item questionnaire, the survey covered the characteristics of the ICU, data on inhaled sedation, and practical aspects of inhaled ICU sedation for both COVID-19 and non-COVID-19 patients. Answers were compared with the previous survey, VOL'ICU. RESULTS Among the 405 ICUs contacted, 25% of the questionnaires were recorded. Most ICU directors (87%) knew about the use of inhaled ICU sedation and 63% of them have an inhaled sedation's device in their unit. The COVID-19 pandemic increased the use of inhaled sedation in French ICUs. The main reasons said by the respondent were "need for additional sedative" (62%), "shortage of intravenous sedatives" (38%) and "involved in a clinical trial" (30%). The main reasons for not using inhaled ICU sedation were "device not available" (76%), "lack of familiarity" (60%) and "no training for the teams" (58%). More than 70% of respondents were overall satisfied with the use of inhaled sedation. Almost 80% of respondents stated that inhaled sedation was a seducing alternative to intravenous sedation for management of COVID-19 patients. CONCLUSION The use of inhaled sedation in ICU has increased fastly in the last 2 years, and is frequently associated with a good satisfaction among the users. Even if the COVID-19 pandemic could have impacted the widespread use of inhaled sedation, it represents an alternative to intravenous sedation for more and more physicians.
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Affiliation(s)
- Raiko Blondonnet
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
- iGReD, CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France
- * E-mail:
| | - Aissatou Balde
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Ruoyang Zhai
- iGReD, CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Bruno Pereira
- Biostatistics Unit, DRCI, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Emmanuel Futier
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
- iGReD, CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Jean-Etienne Bazin
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Thomas Godet
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Jean-Michel Constantin
- Department of Anesthesiology and Critical Care, Pitié-Salpêtrière Hospital, GRC 29, AP-HP, DMU DREAM, Sorbonne University, Paris, France
| | - Céline Lambert
- Biostatistics Unit, DRCI, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Matthieu Jabaudon
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
- iGReD, CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
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13
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Inhaled Sedation in Patients with COVID-19-Related Acute Respiratory Distress Syndrome: An International Retrospective Study. J Clin Med 2022; 12:jcm12010012. [PMID: 36614813 PMCID: PMC9821008 DOI: 10.3390/jcm12010012] [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: 11/17/2022] [Revised: 12/09/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The coronavirus disease 2019 (COVID-19) pandemic and the shortage of intravenous sedatives has led to renewed interest in inhaled sedation for patients with acute respiratory distress syndrome (ARDS). We hypothesized that inhaled sedation would be associated with improved clinical outcomes in COVID-19 ARDS patients. METHODS Retrospective international study including mechanically ventilated patients with COVID-19 ARDS who required sedation and were admitted to 10 European and US intensive care units. The primary endpoint of ventilator-free days through day 28 was analyzed using zero-inflated negative binomial regression, before and after adjustment for site, clinically relevant covariates determined according to the univariate results, and propensity score matching. RESULTS A total of 196 patients were enrolled, 78 of whom died within 28 days. The number of ventilator-free days through day 28 did not differ significantly between the patients who received inhaled sedation for at least 24 h (n = 111) and those who received intravenous sedation only (n = 85), with medians of 0 (interquartile range [IQR] 0-8) and 0 (IQR 0-17), respectively (odds ratio for having zero ventilator-free days through day 28, 1.63, 95% confidence interval [CI], 0.91-2.92, p = 0.10). The incidence rate ratio for the number of ventilator-free days through day 28 if not 0 was 1.13 (95% CI, 0.84-1.52, p = 0.40). Similar results were found after multivariable adjustment and propensity matching. CONCLUSION The use of inhaled sedation in COVID-19 ARDS was not associated with the number of ventilator-free days through day 28.
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14
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Li WK, Chen XJC, Altshuler D, Islam S, Spiegler P, Emerson L, Bender M. The incidence of propofol infusion syndrome in critically-ill patients. J Crit Care 2022; 71:154098. [PMID: 35724444 DOI: 10.1016/j.jcrc.2022.154098] [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: 03/15/2022] [Revised: 05/25/2022] [Accepted: 06/01/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE PRIS is a potentially fatal syndrome characterized by various clinical symptoms and abnormalities. Experts suggest that propofol treatment duration ≥48 h or dose ≥83 μg/kg/min is associated with developing PRIS. We hypothesized PRIS might be underdiagnosed due to the overlap of PRIS clinical manifestations with critical illnesses. MATERIALS AND METHODS Multihospital, retrospective study of adult patients who received continuous propofol infusion ≥48 h or dose ≥60μg/kg/min for >24 h since admission were assessed for the development of PRIS. RESULTS The incidence of PRIS was 2.9% with a PRIS-associated mortality rate of 36.8%. In PRIS patients, propofol was administered at a median dose of 36.4 μg/kg/min and over a median duration of 147.0 h. The development of PRIS was observed at a median of 125.0 h post-propofol initiation and a cumulative dose of 276.5 mg/kg. The development of metabolic acidosis (78.9%), cardiac dysfunction (52.6%), hypertriglyceridemia (100%), and rhabdomyolysis (26.3%) were observed in our PRIS patients. CONCLUSION PRIS can often be overlooked and underdiagnosed. It is important to monitor for early signs of PRIS in patients who are on prolonged propofol infusion. Prompt recognition and interventions can minimize the dangers resulting from PRIS.
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Affiliation(s)
- Wai Kin Li
- New York University Langone Hospital - Long Island, NY, USA.
| | | | - Diana Altshuler
- New York University Langone Hospital - Long Island, NY, USA; New York University Langone Health, NY, USA
| | - Shahidul Islam
- New York University Langone Hospital - Long Island, NY, USA
| | - Peter Spiegler
- New York University Langone Hospital - Long Island, NY, USA
| | - Liane Emerson
- New York University Langone Hospital - Long Island, NY, USA
| | - Michael Bender
- New York University Langone Hospital - Long Island, NY, USA
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15
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Müller-Wirtz LM, Grimm D, Albrecht FW, Fink T, Volk T, Meiser A. Increased Respiratory Drive after Prolonged Isoflurane Sedation: A Retrospective Cohort Study. J Clin Med 2022; 11:jcm11185422. [PMID: 36143068 PMCID: PMC9504554 DOI: 10.3390/jcm11185422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 09/11/2022] [Accepted: 09/12/2022] [Indexed: 11/16/2022] Open
Abstract
Low-dose isoflurane stimulates spontaneous breathing. We, therefore, tested the hypothesis that isoflurane compared to propofol sedation for at least 48 h is associated with increased respiratory drive in intensive care patients after sedation stop. All patients in our intensive care unit receiving at least 48 h of isoflurane or propofol sedation in 2019 were included. The primary outcome was increased respiratory drive over 72 h after sedation stop, defined as an arterial carbon dioxide pressure below 35 mmHg and a base excess more than −2 mmol/L. Secondary outcomes were acid–base balance and ventilatory parameters. We analyzed 64 patients, 23 patients sedated with isoflurane and 41 patients sedated with propofol. Patients sedated with isoflurane were about three times as likely to show increased respiratory drive after sedation stop than those sedated with propofol: adjusted risk ratio [95% confidence interval]: 2.9 [1.3, 6.5], p = 0.010. After sedation stop, tidal volumes were significantly greater and arterial carbon dioxide partial pressures were significantly lower, while respiratory rates did not differ in isoflurane versus propofol-sedated patients. In conclusion, prolonged isoflurane use in intensive care patients is associated with increased respiratory drive after sedation stop. Beneficial effects of isoflurane sedation on respiratory drive may, thus, extend beyond the actual period of sedation.
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Affiliation(s)
- Lukas Martin Müller-Wirtz
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine, 66424 Homburg, Germany
- Outcomes Research Consortium, Cleveland, OH 44195, USA
- Correspondence: (L.M.M.-W.); (A.M.)
| | - Dustin Grimm
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine, 66424 Homburg, Germany
| | - Frederic Walter Albrecht
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine, 66424 Homburg, Germany
| | - Tobias Fink
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine, 66424 Homburg, Germany
- Outcomes Research Consortium, Cleveland, OH 44195, USA
| | - Thomas Volk
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine, 66424 Homburg, Germany
- Outcomes Research Consortium, Cleveland, OH 44195, USA
| | - Andreas Meiser
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine, 66424 Homburg, Germany
- Correspondence: (L.M.M.-W.); (A.M.)
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16
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Peng L, Liu S, Xu J, Xie W, Fang X, Xia T, Gu X. Metformin alleviates prolonged isoflurane inhalation induced cognitive decline via reducing neuroinflammation in adult mice. Int Immunopharmacol 2022; 109:108903. [PMID: 35709590 PMCID: PMC9190296 DOI: 10.1016/j.intimp.2022.108903] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 05/15/2022] [Accepted: 05/24/2022] [Indexed: 12/12/2022]
Abstract
With the widespread use of volatile anesthetic agents in the prolonged sedation for COVID-19 pneumonia and ARDS, there is an urgent need to investigate the effects and treatments of lengthy low-concentration inhaled anesthetics exposure on cognitive function in adults. Previous studies showed that general anesthetics dose- and exposure length-dependently induced neuroinflammatory response and cognitive decline in neonatal and aging animals. The anti-diabetes drug metformin has anti-neuroinflammation effects by modulating microglial polarization and inhibiting astrocyte activation. In this study, we demonstrated that the inhalation of 1.3% isoflurane (a sub-minimal alveolar concentration, sub-MAC) for 6 h impaired recognition of novel objects from Day 1 to Day3 in adult mice. Prolonged sub-MAC isoflurane exposure also triggered typically reactive microglia and A1-like astrocytes in the hippocampus of adult mice on Day 3 after anesthesia. In addition, prolonged isoflurane inhalation switched microglia into a proinflammatory M1 phenotype characterized by elevated CD68 and iNOS as well as decreased arginase-1 and IL-10. Metformin pretreatment before anesthesia enhanced cognitive performance in the novel object test. The positive cellular modifications promoted by metformin pretreatment included the inhibition of reactive microglia and A1-like astrocytes and the polarization of microglia into M2 phenotype in the hippocampus of adult mice. In conclusion, prolonged sub-MAC isoflurane exposure triggered significant hippocampal neuroinflammation and cognitive decline in adult mice which can be alleviated by metformin pretreatment via inhibiting reactive microglia and A1-like astrocytes and promoting microglia polarization toward anti-inflammatory phenotype in the hippocampus.
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Affiliation(s)
- Liangyu Peng
- Department of Anesthesiology, Affiliated Drum Tower Hospital of Medical Department of Nanjing University, Nanjing 210008, Jiangsu, China.
| | - Shuai Liu
- Department of Anesthesiology, Affiliated Drum Tower Hospital of Medical Department of Nanjing University, Nanjing 210008, Jiangsu, China.
| | - Jiyan Xu
- Department of Anesthesiology, Affiliated Drum Tower Hospital of Medical Department of Nanjing University, Nanjing 210008, Jiangsu, China.
| | - Wenjia Xie
- Department of Anesthesiology, Affiliated Drum Tower Hospital of Medical Department of Nanjing University, Nanjing 210008, Jiangsu, China.
| | - Xin Fang
- Department of Anesthesiology, Affiliated Drum Tower Hospital of Medical Department of Nanjing University, Nanjing 210008, Jiangsu, China
| | - Tianjiao Xia
- Medical School of Nanjing University, Nanjing 210093, Jiangsu, China; Jiangsu Key Laboratory of Molecular Medicine, Nanjing University, Nanjing 210093, Jiangsu, China.
| | - Xiaoping Gu
- Department of Anesthesiology, Affiliated Drum Tower Hospital of Medical Department of Nanjing University, Nanjing 210008, Jiangsu, China.
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Landoni G, Belloni O, Russo G, Bonaccorso A, Carà G, Jabaudon M. Inhaled Sedation for Invasively Ventilated COVID-19 Patients: A Systematic Review. J Clin Med 2022; 11:jcm11092500. [PMID: 35566625 PMCID: PMC9105857 DOI: 10.3390/jcm11092500] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 04/20/2022] [Accepted: 04/26/2022] [Indexed: 01/22/2023] Open
Abstract
Background: Volatile anesthetics were used as sedative agents in COVID-19 (Coronavirus Disease 2019) invasively ventilated patients for their potentially beneficial pharmacological effects and due to the temporary shortages of intravenous agents during the pandemic crisis. Methods: Online databases (PubMed, EMBASE, The Cochrane Central Register of Controlled Trial) and the “clinicaltrials.gov” website were searched for studies reporting the use of isoflurane, sevoflurane or desflurane. Results: We identified three manuscripts describing the beneficial effects of isoflurane on 41 COVID-19 patients with acute respiratory distress syndrome (ARDS) in Germany (n = 2) and in the USA (n = 1), in terms of reduction in the use of opioids and other sedatives. We also found a case report of two patients with transient nephrogenic diabetes insipidus, which started after 6 and 8 days of sevoflurane sedation. We identified two randomized controlled trials (RCTs; 92 patients overall), two observational studies (238 patients) on the use of volatile anesthetics in COVID-19 patients that were completed but not yet published, and one RCT interrupted for a low recruitment ratio (19 patients) and thus not published. We also identified five ongoing RCTs on the use of inhaled sedation in ARDS, which are also likely to be recruiting COVID-19 patients and which have currently enrolled a total of >1643 patients. Conclusion: Isoflurane was the most frequently used volatile agent in COVID-19 patients and allowed a reduction in the use of other sedative and analgesic drugs. Randomized evidence is building up and will be useful to confirm or challenge these findings.
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Affiliation(s)
- Giovanni Landoni
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (O.B.); (G.R.); (A.B.); (G.C.)
- School of Medicine, Vita-Salute San Raffaele University, 20132 Milan, Italy
- Correspondence:
| | - Olivia Belloni
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (O.B.); (G.R.); (A.B.); (G.C.)
| | - Giada Russo
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (O.B.); (G.R.); (A.B.); (G.C.)
| | - Alessandra Bonaccorso
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (O.B.); (G.R.); (A.B.); (G.C.)
| | - Gianmarco Carà
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (O.B.); (G.R.); (A.B.); (G.C.)
| | - Matthieu Jabaudon
- Department of Perioperative Medicine, CHU Clermont-Ferrand, F-63000 Clermont-Ferrand, France;
- GReD, Université Clermont Auvergne, CNRS, INSERM, F-63000 Clermont-Ferrand, France
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18
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Meiser A, Volk T, Wallenborn J, Guenther U, Becher T, Bracht H, Schwarzkopf K, Knafelj R, Faltlhauser A, Thal SC, Soukup J, Kellner P, Drüner M, Vogelsang H, Bellgardt M, Sackey P. Inhaled isoflurane via the anaesthetic conserving device versus propofol for sedation of invasively ventilated patients in intensive care units in Germany and Slovenia: an open-label, phase 3, randomised controlled, non-inferiority trial. THE LANCET RESPIRATORY MEDICINE 2021; 9:1231-1240. [PMID: 34454654 DOI: 10.1016/s2213-2600(21)00323-4] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 06/27/2021] [Accepted: 06/29/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Previous studies indicate that isoflurane could be useful for the sedation of patients in the intensive care unit (ICU), but prospective studies evaluating isoflurane's efficacy have been small. The aim of this study was to test whether the sedation with isoflurane was non-inferior to sedation with propofol. METHODS This phase 3, randomised, controlled, open-label non-inferiority trial evaluated the efficacy and safety of up to 54 h of isoflurane compared with propofol in adults (aged ≥18 years) who were invasively ventilated in ICUs in Germany (21 sites) and Slovenia (three sites). Patients were randomly assigned (1:1) to isoflurane inhalation via the Sedaconda anaesthetic conserving device (ACD; Sedana Medical AB, Danderyd, Sweden; ACD-L [dead space 100 mL] or ACD-S [dead space 50 mL]) or intravenous propofol infusion (20 mg/mL) for 48 h (range 42-54) using permuted block randomisation with a centralised electronic randomisation system. The primary endpoint was percentage of time in Richmond Agitation-Sedation Scale (RASS) range -1 to -4, assessed in eligible participants with at least 12 h sedation (the per-protocol population), five or more RASS measurements, and no major protocol violations, with a non-inferiority margin of 15%. Key secondary endpoints were opioid requirements, spontaneous breathing, time to wake-up and extubation, and adverse events. Safety was assessed in all patients who received at least one dose. The trial is complete and registered with EudraCT, 2016-004551-67. FINDINGS Between July 2, 2017, and Jan 12, 2020, 338 patients were enrolled and 301 (89%) were randomly assigned to isoflurane (n=150) or propofol (n=151). 146 patients (97%) in each group completed the 24-h follow-up. 146 (97%) patients in the isoflurane group and 148 (98%) of patients in the propofol group were included in the per-protocol analysis of the primary endpoint. Least-squares mean percentage of time in RASS target range was 90·7% (95% CI 86·8-94·6) for isoflurane and 91·1% (87·2-95·1) for propofol. With isoflurane sedation, opioid dose intensity was 29% lower than with propofol for the overall sedation period (0·22 [0·12-0·34] vs 0·32 [0·21-0·42] mg/kg per h morphine equivalent dose, p=0·0036) and spontaneous breathing was more frequent on day 1 (odds ratio [OR] 1·72 [1·12-2·64], generalised mixed linear model p=0·013, with estimated rates of 50% of observations with isoflurane vs 37% with propofol). Extubation times were short and median wake-up was significantly faster after isoflurane on day 2 (20 min [IQR 10-30] vs 30 min [11-120]; Cox regression p=0·0011). The most common adverse events by treatment group (isoflurane vs propofol) were: hypertension (ten [7%] of 150 vs two [1%] of 151), delirium (eight [5%] vs seven [5%]), oliguria (seven [5%] vs six [4%]), and atrial fibrillation (five [3%] vs four [3%]). INTERPRETATION These results support the use of isoflurane in invasively ventilated patients who have a clinical need for sedation. FUNDING Sedana Medical AB.
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Affiliation(s)
- Andreas Meiser
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany.
| | - Thomas Volk
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
| | - Jan Wallenborn
- Department of Anesthesiology and Intensive Care Medicine, Helios Klinikum Aue, Aue, Germany
| | - Ulf Guenther
- University Clinic of Anaesthesiology, Intensive Care, Emergency Medicine, Pain Therapy, Klinikum Oldenburg, Oldenburg, Germany
| | - Tobias Becher
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Hendrik Bracht
- Department of Emergency Medicine, and Department of Anesthesiology and Intensive Care, University Hospital Ulm, Ulm, Germany
| | - Konrad Schwarzkopf
- Department of Anesthesia and Intensive Care, Klinikum Saarbrücken, Saarbrücken, Germany
| | - Rihard Knafelj
- University Medical Center Ljubljana, Ljubljana, Slovenia
| | | | - Serge C Thal
- Helios University Hospital Wuppertal, University of Witten-Herdecke, Department of Anesthesiology, Wuppertal, Germany; University Medical Center of the Johannes Gutenberg-University Mainz, Department of Anesthesiology, Mainz, Germany
| | - Jens Soukup
- Department of Anaesthesiology, Intensive Care Medicine and Palliative Care Medicine, Carl-Thiem-Hospital, Cottbus, Germany
| | - Patrick Kellner
- Department of Anesthesiology and Intensive Care, University of Lübeck, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Matthias Drüner
- Department of Anaesthesiology and Intensive Care Medicine, Emden Hospital, Emden, Germany
| | - Heike Vogelsang
- St Josef-Hospital Bochum, Department of Anaesthesiology and Intensive Care Medicine, University Hospital of the Ruhr-University Bochum, Bochum, Germany
| | - Martin Bellgardt
- St Josef-Hospital Bochum, Department of Anaesthesiology and Intensive Care Medicine, University Hospital of the Ruhr-University Bochum, Bochum, Germany
| | - Peter Sackey
- Department of Physiology and Pharmacology, Unit of Anesthesiology and Intensive Care, Karolinska Institutet, Stockholm, Sweden
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Sedation in critically ill patients: will the vaporiser replace the syringe? THE LANCET RESPIRATORY MEDICINE 2021; 9:1205-1207. [PMID: 34454655 DOI: 10.1016/s2213-2600(21)00359-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 07/19/2021] [Indexed: 11/22/2022]
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