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Taylor B, Ellis J, Ponty S, Patrick L, Scott TE, Chockalingam N. Effect of volatile anaesthetic agents on intracranial pressure, cerebrovascular flow and autoregulation: a protocol for a systematic review and meta-analysis. BMJ Open 2024; 14:e086727. [PMID: 39322591 PMCID: PMC11425943 DOI: 10.1136/bmjopen-2024-086727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 08/29/2024] [Indexed: 09/27/2024] Open
Abstract
INTRODUCTION The use of volatile anaesthetic agents for the sedation of patients requiring critical care treatment offers several theoretical advantages over intravenous sedation, which may be of benefit in neurocritical care. However, there are concerns that they may increase intracranial pressure. The objective of this systematic review is to assess whether, and if so, to what extent volatile anaesthetic agents affect intracranial pressure, cerebral blood flow (CBF), cerebral oximetry and cerebrovascular autoregulation. If sufficient data exist, subgroup analyses will be conducted in traumatic brain injury and decompressive craniectomy patients. METHODS AND ANALYSIS A database search of PubMed, Medline (including Medline plus), CINAHL (including CINAHL Plus), Embase databases and the Cochrane Central Controlled Trials Register without time limits will be conducted. The search results will be screened by title and abstract by two independent researchers on a rule-in basis against predetermined criteria-controlled studies in humans of contemporary fluorinated volatile anaesthetic agents against a control, which measures intracranial pressure, CBF, cerebral oximetry or cerebrovascular autoregulation. Articles responsive to screening will then be reviewed in full text by two independent researchers, requiring consensus or a tie-break by a third independent researcher. Reference lists and a non-generative AI tool will be examined for missed articles, with all identified articles being reviewed in full text by two independent researchers. The included articles will be assessed for risk of bias and will have data extracted by two independent researchers. If sufficient data exist, a meta-analysis will be performed; otherwise, a narrative description of outcomes will be performed. ETHICS AND DISSEMINATION No ethics approval will be sought for this systematic review. This study has no explicit funding. The results of this study will be disseminated in a peer-reviewed journal, in a conference presentation and on PROSPERO. TRIAL REGISTRATION NUMBER PROSPERO number CRD42023474587.
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Affiliation(s)
- Ben Taylor
- Staffordshire University Faculty of Health Sciences, Stoke-on-Trent, UK
- Keele University Faculty of Medicine & Health Sciences, Keele, Staffordshire, UK
- Academic Department of Military Anaesthesia and Critical Care, MOD, London, Greater London, UK
- University Hospital of North Midlands, Stoke-on-Trent, UK
| | - Jack Ellis
- University Hospital of North Midlands, Stoke-on-Trent, UK
| | - Sam Ponty
- Keele University Faculty of Medicine & Health Sciences, Keele, Staffordshire, UK
| | - Lewis Patrick
- Keele University Faculty of Medicine & Health Sciences, Keele, Staffordshire, UK
| | - Timothy E Scott
- Staffordshire University Faculty of Health Sciences, Stoke-on-Trent, UK
- Academic Department of Military Anaesthesia and Critical Care, MOD, London, Greater London, UK
- University Hospital of North Midlands, Stoke-on-Trent, UK
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Amer M, Hylander Møller M, Alshahrani M, Shehabi Y, Arabi YM, Alshamsi F, Ingi Sigurðsson M, Rehn M, Chew MS, Kalliomäki ML, Lewis K, Al-Suwaidan FA, Al-Dorzi HM, Al-Fares A, Alsadoon N, Bell CM, Groth CM, Parke R, Mehta S, Wischmeyer PE, Al-Omari A, Olkkola KT, Alhazzani W. Ketamine Analgo-sedation for Mechanically Ventilated Critically Ill Adults: A Rapid Practice Guideline from the Saudi Critical Care Society and the Scandinavian Society of Anesthesiology and Intensive Care Medicine. Anesth Analg 2024:00000539-990000000-00925. [PMID: 39207913 DOI: 10.1213/ane.0000000000007173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
BACKGROUND This Rapid Practice Guideline (RPG) aimed to provide evidence‑based recommendations for ketamine analgo-sedation (monotherapy and adjunct) versus non-ketamine sedatives or usual care in adult intensive care unit (ICU) patients on invasive mechanical ventilation (iMV) and to identify knowledge gaps for future research. METHODS The RPG panel comprised 23 multinational multidisciplinary panelists, including a patient representative. An up-to-date systematic review and meta-analysis constituted the evidence base. The Grading Recommendations, Assessment, Development, and Evaluation approach, and the evidence-to-decision framework were used to assess the certainty of evidence and to move from evidence to decision/recommendation. The panel provided input on the balance of the desirable and undesirable effects, certainty of evidence, patients' values and preferences, costs, resources, equity, feasibility, acceptability, and research priorities. RESULTS Data from 17 randomized clinical trials (n=898) and 9 observational studies (n=1934) were included. There was considerable uncertainty about the desirable and undesirable effects of ketamine monotherapy for analgo-sedation. The evidence was very low certainty and downgraded for risk of bias, indirectness, and inconsistency. Uncertainty or variability in values and preferences were identified. Costs, resources, equity, and acceptability were considered varied. Adjunctive ketamine therapy had no effect on mortality (within 28 days) (relative risk [RR] 0.99; 95% confidence interval [CI] 0.76 to 1.27; low certainty), and may slightly reduce iMV duration (days) (mean difference [MD] -0.05 days; 95% CI -0.07 to -0.03; low certainty), and uncertain effect on the cumulative dose of opioids (mcg/kg/h morphine equivalent) (MD -11.6; 95% CI -20.4 to -2.7; very low certainty). Uncertain desirable effects (cumulative dose of sedatives and vasopressors) and undesirable effects (adverse event rate, delirium, arrhythmia, hepatotoxicity, hypersalivation, use of physical restraints) were also identified. A possibility of important uncertainty or variability in patient-important outcomes led to a balanced effect that favored neither the intervention nor the comparison. Cost, resources, and equity were considered varied. CONCLUSION The RPG panel provided two conditional recommendations and suggested (1) against using ketamine as monotherapy analgo-sedation in critically ill adults on iMV when other analgo-sedatives are available; and (2) using ketamine as an adjunct to non-ketamine usual care sedatives (e.g., opioids, propofol, dexmedetomidine) or continuing with non-ketamine usual care sedatives alone. Large-scale trials should provide additional evidence.
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Affiliation(s)
- Marwa Amer
- Medical/Critical Pharmacy Division, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
- College of Medicine and Pharmacy, Alfaisal University, Riyadh, Saudi Arabia
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Guidelines in Intensive Care Medicine, Development and Evaluation (GUIDE) Group, The Research Institute of St. Joe's, Hamilton, Canada
| | - Mohammed Alshahrani
- Department of Emergency and Critical Care, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Yahya Shehabi
- School of Clinical Sciences, Monash University, Clayton Campus, Victoria
- Clinical School of Medicine, University of New South Wales, Randwick Campus, New South Wales, Australia
| | - Yaseen M Arabi
- Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Alain, United Arab Emirates
| | - Martin Ingi Sigurðsson
- Faculty of Medicine, University of Iceland, Iceland
- Division of Anaesthesia and Intensive Care Medicine, Landspitali-The National University Hospital of Iceland, Iceland
| | - Marius Rehn
- Division of Prehospital Services, Air Ambulance Department, Oslo University Hospital, Oslo, Norway
- The Norwegian Air Ambulance Foundation, Oslo, Norway
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Michelle S Chew
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | | | - Kimberley Lewis
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Faisal A Al-Suwaidan
- Division of Neurology, Department of Medicine, Security Forces Hospital, Riyadh, Saudi Arabia
- Neurology Clinical Lead, Ministry of Health, Saudi Arabia
- College of Medicine, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
- College of Medicine, Dar Al-Uloom University, Riyadh, Saudi Arabia
| | - Hasan M Al-Dorzi
- Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Abdulrahman Al-Fares
- Department of Anesthesia, Critical Care Medicine and Pain Medicine, Al-Amiri Hospital, Minister of Health, Kuwait City, Kuwait
- Kuwait Extracorporeal Life Support Program, Al-Amiri Center for Advance Respiratory and Cardiac Failure, Ministry of Health, Kuwait City, Kuwait
| | - Naif Alsadoon
- Alshaya International Trading Company, Riyadh, Saudi Arabia
| | - Carolyn M Bell
- Medical University of South Carolina Hospital Authority, Charleston, SC
- Medical University of South Carolina College of Pharmacy, Charleston, SC
| | | | - Rachael Parke
- School of Nursing University of Auckland, New Zealand
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
| | - Sangeeta Mehta
- Dept. of Medicine, Mount Sinai Hospital; Interdepartmental Division of Intensive Care Medicine, Toronto, Canada
| | - Paul E Wischmeyer
- Deptartments of Anesthesiology and Surgery, Duke University School of Medicine, Durham, NC
| | - Awad Al-Omari
- Dr Sulaiman Al-Habib Medical Group, Critical Care Department, Riyadh, Saudi Arabia
| | - Klaus T Olkkola
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Waleed Alhazzani
- Guidelines in Intensive Care Medicine, Development and Evaluation (GUIDE) Group, The Research Institute of St. Joe's, Hamilton, Canada
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
- Department of Critical Care, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Scientific Research Center, Directorate General of Armed Forces Medical Services, Riyadh, Saudi Arabia
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Amer M, Møller MH, Alshahrani M, Shehabi Y, Arabi YM, Alshamsi F, Sigurðsson MI, Rehn M, Chew MS, Kalliomäki ML, Lewis K, Al-Suwaidan FA, Al-Dorzi HM, Al-Fares A, Alsadoon N, Bell CM, Groth CM, Parke R, Mehta S, Wischmeyer PE, Omeri A, Olkkola KT, Alhazzani W. Ketamine analgo-sedation for mechanically ventilated critically ill adults: A rapid practice guideline from the Saudi Critical Care Society and the Scandinavian Society of Anesthesiology and Intensive Care Medicine. Acta Anaesthesiol Scand 2024. [PMID: 39198198 DOI: 10.1111/aas.14470] [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: 03/18/2024] [Revised: 05/16/2024] [Accepted: 05/29/2024] [Indexed: 09/01/2024]
Abstract
BACKGROUND This Rapid Practice Guideline (RPG) aimed to provide evidence-based recommendations for ketamine analgo-sedation (monotherapy and adjunct) versus non-ketamine sedatives or usual care in adult intensive care unit (ICU) patients on invasive mechanical ventilation (iMV) and to identify knowledge gaps for future research. METHODS The RPG panel comprised 23 multinational multidisciplinary panelists, including a patient representative. An up-to-date systematic review and meta-analysis constituted the evidence base. The Grading Recommendations, Assessment, Development, and Evaluation approach, and the evidence-to-decision framework were used to assess the certainty of evidence and to move from evidence to decision/recommendation. The panel provided input on the balance of the desirable and undesirable effects, certainty of evidence, patients' values and preferences, costs, resources, equity, feasibility, acceptability, and research priorities. RESULTS Data from 17 randomized clinical trials (n = 898) and nine observational studies (n = 1934) were included. There was considerable uncertainty about the desirable and undesirable effects of ketamine monotherapy for analgo-sedation. The evidence was very low certainty and downgraded for risk of bias, indirectness, and inconsistency. Uncertainty or variability in values and preferences were identified. Costs, resources, equity, and acceptability were considered varied. Adjunctive ketamine therapy had no effect on mortality (within 28 days) (relative risk [RR] 0.99; 95% confidence interval [CI] 0.76 to 1.27; low certainty), and may slightly reduce iMV duration (days) (mean difference [MD] -0.05 days; 95% CI -0.07 to -0.03; low certainty), and uncertain effect on the cumulative dose of opioids (mcg/kg/h morphine equivalent) (MD -11.6; 95% CI -20.4 to -2.7; very low certainty). Uncertain desirable effects (cumulative dose of sedatives and vasopressors) and undesirable effects (adverse event rate, delirium, arrhythmia, hepatotoxicity, hypersalivation, use of physical restraints) were also identified. A possibility of important uncertainty or variability in patient-important outcomes led to a balanced effect that favored neither the intervention nor the comparison. Cost, resources, and equity were considered varied. CONCLUSION The RPG panel provided two conditional recommendations and suggested (1) against using ketamine as monotherapy analgo-sedation in critically ill adults on iMV when other analgo-sedatives are available; and (2) using ketamine as an adjunct to non-ketamine usual care sedatives (e.g., opioids, propofol, dexmedetomidine) or continuing with non-ketamine usual care sedatives alone. Large-scale trials should provide additional evidence.
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Affiliation(s)
- Marwa Amer
- Medical/Critical Pharmacy Division, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
- College of Medicine and Pharmacy, Alfaisal University, Riyadh, Saudi Arabia
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Guidelines in Intensive Care Medicine, Development and Evaluation (GUIDE) Group, The Research Institute of St. Joe's, Hamilton, Canada
| | - Mohammed Alshahrani
- Department of Emergency and Critical Care, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Yahya Shehabi
- School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
- Clinical School of Medicine, University of New South Wales, Randwick Campus, New South Wales, Australia
| | - Yaseen M Arabi
- Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Alain, United Arab Emirates
| | - Martin Ingi Sigurðsson
- Faculty of Medicine, University of Iceland, Reykjavík, Iceland
- Division of Anaesthesia and Intensive Care Medicine, Landspitali-The National University Hospital of Iceland, Reykjavík, Iceland
| | - Marius Rehn
- Division of Prehospital Services, Air Ambulance Department, Oslo University Hospital, Oslo, Norway
- The Norwegian Air Ambulance Foundation, Oslo, Norway
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Michelle S Chew
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | | | - Kimberley Lewis
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Faisal A Al-Suwaidan
- Division of Neurology, Department of Medicine, Security Forces Hospital, Riyadh, Saudi Arabia
- Neurology Clinical Lead, Ministry of Health, Riyadh, Saudi Arabia
- College of Medicine, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
- College of Medicine, Dar Al-Uloom University, Riyadh, Saudi Arabia
| | - Hasan M Al-Dorzi
- Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Abdulrahman Al-Fares
- Department of Anesthesia, Critical Care Medicine and Pain Medicine, Al-Amiri Hospital, Minister of Health, Kuwait City, Kuwait
- Kuwait Extracorporeal Life Support Program, Al-Amiri Center for Advance Respiratory and Cardiac Failure, Ministry of Health, Kuwait City, Kuwait
| | - Naif Alsadoon
- Alshaya International Trading Company, Riyadh, Saudi Arabia
| | - Carolyn M Bell
- Medical University of South Carolina Hospital Authority, Charleston, South Carolina, USA
- Medical University of South Carolina College of Pharmacy, Charleston, South Carolina, USA
| | | | - Rachael Parke
- School of Nursing University of Auckland, Auckland, New Zealand
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
| | - Sangeeta Mehta
- Department of Medicine, Mount Sinai Hospital; Interdepartmental Division of Intensive Care Medicine, Toronto, Canada
| | - Paul E Wischmeyer
- Deptartments of Anesthesiology and Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Awad Omeri
- Critical Care Department, Dr Sulaiman Al-Habib Medical Group, Riyadh, Saudi Arabia
| | - Klaus T Olkkola
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Waleed Alhazzani
- Guidelines in Intensive Care Medicine, Development and Evaluation (GUIDE) Group, The Research Institute of St. Joe's, Hamilton, Canada
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
- Department of Critical Care, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Scientific Research Center, Directorate General of Armed Forces Medical Services, Riyadh, Saudi Arabia
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Andreasen TH, Madsen FA, Barbateskovic M, Lindschou J, Gluud C, Møller K. Ketamine for Critically Ill Patients with Severe Acute Brain Injury: A Systematic Review with Meta-analysis and Trial Sequential Analysis of Randomized Clinical Trials. Neurocrit Care 2024:10.1007/s12028-024-02075-2. [PMID: 39085508 DOI: 10.1007/s12028-024-02075-2] [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: 02/23/2024] [Accepted: 07/09/2024] [Indexed: 08/02/2024]
Abstract
BACKGROUND Patients with severe acute brain injury have a high risk of a poor clinical outcome due to primary and secondary brain injury. Ketamine reportedly inhibits cortical spreading depolarization, an electrophysiological phenomenon that has been associated with secondary brain injury, making ketamine potentially attractive for patients with severe acute brain injury. The aim of this systematic review is to explore the current literature regarding ketamine for patients with severe acute brain injury. METHODS We systematically searched international databases for randomized clinical trials comparing ketamine by any regimen versus placebo, no intervention, or any control drug for patients with severe acute brain injury. Two authors independently reviewed and selected trials for inclusion, extracted data, assessed risk of bias, and performed analysis using Review Manager and Trial Sequential Analysis. Evidence certainty was assessed using Grading of Recommendations Assessment, Development and Evaluation. The primary outcomes were the proportion of participants with an unfavorable functional outcome, the proportion of participants with one or more serious adverse events, and quality of life. RESULTS We identified five randomized trials comparing ketamine versus sufentanil, fentanyl, other sedatives, or saline (total N = 149 participants). All outcomes were at overall high risk of bias. The proportions of participants with one or more serious adverse events did not differ between ketamine and sufentanil or fentanyl (relative risk 1.45, 95% confidence interval 0.81-2.58; very low certainty). Trial sequential analysis showed that further trials are needed. CONCLUSIONS The level of evidence regarding the effects of ketamine on functional outcome and serious adverse events in patients with severe acute brain injury is very low. Ketamine may markedly, modestly, or not at all affect these outcomes. Large randomized clinical trials at low risk of bias are needed.
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Affiliation(s)
- Trine Hjorslev Andreasen
- Department of Neurosurgery, Neuroscience Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.
| | - Frederik Andreas Madsen
- Department of Neuroanaesthesiology, Neuroscience Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Marija Barbateskovic
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Jane Lindschou
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Kirsten Møller
- Department of Neuroanaesthesiology, Neuroscience Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, The Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Haberl H, Unterberg M, Adamzik M, Hagedorn A, Wolf A. [Current Aspects of Intensive Medical Care for Traumatic Brain Injury - Part 1 - Primary Treatment Strategies, Haemodynamic Management and Multimodal Monitoring]. Anasthesiol Intensivmed Notfallmed Schmerzther 2024; 59:450-465. [PMID: 39074790 DOI: 10.1055/a-2075-9351] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2024]
Abstract
This two-part article deals with the intensive medical care of traumatic brain injury. Part 1 addresses the primary treatment strategy, haemodynamic management and multimodal monitoring, Part 2 secondary treatment strategies, long-term outcome, neuroprognostics and chronification. Traumatic brain injury is a complex clinical entity with a high mortality rate. The primary aim is to maintain homeostasis based on physiological targeted values. In addition, further therapy must be geared towards intracranial pressure. In addition to this, there are other monitoring options that appear sensible from a pathophysiological point of view with appropriate therapy adjustment. However, there is still a lack of data on their effectiveness. A further aspect is the inflammation of the cerebrum with the "cross-talk" of the organs, which has a significant influence on further intensive medical care.
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Kornilov E, Baker Erdman H, Kahana E, Fireman S, Zarchi O, Israelashvili M, Reiner J, Glik A, Weiss P, Paz R, Bergman H, Tamir I. Interleaved Propofol-Ketamine Maintains DBS Physiology and Hemodynamic Stability: A Double-Blind Randomized Controlled Trial. Mov Disord 2024; 39:694-705. [PMID: 38396358 DOI: 10.1002/mds.29746] [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: 10/10/2023] [Revised: 12/18/2023] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND The gold standard anesthesia for deep brain stimulation (DBS) surgery is the "awake" approach, using local anesthesia alone. Although it offers high-quality microelectrode recordings and therapeutic-window assessment, it potentially causes patients extreme stress and might result in suboptimal surgical outcomes. General anesthesia or deep sedation is an alternative, but may reduce physiological testing reliability and lead localization accuracy. OBJECTIVES The aim is to investigate a novel anesthesia regimen of ketamine-induced conscious sedation for the physiological testing phase of DBS surgery. METHODS Parkinson's patients undergoing subthalamic DBS surgery were randomly divided into experimental and control groups. During physiological testing, the groups received 0.25 mg/kg/h ketamine infusion and normal saline, respectively. Both groups had moderate propofol sedation before and after physiological testing. The primary outcome was recording quality. Secondary outcomes included hemodynamic stability, lead accuracy, motor and cognitive outcome, patient satisfaction, and adverse events. RESULTS Thirty patients, 15 from each group, were included. Intraoperatively, the electrophysiological signature and lead localization were similar under ketamine and saline. Tremor amplitude was slightly lower under ketamine. Postoperatively, patients in the ketamine group reported significantly higher satisfaction with anesthesia. The improvement in Unified Parkinson's disease rating scale part-III was similar between the groups. No negative effects of ketamine on hemodynamic stability or cognition were reported perioperatively. CONCLUSIONS Ketamine-induced conscious sedation provided high quality microelectrode recordings comparable with awake conditions. Additionally, it seems to allow superior patient satisfaction and hemodynamic stability, while maintaining similar post-operative outcomes. Therefore, it holds promise as a novel alternative anesthetic regimen for DBS. © 2024 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Evgeniya Kornilov
- Department of Anesthesiology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
- Department of Neurobiology, Weizmann Institute of Science, Rehovot, Israel
| | - Halen Baker Erdman
- Department of Medical Neurobiology, Hebrew University, Jerusalem, Israel
| | - Eilat Kahana
- Department of Anesthesiology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
| | - Shlomo Fireman
- Department of Anesthesiology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
| | - Omer Zarchi
- Intraoperative Neurophysiology Unit, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
| | | | - Johnathan Reiner
- Department of Neurology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
| | - Amir Glik
- Department of Neurology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
- Cognitive Neurology Clinic, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Penina Weiss
- Occupational Therapy Department, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
| | - Rony Paz
- Department of Neurobiology, Weizmann Institute of Science, Rehovot, Israel
| | - Hagai Bergman
- Department of Medical Neurobiology, Hebrew University, Jerusalem, Israel
- Department of Neurosurgery, Hadassah Medical Center, Hebrew University, Jerusalem, Israel
- The Edmond and Lily Safra Center for Brain Sciences, Hebrew University, Jerusalem, Israel
| | - Idit Tamir
- Department of Neurosurgery, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
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Mansvelder FJ, Bossers SM, Loer SA, Bloemers FW, Van Lieshout EMM, Den Hartog D, Hoogerwerf N, van der Naalt J, Absalom AR, Peerdeman SM, Bulte CSE, Schwarte LA, Schober P. Etomidate versus Ketamine as Prehospital Induction Agent in Patients with Suspected Severe Traumatic Brain Injury. Anesthesiology 2024; 140:742-751. [PMID: 38190220 DOI: 10.1097/aln.0000000000004894] [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: 01/09/2024]
Abstract
BACKGROUND Severe traumatic brain injury is a leading cause of morbidity and mortality among young people around the world. Prehospital care focuses on the prevention and treatment of secondary brain injury and commonly includes tracheal intubation after induction of general anesthesia. The choice of induction agent in this setting is controversial. This study therefore investigated the association between the chosen induction medication etomidate versus S(+)-ketamine and the 30-day mortality in patients with severe traumatic brain injury who received prehospital airway management in the Netherlands. METHODS This study is a retrospective analysis of the prospectively collected observational data of the Brain Injury: Prehospital Registry of Outcomes, Treatments and Epidemiology of Cerebral Trauma (BRAIN-PROTECT) cohort study. Patients with suspected severe traumatic brain injury who were transported to a participating trauma center and who received etomidate or S(+)-ketamine for prehospital induction of anesthesia for advanced airway management were included. Statistical analyses were performed with multivariable logistic regression and inverse probability of treatment weighting analysis. RESULTS In total, 1,457 patients were eligible for analysis. No significant association between the administered induction medication and 30-day mortality was observed in unadjusted analyses (32.9% mortality for etomidate versus 33.8% mortality for S(+)-ketamine; P = 0.716; odds ratio, 1.04; 95% CI, 0.83 to 1.32; P = 0.711), as well as after adjustment for potential confounders (odds ratio, 1.08; 95% CI, 0.67 to 1.73; P = 0.765; and risk difference 0.017; 95% CI, -0.051 to 0.084; P = 0.686). Likewise, in planned subgroup analyses for patients with confirmed traumatic brain injury and patients with isolated traumatic brain injury, no significant differences were found. Consistent results were found after multiple imputations of missing data. CONCLUSIONS The analysis found no evidence for an association between the use of etomidate or S(+)-ketamine as an anesthetic agent for intubation in patients with traumatic brain injury and mortality after 30 days in the prehospital setting, suggesting that the choice of induction agent may not influence the patient mortality rate in this population. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Floor J Mansvelder
- Department of Anesthesiology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Sebastiaan M Bossers
- Department of Anesthesiology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Stephan A Loer
- Department of Anesthesiology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Frank W Bloemers
- Department of Surgery, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Esther M M Van Lieshout
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Dennis Den Hartog
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Nico Hoogerwerf
- Department of Anesthesiology, Radboud University Medical Center, Nijmegen, The Netherlands; and Helicopter Emergency Medical Service Lifeliner 3, Volkel, The Netherlands
| | - Joukje van der Naalt
- Department of Neurology, University Medical Center Groningen, Groningen, The Netherlands
| | - Anthony R Absalom
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Saskia M Peerdeman
- Department of Neurosurgery, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, The Netherlands
| | - Carolien S E Bulte
- Department of Anesthesiology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; and Helicopter Emergency Medical Service Lifeliner 1, Amsterdam, The Netherlands
| | - Lothar A Schwarte
- Department of Anesthesiology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; and Helicopter Emergency Medical Service Lifeliner 1, Amsterdam, The Netherlands
| | - Patrick Schober
- Department of Anesthesiology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; Helicopter Emergency Medical Service Lifeliner 1, Amsterdam, The Netherlands; and Department of Neurosurgery, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, The Netherlands
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8
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Faísco A, Dinis R, Seixas T, Lopes L. Ketamine in Chronic Pain: A Review. Cureus 2024; 16:e53365. [PMID: 38435232 PMCID: PMC10908414 DOI: 10.7759/cureus.53365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2024] [Indexed: 03/05/2024] Open
Abstract
Ketamine has been used in the treatment of several pain syndromes, particularly those with a relevant neuropathic component. Sub-anesthetic doses of ketamine produce a potent analgesic effect, due to its inhibition of N-methyl-D-aspartate receptors and enhancement of descending inhibitory pathways. Its short-term analgesic effect is well-documented perioperatively, with an associated reduction in postoperative chronic pain and opioid consumption. Despite some evidence regarding its long-term benefits, the number of clinical studies is still limited. In addition to its analgesic effects, ketamine also possesses an anti-depressive action, which might be useful in the treatment of chronic pain patients. Several side effects have been described, the psychomimetic ones being the most relevant due to their impact on treatment adhesion. At present, co-administration of ketamine and benzodiazepines or α2-agonists facilitates its clinical application. Despite current evidence and increasing use, further investigation is still needed regarding its long-term safety profile and clearer risk-benefit analysis.
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Affiliation(s)
- Ana Faísco
- Department of Anaesthesiology, Hospital Professor Doutor Fernando Fonseca, Amadora, PRT
| | - Rita Dinis
- Department of Anaesthesiology, Hospital Professor Doutor Fernando Fonseca, Amadora, PRT
| | - Tânia Seixas
- Department of Anaesthesiology, Hospital Professor Doutor Fernando Fonseca, Amadora, PRT
| | - Luís Lopes
- Department of Anaesthesiology, Hospital Professor Doutor Fernando Fonseca, Amadora, PRT
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9
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Abdildin Y, Tapinova K, Nemerenova A, Viderman D. The impact of ketamine on outcomes in critically ill patients: a systematic review with meta-analysis and trial sequential analysis of randomized controlled trials. Acute Crit Care 2024; 39:34-46. [PMID: 38476062 PMCID: PMC11002615 DOI: 10.4266/acc.2023.00829] [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: 06/22/2023] [Revised: 12/25/2023] [Accepted: 01/03/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND This meta-analysis aims to evaluate the effects of ketamine in critically ill intensive care unit (ICU) patients. METHODS We searched for randomized controlled trials (RCTs) in PubMed, Scopus, and the Cochrane Library; the search was performed initially in January but was repeated in December of 2023. We focused on ICU patients of any age. We included studies that compared ketamine with other traditional agents used in the ICU. We synthesized evidence using RevMan v5.4 and presented the results as forest plots. We also used trial sequential analysis (TSA) software v. 0.9.5.10 Beta and presented results as TSA plots. For synthesizing results, we used a random-effects model and reported differences in outcomes of two groups in terms of mean difference (MD), standardized MD, and risk ratio with 95% confidence interval. We assessed the risk of bias using the Cochrane RoB tool for RCTs. Our outcomes were mortality, pain, opioid and midazolam requirements, delirium rates, and ICU length of stay. RESULTS Twelve RCTs involving 805 ICU patients (ketamine group, n=398; control group, n=407) were included in the meta-analysis. The ketamine group was not superior to the control group in terms of mortality (in five studies with 318 patients), pain (two studies with 129 patients), mean and cumulative opioid consumption (six studies with 494 patients), midazolam consumption (six studies with 304 patients), and ICU length of stay (three studies with 270 patients). However, the model favored the ketamine group over the control group in delirium rate (four studies with 358 patients). This result is significant in terms of conventional boundaries (alpha=5%) but is not robust in sequential analysis. The applicability of the findings is limited by the small number of patients pooled for each outcome. CONCLUSIONS Our meta-analysis did not demonstrate differences between ketamine and control groups regarding any outcome except delirium rate, where the model favored the ketamine group over the control group. However, this result is not robust as sensitivity analysis and trial sequential analysis suggest that more RCTs should be conducted in the future.
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Affiliation(s)
- Yerkin Abdildin
- Department of Mechanical and Aerospace Engineering, School of Engineering and Digital Sciences, Nazarbayev University, Astana, Kazakhstan
| | - Karina Tapinova
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Assel Nemerenova
- Department of Mechanical and Aerospace Engineering, School of Engineering and Digital Sciences, Nazarbayev University, Astana, Kazakhstan
| | - Dmitriy Viderman
- Department of Surgery, School of Medicine, Nazarbayev University, Astana, Kazakhstan
- Department of Anesthesiology, Intensive Care, and Pain Medicine, National Research Oncology Center, Astana, Kazakhstan
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10
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Wei Z, Yu H, Zhao H, Wei M, Xing H, Pei J, Yang Y, Ren K. Broadening horizons: ferroptosis as a new target for traumatic brain injury. BURNS & TRAUMA 2024; 12:tkad051. [PMID: 38250705 PMCID: PMC10799763 DOI: 10.1093/burnst/tkad051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/24/2023] [Accepted: 10/15/2023] [Indexed: 01/23/2024]
Abstract
Traumatic brain injury (TBI) is a leading cause of death and disability worldwide, with ~50 million people experiencing TBI each year. Ferroptosis, a form of regulated cell death triggered by iron ion-catalyzed and reactive oxygen species-induced lipid peroxidation, has been identified as a potential contributor to traumatic central nervous system conditions, suggesting its involvement in the pathogenesis of TBI. Alterations in iron metabolism play a crucial role in secondary injury following TBI. This study aimed to explore the role of ferroptosis in TBI, focusing on iron metabolism disorders, lipid metabolism disorders and the regulatory axis of system Xc-/glutathione/glutathione peroxidase 4 in TBI. Additionally, we examined the involvement of ferroptosis in the chronic TBI stage. Based on these findings, we discuss potential therapeutic interventions targeting ferroptosis after TBI. In conclusion, this review provides novel insights into the pathology of TBI and proposes potential therapeutic targets.
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Affiliation(s)
- Ziqing Wei
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, No. 1, Jianshe East Road, Erqi District, Zhengzhou, China
- Henan Key Laboratory of Cerebrovascular Diseases, The First Affiliated Hospital of Zhengzhou University, No. 1, Jianshe East Road, Erqi District, Zhengzhou, China
- Clinical Systems Biology Laboratories, The First Affiliated Hospital of Zhengzhou University, No. 1, Longhu Middle Ring Road, Jinshui District, Zhengzhou, China
| | - Haihan Yu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, No. 1, Jianshe East Road, Erqi District, Zhengzhou, China
| | - Huijuan Zhao
- Henan International Joint Laboratory of Thrombosis and Hemostasis, College of Basic Medicine and Forensic Medicine, Henan University of Science and Technology, No. 1, Longhu Middle Ring Road, Jinshui District, Luoyang, China
| | - Mingze Wei
- The Second Clinical Medical College, Harbin Medical University, No. 263, Kaiyuan Avenue, Luolong District, Harbin, China
| | - Han Xing
- Department of Pharmacy, the First Affiliated Hospital of Zhengzhou University, No. 246, Xuefu Road, Nangang District, Zhengzhou 450052, China
- Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, No. 1, Jianshe East Road, Erqi District, Zhengzhou 450052, China
| | - Jinyan Pei
- Quality Management Department, Henan No.3 Provincial People’s Hospital, No. 198, Funiu Road, Zhongyuan District, Henan province, Zhengzhou 450052, China
| | - Yang Yang
- Clinical Systems Biology Research Laboratories, Translational Medicine Center, the First Affiliated Hospital of Zhengzhou University, No. 198, Funiu Road, Zhongyuan District, Zhengzhou 450052, China
| | - Kaidi Ren
- Department of Pharmacy, the First Affiliated Hospital of Zhengzhou University, No. 246, Xuefu Road, Nangang District, Zhengzhou 450052, China
- Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, No. 1, Jianshe East Road, Erqi District, Zhengzhou 450052, China
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11
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Hendrikse C, Ngah V, Kallon II, Leong TD, McCaul M. Ketamine as adjunctive or monotherapy for post-intubation sedation in patients with trauma on mechanical ventilation: A rapid review. Afr J Emerg Med 2023; 13:313-321. [PMID: 38033380 PMCID: PMC10682541 DOI: 10.1016/j.afjem.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 09/29/2023] [Accepted: 10/20/2023] [Indexed: 12/02/2023] Open
Abstract
Background The effectiveness of ketamine as adjunctive or monotherapy for post-intubation sedation in adults with trauma on mechanical ventilation is unclear. Methods A rapid review of systematic reviews of randomized controlled trials, then randomized controlled trials or observational studies was conducted searching three electronic databases (PubMed, Embase, Cochrane Library) and one clinical trial registry on June 1, 2022. We used a prespecified protocol following Cochrane rapid review methods. Results We identified eight systematic reviews of randomized controlled trials and observational studies. Among the included reviews, only the most relevant, up to date, highest quality-assessed reviews and reviews that reported on critical outcomes were considered. Adjunctive ketamine showed a morphine sparing effect (MD -13.19 µmg kg-1 h-1, 95 % CI -22.10 to -4.28, moderate certainty of evidence, 6 RCTs), but no to little effect on midazolam sparing effect (MD 0.75 µmg kg-1 h-1, 95 % CI -1.11 to 2.61, low certainty of evidence, 6 RCTs) or duration of mechanical ventilation in days (MD -0.17 days, 95 % CI -3.03 to 2.69, moderate certainty of evidence, 3 RCTs).Adjunctive ketamine therapy may reduce mortality (OR 0.88, 95 % CI 0.54 to 1.43, P = 0.60, very low certainty of evidence, 5 RCTs, n = 3076 patients) resulting in 30 fewer deaths per 1000, ranging from 132 fewer to 87 more, but the evidence is very uncertain. Ketamine results in little to no difference in length of ICU stay (MD 0.04 days, 95 % CI -0.12 to 0.20, high certainty of evidence, 5 RCTs n = 390 patients) or length of hospital stay (MD -0.53 days, 95 % CI -1.36 to 0.30, high certainty of evidence, 5 RCTs, n = 277 patients).Monotherapy may have a positive effect on respiratory and haemodynamic outcomes, however the evidence is very uncertain. Conclusion Adjunctive ketamine for post-intubation analgosedation results in a moderate meaningful net benefit but there is uncertainty for benefit and harms as monotherapy.
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Affiliation(s)
- C Hendrikse
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
- PHC/Adult Hospital Level Committee (2019-2023), South Africa
| | - V Ngah
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, South Africa
| | - II Kallon
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, South Africa
| | - T D Leong
- Secretariat to the PHC/Adult Hospital Level Committee (2019-2022), Secretariat to the National Essential Medicines List Committee (2012-2022), South Africa
- Health Systems Research Unit, South African Medical Research Council, South Africa
- South African GRADE Network, Stellenbosch University, South Africa
| | - M McCaul
- PHC/Adult Hospital Level Committee (2019-2023), South Africa
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, South Africa
- South African GRADE Network, Stellenbosch University, South Africa
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12
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Knack SKS, Prekker ME, Moore JC, Klein LR, Atkins AH, Miner JR, Driver BE. The Effect of Ketamine Versus Etomidate for Rapid Sequence Intubation on Maximum Sequential Organ Failure Assessment Score: A Randomized Clinical Trial. J Emerg Med 2023; 65:e371-e382. [PMID: 37741737 DOI: 10.1016/j.jemermed.2023.06.009] [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: 03/16/2023] [Revised: 05/22/2023] [Accepted: 06/13/2023] [Indexed: 09/25/2023]
Abstract
BACKGROUND The use of induction agents for rapid sequence intubation (RSI) has been associated with hypotension in critically ill patients. Choice of induction agent may be important and the most commonly used agents are etomidate and ketamine. OBJECTIVE This study aimed to compare the effects of a single dose of ketamine vs. etomidate for RSI on maximum Sequential Organ Failure Assessment (SOFA) score and incidence of hypotension. METHODS This single-center, randomized, parallel-group trial compared the use of ketamine and etomidate for RSI in critically ill adult patients in the emergency department. The study was performed under Exception from Informed Consent. The primary outcome was the maximum SOFA score within 3 days of hospitalization. RESULTS A total of 143 patients were enrolled in the trial, 70 in the ketamine group and 73 in the etomidate group. Maximum median SOFA score for the ketamine group was 6.5 (interquartile range [IQR] 5-9) vs. 7 (IQR 5-9) for etomidate with no significant difference (-0.2; 95% CI -1.4 to 1.1; p = 0.79). The incidence of post-intubation hypotension was 28% in the ketamine group vs. 26% in the etomidate group (difference 2%; 95% CI -13% to 17%). There were no significant differences in intensive care unit outcomes. Thirty-day mortality rate for the ketamine group was 11% (8 deaths) and for the etomidate group was 21% (15 deaths), which was not statistically different. CONCLUSIONS There were no significant differences in maximum SOFA score or post-intubation hypotension between critically ill adults receiving ketamine vs. etomidate for RSI.
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Affiliation(s)
- Sarah K S Knack
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Matthew E Prekker
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota; Department of Medicine, Division of Pulmonary and Critical Care, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Johanna C Moore
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Lauren R Klein
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Alexandra H Atkins
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - James R Miner
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
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13
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Rowe CJ, Mang J, Huang B, Dommaraju K, Potter BK, Schobel SA, Gann ER, Davis TA. Systemic inflammation induced from remote extremity trauma is a critical driver of secondary brain injury. Mol Cell Neurosci 2023; 126:103878. [PMID: 37451414 DOI: 10.1016/j.mcn.2023.103878] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 06/26/2023] [Accepted: 07/04/2023] [Indexed: 07/18/2023] Open
Abstract
Blast exposure, commonly experienced by military personnel, can cause devastating life-threatening polysystem trauma. Despite considerable research efforts, the impact of the systemic inflammatory response after major trauma on secondary brain injury-inflammation is largely unknown. The aim of this study was to identify markers underlying the susceptibility and early onset of neuroinflammation in three rat trauma models: (1) blast overpressure exposure (BOP), (2) complex extremity trauma (CET) involving femur fracture, crush injury, tourniquet-induced ischemia, and transfemoral amputation through the fracture site, and (3) BOP+CET. Six hours post-injury, intact brains were harvested and dissected to obtain biopsies from the prefrontal cortex, striatum, neocortex, hippocampus, amygdala, thalamus, hypothalamus, and cerebellum. Custom low-density microarray datasets were used to identify, interpret and visualize genes significant (p < 0.05 for differential expression [DEGs]; 86 neuroinflammation-associated) using a custom python-based computer program, principal component analysis, heatmaps and volcano plots. Gene set and pathway enrichment analyses of the DEGs was performed using R and STRING for protein-protein interaction (PPI) to identify and explore key genes and signaling networks. Transcript profiles were similar across all regions in naïve brains with similar expression levels involving neurotransmission and transcription functions and undetectable to low-levels of inflammation-related mediators. Trauma-induced neuroinflammation across all anatomical brain regions correlated with injury severity (BOP+CET > CET > BOP). The most pronounced differences in neuroinflammatory-neurodegenerative gene regulation were between blast-associated trauma (BOP, BOP+CET) and CET. Following BOP, there were few DEGs detected amongst all 8 brain regions, most were related to cytokines/chemokines and chemokine receptors, where PPI analysis revealed Il1b as a potential central hub gene. In contrast, CET led to a more excessive and diverse pro-neuroinflammatory reaction in which Il6 was identified as the central hub gene. Analysis of the of the BOP+CET dataset, revealed a more global heightened response (Cxcr2, Il1b, and Il6) as well as the expression of additional functional regulatory networks/hub genes (Ccl2, Ccl3, and Ccl4) which are known to play a critical role in the rapid recruitment and activation of immune cells via chemokine/cytokine signaling. These findings provide a foundation for discerning pathophysiological consequences of acute extremity injury and systemic inflammation following various forms of trauma in the brain.
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Affiliation(s)
- Cassie J Rowe
- Cell Biology and Regenerative Medicine Program, Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA; Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA.
| | - Josef Mang
- Cell Biology and Regenerative Medicine Program, Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA; F. Edward Hebert School of Medicine, Uniformed Services University, Bethesda, MD 20814, USA.
| | - Benjamin Huang
- Cell Biology and Regenerative Medicine Program, Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA; F. Edward Hebert School of Medicine, Uniformed Services University, Bethesda, MD 20814, USA.
| | - Kalpana Dommaraju
- Student Bioinformatics Initiative (SBI), Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.
| | - Benjamin K Potter
- Cell Biology and Regenerative Medicine Program, Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.
| | - Seth A Schobel
- Cell Biology and Regenerative Medicine Program, Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA; Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA; Surgical Critical Care Initiative (SC2i), Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.
| | - Eric R Gann
- Cell Biology and Regenerative Medicine Program, Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA; Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA; Surgical Critical Care Initiative (SC2i), Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.
| | - Thomas A Davis
- Cell Biology and Regenerative Medicine Program, Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.
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Spencer HF, Boese M, Berman RY, Radford KD, Choi KH. Effects of a Subanesthetic Ketamine Infusion on Inflammatory and Behavioral Outcomes after Closed Head Injury in Rats. Bioengineering (Basel) 2023; 10:941. [PMID: 37627826 PMCID: PMC10452037 DOI: 10.3390/bioengineering10080941] [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: 06/28/2023] [Revised: 07/28/2023] [Accepted: 08/03/2023] [Indexed: 08/27/2023] Open
Abstract
Traumatic brain injury (TBI) affects millions of people annually, and most cases are classified as mild TBI (mTBI). Ketamine is a potent trauma analgesic and anesthetic with anti-inflammatory properties. However, ketamine's effects on post-mTBI outcomes are not well characterized. For the current study, we used the Closed-Head Impact Model of Engineered Rotational Acceleration (CHIMERA), which replicates the biomechanics of a closed-head impact with resulting free head movement. Adult male Sprague-Dawley rats sustained a single-session, repeated-impacts CHIMERA injury. An hour after the injury, rats received an intravenous ketamine infusion (0, 10, or 20 mg/kg, 2 h period), during which locomotor activity was monitored. Catheter blood samples were collected at 1, 3, 5, and 24 h after the CHIMERA injury for plasma cytokine assays. Behavioral assays were conducted on post-injury days (PID) 1 to 4 and included rotarod, locomotor activity, acoustic startle reflex (ASR), and pre-pulse inhibition (PPI). Brain tissue samples were collected at PID 4 and processed for GFAP (astrocytes), Iba-1 (microglia), and silver staining (axonal injury). Ketamine dose-dependently altered locomotor activity during the infusion and reduced KC/GRO, TNF-α, and IL-1β levels after the infusion. CHIMERA produced a delayed deficit in rotarod performance (PID 3) and significant axonal damage in the optic tract (PID 4), without significant changes in other behavioral or histological measures. Notably, subanesthetic doses of intravenous ketamine infusion after mTBI did not produce adverse effects on behavioral outcomes in PID 1-4 or neuroinflammation on PID 4. A further study is warranted to thoroughly investigate beneficial effects of IV ketamine on mTBI given multi-modal properties of ketamine in traumatic injury and stress.
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Affiliation(s)
- Haley F. Spencer
- Program in Neuroscience, Uniformed Services University, 4301 Jones Bridge Rd, Bethesda, MD 20814, USA;
- Center for the Study of Traumatic Stress, Uniformed Services University, 4301 Jones Bridge Rd, Bethesda, MD 20814, USA;
| | - Martin Boese
- Daniel K. Inouye Graduate School of Nursing, Uniformed Services University, 4301 Jones Bridge Rd, Bethesda, MD 20814, USA; (M.B.); (K.D.R.)
| | - Rina Y. Berman
- Center for the Study of Traumatic Stress, Uniformed Services University, 4301 Jones Bridge Rd, Bethesda, MD 20814, USA;
| | - Kennett D. Radford
- Daniel K. Inouye Graduate School of Nursing, Uniformed Services University, 4301 Jones Bridge Rd, Bethesda, MD 20814, USA; (M.B.); (K.D.R.)
| | - Kwang H. Choi
- Program in Neuroscience, Uniformed Services University, 4301 Jones Bridge Rd, Bethesda, MD 20814, USA;
- Center for the Study of Traumatic Stress, Uniformed Services University, 4301 Jones Bridge Rd, Bethesda, MD 20814, USA;
- Daniel K. Inouye Graduate School of Nursing, Uniformed Services University, 4301 Jones Bridge Rd, Bethesda, MD 20814, USA; (M.B.); (K.D.R.)
- Department of Psychiatry, Center for the Study of Traumatic Stress, Uniformed Services University, 4301 Jones Bridge Rd, Bethesda, MD 20814, USA
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15
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Riccardi A, Guarino M, Serra S, Spampinato MD, Vanni S, Shiffer D, Voza A, Fabbri A, De Iaco F. Narrative Review: Low-Dose Ketamine for Pain Management. J Clin Med 2023; 12:jcm12093256. [PMID: 37176696 PMCID: PMC10179418 DOI: 10.3390/jcm12093256] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 04/14/2023] [Accepted: 04/28/2023] [Indexed: 05/15/2023] Open
Abstract
Pain is the leading cause of medical consultations and occurs in 50-70% of emergency department visits. To date, several drugs have been used to manage pain. The clinical use of ketamine began in the 1960s and it immediately emerged as a manageable and safe drug for sedation and anesthesia. The analgesic properties of this drug were first reported shortly after its use; however, its psychomimetic effects have limited its use in emergency departments. Owing to the misuse and abuse of opioids in some countries worldwide, ketamine has become a versatile tool for sedation and analgesia. In this narrative review, ketamine's role as an analgesic is discussed, with both known and new applications in various contexts (acute, chronic, and neuropathic pain), along with its strengths and weaknesses, especially in terms of psychomimetic, cardiovascular, and hepatic effects. Moreover, new scientific evidence has been reviewed on the use of additional drugs with ketamine, such as magnesium infusion for improving analgesia and clonidine for treating psychomimetic symptoms. Finally, this narrative review was refined by the experience of the Pain Group of the Italian Society of Emergency Medicine (SIMEU) in treating acute and chronic pain with acute manifestations in Italian Emergency Departments.
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Affiliation(s)
| | - Mario Guarino
- Emergency Department, Centro Traumatologico Ortopedico, Azienda Ospedaliera di Rilievo Nazionale dei Colli, 80131 Napoli, Italy
| | - Sossio Serra
- Emergency Department, Maurizio Bufalini Hospital, 47522 Cesena, Italy
| | | | - Simone Vanni
- Dipartimento Emergenza e Area Critica, Azienda USL Toscana Centro Struttura Complessa di Medicina d'Urgenza, 50053 Empoli, Italy
| | - Dana Shiffer
- Emergency Department, Humanitas University, Via Rita Levi Montalcini 4, 20089 Milan, Italy
| | - Antonio Voza
- Emergency Department, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Andrea Fabbri
- Emergency Department, AUSL Romagna, Presidio Ospedaliero Morgagni-Pierantoni, 47121 Forlì, Italy
| | - Fabio De Iaco
- Emergency Department, Ospedale Maria Vittoria, 10144 Turin, Italy
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Laws JC, Vance EH, Betters KA, Anderson JJ, Fleishman S, Bonfield CM, Wellons JC, Xu M, Slaughter JC, Giuse DA, Patel N, Jordan LC, Wolf MS. Acute Effects of Ketamine on Intracranial Pressure in Children With Severe Traumatic Brain Injury. Crit Care Med 2023; 51:563-572. [PMID: 36825892 DOI: 10.1097/ccm.0000000000005806] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
OBJECTIVES The acute cerebral physiologic effects of ketamine in children have been incompletely described. We assessed the acute effects of ketamine on intracranial pressure (ICP) and cerebral perfusion pressure (CPP) in children with severe traumatic brain injury (TBI). DESIGN In this retrospective observational study, patients received bolus doses of ketamine for sedation or as a treatment for ICP crisis (ICP > 20 mm Hg for > 5 min). Administration times were synchronized with ICP and CPP recordings at 1-minute intervals logged in an automated database within the electronic health record. ICP and CPP were each averaged in epochs following drug administration and compared with baseline values. Age-based CPP thresholds were subtracted from CPP recordings and compared with baseline values. Trends in ICP and CPP over time were assessed using generalized least squares regression. SETTING A 30-bed tertiary care children's hospital PICU. PATIENTS Children with severe TBI who underwent ICP monitoring. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We analyzed data from 33 patients, ages 1 month to 16 years, 22 of whom received bolus doses of ketamine, with 127 doses analyzed. Demographics, patient, and injury characteristics were similar between patients who did versus did not receive ketamine boluses. In analysis of the subset of ketamine doses used only for sedation, there was no significant difference in ICP or CPP from baseline. Eighteen ketamine doses were given during ICP crises in 11 patients. ICP decreased following these doses and threshold-subtracted CPP rose. CONCLUSIONS In this retrospective, exploratory study, ICP did not increase following ketamine administration. In the setting of a guidelines-based protocol, ketamine was associated with a reduction in ICP during ICP crises. If these findings are reproduced in a larger study, ketamine may warrant consideration as a treatment for intracranial hypertension in children with severe TBI.
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Affiliation(s)
- Jennifer C Laws
- Division of Critical Care Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - E Haley Vance
- Division of Pediatric Neurological Surgery, Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Kristina A Betters
- Division of Critical Care Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Jessica J Anderson
- Department of Pharmacy, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN
| | | | - Christopher M Bonfield
- Division of Pediatric Neurological Surgery, Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - John C Wellons
- Division of Pediatric Neurological Surgery, Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Meng Xu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - James C Slaughter
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Dario A Giuse
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | - Neal Patel
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | - Lori C Jordan
- Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Michael S Wolf
- Division of Critical Care Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
- Division of Pediatric Neurological Surgery, Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN
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17
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Torres Soblechero L, Ocampo Benegas DE, Manrique Martín G, Butragueño Laiseca L, Leal Barceló AM, Parreño Marchante A, López-Herce Cid J, Mencía Bartolome S. Prospective observational study on the use of continuous intravenous ketamine and propofol infusion for prolonged sedation in critical care. An Pediatr (Barc) 2023; 98:276-282. [PMID: 36925340 DOI: 10.1016/j.anpede.2023.02.014] [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: 09/20/2022] [Accepted: 12/19/2022] [Indexed: 03/15/2023] Open
Abstract
INTRODUCTION Analgesia and sedation are a priority in paediatric intensive care. The combination of ketamine and propofol is a possible option in patients requiring prolonged or difficult sedation and to reduce the use of benzodiazepines and opiates. The aim of this study was to assess the efficacy and safety of combination ketamine and propofol in continuous infusion for prolonged analgesia/sedation in the paediatric intensive care setting. PATIENTS AND METHODS Prospective, observational single-group cohort study in patients aged 1 month to 16 years admitted to the paediatric intensive care unit in 2016-2018 that received ketamine and propofol in continuous infusion for analgesia and sedation. We collected data on demographic and clinical characteristics, analgesia and sedation scores (MAPS, COMFORT-B and SOPHIA), haemodynamic parameters and adverse events. RESULTS The study included 32 patients. The maximum dose of ketamine was 1.5 mg/kg/h (interquartile range [IQR], 1-2 mg/kg/h) and the infusion duration was 5 days (IQR, 3-5 days). The maximum dose of propofol was 3.2 mg/kg/h (IQR, 2.5-3.6 mg/kg/h) and the infusion duration, 5 days (IQR, 3-5 days). Thirty (93.7%) patients had previously received midazolam and 29 (90.6%) fentanyl. Analgesia scores did not change after initiation of the ketamine and propofol infusion. There was a statistically significant increase in the COMFORT-B score, but the score remained in the adequate sedation range (12-17). There were small but statistically significant decreases in the mean arterial pressure (from 64 mmHg to 60 mmHg; P = .006) and the diastolic blood pressure (from 50.5 to 48 mmHg; P = .023) 1 h after the initiation of the ketamine and propofol infusion, but this difference was not observed 12 h later and did not require administration of vasoactive drugs. No other major adverse events were detected during the infusion. CONCLUSIONS The combination of ketamine and propofol in continuous infusion is a safe treatment in critically ill children that makes it possible to achieve an appropriate level of analgesia and sedation without relevant haemodynamic repercussions.
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Affiliation(s)
- Laura Torres Soblechero
- Unidad de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
| | - Doris Elena Ocampo Benegas
- Unidad de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Gema Manrique Martín
- Unidad de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Laura Butragueño Laiseca
- Unidad de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Andrea María Leal Barceló
- Unidad de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Jesús López-Herce Cid
- Unidad de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Santiago Mencía Bartolome
- Unidad de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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18
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Neurosurgical Anesthesia: Optimizing Outcomes with Agent Selection. Biomedicines 2023; 11:biomedicines11020372. [PMID: 36830909 PMCID: PMC9953550 DOI: 10.3390/biomedicines11020372] [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: 01/13/2023] [Accepted: 01/22/2023] [Indexed: 01/31/2023] Open
Abstract
Anesthesia in neurosurgery embodies a vital element in the development of neurosurgical intervention. This undisputed interest has offered surgeons and anesthesiologists an array of anesthetic selections to utilize, though with this allowance comes the equally essential requirement of implementing a maximally appropriate agent. To date, there remains a lack of consensus and official guidance on optimizing anesthetic choice based on operating priorities including hemodynamic parameters (e.g., CPP, ICP, MAP) in addition to the route of procedure and pathology. In this review, the authors detail the development of neuroanesthesia, summarize the advantages and drawbacks of various anesthetic classes and agents, while lastly cohesively organizing the current literature of randomized trials on neuroanesthesia across various procedures.
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19
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Torres Soblechero L, Ocampo Benegas DE, Manrique Martín G, Butragueño Laiseca L, Leal Barceló AM, Parreño Marchante A, López-Herce Cid J, Mencía Bartolome S. Uso concomitante de ketamina y propofol en perfusión continua en cuidados intensivos: eficacia y seguridad para analgesia y sedación prolongada. An Pediatr (Barc) 2023. [DOI: 10.1016/j.anpedi.2022.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
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20
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Morton S, Dawson J, Wareham G, Broomhead R, Sherren P. The Prehospital Emergency Anaesthetic in 2022. Air Med J 2022; 41:530-535. [PMID: 36494168 DOI: 10.1016/j.amj.2022.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/28/2022] [Accepted: 08/15/2022] [Indexed: 12/14/2022]
Abstract
Prehospital emergency anesthesia (PHEA) is a commonly performed prehospital procedure with inherent risks. The processes and drug regimens behind PHEA are continually updated by prehospital teams across the country as part of their governance structure. Essex & Herts Air Ambulance has recently updated this practice by reviewing the entire process of performing PHEA. Through experiential learning in a high-volume service, audit, and a contemporary literature review, a new standard operating procedure has been developed to combat common problems, such as hypotension, associated with the more traditional methods of performing PHEA. The aim of this article was to summarize the literature behind this new standard operating procedure, systematically breaking down the core components of performing a PHEA and the rationale behind them. The key components identified in the review are indications for PHEA, airway assessment, peri-intubation oxygenation, preparation for PHEA, drug dosing, special circumstances, and failed intubation. One significant change is the drug dosage regimen; 1 μg/kg fentanyl, 2 mg/kg ketamine, and 2 mg/kg rocuronium is recommended as the main drug dosing regimen for both medical and trauma patients. Other changes include preoxygenation with a nasal cannula in addition to the nonrebreather mask, optimizing patients in the preparation phase by considering inopressors or fluid bolus and ensuring a "sterile cockpit" to control the surrounding environment to ensure the first intubation attempt is the best attempt.
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Affiliation(s)
- Sarah Morton
- Essex & Herts Air Ambulance, Flight House, Essex, United Kingdom; Department of Surgery, Imperial College, London, United Kingdom
| | - Jonathan Dawson
- Essex & Herts Air Ambulance, Flight House, Essex, United Kingdom
| | - Gaynor Wareham
- Essex & Herts Air Ambulance, Flight House, Essex, United Kingdom
| | - Robert Broomhead
- Essex & Herts Air Ambulance, Flight House, Essex, United Kingdom
| | - Peter Sherren
- Essex & Herts Air Ambulance, Flight House, Essex, United Kingdom; Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom.
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21
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Spencer HF, Berman RY, Boese M, Choi KH. Ketamine, a trauma analgesic with sex-specific immunomodulatory function. Neural Regen Res 2022; 18:1263-1264. [PMID: 36453405 PMCID: PMC9838170 DOI: 10.4103/1673-5374.358617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- Haley F. Spencer
- Program in Neuroscience, Uniformed Services University, Bethesda, MD, USA
| | - Rina Y. Berman
- Center for the Study of Traumatic Stress, Uniformed Services University, Bethesda, MD, USA
| | - Martin Boese
- Daniel K. Inouye Graduate School of Nursing, Uniformed Services University, Bethesda, MD, USA
| | - Kwang H. Choi
- Program in Neuroscience, Uniformed Services University, Bethesda, MD, USA,Center for the Study of Traumatic Stress, Uniformed Services University, Bethesda, MD, USA,Daniel K. Inouye Graduate School of Nursing, Uniformed Services University, Bethesda, MD, USA,Department of Psychiatry, F. E. Hébert School of Medicine, Uniformed Services University, Bethesda, MD, USA,Correspondence to: Kwang H. Choi, .
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22
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Mazandi VM, Lang SS, Rahman RK, Nishisaki A, Beaulieu F, Zhang B, Griffis H, Tucker AM, Storm PB, Heuer GG, Gajjar AA, Ampah SB, Kirschen MP, Topjian AA, Yuan I, Francoeur C, Kilbaugh TJ, Huh JW. Co-administration of Ketamine in Pediatric Patients with Neurologic Conditions at Risk for Intracranial Hypertension. Neurocrit Care 2022; 38:242-253. [PMID: 36207491 DOI: 10.1007/s12028-022-01611-2] [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: 03/23/2022] [Accepted: 08/15/2022] [Indexed: 10/10/2022]
Abstract
BACKGROUND Ketamine has traditionally been avoided as an induction agent for tracheal intubation in patients with neurologic conditions at risk for intracranial hypertension due to conflicting data in the literature. The objective of this study was to evaluate and compare the effects of ketamine versus other medications as the primary induction agent on peri-intubation neurologic, hemodynamic and respiratory associated events in pediatric patients with neurologic conditions at risk for intracranial hypertension. METHODS This retrospective observational study enrolled patients < 18 years of age at risk for intracranial hypertension who were admitted to a quaternary children's hospital between 2015 and 2020. Associated events included neurologic, hemodynamic and respiratory outcomes comparing primary induction agents of ketamine versus non-ketamine for tracheal intubation. RESULTS Of 143 children, 70 received ketamine as the primary induction agent prior to tracheal intubation. Subsequently after tracheal intubation, all the patients received adjunct analgesic and sedative medications (fentanyl, midazolam, and/or propofol) at doses that were inadequate to induce general anesthesia but would keep them comfortable for further diagnostic workup. There were no significant differences between associated neurologic events in the ketamine versus non-ketamine groups (p = 0.42). This included obtaining an emergent computed tomography scan (p = 0.28), an emergent trip to the operating room within 5 h of tracheal intubation (p = 0.6), and the need for hypertonic saline administration within 15 min of induction drug administration for tracheal intubation (p = 0.51). There were two patients who had clinical and imaging evidence of herniation, which was not more adversely affected by ketamine compared with other medications (p = 0.49). Of the 143 patients, 23 had pre-intubation and post-intubation intracranial pressure values recorded; 11 received ketamine, and 3 of these patients had intracranial hypertension that resolved or improved, whereas the remaining 8 children had intracranial pressure within the normal range that was not exacerbated by ketamine. There were no significant differences in overall associated hemodynamic or respiratory events during tracheal intubation and no 24-h mortality in either group. CONCLUSIONS The administration of ketamine as the primary induction agent prior to tracheal intubation in combination with other agents after tracheal intubation in children at risk for intracranial hypertension was not associated with an increased risk of peri-intubation associated neurologic, hemodynamic or respiratory events compared with those who received other induction agents.
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Affiliation(s)
- Vanessa M Mazandi
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard, 6 Wood Center, Philadelphia, PA, 19104, USA.
| | - Shih-Shan Lang
- Division of Neurosurgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Raphia K Rahman
- Division of Neurosurgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Rowan School of Osteopathic Medicine, Stratford, NJ, USA
| | - Akira Nishisaki
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard, 6 Wood Center, Philadelphia, PA, 19104, USA
| | - Forrest Beaulieu
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard, 6 Wood Center, Philadelphia, PA, 19104, USA.,Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Bingqing Zhang
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Heather Griffis
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alexander M Tucker
- Division of Neurosurgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Phillip B Storm
- Division of Neurosurgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Greg G Heuer
- Division of Neurosurgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Avi A Gajjar
- Division of Neurosurgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Chemistry, Union College, Schenectady, NY, USA
| | - Steve B Ampah
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Matthew P Kirschen
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard, 6 Wood Center, Philadelphia, PA, 19104, USA
| | - Alexis A Topjian
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard, 6 Wood Center, Philadelphia, PA, 19104, USA
| | - Ian Yuan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard, 6 Wood Center, Philadelphia, PA, 19104, USA
| | - Conall Francoeur
- Department of Pediatrics, CHU de Québec-Université Laval Research Center, Quebec City, QC, Canada
| | - Todd J Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard, 6 Wood Center, Philadelphia, PA, 19104, USA
| | - Jimmy W Huh
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard, 6 Wood Center, Philadelphia, PA, 19104, USA
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23
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Pediatric Neuroanesthesia — a Review of the Recent Literature. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-022-00540-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Abstract
Purpose of Review
Pediatric neuroanesthesia is a growing and still challenging subspecialty. The purpose of this review is to summarize the available knowledge and highlight the most recent findings of the literature on non-traumatic pediatric neuroanesthesia care.
Recent Findings
Several human studies have confirmed the negative effects of early life anesthetic exposure. According to non-human studies, volatile anesthetics and opioids contribute to tumor progression. Tranexamic acid effectively reduces perioperative blood loss; it is used in several different doses without standard guidelines on optimal dosing. The widespread use of neuromonitoring has necessitated the development of anesthetic methods that do not affect neuromuscular transmission.
Summary
Pediatric anesthetic neurotoxicity, management of intraoperative bleeding, and the effect of anesthesia on tumor growth are among the most debated and researched topics in pediatric neuroanesthesia. The lack of evidence and clinical guidelines underlines the need for further large prospective studies in this subspecialty.
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24
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Rueda Carrillo L, Garcia KA, Yalcin N, Shah M. Ketamine and Its Emergence in the Field of Neurology. Cureus 2022; 14:e27389. [PMID: 36046286 PMCID: PMC9419113 DOI: 10.7759/cureus.27389] [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] [Accepted: 07/27/2022] [Indexed: 11/15/2022] Open
Abstract
The quest for a safe and effective anesthetic medication in the mid-20th century led to the discovery of CI-581, which was later named ketamine. Ketamine was labeled a “dissociative anesthetic” due to the state of sensory deprivation that it induces in the subjects receiving it. Although it enjoyed widespread use at the beginning of the Vietnam war, its use rapidly waned due to its psychedelic effect and it became more popular as a recreational drug, and in the field of veterinary medicine. However, as we gained more knowledge about its multiple sites of action, it has reemerged as a useful anesthetic/analgesic agent. In the last decade, the field of neurology has witnessed the growing use of ketamine for the treatment of several neurological conditions including migraine, status epilepticus, stroke, and traumatic brain injury (TBI). Ketamine acts primarily as a non-competitive N-methyl-D-aspartate (NMDA) receptor antagonist. The binding of ketamine to NMDA receptors leads to decreased frequency and duration of Ca+2 channel opening and thus inhibits glutaminergic transmission. This mechanism has proven to be neuroprotective in several neurological conditions. Ketamine does not increase intracranial pressure (ICP), and it maintains cerebral perfusion pressure (CPP) by increasing cerebral blood flow. Ketamine has also been shown to inhibit massive slow waves of neurological depolarizations called cortical spreading depolarizations (CSD), usually seen during acute neurological injury and are responsible for further neurological deterioration. Unlike other anesthetic agents, ketamine does not cause cardiac or respiratory suppression. All these favorable mechanisms and cerebral/hemodynamic actions have led to increased interest among clinicians and researchers regarding the novel uses of ketamine. This review will focus on the use of ketamine for various neurological indications.
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25
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Bali A, Dang AK, Gonzalez DA, Kumar R, Asif S. Clinical Uses of Ketamine in Children: A Narrative Review. Cureus 2022; 14:e27065. [PMID: 35989801 PMCID: PMC9389002 DOI: 10.7759/cureus.27065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2022] [Indexed: 11/05/2022] Open
Abstract
Ketamine is a phencyclidine derivative that acts as a noncompetitive N-methyl-D-aspartate as well as a glutamate receptor antagonist. It also has other minor mechanisms that contribute to its extensive drug profile. Ketamine is a bronchodilator and maintains normal airway reflexes and, thus, permits spontaneous respiration. This, coupled with the fact that it produces potent analgesia, makes it highly suitable for children. Despite its many merits, the drug’s side effects, along with its cultural image of being a drug of abuse, a drug used in veterinary medicine, or a “date-rape drug” have sullied its reputation within the armamentarium of medicine. Even though it is widely used in developing countries, its use in Western nations has diminished. We have strived to explore the various clinical uses of ketamine in children through this article. In addition, the article also highlights how some of the fears associated with using the drug are unfounded and provides ways by which the drug’s side effects can be prevented and managed.
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26
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Soto-Edwards A, Kawamoto A, Peters A. Effective Use of Ketamine-Dexmedetomidine Following Propofol-Induced Hyperlactatemia: A Case Report. Cureus 2022; 14:e25764. [PMID: 35812601 PMCID: PMC9270096 DOI: 10.7759/cureus.25764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2022] [Indexed: 11/05/2022] Open
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27
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Spencer HF, Berman RY, Boese M, Zhang M, Kim SY, Radford KD, Choi KH. Effects of an intravenous ketamine infusion on inflammatory cytokine levels in male and female Sprague-Dawley rats. J Neuroinflammation 2022; 19:75. [PMID: 35379262 PMCID: PMC8981848 DOI: 10.1186/s12974-022-02434-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 03/20/2022] [Indexed: 12/29/2022] Open
Abstract
Background Ketamine, a multimodal dissociative anesthetic drug, is widely used as an analgesic following traumatic injury. Although ketamine may produce anti-inflammatory effects when administered after injury, the immunomodulatory properties of intravenous (IV) ketamine in a non-inflammatory condition are unclear. In addition, most preclinical studies use an intraperitoneal (IP) injection of ketamine, which limits its clinical translation as patients usually receive an IV ketamine infusion after injury. Methods Here, we administered sub-anesthetic doses of a single IV ketamine infusion (0, 10, or 40 mg/kg) to male and female Sprague–Dawley rats over a 2-h period. We collected blood samples at 2- and 4-h post-ketamine infusion to determine plasma inflammatory cytokine levels using multiplex immunoassays. Results The 10 mg/kg ketamine infusion reduced spontaneous locomotor activity in male and female rats, while the 40 mg/kg infusion stimulated activity in female, but not male, rats. The IV ketamine infusion produced dose-dependent and sex-specific effects on plasma inflammatory cytokine levels. A ketamine infusion reduced KC/GRO and tumor necrosis factor alpha (TNF-α) levels in both male and female rats, interleukin-6 (IL-6) levels in female rats, and interleukin-10 (IL-10) levels in male rats. However, most cytokine levels returned to control levels at 4-h post-infusion, except for IL-6 levels in male rats and TNF-α levels in female rats, indicating a different trajectory of certain cytokine changes over time following ketamine administration. Conclusions The current findings suggest that sub-anesthetic doses of an IV ketamine infusion may produce sex-related differences in the effects on peripheral inflammatory markers in rodents, and further research is warranted to determine potential therapeutic effects of an IV ketamine infusion in an inflammatory condition.
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Affiliation(s)
- Haley F Spencer
- Program in Neuroscience, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA.,Center for the Study of Traumatic Stress, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA
| | - Rina Y Berman
- Center for the Study of Traumatic Stress, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA
| | - Martin Boese
- Daniel K. Inouye Graduate School of Nursing, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA
| | - Michael Zhang
- Center for the Study of Traumatic Stress, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA
| | - Sharon Y Kim
- Program in Neuroscience, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA
| | - Kennett D Radford
- Daniel K. Inouye Graduate School of Nursing, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA
| | - Kwang H Choi
- Program in Neuroscience, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA. .,Center for the Study of Traumatic Stress, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA. .,Daniel K. Inouye Graduate School of Nursing, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA. .,Department of Psychiatry, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA.
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28
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Greisman JD, Olmsted ZT, Crorkin PJ, Dallimore CA, Zhigin V, Shlifer A, Bedi AD, Kim JK, Nelson P, Sy HL, Patel KV, Ellis JA, Boockvar J, Langer DJ, D'Amico RS. Enhanced Recovery After Surgery (ERAS) for Cranial Tumor Resection: A Review. World Neurosurg 2022; 163:104-122.e2. [PMID: 35381381 DOI: 10.1016/j.wneu.2022.03.118] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 03/25/2022] [Accepted: 03/26/2022] [Indexed: 11/15/2022]
Abstract
Enhanced Recovery After Surgery (ERAS) protocols describe a standardized method of preoperative, perioperative, and postoperative care to enhance outcomes and minimize complication risks surrounding elective surgical intervention. A growing body of evidence is being generated as we learn to apply principles of ERAS standardization to neurosurgical patients. First applied in spinal surgery, ERAS protocols have been extended to cranial neuro-oncological procedures. This review synthesizes recent findings to generate evidence-based guidelines to manage neurosurgical oncology patients with standardized systems and assess ability of these systems to coordinate multidisciplinary, patient-centric care efforts. Furthermore, we highlight the potential utility of multimedia, app-based communication platforms to facilitate patient education, autonomy, and team communication within each of the three settings.
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Affiliation(s)
- Jacob D Greisman
- Department of Neurosurgery, Lenox Hill Hospital/Northwell Health, New York, NY.
| | - Zachary T Olmsted
- Department of Neurosurgery, Lenox Hill Hospital/Northwell Health, New York, NY
| | - Patrick J Crorkin
- Department of Neurosurgery, Lenox Hill Hospital/Northwell Health, New York, NY
| | - Colin A Dallimore
- Department of Neurosurgery, Lenox Hill Hospital/Northwell Health, New York, NY
| | - Vadim Zhigin
- Department of Neurosurgery, Lenox Hill Hospital/Northwell Health, New York, NY
| | - Artur Shlifer
- Department of Neurosurgery, Lenox Hill Hospital/Northwell Health, New York, NY
| | - Anupama D Bedi
- Department of Neurosurgery, Lenox Hill Hospital/Northwell Health, New York, NY
| | - Jane K Kim
- Department of Anesthesiology, Lenox Hill Hospital/Northwell Health, New York, NY
| | - Priscilla Nelson
- Department of Anesthesiology, Lenox Hill Hospital/Northwell Health, New York, NY
| | - Heustein L Sy
- Department of Neurosurgery, Lenox Hill Hospital/Northwell Health, New York, NY
| | - Kiran V Patel
- Department of Neurosurgery, Lenox Hill Hospital/Northwell Health, New York, NY
| | - Jason A Ellis
- Department of Neurosurgery, Lenox Hill Hospital/Northwell Health, New York, NY
| | - John Boockvar
- Department of Neurosurgery, Lenox Hill Hospital/Northwell Health, New York, NY
| | - David J Langer
- Department of Neurosurgery, Lenox Hill Hospital/Northwell Health, New York, NY
| | - Randy S D'Amico
- Department of Neurosurgery, Lenox Hill Hospital/Northwell Health, New York, NY
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Casamento A, Niccol T. Efficacy and safety of ketamine in mechanically ventilated intensive care unit patients: a scoping review. CRIT CARE RESUSC 2022; 24:71-82. [PMID: 38046843 PMCID: PMC10692604 DOI: 10.51893/2022.1.oa9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives: Mechanically ventilated patients account for about one-third of all admissions to the intensive care unit (ICU). Ketamine has been conditionally recommended to aid with analgesia in such patients, with low quality of evidence available to support this recommendation. We aimed to perform a narrative scoping review of the current knowledge of the use of ketamine, with a specific focus on mechanically ventilated ICU patients. Methods: We searched MEDLINE and EMBASE for relevant articles. Bibliographies of retrieved articles were examined for references of potential relevance. We included studies that described the use of ketamine for postoperative and emergency department management of pain and in the critically unwell, mechanically ventilated population. Results: There are few randomised controlled trials evaluating ketamine's utility in the ICU. The evidence is predominantly retrospective and observational in nature and the results are heterogeneous. Available evidence is summarised in a descriptive manner, with a division made between high dose and low dose ketamine. Ketamine's pharmacology and use as an analgesic agent outside of the ICU is briefly discussed, followed by evidence for use in the ICU setting, with particular emphasis on analgesia, sedation and intubation. Finally, data on adverse effects including delirium, coma, haemodynamic adverse effects, raised intracranial pressure, hypersalivation and laryngospasm are presented. Conclusions: Ketamine is used in mechanically ventilated ICU patients with several potentially positive clinical effects. However, it has a significant side effect profile, which may limit its use in these patients. The role of low dose ketamine infusion in mechanically ventilated ICU patients is not well studied and requires investigation in high quality, prospective randomised trials.
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Affiliation(s)
- Andrew Casamento
- Intensive Care Unit, Austin Health, Melbourne, VIC, Australia
- Intensive Care Unit, Northern Hospital, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
| | - Thomas Niccol
- Intensive Care Unit, Austin Health, Melbourne, VIC, Australia
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Khoujah D, Chang WTW. The emergency neurology literature 2020. Am J Emerg Med 2022; 54:1-7. [DOI: 10.1016/j.ajem.2022.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 01/03/2022] [Accepted: 01/10/2022] [Indexed: 10/19/2022] Open
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Browne CA, Hildegard A Wulf BA, Jacobson ML, Oyola M, Wu TJ, Lucki I. Long-term increase in sensitivity to ketamine's behavioral effects in mice exposed to mild blast induced traumatic brain injury. Exp Neurol 2021; 350:113963. [PMID: 34968423 DOI: 10.1016/j.expneurol.2021.113963] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 11/23/2021] [Accepted: 12/22/2021] [Indexed: 11/04/2022]
Abstract
Neurobehavioral deficits emerge in nearly 50% of patients following a mild traumatic brain injury (TBI) and may persist for months. Ketamine is used frequently as an anesthetic, analgesic and for management of persistent psychiatric complications. Although ketamine may produce beneficial effects in patients with a history of TBI, differential sensitivity to its impairing effects could make the therapeutic use of ketamine in TBI patients unsafe. This series of studies examined male C57BL/6 J mice exposed to a mild single blast overpressure (mbTBI) for indications of altered sensitivity to ketamine at varying times after injury. Dystaxia (altered gait), diminished sensorimotor gating (reduced prepulse inhibition) impaired working memory (step-down inhibitory avoidance) were examined in mbTBI and sham animals 15 min following intraperitoneal injections of saline or R,S-ketamine hydrochloride, from day 7-16 post injury and again from day 35-43 post injury. Behavioral performance in the forced swim test and sucrose preference test were evaluated on day 28 and day 74 post injury respectively, 24 h following drug administration. Dynamic gait stability was compromised in mbTBI mice on day 7 and 35 post injury and further exacerbated following ketamine administration. On day 14 and 42 post injury, prepulse inhibition was robustly decreased by mbTBI, which ketamine further reduced. Ketamine-associated memory impairment was apparent selectively in mbTBI animals 1 h, 24 h and day 28 post shock (tested on day 15/16/43 post injury). Ketamine selectively reduced immobility scores in the FST in mbTBI animals (day 28) and reversed mbTBI induced decreases in sucrose consumption (Day 74). These results demonstrate increased sensitivity to ketamine in mice when tested for extended periods after TBI. The results suggest that ketamine may be effective for treating neuropsychiatric complications that emerge after TBI but urge caution when used in clinical practice for enhanced sensitivity to its side effects in this patient population.
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Affiliation(s)
- Caroline A Browne
- Department of Pharmacology & Molecular Therapeutics, Uniformed Services University, Bethesda, MD 20814, United States of America.
| | - B A Hildegard A Wulf
- Department of Pharmacology & Molecular Therapeutics, Uniformed Services University, Bethesda, MD 20814, United States of America
| | - Moriah L Jacobson
- Department of Pharmacology & Molecular Therapeutics, Uniformed Services University, Bethesda, MD 20814, United States of America
| | - Mario Oyola
- Department of Gynecologic Surgery & Obstetrics, Uniformed Services University, Bethesda, MD 20814, United States of America
| | - T John Wu
- Department of Gynecologic Surgery & Obstetrics, Uniformed Services University, Bethesda, MD 20814, United States of America
| | - Irwin Lucki
- Department of Pharmacology & Molecular Therapeutics, Uniformed Services University, Bethesda, MD 20814, United States of America
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Madsen FA, Andreasen TH, Lindschou J, Gluud C, Møller K. Ketamine for critically ill patients with severe acute brain injury: Protocol for a systematic review with meta-analysis and Trial Sequential Analysis of randomised clinical trials. PLoS One 2021; 16:e0259899. [PMID: 34780543 PMCID: PMC8592463 DOI: 10.1371/journal.pone.0259899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 10/28/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Intensive care for patients with severe acute brain injury aims both to treat the immediate consequences of the injury and to prevent and treat secondary brain injury to ensure a good functional outcome. Sedation may be used to facilitate mechanical ventilation, for treating agitation, and for controlling intracranial pressure. Ketamine is an N-methyl-D-aspartate receptor antagonist with sedative, analgesic, and potentially neuroprotective properties. We describe a protocol for a systematic review of randomised clinical trials assessing the beneficial and harmful effects of ketamine for patients with severe acute brain injury. METHODS AND ANALYSIS We will systematically search international databases for randomised clinical trials, including CENTRAL, MEDLINE, Embase, and trial registries. Two authors will independently review and select trials for inclusion, and extract data. We will compare ketamine by any regimen versus placebo, no intervention, or other sedatives or analgesics for patients with severe acute brain injury. The primary outcomes will be functional outcome at maximal follow up, quality of life, and serious adverse events. We will also assess secondary and exploratory outcomes. The extracted data will be analysed using Review Manager and Trials Sequential Analysis. Evidence certainty will be graded using GRADE. ETHICS AND DISSEMINATION The results of the systematic review will be disseminated through peer-reviewed publication. With the review, we hope to inform future randomised clinical trials and improve clinical practice. PROSPERO NO CRD42021210447.
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Affiliation(s)
- Frederik Andreas Madsen
- Department of Neuroanaesthesiology, Neuroscience Centre, Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark
| | - Trine Hjorslev Andreasen
- Department of Neurosurgery, Neuroscience Centre, Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jane Lindschou
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Kirsten Møller
- Department of Neuroanaesthesiology, Neuroscience Centre, Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Review and Updates on the Treatment of Refractory and Super Refractory Status Epilepticus. J Clin Med 2021; 10:jcm10143028. [PMID: 34300194 PMCID: PMC8304618 DOI: 10.3390/jcm10143028] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 06/30/2021] [Accepted: 07/03/2021] [Indexed: 02/07/2023] Open
Abstract
Refractory and super-refractory status epilepticus (RSE and SRSE) are life-threatening conditions requiring prompt initiation of appropriate treatment to avoid permanent neurological damage and reduce morbidity and mortality. RSE is defined as status epilepticus that persists despite administering at least two appropriately dosed parenteral medications, including a benzodiazepine. SRSE is status epilepticus that persists at least 24 h after adding at least one appropriately dosed continuous anesthetic (i.e., midazolam, propofol, pentobarbital, and ketamine). Other therapeutic interventions include immunotherapy, neuromodulation, ketogenic diet, or even surgical intervention in certain cases. Continuous electroencephalogram is an essential monitoring tool for diagnosis and treatment. In this review, we focus on the diagnosis and treatment of RSE and SRSE.
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Zhou JY, Hamilton P, Macres S, Peña M, Tang S. Update on Ketamine. Adv Anesth 2021; 38:97-113. [PMID: 34106842 DOI: 10.1016/j.aan.2020.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Jon Y Zhou
- UC Davis Department of Anesthesiology and Pain Medicine, UC Davis Medical Center, 4150 V Street, Suite 1200 PSSB, Sacramento, CA 95817, USA.
| | - Perry Hamilton
- UC Davis Department of Anesthesiology and Pain Medicine, UC Davis Medical Center, 4150 V Street, Suite 1200 PSSB, Sacramento, CA 95817, USA. https://twitter.com/pvham1011
| | - Stephen Macres
- UC Davis Department of Anesthesiology and Pain Medicine, UC Davis Medical Center, 4150 V Street, Suite 1200 PSSB, Sacramento, CA 95817, USA
| | - Matthew Peña
- UC Davis Department of Anesthesiology and Pain Medicine, UC Davis Medical Center, 4150 V Street, Suite 1200 PSSB, Sacramento, CA 95817, USA
| | - Schirin Tang
- UC Davis Department of Anesthesiology and Pain Medicine, UC Davis Medical Center, 4150 V Street, Suite 1200 PSSB, Sacramento, CA 95817, USA. https://twitter.com/SchirinMD
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Acquisto NM, Slocum GW, Bilhimer MH, Awad NI, Justice SB, Kelly GF, Makhoul T, Patanwala AE, Peksa GD, Porter B, Truoccolo DMS, Treu CN, Weant KA, Thomas MC. Key articles and guidelines for the emergency medicine clinical pharmacist: 2011-2018 update. Am J Health Syst Pharm 2021; 77:1284-1335. [PMID: 32766731 DOI: 10.1093/ajhp/zxaa178] [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: 11/13/2022] Open
Abstract
PURPOSE To summarize recently published research reports and practice guidelines on emergency medicine (EM)-related pharmacotherapy. SUMMARY Our author group was composed of 14 EM pharmacists, who used a systematic process to determine main sections and topics for the update as well as pertinent literature for inclusion. Main sections and topics were determined using a modified Delphi method, author and peer reviewer groups were formed, and articles were selected based on a comprehensive literature review and several criteria for each author-reviewer pair. These criteria included the document "Oxford Centre for Evidence-based Medicine - Levels of Evidence (March 2009)" but also clinical implications, interest to reader, and belief that a publication was a "key article" for the practicing EM pharmacist. A total of 105 articles published from January 2011 through July 2018 were objectively selected for inclusion in this review. This was not intended as a complete representation of all available pertinent literature. The reviewed publications address the management of a wide variety of disease states and topic areas that are commonly found in the emergency department: analgesia and sedation, anticoagulation, cardiovascular emergencies, emergency preparedness, endocrine emergencies, infectious diseases, neurology, pharmacy services and patient safety, respiratory care, shock, substance abuse, toxicology, and trauma. CONCLUSION There are many important recent additions to the EM-related pharmacotherapy literature. As is evident with the surge of new studies, guidelines, and reviews in recent years, it is vital for the EM pharmacist to continue to stay current with advancing practice changes.
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Affiliation(s)
- Nicole M Acquisto
- Department of Pharmacy and Department of Emergency Medicine, University of Rochester Medical Center, Rochester, NY
| | - Giles W Slocum
- Department of Pharmacy, Rush University Medical Center, Chicago, IL
| | | | - Nadia I Awad
- Department of Pharmacy, Robert Wood Johnson University Hospital, New Brunswick, NJ
| | | | - Gregory F Kelly
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Therese Makhoul
- Department of Pharmacy, Santa Rosa Memorial Hospital, Santa Rosa, CA
| | - Asad E Patanwala
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Gary D Peksa
- Department of Pharmacy, Rush University Medical Center, Chicago, IL
| | - Blake Porter
- Department of Pharmacy, University of Vermont Medical Center, Burlington, VT
| | | | - Cierra N Treu
- Department of Pharmacy, NewYork Presbyterian-Brooklyn Methodist Hospital, Brooklyn, NY
| | - Kyle A Weant
- Medical University of South Carolina College of Pharmacy, Medical University of South Carolina, Charleston, SC
| | - Michael C Thomas
- McWhorter School of Pharmacy, Samford University, Birmingham, AL
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Avery P, Morton S, Raitt J, Lossius HM, Lockey D. Rapid sequence induction: where did the consensus go? Scand J Trauma Resusc Emerg Med 2021; 29:64. [PMID: 33985541 PMCID: PMC8116824 DOI: 10.1186/s13049-021-00883-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 04/28/2021] [Indexed: 12/15/2022] Open
Abstract
Background Rapid Sequence Induction (RSI) was introduced to minimise the risk of aspiration of gastric contents during emergency tracheal intubation. It consisted of induction with the use of thiopentone and suxamethonium with the application of cricoid pressure. This narrative review describes how traditional RSI has been modified in the UK and elsewhere, aiming to deliver safe and effective emergency anaesthesia outside the operating room environment. Most of the key aspects of traditional RSI – training, technique, drugs and equipment have been challenged and often significantly changed since the procedure was first described. Alterations have been made to improve the safety and quality of the intervention while retaining the principles of rapidly securing a definitive airway and avoiding gastric aspiration. RSI is no longer achieved by an anaesthetist alone and can be delivered safely in a variety of settings, including in the pre-hospital environment. Conclusion The conduct of RSI in current emergency practice is far removed from the original descriptions of the procedure. Despite this, the principles – rapid delivery of a definitive airway and avoiding aspiration, are still highly relevant and the indications for RSI remain relatively unchanged.
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Affiliation(s)
- Pascale Avery
- Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB, UK.
| | - Sarah Morton
- Essex & Herts Air Ambulance, Flight House, Earls Colne, Colchester, Essex, CO6 2NS, UK
| | - James Raitt
- Thames Valley Air Ambulance Stokenchurch House, Oxford Rd, Stokenchurch, High Wycombe, HP14 3SX, UK
| | | | - David Lockey
- Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB, UK.,Blizard Institute, Queen Mary University, Whitechapel, London, E1 2AT, UK
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Abstract
Ketamine is a dissociative anesthetic used increasingly as analgesia for different manifestations of pain, including acute, chronic, cancer and perioperative pain as well as pain in the critically ill patient population. Its distinctive pharmacologic properties may provide benefits to individuals suffering from pain, including increased pain control and reduction in opioid consumption and tolerance. Despite wide variability in proposed dosing and method of administration when used for analgesia, it is important all clinicians be familiar with the pharmacodynamics of ketamine in order to appropriately anticipate its therapeutic and adverse effects.
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Affiliation(s)
- Kelsea Caruso
- Kelsea Caruso, PharmD, Emergency Medicine Clinical Pharmacist, Northwestern Memorial Hospital, Chicago, IL
- Dion Tyler, PharmD, PGY2 Emergency Medicine Pharmacy Resident, Rosalind Franklin University of Medicine and Science and Northwestern Memorial Hospital, Chicago, IL
- Abbie Lyden, PharmD, BCPS , Associate Professor, Rosalind Franklin University of Medicine and Science, and Emergency Medicine Clinical Pharmacist, Northwestern Memorial Hospital, Chicago, IL
| | - Dion Tyler
- Kelsea Caruso, PharmD, Emergency Medicine Clinical Pharmacist, Northwestern Memorial Hospital, Chicago, IL
- Dion Tyler, PharmD, PGY2 Emergency Medicine Pharmacy Resident, Rosalind Franklin University of Medicine and Science and Northwestern Memorial Hospital, Chicago, IL
- Abbie Lyden, PharmD, BCPS , Associate Professor, Rosalind Franklin University of Medicine and Science, and Emergency Medicine Clinical Pharmacist, Northwestern Memorial Hospital, Chicago, IL
| | - Abbie Lyden
- Kelsea Caruso, PharmD, Emergency Medicine Clinical Pharmacist, Northwestern Memorial Hospital, Chicago, IL
- Dion Tyler, PharmD, PGY2 Emergency Medicine Pharmacy Resident, Rosalind Franklin University of Medicine and Science and Northwestern Memorial Hospital, Chicago, IL
- Abbie Lyden, PharmD, BCPS , Associate Professor, Rosalind Franklin University of Medicine and Science, and Emergency Medicine Clinical Pharmacist, Northwestern Memorial Hospital, Chicago, IL
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Kumar A, Kohli A. Comeback of ketamine: resurfacing facts and dispelling myths. Korean J Anesthesiol 2021; 74:103-114. [PMID: 33423410 PMCID: PMC8024210 DOI: 10.4097/kja.20663] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 01/10/2021] [Accepted: 01/10/2021] [Indexed: 11/17/2022] Open
Abstract
Initially known as CI-581, ketamine was first synthesized in 1962 as a replacement from phencyclidine. It has since been used as an anesthetic and analgesic. In addition, it has bronchodilating, sedative, and amnestic properties, preserving airway reflexes and sympathetic nervous system tone. Since the discovery of ketamine, it has been a major topic of discussion due to controversies regarding its usage in particular sets of patients. In the past 50 years, despite its potential benefits, it is not commonly used because of concerns of "emergence phenomenon," its use as a substance of abuse, and its systemic side effects. Since 2012, three World Health Organization reviews on ketamine have addressed its international control. Researchers have been studying this wonder drug for a decade worldwide. Many myths of ketamine regarding emergence phenomenon and its use in traumatic brain injury and open eye injury have been disproved in recent times. It is becoming popular in pre-hospital settings, critical care, emergency medicine, low-dose acute pain services, and adjuvant in regional anesthesia techniques. This review highlights the current consensus on the various applications of ketamine in the literature.
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Affiliation(s)
- Abhijit Kumar
- Department of Anesthesiology, VMMC and Safdarjung Hospital, New Delhi, India
| | - Amit Kohli
- Department of Anesthesiology, Maulana Azad Medical College, New Delhi, India
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Jamal D, Powell C. Paediatric procedural sedation in the emergency department: is ketamine safe? Arch Dis Child Educ Pract Ed 2021; 106:120-124. [PMID: 32522748 DOI: 10.1136/archdischild-2019-318610] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 03/31/2020] [Accepted: 05/12/2020] [Indexed: 11/03/2022]
Affiliation(s)
- Dried Jamal
- Pediatric Emergency, Sidra Medical and Research Center, Doha, Qatar
| | - Colin Powell
- Emergency Medicine, Sidra Medical and Research Center, Doha, Qatar .,Division of Population Medicine, Cardiff University School of Medicine, Cardiff, UK
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Abstract
CASE DESCRIPTION A 10-year-old 7-kg (15.4-lb) neutered male Shih Tzu was referred for evaluation because of a sudden onset of dullness and intermittent vomiting of 1 to 2 weeks' duration. Two days prior to evaluation, clinical signs had worsened and 1 seizure was reported. CLINICAL FINDINGS A 3.5 × 2.5-cm soft, dome-shaped mass of the right occipital region of the head was noted on physical examination. Radiography and CT confirmed the presence of the mass and indicated its intra- and extracranial expansion. The MRI images showed compression of the cerebellum by the mass, with distinct margins of hypointensity on both T1- and T2-weighted images. TREATMENT AND OUTCOME Surgery was performed, and the mass was completely excised. The dog had mild ataxia, hypermetria, and head tremors after surgery. Histologic examination of the mass yielded a diagnosis of intradiploic epidermoid cyst. On examination 3 weeks after surgery, the previous neurologic signs had resolved. On examination 25 months after surgery, the dog remained free of clinical signs. CLINICAL RELEVANCE The present report described the clinical signs, diagnostic imaging results, and successful surgical removal of an intradiploic epidermoid cyst in a dog. Long-term prognosis may be good with complete removal of intradiploic epidermoid cysts in dogs.
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Schauer SG, Naylor JF, Davis WT, Borgman MA, April MD. An Analysis of Prolonged, Continuous Ketamine Infusions. Mil Med 2021; 187:e547-e553. [PMID: 33492388 DOI: 10.1093/milmed/usaa481] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 09/21/2020] [Accepted: 01/22/2021] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Opioids carry high risk of dependence, and patients can rapidly build tolerance after repetitive dosing. Low-dose ketamine is an analgesic agent alternative that provides more hemodynamic stability. We sought to describe the effects of prolonged ketamine use in non-burn patients. MATERIALS AND METHODS We queried the electronic health system at the Brooke Army Medical Center for patient encounters with ketamine infusions lasting >72 hours. We abstracted data describing demographics, vital signs, ketamine infusion dose and duration, and discharge diagnoses potentially relevant to ketamine side effects. RESULTS We identified 194 subjects who met the study inclusion criteria. The median age was 39 years, most were male (67.0%), and most were primarily admitted for a non-trauma reason (59.2%). The mean ketamine drip strength was 43.9 mg/h (95% CI, 36.7-51.1; range 0.1-341.6) and the mean drip length was 130.8 hours (95% CI, 120.3-141.2; range 71-493). Most subjects underwent mechanical ventilation (56.1%) at some point during the infusion and most survived to hospital discharge (83.5%). On a per-day basis, the average heart rate was 93 beats per minute, systolic blood pressure was 128 mmHg, diastolic blood pressure was 71 mmHg, oxygen saturation was 96%, and respiratory rate was 22 respirations per minute. CONCLUSIONS We demonstrate that continuous ketamine infusions provide a useful adjunct for analgesia and/or sedation. Further development of this adjunct modality may serve as an alternative agent to opioids.
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Affiliation(s)
- Steven G Schauer
- Combat Mortality Prevention Division, US Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, TX, USA.,Department of Emergency Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, TX, USA.,Department of Pediatrics, 59th Medical Wing, JBSA Lackland, San Antonio, TX, USA.,Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Jason F Naylor
- Department of Emergency Medicine, Madigan Army Medical Center, Joint Base Lewis McChord, Tacoma, Washington, DC, USA
| | - William T Davis
- Department of Emergency Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, TX, USA.,Department of Pediatrics, 59th Medical Wing, JBSA Lackland, San Antonio, TX, USA.,Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Matthew A Borgman
- 2nd Brigade, 4th Infantry Division, Fort Carson, Colorado Springs, CO, USA.,Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Michael D April
- 2nd Brigade, 4th Infantry Division, Fort Carson, Colorado Springs, CO, USA
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Serfozo K, Tarnal V. Anesthetic Management of Patients Undergoing Open Suboccipital Surgery. Anesthesiol Clin 2021; 39:93-111. [PMID: 33563388 DOI: 10.1016/j.anclin.2020.11.001] [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: 11/29/2022]
Abstract
The posterior cranial fossa with its complex anatomy houses key pathways regulating consciousness, autonomic functions, motor and sensory pathways, and cerebellar centers regulating balance and gait. The most common posterior fossa pathologies for which neurosurgical intervention may be necessary include cerebellopontine angle tumors, aneurysms, and metastatic lesions. The posterior cranial fossa can be accessed from variations of the supine, lateral, park-bench, prone, and sitting positions. Notable complications from positioning include venous air embolism, paradoxic air embolism, tension pneumocephalus, nerve injuries, quadriplegia, and macroglossia. An interdisciplinary approach with careful planning, discussion, and clinical management contributes to improved outcomes and reduced complications.
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Affiliation(s)
- Kelsey Serfozo
- Department of Anesthesiology, University Hospital, University of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5048, USA
| | - Vijay Tarnal
- Department of Anesthesiology, University Hospital, University of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5048, USA.
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Godoy DA, Badenes R, Pelosi P, Robba C. Ketamine in acute phase of severe traumatic brain injury "an old drug for new uses?". CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:19. [PMID: 33407737 PMCID: PMC7788834 DOI: 10.1186/s13054-020-03452-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 12/22/2020] [Indexed: 01/02/2023]
Abstract
Maintaining an adequate level of sedation and analgesia plays a key role in the management of traumatic brain injury (TBI). To date, it is unclear which drug or combination of drugs is most effective in achieving these goals. Ketamine is an agent with attractive pharmacological and pharmacokinetics characteristics. Current evidence shows that ketamine does not increase and may instead decrease intracranial pressure, and its safety profile makes it a reliable tool in the prehospital environment. In this point of view, we discuss different aspects of the use of ketamine in the acute phase of TBI, with its potential benefits and pitfalls.
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Affiliation(s)
- Daniel Agustin Godoy
- Neurointensive Care Unit, Sanatorio Pasteur, Catamarca, Argentina.,Intensive Care Unit, Hospital Carlos Malbran, Catamarca, Argentina
| | - Rafael Badenes
- Anesthesiology and Surgical-Trauma Intensive Care, University Clinic Hospital, Valencia, Spain.,Department of Surgery, University of Valencia, Valencia, Spain.,INCLIVA Research Medical Institute, Valencia, Valencia, Spain
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy. .,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.
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Prakash S, Gupta AK, Meena JP, Seth R. A review of the clinical applications of ketamine in pediatric oncology. Pediatr Blood Cancer 2021; 68:e28785. [PMID: 33128439 DOI: 10.1002/pbc.28785] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 10/16/2020] [Accepted: 10/19/2020] [Indexed: 12/30/2022]
Abstract
Ketamine is a dissociative anesthetic agent with excellent analgesic properties and a favorable safety profile. The feasibility and efficacy of various routes of administration have been established, including intravenous (IV), intramuscular (IM), oral, intranasal, rectal, and transdermal routes. The advent of newer anesthetic agents has led to a decline in the use of ketamine as an anesthetic, but its utility in short-term sedation and analgesia has expanded. Its value for chronic pain management in children with cancer is being increasingly recognized but requires more evidence. The use of topical ketamine is largely in investigational stages. Medical use of ketamine is, to a great extent, free from significant long-term neurological side effects. The objective of this review is to provide a brief account of the pharmacology of ketamine and primarily focus on the clinical applications of ketamine in pediatric oncology.
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Affiliation(s)
- Satya Prakash
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Aditya Kumar Gupta
- Division of Pediatric Oncology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Jagdish Prasad Meena
- Division of Pediatric Oncology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Rachna Seth
- Division of Pediatric Oncology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
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Gaspard N. Super K for Super-R(efractory) Status Epilepticus: Bringing Down Seizures While Keeping Up Blood Pressure With Ketamine. Epilepsy Curr 2020; 21:36-39. [PMID: 34025272 PMCID: PMC7863299 DOI: 10.1177/1535759720975740] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Ketamine to treat super-refractory status epilepticus Alkhachroum A, Der-Nigoghossian CA, Mathews E, Massad N, Letchinger R, Doyle K, Chiu W-T, Kromm J, Rubinos C, Velazquez A, Roh D, Agarwal S, Park S, Connolly S, Claassen J. Neurology. 2020;95(16):e2286-e2294. doi: 10.1212/WNL.0000000000010611. Objective: To test ketamine infusion efficacy in the treatment of superrefractory status epilepticus (SRSE), we studied patients with SRSE who were treated with ketamine retrospectively. We also studied the effect of high doses of ketamine on brain physiology as reflected by invasive multimodality monitoring (MMM). Methods: We studied a consecutive series of 68 patients with SRSE who were admitted between 2009 and 2018, treated with ketamine, and monitored with scalp EEG. Eleven of these patients underwent MMM at the time of ketamine administration. We compared patients who had seizure cessation after ketamine initiation to those who did not. Results: Mean age was 53 ± 18 years and 46% of patients were female. Seizure burden decreased by at least 50% within 24 hours of starting ketamine in 55 (81%) patients, with complete cessation in 43 (63%). Average dose of ketamine infusion was 2.2 ± 1.8 mg/kg/h, with median duration of 2 (1-4) days. Average dose of midazolam was 1.0 ± 0.8 mg/kg/h at the time of ketamine initiation and was started at a median of 0.4 (0.1-1.0) days before ketamine. Using a generalized linear mixed effect model, ketamine was associated with stable mean arterial pressure (odds ratio = 1.39, 95% CI: 1.38-1.40) and with decreased vasopressor requirements over time. We found no effect on intracranial pressure, cerebral blood flow, or cerebral perfusion pressure. Conclusion: Ketamine treatment was associated with a decrease in seizure burden in patients with SRSE. Our data support the notion that high-dose ketamine infusions are associated with decreased vasopressor requirements without increased intracranial pressure. Classification of Evidence: This study provides Class IV evidence that ketamine decreases seizures in patients with SRSE.
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Fisher AD, DesRosiers TT, Drew BG. Prehospital Analgesia and Sedation: a Perspective from the Battlefield. CURRENT TRAUMA REPORTS 2020. [DOI: 10.1007/s40719-020-00199-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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48
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Der-Nigoghossian C, Tesoro EP, Strein M, Brophy GM. Principles of Pharmacotherapy of Seizures and Status Epilepticus. Semin Neurol 2020; 40:681-695. [PMID: 33176370 DOI: 10.1055/s-0040-1718721] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Status epilepticus is a neurological emergency with an outcome that is highly associated with the initial pharmacotherapy management that must be administered in a timely fashion. Beyond first-line therapy of status epilepticus, treatment is not guided by robust evidence. Optimal pharmacotherapy selection for individual patients is essential in the management of seizures and status epilepticus with careful evaluation of pharmacokinetic and pharmacodynamic factors. With the addition of newer antiseizure agents to the market, understanding their role in the management of status epilepticus is critical. Etiology-guided therapy should be considered in certain patients with drug-induced seizures, alcohol withdrawal, or autoimmune encephalitis. Some patient populations warrant special consideration, such as pediatric, pregnant, elderly, and the critically ill. Seizure prophylaxis is indicated in select patients with acute neurological injury and should be limited to the acute postinjury period.
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Affiliation(s)
- Caroline Der-Nigoghossian
- Department of Pharmacy, Neurosciences Intensive Care Unit, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Eljim P Tesoro
- Department of Pharmacy Practice (MC 886), College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
| | - Micheal Strein
- Pharmacotherapy and Outcomes Science and Neurosurgery, Medical College of Virginia Campus, Virginia Commonwealth University, Richmond, Virginia
| | - Gretchen M Brophy
- Pharmacotherapy and Outcomes Science and Neurosurgery, Medical College of Virginia Campus, Virginia Commonwealth University, Richmond, Virginia
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Khozenko A, Lamperti M, Velly L, Simeone P, Tufegdzic B. Role of anaesthesia in neurosurgical enhanced recovery programmes. Best Pract Res Clin Anaesthesiol 2020; 35:241-253. [PMID: 34030808 DOI: 10.1016/j.bpa.2020.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 10/29/2020] [Accepted: 11/02/2020] [Indexed: 12/12/2022]
Abstract
The application of Enhanced Recovery After Surgery (ERAS) in neurosurgical practice is a relatively new concept. A limited number of studies involving ERAS protocols within neurosurgery, specifically for elective craniotomy, have been published, contrary to the ERAS spine surgery pathways that are now promoted by numerous national and international dedicated surgical societies and hospitals. In this review, we want to present the patient surgical journey from an anaesthesia perspective through the key components that can be included in the ERAS pathways for neurosurgical procedures, both craniotomies and major spine surgery.
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Affiliation(s)
- Andrey Khozenko
- Anaesthesiology Institute, Cleveland Clinic Abu Dhabi, Al Maryah Island, PO box 112412, Abu Dhabi, United Arab Emirates
| | - Massimo Lamperti
- Anaesthesiology Institute, Cleveland Clinic Abu Dhabi, Al Maryah Island, PO box 112412, Abu Dhabi, United Arab Emirates.
| | - Lionel Velly
- Aix Marseille Univ, AP-HM, Department of Anesthesiology and Critical Care Medicine, University Hospital Timone, 264 rue saint Pierre, 13005, CEDEX 5, Marseille, France.
| | - Pierre Simeone
- Aix Marseille Univ, AP-HM, Department of Anesthesiology and Critical Care Medicine, University Hospital Timone, 264 rue saint Pierre, 13005, CEDEX 5, Marseille, France.
| | - Boris Tufegdzic
- Anaesthesiology Institute, Cleveland Clinic Abu Dhabi, Al Maryah Island, PO box 112412, Abu Dhabi, United Arab Emirates.
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Shriki J, Galvagno SM. Sedation for Rapid Sequence Induction and Intubation of Neurologically Injured Patients. Emerg Med Clin North Am 2020; 39:203-216. [PMID: 33218658 DOI: 10.1016/j.emc.2020.09.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
There are subtle physiologic and pharmacologic principles that should be understood for patients with neurologic injuries. These principles are especially true for managing patients with traumatic brain injuries. Prevention of hypotension and hypoxemia are major goals in the management of these patients. This article discusses the physiology, pitfalls, and pharmacology necessary to skillfully care for this subset of patients with trauma. The principles endorsed in this article are applicable both for patients with traumatic brain injury and those with spinal cord injuries.
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Affiliation(s)
- Jesse Shriki
- Surgical Critical Care, R Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD 21201, USA.
| | - Samuel M Galvagno
- Multi Trauma Critical Care Unit, R Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD, USA
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