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Oatts JT, Shen S, Zhu H, Gong Q, Yu Y, Ying GS, Han Y, Liu H. A Prospective Study of the Effects of General Anesthesia on Intraocular Pressure in Healthy Children. OPHTHALMOLOGY SCIENCE 2024; 4:100455. [PMID: 38313401 PMCID: PMC10837640 DOI: 10.1016/j.xops.2023.100455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 12/07/2023] [Accepted: 12/11/2023] [Indexed: 02/06/2024]
Abstract
Purpose To determine the effect of general anesthesia on intraocular pressure (IOP) in children with no intraocular pathology and determine which postanesthetic time point is most predictive of preinduction IOP. Design Prospective observational study. Participants Children with no intraocular pathology ≤ 18 years scheduled for general anesthesia as part of their routine care followed by a pediatric ophthalmologist at Nanjing Medical University. Methods Participants underwent a standardized general anesthetic protocol using a mask induction with sevoflurane and propofol maintenance. Intraocular pressure was measured at the following 7 time points: preinduction (taken in the preoperative area), postinduction minutes 1, 3, and 5, and postairway placement minutes 1, 3, and 5 for a total time period of 10 minutes after induction. A generalized estimating equation was used to evaluate the effect of anesthesia on IOP and the effect of patient factors (age, gender, vital signs, and airway type) on preanesthetic and postanesthetic IOP. An IOP prediction model was developed using the postanesthesia IOP measurements for predicting preinduction IOP. Main Outcome Measures Intraocular pressure and change in IOP at prespecified time points. Results Eighty-five children were enrolled with a mean ± standard deviation (SD) age of 7.5 ± 2.9 years. Mean ± SD preinduction IOP was 20.1 ± 3.7 mmHg. Overall, IOP was lowest at 3 minutes postinduction, decreased to a mean of 13.4 ± 3.7 mmHg (P < 0.001). After this, IOP rose 5 minutes postinduction to 16.5 ± 4.2 mmHg, which did not reach preinduction IOP levels (P < 0.001). The IOP prediction model showed that combining 1 minute postinduction and 3 minutes postairway was most predictive (R2 = 0.13), whereas 1 minute postairway was least predictive of preinduction IOP (R2 = 0.01). Conclusions After the induction of general anesthesia in children, IOP temporarily decreases with a trough at 3 minutes postinduction before increasing and remaining stable just below preinduction levels. Intraocular pressure measurements taken 1 minute after induction with 3 minutes after airway placement are most predictive of preinduction IOP, though predictive value is relatively low. Financial Disclosures Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
- Julius T. Oatts
- Department of Ophthalmology, University of California, San Francisco, San Francisco, California
| | - Shiya Shen
- Department of Ophthalmology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Hui Zhu
- Department of Ophthalmology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Qi Gong
- Department of Ophthalmology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Yinxi Yu
- Center for Preventive Ophthalmology and Biostatistics, Department of Ophthalmology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gui-shuang Ying
- Center for Preventive Ophthalmology and Biostatistics, Department of Ophthalmology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ying Han
- Department of Ophthalmology, University of California, San Francisco, San Francisco, California
| | - Hu Liu
- Department of Ophthalmology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
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Araki T, Shimazawa M, Nakamura S, Otsu W, Numata Y, Sakata M, Kabayama K, Tsusaki H, Hara H. Investigation into the usefulness of cynomolgus monkeys with spontaneously elevated intraocular pressure as a model for glaucoma treatment research. J Pharmacol Sci 2024; 154:52-60. [PMID: 38246728 DOI: 10.1016/j.jphs.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 11/30/2023] [Accepted: 12/07/2023] [Indexed: 01/23/2024] Open
Abstract
Many glaucoma treatments focus on lowering intraocular pressure (IOP), with novel drugs continuing to be developed. One widely used model involves raising IOP by applying a laser to the trabecular iris angle (TIA) of cynomolgus monkeys to damage the trabecular meshwork. This model, however, presents challenges such as varying IOP values, potential trabecular meshwork damage, and risk of animal distress. This study investigated whether animals with naturally high IOP (>25 mmHg) could be used to effectively evaluate IOP-lowering drugs, thereby possibly replacing laser-induced models. Relationships between TIA size, IOP, and pupil diameter were also examined. Three representative IOP-lowering drugs (latanoprost, timolol, ripasudil) were administered, followed by multiple IOP measurements and assessment of corneal thickness, TIA, and pupil diameter via anterior segment optical coherence tomography (AS-OCT). There was a positive correlation was noted between IOP and corneal thickness before instillation, and a negative correlation between IOP and TIA before instillation. Our findings suggest animals with naturally high IOP could be beneficial for glaucoma research and development as a viable replacement for the laser-induced model and that measuring TIA using AS-OCT along with IOP yields a more detailed evaluation.
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Affiliation(s)
- Tomoaki Araki
- Shin Nippon Biomedical Laboratories Ltd. Drug Safety Research Laboratories (SNBL DSR), Kagoshima, Japan
| | - Masamitsu Shimazawa
- Molecular Pharmacology, Department of Biofunctional Evaluation, Gifu Pharmaceutical University, Gifu, Japan; Biomedical Research, Gifu Pharmaceutical University, Gifu, Japan.
| | - Shinsuke Nakamura
- Molecular Pharmacology, Department of Biofunctional Evaluation, Gifu Pharmaceutical University, Gifu, Japan
| | - Wataru Otsu
- Biomedical Research, Gifu Pharmaceutical University, Gifu, Japan
| | - Yosuke Numata
- Shin Nippon Biomedical Laboratories Ltd. Drug Safety Research Laboratories (SNBL DSR), Kagoshima, Japan
| | - Megumi Sakata
- Shin Nippon Biomedical Laboratories Ltd. Drug Safety Research Laboratories (SNBL DSR), Kagoshima, Japan
| | - Koji Kabayama
- Shin Nippon Biomedical Laboratories Ltd. Drug Safety Research Laboratories (SNBL DSR), Kagoshima, Japan
| | - Hideshi Tsusaki
- Shin Nippon Biomedical Laboratories Ltd. Drug Safety Research Laboratories (SNBL DSR), Kagoshima, Japan; Biomedical Research, Gifu Pharmaceutical University, Gifu, Japan
| | - Hideaki Hara
- Molecular Pharmacology, Department of Biofunctional Evaluation, Gifu Pharmaceutical University, Gifu, Japan; Biomedical Research, Gifu Pharmaceutical University, Gifu, Japan
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Engstrom K, Brown CS, Mattson AE, Lyons N, Rech MA. Pharmacotherapy optimization for rapid sequence intubation in the emergency department. Am J Emerg Med 2023; 70:19-29. [PMID: 37196592 DOI: 10.1016/j.ajem.2023.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 05/04/2023] [Accepted: 05/04/2023] [Indexed: 05/19/2023] Open
Abstract
PURPOSE Rapid-sequence intubation (RSI) is the process of administering a sedative and neuromuscular blocking agent (NMBA) in rapid succession to facilitate endotracheal intubation. It is the most common and preferred method for intubation of patients presenting to the emergency department (ED). The selection and use of medications to facilitate RSI is critical for success. The purpose of this review is to describe pharmacotherapies used during the RSI process, discuss current clinical controversies in RSI medication selection, and review pharmacotherapy considerations for alternative intubation methods. SUMMARY There are several steps to the intubation process requiring medication considerations, including pretreatment, induction, paralysis, and post-intubation sedation and analgesia. Pretreatment medications include atropine, lidocaine, and fentanyl; but use of these agents in clinical practice has fallen out of favor as there is limited evidence for their use outside of select clinical scenarios. There are several options for induction agents, though etomidate and ketamine are the most used due to their more favorable hemodynamic profiles. Currently there is retrospective evidence that etomidate may produce less hypotension than ketamine in patients presenting with shock or sepsis. Succinylcholine and rocuronium are the preferred neuromuscular blocking agents, and the literature suggests minimal differences between succinylcholine and high dose rocuronium in first-pass success rates. Selection between the two is based on patient specific factors, half-life and adverse effect profiles. Finally, medication-assisted preoxygenation and awake intubation are less common methods for intubation in the ED but require different considerations for medication use. AREAS FOR FUTURE RESEARCH The optimal selection, dosing, and administration of RSI medications is complicated, and further research is needed in several areas. Additional prospective studies are needed to determine optimal induction agent selection and dosing in patients presenting with shock or sepsis. Controversy exists over optimal medication administration order (paralytic first vs induction first) and medication dosing in obese patients, but there is insufficient evidence to significantly alter current practices regarding medication dosing and administration. Further research examining awareness with paralysis during RSI is needed before definitive and widespread practice changes to medication use during RSI can be made.
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Affiliation(s)
- Kellyn Engstrom
- Department of Pharmacy, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55905, United States of America.
| | - Caitlin S Brown
- Department of Pharmacy, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Alicia E Mattson
- Department of Pharmacy, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Neal Lyons
- Loyola University Chicago, Loyola University Medical Center, Stritch School of Medicine, Department of Emergency Medicine, S 1st Ave, Maywood, IL 60153, United States of America; Loyola University Medical Center, Department of Pharmacy, S 1st Ave, Maywood, IL 60153, United States of America
| | - Megan A Rech
- Loyola University Chicago, Loyola University Medical Center, Stritch School of Medicine, Department of Emergency Medicine, S 1st Ave, Maywood, IL 60153, United States of America; Loyola University Medical Center, Department of Pharmacy, S 1st Ave, Maywood, IL 60153, United States of America
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Osama NA, Mohamed MK, Aboul Fetouh IS, Sherif NA. Ketamine versus midazolam as an adjuvant to peribulbar block using a single inferonasal injection in patients undergoing vitreoretinal surgery: A randomized controlled trial. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2023; 70:276-283. [PMID: 36934847 DOI: 10.1016/j.redare.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 03/13/2022] [Indexed: 04/23/2023]
Abstract
INTRODUCTION AND OBJECTIVES This study aimed to assess the safety and efficacy of midazolam and ketamine as adjuvants to the peribulbar block in vitreoretinal surgeries. PATIENTS AND METHODS This randomized controlled trial included 93 adult patients undergoing vitreoretinal surgeries performed with peribulbar anaesthesia. Patients were randomly allocated to 3 groups (31 participants each): control (standard anaesthetic mixture), midazolam (standard mixture + midazolam), and ketamine (standard mixture + ketamine). The primary outcomes were onset of globe akinesia and duration of analgesia. Secondary outcomes were duration of motor blockade, onset of corneal anaesthesia and lid akinesia, and changes in vital data (blood pressure, oxygen saturation, and pulse rate). RESULTS The ketamine group vs. the control and midazolam groups showed the most rapid onset of lid and globe akinesia (p < 0.001) and corneal anaesthesia (0.7 ± 0.2 vs. 1.5 ± 0.5 and 1.2 ± 0.4, respectively; p < 0.001) and the longest duration of both analgesia (3.7 ± 0.6 vs. 2.3 ± 0.4 and 3.1 ± 0.6, respectively; p < 0.001) and akinesia (3.8 ± 0.5 vs. 3.0 ± 0.4, and 3.7 ± 0.5, respectively; p < 0.001). The midazolam group showed better outcomes than controls, but the drug was less effective than ketamine. There were no significant differences in vital data among groups (p > 0.05). CONCLUSIONS Ketamine is an effective adjuvant for peribulbar blockade. It enhances both motor and sensory blockade by hastening onset and prolonging duration. These effects are desirable in lengthier ophthalmic procedures such as vitreoretinal surgeries. The effects of ketamine were superior to those of midazolam.
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Affiliation(s)
- Noha A Osama
- Department of Anesthesia, Research Institute of Ophthalmology, Giza, Egypt.
| | - Mayada K Mohamed
- Department of Anesthesia, Research Institute of Ophthalmology, Giza, Egypt
| | | | - Norhan A Sherif
- Department of Anesthesia, Research Institute of Ophthalmology, Giza, Egypt
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Beach KM, Hung LF, Lou L, Ostrin LA. Diurnal Variation and Effects of Dilation and Sedation on Intraocular Pressure in Infant Rhesus Monkeys. Curr Eye Res 2023; 48:289-296. [PMID: 36357337 PMCID: PMC10006333 DOI: 10.1080/02713683.2022.2141782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 10/26/2022] [Indexed: 11/12/2022]
Abstract
PURPOSE Intraocular pressure (IOP) is an important factor in numerous ocular conditions and research areas, including eye growth and myopia. In infant monkeys, IOP is typically measured under anesthesia. This study aimed to establish a method for awake IOP measurement in infant rhesus monkeys, determine diurnal variation, and assess the effects of dilation and sedation. METHODS Awake IOP (iCare TonoVet) was measured every 2 h from 7:30 am to 5:30 pm to assess potential diurnal variations in infant rhesus monkeys (age 3 weeks, n = 11). The following day, and every 2 weeks to age 15 weeks, IOP was measured under three conditions: (1) awake, (2) awake and dilated (tropicamide 0.5%), and (3) sedated (ketamine and acepromazine) and dilated. Intraclass correlation coefficient (ICC) was used to determine intersession repeatability, and repeated measures. ANOVA was used to determine effects of age and condition. RESULTS At age 3 weeks, mean (±SEM) awake IOP was 15.4 ± 0.6 and 15.2 ± 0.7 mmHg for right and left eyes, respectively (p=.59). The ICC between sessions was 0.63[-0.5 to 0.9], with a mean difference of 2.2 ± 0.3 mmHg. Diurnal IOP from 7:30 am to 5:30 pm showed no significant variation (p=.65). From 3 to 15 weeks of age, there was a significant effect of age (p=.01) and condition (p<.001). Across ages, IOP was 17.8 ± 0.7 mmHg while awake and undilated, 18.4 ± 0.2 mmHg awake and dilated, and 11.0 ± 0.3 mmHg after sedation and dilation. CONCLUSIONS Awake IOP measurement was feasible in young rhesus monkeys. No significant diurnal variations in IOP were observed between 7:30 am and 5:30 pm at age 3 weeks. In awake monkeys, IOP was slightly higher after mydriasis and considerably lower after sedation. Findings show that IOP under ketamine/acepromazine anesthesia is significantly different than awake IOP in young rhesus monkeys.
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Affiliation(s)
- Krista M Beach
- University of Houston College of Optometry, Houston, TX, United States
| | - Li-Fang Hung
- University of Houston College of Optometry, Houston, TX, United States
| | - Linjiang Lou
- University of Houston College of Optometry, Houston, TX, United States
| | - Lisa A Ostrin
- University of Houston College of Optometry, Houston, TX, United States
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Shilo-Benjamini Y, Pe'er O, Abu Ahmad W, Ofri R. Effect of anesthetic induction with propofol, alfaxalone or ketamine on intraocular pressure in cats: a randomized masked clinical investigation. Vet Anaesth Analg 2023; 50:63-71. [PMID: 36528512 DOI: 10.1016/j.vaa.2022.11.005] [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: 08/13/2022] [Revised: 11/11/2022] [Accepted: 11/13/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To compare the effect of propofol, alfaxalone and ketamine on intraocular pressure (IOP) in cats. STUDY DESIGN Prospective, masked, randomized clinical trial. ANIMALS A total of 43 ophthalmologically normal cats scheduled to undergo general anesthesia for various procedures. METHODS Following baseline IOP measurements using applanation tonometry, anesthesia was induced with propofol (n = 15), alfaxalone (n = 14) or ketamine (n = 14) administered intravenously to effect. Then, midazolam (0.3 mg kg-1) was administered intravenously and endotracheal intubation was performed without application of topical anesthesia. The IOP was measured following each intervention. Data was analyzed using one-way anova and repeated-measures mixed design with post hoc analysis. A p-value <0.05 was considered significant. RESULTS Mean ± standard error IOP at baseline was not different among groups (propofol, 18 ± 0.6; alfaxalone, 18 ± 0.7; ketamine, 17 ± 0.5 mmHg). Following induction of anesthesia, IOP increased significantly compared with baseline in the propofol (20 ± 0.7 mmHg), but not in the alfaxalone (19 ± 0.8 mmHg) or ketamine (16 ± 0.7 mmHg) groups. Midazolam administration resulted in significant decrease from the previous measurement in the alfaxalone group (16 ± 0.7 mmHg), but not in the propofol group (19 ± 0.7 mmHg) or the ketamine (16 ± 0.8 mmHg) group. A further decrease was measured after intubation in the alfaxalone group (15 ± 0.9 mmHg). CONCLUSIONS AND CLINICAL RELEVANCE Propofol should be used with caution in cats predisposed to perforation or glaucoma, as any increase in IOP should be avoided.
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Affiliation(s)
- Yael Shilo-Benjamini
- Koret School of Veterinary Medicine, The Robert H. Smith Faculty of Agriculture, Food and Environment, The Hebrew University of Jerusalem, Rehovot, Israel.
| | - Oren Pe'er
- Koret School of Veterinary Medicine, The Robert H. Smith Faculty of Agriculture, Food and Environment, The Hebrew University of Jerusalem, Rehovot, Israel
| | - Wiessam Abu Ahmad
- Koret School of Veterinary Medicine, The Robert H. Smith Faculty of Agriculture, Food and Environment, The Hebrew University of Jerusalem, Rehovot, Israel
| | - Ron Ofri
- Koret School of Veterinary Medicine, The Robert H. Smith Faculty of Agriculture, Food and Environment, The Hebrew University of Jerusalem, Rehovot, Israel
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Hampton JP, Hommer K, Musselman M, Bilhimer M. Rapid sequence intubation and the role of the emergency medicine pharmacist: 2022 update. Am J Health Syst Pharm 2022; 80:182-195. [PMID: 36306474 PMCID: PMC9620375 DOI: 10.1093/ajhp/zxac326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Indexed: 12/05/2022] Open
Abstract
PURPOSE The dosing, potential adverse effects, and clinical outcomes of the most commonly utilized pharmacologic agents for rapid sequence intubation (RSI) are reviewed for the practicing emergency medicine pharmacist (EMP). SUMMARY RSI is the process of establishing a safe, functional respiratory system in patients unable to effectively breathe on their own. Various medications are chosen to sedate and even paralyze the patient to facilitate an efficient endotracheal intubation. The mechanism of action and pharmacokinetic/pharmacodynamic profiles of these agents were described in a 2011 review. Since then, the role of the EMP as well as the published evidence regarding RSI agents, including dosing, adverse effects, and clinical outcomes, has grown. It is necessary for the practicing EMP to update previous practice patterns in order to continue to provide optimal patient care. CONCLUSION While the agents used in RSI have changed little, knowledge regarding optimal dosing, appropriate patient selection, and possible adverse effects continues to be gained. The EMP is a key member of the bedside care team and uniquely positioned to communicate this evolving data.
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Affiliation(s)
- Jeremy P Hampton
- University of Missouri-Kansas City School of Pharmacy, Kansas City, MO, and University Health Kansas City, Kansas City, MO, USA
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Lengvenyte A, Strumila R, Olié E, Courtet P. Ketamine and esketamine for crisis management in patients with depression: Why, whom, and how? Eur Neuropsychopharmacol 2022; 57:88-104. [PMID: 35219097 DOI: 10.1016/j.euroneuro.2022.02.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 02/02/2022] [Accepted: 02/04/2022] [Indexed: 12/13/2022]
Abstract
Currently, only a limited number of interventions can rapidly relieve depressive symptomatology in patients with major depressive disorder or bipolar disorder experiencing extreme distress. Such crises, especially when suicide attempt or ideation is involved, are a major risk factor of suicide. Ketamine, a N-methyl-d-aspartate glutamate receptor antagonist, and its enantiomer esketamine rapidly reduce depressive symptoms in depressed patients with current suicidal ideation. Recently, esketamine has been approved for use in patients with depression at risk of suicide and for psychiatric emergency by major medical agencies in the United States and Europe, whereas ketamine is increasingly used off-label. However, there is currently limited guidance on why, when, and how to use these drugs in patients with depression to treat a crisis. In this review article, we provide a succinct overview of the cellular and molecular mechanisms of action of ketamine and esketamine, and of the functional brain changes following their administration. We also summarize the major clinical studies on ketamine and esketamine efficacy in patients experiencing a crisis (generally, suicidal ideation), and propose a profile of patients who can benefit most from such drugs, on the basis of neurobiological and clinical observations. Finally, we describe the administration mode, the efficacy and tolerability profiles, the side effect management, possible concomitant treatments and the issue of deprescribing.
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Affiliation(s)
- Aiste Lengvenyte
- Department of Emergency Psychiatry and Acute Care, CHU Montpellier, France; IGF, University of Montpellier, CNRS, INSERM, Montpellier, France; Psychiatric Clinic, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.
| | - Robertas Strumila
- Department of Emergency Psychiatry and Acute Care, CHU Montpellier, France; IGF, University of Montpellier, CNRS, INSERM, Montpellier, France; Psychiatric Clinic, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Emilie Olié
- Department of Emergency Psychiatry and Acute Care, CHU Montpellier, France; IGF, University of Montpellier, CNRS, INSERM, Montpellier, France
| | - Philippe Courtet
- Department of Emergency Psychiatry and Acute Care, CHU Montpellier, France; IGF, University of Montpellier, CNRS, INSERM, Montpellier, France
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Jarvis JL, Lyng JW, Miller BL, Perlmutter MC, Abraham H, Sahni R. Prehospital Drug Assisted Airway Management: An NAEMSP Position Statement and Resource Document. PREHOSP EMERG CARE 2022; 26:42-53. [PMID: 35001829 DOI: 10.1080/10903127.2021.1990447] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Airway management is a critical intervention for patients with airway compromise, respiratory failure, and cardiac arrest. Many EMS agencies use drug-assisted airway management (DAAM) - the administration of sedatives alone or in combination with neuromuscular blockers - to facilitate advanced airway placement in patients with airway compromise or impending respiratory failure who also have altered mental status, agitation, or intact protective airway reflexes. While DAAM provides several benefits including improving laryngoscopy and making insertion of endotracheal tubes and supraglottic airways easier, DAAM also carries important risks. NAEMSP recommends:DAAM is an appropriate tool for EMS clinicians in systems with clear guidelines, sufficient training, and close EMS physician oversight. DAAM should not be used in settings without adequate resources.EMS physicians should develop clinical guidelines informed by evidence and oversee the training and credentialing for safe and effective DAAM.DAAM programs should include best practices of airway management including patient selection, assessmenct and positioning, preoxygenation strategies including apneic oxygenation, monitoring and management of physiologic abnormalities, selection of medications, post-intubation analgesia and sedation, equipment selection, airway confirmation and monitoring, and rescue airway techniques.Post-DAAM airway placement must be confirmed and continually monitored with waveform capnography.EMS clinicians must have the necessary equipment and training to manage patients with failed DAAM, including bag mask ventilation, supraglottic airway devices and surgical airway approaches.Continuous quality improvement for DAAM must include assessment of individual and aggregate performance metrics. Where available for review, continuous physiologic recordings (vital signs, pulse oximetry, and capnography), audio and video recordings, and assessment of patient outcomes should be part of DAAM continuous quality improvement.
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Kear B, Gold CR, Bhola R. Bilateral Acute Angle-Closure Glaucoma: A Case Report of an Unusual Cause of Acute Headache in a Child. Clin Pract Cases Emerg Med 2021; 5:443-446. [PMID: 34813440 PMCID: PMC8610455 DOI: 10.5811/cpcem.2021.7.52671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 07/26/2021] [Indexed: 11/11/2022] Open
Abstract
Introduction Acute angle-closure glaucoma (AACG) is typically considered a disease of adulthood. However, AACG may occasionally be seen in children. The clinical presentation is similar to adults, including headache, vomiting, and eye pain. However, the etiology of angle closure in children is different and most often associated with congenital anterior segment abnormalities. A precipitating factor of AACG in children with previous established, anterior segment abnormalities is eye dilation, which may occur during routine ophthalmological examination with topical mydriasis, or physiologic mydriasis upon entering a dark room. Case Report We describe a 5-year-old child with a history of severe prematurity and retinopathy of prematurity (ROP) presenting with bilateral AACG following a routine outpatient, dilated ophthalmological examination. While angle-closure glaucoma has previously been reported in cases of ROP, a bilateral acute attack of AACG following pupil dilation in regressed ROP has hitherto been unreported. Conclusion Given the association of ROP and AACG, it can be expected that as the survival rate of premature infants improves, the incidence of ROP and AACG may also increase. It is therefore prudent for the emergency physician to have AACG on the differential for pediatric patients with headache and eye pain.
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Affiliation(s)
- Breelan Kear
- Providence St. Joseph Hospital Orange, Department of Emergency Medicine, Orange, California
| | - Claudia R Gold
- CHOC Children's Hospital, Department of Pediatric Emergency Medicine, Orange, California
| | - Rahul Bhola
- CHOC Children's Hospital, Department of Pediatric Emergency Medicine, Orange, California
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11
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Nicou CM, Pillai A, Passaglia CL. Effects of acute stress, general anesthetics, tonometry, and temperature on intraocular pressure in rats. Exp Eye Res 2021; 210:108727. [PMID: 34390732 DOI: 10.1016/j.exer.2021.108727] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 07/30/2021] [Accepted: 08/10/2021] [Indexed: 10/20/2022]
Abstract
Intraocular pressure (IOP) is important for eye health as abnormal levels can led to ocular tissue damage. IOP is typically estimated by tonometry, which only provides snapshots of pressure history. Tonometry also requires subject cooperation and corneal contact that may influence IOP readings. The aim of this research was to investigate IOP dynamics of conscious animals in response to stressors, common anesthetics, tonometry, and temperature manipulations. An eye of male Brown-Norway rats was implanted with a fluid-filled cannula connected to a wireless telemetry system that records IOP continuously. Stress effects were examined by restricting animal movements. Anesthetic effects were examined by varying isoflurane concentration or injecting a bolus of ketamine. Tonometry effects were examined using applanation and rebound tonometers. Temperature effects were examined by exposing anesthetized and conscious animals to warm or cool surfaces. Telemetry recordings revealed that IOP fluctuates spontaneously by several mmHg, even in idle and anesthetized animals. Environmental disturbances also caused transient IOP fluctuations that were synchronous in recorded animals and could last over a half hour. Animal immobilization produced a rapid sustained elevation of IOP that was blocked by anesthetics, whereas little-to-no IOP change was detected in isoflurane- or ketamine-anesthetized animals if body temperature (BT) was maintained. IOP and BT decreased precipitously when heat support was not provided and were highly correlated during surface temperature manipulations. Surface temperature had no impact on IOP of conscious animals. IOP increased slightly during applanation tonometry but not rebound tonometry. The results show that IOP is dynamically modulated by internal and external factors that can activate rapidly and last long beyond the initiating event. Wireless telemetry indicates that animal interaction induces startle and stress responses that raise IOP. Anesthesia blocks these responses, which allows for better tonometry estimates of resting IOP provided that BT is controlled.
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Affiliation(s)
- Christina M Nicou
- Medical Engineering Department, University of South Florida, Tampa, FL, 33620, USA
| | - Aditi Pillai
- Medical Engineering Department, University of South Florida, Tampa, FL, 33620, USA
| | - Christopher L Passaglia
- Medical Engineering Department, University of South Florida, Tampa, FL, 33620, USA; Ophthalmology Department, University of South Florida, Tampa, FL, 33620, USA.
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Groombridge C, Maini A, Mathew J, O'Keeffe F, Noonan M, Smit DV, Fitzgerald M, Hall A. Orbital decompression. Emerg Med Australas 2021; 33:552-554. [PMID: 33709505 DOI: 10.1111/1742-6723.13768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 02/22/2021] [Indexed: 11/28/2022]
Abstract
A trauma patient with orbital compartment syndrome may lose vision within hours of the injury. This article describes an approach to decompressing the orbit which may be sight-saving.
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Affiliation(s)
| | - Amit Maini
- National Trauma Research Institute, Alfred Health, Melbourne, Victoria, Australia
| | - Joseph Mathew
- National Trauma Research Institute, Alfred Health, Melbourne, Victoria, Australia
| | - Francis O'Keeffe
- National Trauma Research Institute, Alfred Health, Melbourne, Victoria, Australia
| | - Mike Noonan
- National Trauma Research Institute, Alfred Health, Melbourne, Victoria, Australia
| | - De Villiers Smit
- National Trauma Research Institute, Alfred Health, Melbourne, Victoria, Australia
| | - Mark Fitzgerald
- National Trauma Research Institute, Alfred Health, Melbourne, Victoria, Australia
| | - Anthony Hall
- National Trauma Research Institute, Alfred Health, Melbourne, Victoria, Australia
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Roy Chowdhury U, Kudgus RA, Holman BH, Rinkoski TA, Hann CR, Bahler CK, McCloud E, Appt SE, Reid JM, Dosa PI, Fautsch MP. Pharmacological Profile and Ocular Hypotensive Effects of Cromakalim Prodrug 1, a Novel ATP-Sensitive Potassium Channel Opener, in Normotensive Dogs and Nonhuman Primates. J Ocul Pharmacol Ther 2021; 37:251-260. [PMID: 33784195 PMCID: PMC8215408 DOI: 10.1089/jop.2020.0137] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 02/27/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose: To evaluate pharmacokinetic parameters and ocular hypotensive effects of cromakalim prodrug 1 (CKLP1) in normotensive large animal models. Methods: Optimal CKLP1 concentration was determined by dose response and utilized in short- (5-8 days) and long-term (60 days) evaluation in hound dogs (n = 5) and African Green Monkeys (n = 5). Blood pressure was recorded 3-5 times per week with a tail cuff. Concentrations of CKLP1 and the parent compound levcromakalim were assessed in hound dog plasma and select tissues by LC-MS/MS after bilateral ocular treatment with CKLP1 for 8 days. Pharmacokinetic parameters were calculated from days 1, 4, and 8 data. After necropsy, histology was assessed in 43 tissue samples from each animal. Results: In hound dogs and African Green monkeys, 10 mM CKLP1 (optimal concentration) significantly lowered intraocular pressure (IOP) by 18.9% ± 1.1% and 16.7% ± 6.7%, respectively, compared with control eyes (P < 0.05). During treatment, no significant change in systolic or diastolic blood pressure was observed in either species (P > 0.1). Average values for half-life of CKLP1 was 295.3 ± 140.4 min, Cmax, 10.5 ± 1.6 ng/mL, and area under the concentration vs. time curve (AUClast) 5261.4 ± 918.9 ng·min/mL. For levcromakalim, average values of half-life were 96.2 ± 27 min, Cmax 1.2 ± 0.2 ng/mL, and AUClast 281.2 ± 110.8 ng·min/mL. No significant pathology was identified. Conclusions: CKLP1 lowered IOP in hound dogs and African green monkeys with no effect on systemic blood pressure. Ocular topical treatment of CKLP1 showed excellent tolerability even after extended treatment periods.
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Affiliation(s)
- Uttio Roy Chowdhury
- Department of Ophthalmology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Rachel A. Kudgus
- Department of Oncology Research, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Bradley H. Holman
- Department of Ophthalmology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Tommy A. Rinkoski
- Department of Ophthalmology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Cheryl R. Hann
- Department of Ophthalmology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Cindy K. Bahler
- Department of Ophthalmology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Eric McCloud
- Department of Pathology, Section of Comparative Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Susan E. Appt
- Department of Pathology, Section of Comparative Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Joel M. Reid
- Department of Oncology Research, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Peter I. Dosa
- Department of Medicinal Chemistry, Institute for Therapeutics Discovery and Development, University of Minnesota, Minneapolis, Minnesota, USA
| | - Michael P. Fautsch
- Department of Ophthalmology, Mayo Clinic Rochester, Rochester, Minnesota, USA
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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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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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Ali HM, Elbadawy AM. Comparative Study of Retrobulbar Block versus Ketamine Infusion during Eye Enucleation/Evisceration (Randomized Controlled Trial). Anesth Essays Res 2020; 14:92-99. [PMID: 32843800 PMCID: PMC7428106 DOI: 10.4103/aer.aer_146_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 01/02/2020] [Accepted: 01/07/2020] [Indexed: 11/04/2022] Open
Abstract
Background The aim of this study is to compare the safety and efficacy of retrobulbar block versus intraoperative ketamine infusion in eye enucleation or evisceration under general anesthesia. Materials and Methods Forty-five patients belonging to American Society of Anesthesiologists Physical Status I and II undergoing eye enucleation or evisceration were randomly allocated to three equal groups (15 patients each). General anesthesia was used as the standardized technique in all patients. Group R received a single retrobulbar injection, Group K received intravenous ketamine infusion, and Group C received normal saline with the same rate of ketamine infusion. Intraoperative heart rate and mean arterial pressure, recovery time, postoperative pain score, time to first rescue analgesic, number of patients who required rescue analgesia, and any adverse events were reported. Results Postoperative pain Visual Analog Scale was significantly lower in R and K groups in comparison to the C group and was significantly higher in K than R group at 3, 6, 12, and 24 h. In addition, the time to first rescue analgesic was significantly longer in R group (429 ± 54 min) than that in K group (272 ± 34 min), but compared to both groups, it was longer in C group (52 ± 7 min). In K group, the recovery time was longer with higher sedation score in comparison to the other two groups. Conclusions Single retrobulbar injection and low-dose ketamine infusion are safe and effective when used as adjuvants to general anesthesia, but retrobulbar block provides better control of postoperative pain with prolonged time to first rescue analgesic and reduced analgesic consumption.
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Affiliation(s)
- Hassan Mohamed Ali
- Department of Anesthesia, Faculty of Medicine, Cairo University, Cairo, Egypt
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Morgan MM, Perina DG, Acquisto NM, Fallat ME, Gallagher JM, Brown KM, Ho J, Burnett A, Lairet J, Rowe D, Gestring ML. Ketamine Use in Prehospital and Hospital Treatment of the Acute Trauma Patient: A Joint Position Statement. PREHOSP EMERG CARE 2020; 25:588-592. [DOI: 10.1080/10903127.2020.1801920] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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18
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Effect of general anaesthesia on intraocular pressure in paediatric patients: a systematic review. Eye (Lond) 2020; 35:1205-1212. [PMID: 32690926 DOI: 10.1038/s41433-020-1093-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 06/26/2020] [Accepted: 07/08/2020] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVES Assessment of the impact of general anaesthetic agents on intraocular pressure (IOP) in children via systematic review. METHODS Pubmed, Embase, and CENTRAL databases were systematically searched to identify randomised controlled trials, prospective, and interventional studies. The search included all studies through October 5, 2018 with no date or language restrictions. A linear mixed-effects regression analysis was performed to study the change in IOP after general anaesthesia (GA). RESULTS The strategy identified 518 studies that met search criteria. Six studies (531 eyes) were included for quantitative synthesis. Seven categories of mixed and non-mixed induction and maintenance agents were compared. When assessing all agents utilising a model of mean IOP as a function of time, IOP decreased after induction phase at a rate of -0.59 ± 0.19 mmHg/min (P value = 0.006). CONCLUSIONS This systematic review showed that most anaesthetic agents significantly decrease IOP over time after the induction phase of general anaesthesia in children. An understanding of the effects of GA on IOP is critical for those performing paediatric ophthalmic examinations under anaesthesia.
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Markovitz M, Hamburger J, Fromm BS, Carr B, Zhang XC. Removal of an Impaled Intraocular Hair Comb Following Self-inflicted Trauma. Clin Pract Cases Emerg Med 2020; 4:8-11. [PMID: 32064414 PMCID: PMC7012553 DOI: 10.5811/cpcem.2019.10.44460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 10/09/2019] [Accepted: 10/17/2019] [Indexed: 11/25/2022] Open
Abstract
Ocular trauma is one of the most common and vision-threatening ophthalmic presentations with a wide spectrum of complications, such as bleeding, infection, vision loss, and enucleation. A 64-year-old-male presented to the emergency department (ED) with a self-inflicted orbital penetrating injury with a hair comb. Computed tomography showed the comb traversed the medial orbit inferior to the medial rectus but did not damage the optic nerve; there were no globe or orbital wall fractures. His ocular exam was significant for a right eye afferent pupillary defect and decreased visual acuity 20/800, consistent with optic neuropathy. Primary concerns were stabilizing and removing the foreign body without causing further damage in the setting of an uncooperative patient. The comb was removed with the aid of local and systemic analgesia using gentle traction and normal saline irrigation. The patient was admitted for systemic and topical antibiotics and showed improvement in visual acuity and resolution of his optic neuropathy. This case illustrates the importance of rapid ED assessment and management of complex penetrating ocular trauma. Examination should specifically look for signs of globe rupture and optic nerve injury. Expedited foreign body removal should be managed together with an ophthalmologist with procedural sedation and broad-spectrum antibiotics to avoid further visual and infectious complications.
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Affiliation(s)
- Michele Markovitz
- Wills Eye Hospital, Department of Ophthalmology, Philadelphia, Pennsylvania
| | | | - Brian S Fromm
- Thomas Jefferson University, Department of Emergency Medicine, Philadelphia, Pennsylvania
| | - Brendan Carr
- Thomas Jefferson University, Department of Emergency Medicine, Philadelphia, Pennsylvania
| | - Xiao Chi Zhang
- Thomas Jefferson University, Department of Emergency Medicine, Philadelphia, Pennsylvania
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Algın A, Yıldırım Ç, Hökenek NM. The Use of Ketamine in Trauma Patients. ANKARA MEDICAL JOURNAL 2019. [DOI: 10.17098/amj.652006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Jasien JV, Girkin CA, Downs JC. Effect of Anesthesia on Intraocular Pressure Measured With Continuous Wireless Telemetry in Nonhuman Primates. Invest Ophthalmol Vis Sci 2019; 60:3830-3834. [PMID: 31529079 PMCID: PMC6750888 DOI: 10.1167/iovs.19-27758] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 08/09/2019] [Indexed: 12/28/2022] Open
Abstract
Purpose To compare the effects of both injectable anesthesia (ketamine/dexmedetomidine versus ketamine/xylazine) and inhalant anesthesia (isoflurane) on IOP using continuous, bilateral IOP telemetry in nonhuman primates (NHP). Methods Bilateral IOP was recorded continuously using a proven implantable telemetry system in five different sessions at least 2 weeks apart in four male rhesus macaques under two conditions: ketamine (3 mg/kg) with dexmedetomidine (50 μg/kg) or ketamine with xylazine (0.5 mg/kg) for induction, both followed by isoflurane for maintenance. IOP transducers were calibrated via anterior chamber manometry. Bilateral IOP was averaged over 2 minutes after injectable anesthetic induction and again after isoflurane inhalant had stabilized the anesthetic plane, then compared to baseline IOP measurements acquired immediately prior to anesthesia (both before and after initial human contact). Results When compared to pre-contact baseline measurements, ketamine/dexmedetomidine injectable anesthesia lowers IOP by 1.5 mm Hg on average (P < 0.05), but IOP did not change with ketamine/xylazine anesthesia. IOP returned to baseline levels shortly after isoflurane gas anesthesia was initiated. However, injectable anesthesia lowered IOP by an average of 5.4 mm Hg when compared to that measured after initial human contact (P < 0.01). Conclusions Anesthetic effects on IOP are generally small when compared to precontact baseline but much larger when compared to IOP measures taken after human contact, indicating that IOP is temporarily elevated due to acute stress (similar to a "white coat effect") and then decreased with anesthetic relaxation. Anesthetic induction with ketamine/xylazine and maintenance with isoflurane gas should be used when IOP is measured postanesthesia.
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Affiliation(s)
- Jessica V. Jasien
- Vision Science Graduate Program, School of Optometry, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Christopher A. Girkin
- Department of Ophthalmology and Visual Sciences, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - J. Crawford Downs
- Department of Ophthalmology and Visual Sciences, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States
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Childers R, Vilke G. Ketamine for Acute Agitation. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2019. [DOI: 10.1007/s40138-019-00177-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Schwenk ES, Viscusi ER, Buvanendran A, Hurley RW, Wasan AD, Narouze S, Bhatia A, Davis FN, Hooten WM, Cohen SP. Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management From the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists. Reg Anesth Pain Med 2018; 43:456-466. [PMID: 29870457 PMCID: PMC6023582 DOI: 10.1097/aap.0000000000000806] [Citation(s) in RCA: 109] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2018] [Indexed: 01/11/2023]
Abstract
BACKGROUND Ketamine infusions have been used for decades to treat acute pain, but a recent surge in usage has made the infusions a mainstay of treatment in emergency departments, in the perioperative period in individuals with refractory pain, and in opioid-tolerant patients. The widespread variability in patient selection, treatment parameters, and monitoring indicates a need for the creation of consensus guidelines. METHODS The development of acute pain ketamine guidelines grew as a corollary from the genesis of chronic pain ketamine guidelines. The charge for the development of acute pain ketamine guidelines was provided by the Boards of Directors of both the American Society of Regional Anesthesia and Pain Medicine and the American Academy of Pain Medicine, who approved the document along with the American Society of Anesthesiologists' Committees on Pain Medicine and Standards and Practice Parameters. The committee chair developed questions based on input from the committee during conference calls, which the committee then refined. Groups of 3 to 5 panel members and the committee chair were responsible for answering individual questions. After preliminary consensus was achieved, the entire committee made further revisions via e-mail and conference calls. RESULTS Consensus guidelines were prepared in the following areas: indications, contraindications for acute pain and whether they differ from those for chronic pain, the evidence for the use of ketamine as an adjunct to opioid-based therapy, the evidence supporting patient-controlled ketamine analgesia, the use of nonparenteral forms of ketamine, and the subanesthetic dosage range and whether the evidence supports those dosages for acute pain. The group was able to reach consensus on the answers to all questions. CONCLUSIONS Evidence supports the use of ketamine for acute pain in a variety of contexts, including as a stand-alone treatment, as an adjunct to opioids, and, to a lesser extent, as an intranasal formulation. Contraindications for acute pain are similar to those for chronic pain, partly based on the observation that the dosage ranges are similar. Larger studies evaluating different acute pain conditions are needed to enhance patient selection, determine the effectiveness of nonparenteral ketamine alternatives, define optimal treatment parameters, and develop protocols optimizing safety and access to care.
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Affiliation(s)
- Eric S. Schwenk
- From the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Eugene R. Viscusi
- From the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | | | - Robert W. Hurley
- Departments of Anesthesiology and Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC
| | - Ajay D. Wasan
- Departments of Anesthesiology and Psychiatry, University of Pittsburgh, Pittsburgh, PA
| | - Samer Narouze
- Departments of Anesthesiology and Neurosurgery, Western Reserve Hospital, Akron, OH
| | - Anuj Bhatia
- Department of Anesthesiology, University of Toronto, Toronto, Ontario, Canada
| | - Fred N. Davis
- Procare Pain Solutions and Department of Anesthesiology, Michigan State University College of Human Medicine, Grand Rapids, MI
| | - William M. Hooten
- Departments of Anesthesiology and Psychiatry, Mayo College of Medicine, Rochester, MN; and
| | - Steven P. Cohen
- Departments of Anesthesiology and Critical Care Medicine, Neurology, and Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, and Uniformed Services University of the Health Sciences, Bethesda, MD
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Cohen SP, Bhatia A, Buvanendran A, Schwenk ES, Wasan AD, Hurley RW, Viscusi ER, Narouze S, Davis FN, Ritchie EC, Lubenow TR, Hooten WM. Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Chronic Pain From the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists. Reg Anesth Pain Med 2018; 43:521-546. [PMID: 29870458 PMCID: PMC6023575 DOI: 10.1097/aap.0000000000000808] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2018] [Indexed: 01/06/2023]
Abstract
BACKGROUND Over the past 2 decades, the use of intravenous ketamine infusions as a treatment for chronic pain has increased dramatically, with wide variation in patient selection, dosing, and monitoring. This has led to a chorus of calls from various sources for the development of consensus guidelines. METHODS In November 2016, the charge for developing consensus guidelines was approved by the boards of directors of the American Society of Regional Anesthesia and Pain Medicine and, shortly thereafter, the American Academy of Pain Medicine. In late 2017, the completed document was sent to the American Society of Anesthesiologists' Committees on Pain Medicine and Standards and Practice Parameters, after which additional modifications were made. Panel members were selected by the committee chair and both boards of directors based on their expertise in evaluating clinical trials, past research experience, and clinical experience in developing protocols and treating patients with ketamine. Questions were developed and refined by the committee, and the groups responsible for addressing each question consisted of modules composed of 3 to 5 panel members in addition to the committee chair. Once a preliminary consensus was achieved, sections were sent to the entire panel, and further revisions were made. In addition to consensus guidelines, a comprehensive narrative review was performed, which formed part of the basis for guidelines. RESULTS Guidelines were prepared for the following areas: indications; contraindications; whether there was evidence for a dose-response relationship, or a minimum or therapeutic dose range; whether oral ketamine or another N-methyl-D-aspartate receptor antagonist was a reasonable treatment option as a follow-up to infusions; preinfusion testing requirements; settings and personnel necessary to administer and monitor treatment; the use of preemptive and rescue medications to address adverse effects; and what constitutes a positive treatment response. The group was able to reach consensus on all questions. CONCLUSIONS Evidence supports the use of ketamine for chronic pain, but the level of evidence varies by condition and dose range. Most studies evaluating the efficacy of ketamine were small and uncontrolled and were either unblinded or ineffectively blinded. Adverse effects were few and the rate of serious adverse effects was similar to placebo in most studies, with higher dosages and more frequent infusions associated with greater risks. Larger studies, evaluating a wider variety of conditions, are needed to better quantify efficacy, improve patient selection, refine the therapeutic dose range, determine the effectiveness of nonintravenous ketamine alternatives, and develop a greater understanding of the long-term risks of repeated treatments.
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Affiliation(s)
- Steven P. Cohen
- From the Departments of Anesthesiology & Critical Care Medicine, Neurology, and Physical Medicine & Rehabilitation, Johns Hopkins School of Medicine; and
- Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Anuj Bhatia
- Department of Anesthesiology, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada
| | | | - Eric S. Schwenk
- Department of Anesthesiology, Jefferson Medical College, Philadelphia; and
| | - Ajay D. Wasan
- Departments of Anesthesiology and Psychiatry, University of Pittsburgh, Pittsburgh, PA
| | - Robert W. Hurley
- Departments of Anesthesiology and Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC
| | - Eugene R. Viscusi
- Department of Anesthesiology, Jefferson Medical College, Philadelphia; and
| | - Samer Narouze
- Departments of Anesthesiology and Neurosurgery, Western Reserve Hospital, Akron, OH
| | - Fred N. Davis
- Procare Pain Solutions and
- Department of Anesthesiology, Michigan State University College of Human Medicine, Grand Rapids, MI
| | - Elspeth C. Ritchie
- Department of Psychiatry, Uniformed Services University of the Health Sciences, Georgetown University School of Medicine, Bethesda, MD; and
- Howard University College of Medicine, Washington, DC; and
| | | | - William M. Hooten
- Departments of Anesthesiology and Psychiatry, Mayo College of Medicine, Rochester, MN
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Kelly DJ, Farrell SM. Physiology and Role of Intraocular Pressure in Contemporary Anesthesia. Anesth Analg 2018; 126:1551-1562. [DOI: 10.1213/ane.0000000000002544] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Webb TR, Wyman M, Smith JA, Ueyama Y, Muir WW. Effects of propofol on intraocular pressure in premedicated and nonpremedicated dogs with and without glaucoma. J Am Vet Med Assoc 2018; 252:823-829. [PMID: 29553899 DOI: 10.2460/javma.252.7.823] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To establish a study cutoff for evidence of glaucoma on the basis of IOP measurements from a large population of healthy dogs and to assess the effects of IV propofol administration on IOPs in premedicated and nonpremedicated dogs with and without glaucoma defined by this method. DESIGN Prospective, descriptive study. ANIMALS 234 client-owned dogs. PROCEDURES IOPs measured in 113 healthy dogs (226 eyes) were used to calculate an IOP value indicative of glaucoma. The IOPs were measured in an additional 121 dogs (237 eyes) undergoing ophthalmic surgery. Midazolam-butorphanol was administered IV as preanesthetic medication to 15 and 87 dogs with and without glaucoma, respectively. A placebo (lactated Ringer solution) was administered IV to 8 and 11 dogs with and without glaucoma, respectively. Anesthesia of surgical patients was induced with propofol IV to effect. The IOPs and physiologic variables of interest were recorded before (baseline) and after preanesthetic medication or placebo administration and after propofol administration. RESULTS An IOP > 25 mm Hg was deemed indicative of glaucoma. Compared with baseline measurements, mean IOP was increased after propofol administration in nonpremedicated dogs without glaucoma and unchanged in nonpremedicated dogs with glaucoma. Propofol-associated increases in IOP were blunted in premedicated dogs without glaucoma; IOP in affected eyes of premedicated dogs with glaucoma was decreased after preanesthetic medication and after propofol administration. CONCLUSIONS AND CLINICAL RELEVANCE Results indicated that preexisting IOP influences the response to anesthetic drugs, and administration of preanesthetic medication with muscle-relaxing properties may blunt or reduce propofol-induced increases in IOP. Further research with a larger number of dogs is needed to confirm our results in dogs with glaucoma.
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Prevalence of primary open-angle glaucoma among patients with obstructive sleep apnea. Oral Surg Oral Med Oral Pathol Oral Radiol 2018; 126:226-230. [PMID: 29506916 DOI: 10.1016/j.oooo.2018.01.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 12/21/2017] [Accepted: 01/20/2018] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Our objective was to determine primary open-angle glaucoma (POAG) prevalence among obstructive sleep apnea (OSA) patients because the perioperative environment risks further damaging the optic nerve. STUDY DESIGN We analyzed a "convenience sample" referred by Sleep Medicine for oral appliances because of continuous positive airway pressure intolerance. We determined the aggregate prevalence of the 3 POAG subtypes-"classic" open-angle glaucoma (COAG), normal-tension glaucoma (NTG), and open-angle glaucoma suspect (OAGS)-among the index population and compared it with that of same hospital's general population. Similarly determined were associations between OSA severity levels (apnea-hypopnea index [AHI]) and POAG subtypes. RESULTS Among the study sample of 225 patients with OSA (96.4% male; mean age 58.5 ± 12.3 years), 47 (20.9%) had POAG, with a subtype distribution of COAG: 12 (25.5%), NTG: 8 (17.0%), and OAGS: 27 (57.4%). The POAG prevalence rate among medical center's general population was 2.5%, which was significantly less (P < .00001) than among those with comorbid OSA. Severity of the breathing disorder (AHI) failed to identify a significant correlation to any POAG subtype (P > .05). CONCLUSION The significant prevalence of POAG among OSA sufferers suggests need for preoperative consultations from an ophthalmologist to determine eye health and possibly an anesthesiologist to avoid potential vision loss.
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Wedmore IS, Butler FK. Battlefield Analgesia in Tactical Combat Casualty Care. Wilderness Environ Med 2018; 28:S109-S116. [PMID: 28601204 DOI: 10.1016/j.wem.2017.04.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2016] [Revised: 04/10/2017] [Accepted: 04/12/2017] [Indexed: 10/19/2022]
Abstract
At the start of the Afghanistan conflict, battlefield analgesia for US military casualties was achieved primarily through the use of intramuscular (IM) morphine. This is a suboptimal choice, since IM morphine is slow-acting, leading to delays in effective pain relief and the risk of overdose and death when dosing is repeated in order to hasten the onset of analgesia. Advances in battlefield analgesia, pioneered initially by Tactical Combat Casualty Care (TCCC), and the Army's 75th Ranger Regiment, have now been incorporated into the Triple-Option Analgesia approach. This novel strategy has gained wide acceptance in the US military. It calls for battlefield analgesia to be achieved using 1 or more of 3 options depending on the casualty's status: 1) the meloxicam and acetaminophen in the combat wound medication pack (CWMP) for casualties with relatively minor pain that are still able to function effectively as combatants if their sensorium is not altered by analgesic medications; 2) oral transmucosal fentanyl citrate (OTFC) for casualties who have moderate to severe pain, but who are not in hemorrhagic shock or respiratory distress, and are not at significant risk for developing either condition; or 3) ketamine for casualties who have moderate to severe pain, but who are in hemorrhagic shock or respiratory distress or are at significant risk for developing either condition. Ketamine may also be used to increase analgesic effect for casualties who have previously been given opioid medication. The present paper outlines the evolution and evidence base for battlefield analgesia as currently recommended by TCCC. It is not intended to be a comprehensive review of all prehospital analgesic options.
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Affiliation(s)
- Ian S Wedmore
- Madigan Army Medical Center, Tacoma, Washington (Dr Wedmore) and the Joint Trauma System, San Antonio, TX (Dr Butler).
| | - Frank K Butler
- Madigan Army Medical Center, Tacoma, Washington (Dr Wedmore) and the Joint Trauma System, San Antonio, TX (Dr Butler)
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van der Walt JG, Roodt F, Tinley C. How does sevoflurane induction, followed by a ketamine maintenance infusion, affect intraocular pressure? Establishment of an anaesthetic protocol for paediatric glaucoma examinations under anaesthesia. Br J Ophthalmol 2017; 102:902-905. [PMID: 29051328 DOI: 10.1136/bjophthalmol-2017-310872] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 08/25/2017] [Accepted: 09/30/2017] [Indexed: 11/03/2022]
Abstract
Accurate measurement of intraocular pressure (IOP) is essential in paediatric glaucoma management. Children require serial measurements and examination under anaesthesia (EUA). Most anaesthetic agents reduce IOP, and the ideal time to measure IOP under anaesthesia is questionable. STUDY PURPOSE To determine the effect of sevoflurane induction, followed by intravenous ketamine infusion on IOP, in children undergoing EUA for glaucoma or suspected glaucoma, and to establish the earliest time point at which reliable, repeatable IOP measurements can be obtained under anaesthesia. METHOD A prospective, descriptive study of IOP changes occurring in children requiring EUAs. A standardised anaesthetic protocol: sevoflurane induction, intravenous cannulation, 2 mg/kg intravenous ketamine bolus and 4 mg/kg/hour maintenance for 15 min. IOP measurements (taken supine with a Perkins applanation tonometer) and physiological variables were recorded. RESULTS IOPs were measured in 25 children (50 eyes). Twenty-six eyes (52%) were glaucomatous. Mean patient age was 29 months (2-88 months). Physiological variables returned to baseline at 8 min, correlating with recorded sevoflurane elimination. Mean IOP after sevoflurane induction was 3.68 mm Hg lower than with ketamine maintenance at 15 min (95% CI 1.35 to 6.02 mm Hg) (p=0.002). Contrastingly, the difference in IOP between ketamine anaesthesia at 15 min and near wakefulness was 0.28 mm Hg (95% CI -2.23 to 2.79 mm Hg) (p=0.826). CONCLUSION Sevoflurane's IOP-lowering effect is reversed 15 min after the discontinuation of the inhalational gas, if anaesthesia is maintained with an intravenous ketamine infusion. IOP measurements appear to stabilise at this time point until the point of near wakefulness and may reflect awake values.
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Affiliation(s)
- Jessica Gwendoline van der Walt
- Department of Anaesthesia, University of Cape Town, Cape Town, South Africa.,Department of Anaesthesia, Victoria Hospital, Cape Town, South Africa
| | - Francois Roodt
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa.,Department of Anaesthesia, Groote Schuur Hospital, Cape Town, South Africa.,Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Christopher Tinley
- Red Cross War Memorial Children's Hospital, Cape Town, South Africa.,Department of Ophthalmology, University of Cape Town, Cape Town, Western Cape, South Africa
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A Novel Agent for Management of Agitated Delirium: A Case Series of Ketamine Utilization in the Pediatric Emergency Department. Pediatr Emerg Care 2017; 33:e58-e62. [PMID: 26466151 DOI: 10.1097/pec.0000000000000578] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Control of the agitated patient in the emergency department is challenging. Many options exist for chemical sedation, but most have suboptimal pharmacodynamic action, and many have undesirable adverse effects. There are reports of ketamine administration for control of agitation prehospital and in traumatically injured patients. Ketamine is a noncompetitive N-methyl-D-aspartic acid receptor antagonist, making it an effective dissociative agent. We present 5 cases of ketamine administration to manage agitated adolescent patients with underlying psychiatric disease and/or drug intoxication. Ketamine, as a dissociative agent, may be an alternative pharmacological consideration for the control of agitation in patients with undifferentiated agitated delirium.
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Mikhail M, Sabri K, Levin AV. Effect of anesthesia on intraocular pressure measurement in children. Surv Ophthalmol 2017; 62:648-658. [PMID: 28438591 DOI: 10.1016/j.survophthal.2017.04.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 04/11/2017] [Accepted: 04/13/2017] [Indexed: 12/20/2022]
Abstract
Measurement of the intraocular pressure (IOP) is central to the diagnosis and management of pediatric glaucoma. An examination under anesthesia is often necessary in pediatric patients. Different agents used for sedation or general anesthesia have varied effects on IOP. Hemodynamic factors, methods of airway management, tonometry technique, and body positioning can all affect IOP measurements. The most accurate technique is one that reflects the awake IOP. We review factors affecting IOP measurements in the pediatric population and provide recommendations on the most accurate means to measure IOP under anesthesia based on the present literature.
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Affiliation(s)
- Mikel Mikhail
- Department of Ophthalmology, McGill University, Montreal, Quebec, Canada
| | - Kourosh Sabri
- Division of Ophthalmology, Department of Surgery, McMaster University, Hamilton, Ontario, Canada; McMaster Pediatric Surgery Research Collaborative, Department of Surgery, McMaster University, Hamilton, Ontario, Canada; McMaster Pediatric Eye Research Group, Department of Surgery, McMaster University, Hamilton, Ontario, Canada.
| | - Alex V Levin
- Pediatric Ophthalmology and Ocular Genetics, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Termühlen J, Gottschalk A, Eter N, Hoffmann EM, Van Aken H, Grenzebach U, Prokosch V. Does general anesthesia have a clinical impact on intraocular pressure in children? Paediatr Anaesth 2016; 26:936-41. [PMID: 27377361 DOI: 10.1111/pan.12955] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/27/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Reliable measurement of intraocular pressure (IOP) is crucial in pediatric patients with suspected glaucoma. General anesthesia (GA) is usually needed in infants to allow a thorough examination. However, anesthesia itself may influence IOP, depending on the type used and the depth of sedation. The purpose of this study was to evaluate the normal distribution of IOP during GA in healthy children and to analyze differences in IOP relative to the anesthetics used and the measurement time point. METHODS Approval for this observational study was received from the local institutional review boards and written informed consent was obtained from the children's parents. A total of 100 pediatric patients with no history of glaucoma scheduled for nonintraocular surgery underwent general anesthesia, induced with sevoflurane (s) or propofol (p) and maintained with either sevoflurane with remifentanil (S) or propofol with remifentanil (P). The patients were grouped to one of four subgroups (sS, sP, pP, pS) depending on the anesthetics used during induction and maintenance. Hemodynamic parameters and IOP were measured in both eyes at four defined time points: before anesthesia induction (M1); in apnea immediately after induction and before insertion of a laryngeal mask airway (M2); in deep anesthesia during mechanical ventilation (M3); and after extubation (M4), using a handheld Perkins applanation tonometer. Differences in IOP in both eyes during the measurement periods were analyzed using multivariate repeated-measures analysis of variance and Tukey-HSD as a posthoc test with statistical significance set at P < 0.05. Pearson correlation coefficient was used to investigate further relationships between heart rate, systolic blood pressure, and IOP. RESULTS General anesthesia reduced IOP significantly. The mean IOP was normally distributed, with a mean of 7.4 ± 2.89 mmHg at M1. It decreased significantly to a minimum of 5.6 ± 3.04 mmHg (P < 0.01) at M2 and increased significantly to 7.2 ± 2.51 mmHg (P < 0.01) at M3 and again to 8.4 ± 3.72 mmHg (P = 0.03) at M4. All four subgroups (sS, sP, pP, pS) showed comparable decreases in IOP between M1 and M2. During deep anesthesia (M3) and during reversal (M4), the IOP increased again in all groups. During reversal (M4), however, the sS group had a significantly lower IOP than the pP group (P = 0.001) and sP group (P = 0.02). There were no correlations between changes in IOP and gender, age, or type of surgery. CONCLUSIONS Sevoflurane and propofol, both in combination with remifentanil, significantly lower IOP in children. Individual IOP levels rise and fall during anesthesia, depending on the time point of measurement. The lowest IOP can be measured immediately after induction of anesthesia. This needs to be taken into account when measuring IOP in children.
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Affiliation(s)
- Julia Termühlen
- Department of Ophthalmology, University of Muenster Medical Center, Muenster, Germany
| | - Antje Gottschalk
- Department of Anesthesiology, Intensive-Care Medicine and Pain Therapy, Muenster University Hospital, Muenster, Germany
| | - Nicole Eter
- Department of Ophthalmology, University of Muenster Medical Center, Muenster, Germany
| | - Esther M Hoffmann
- Department of Ophthalmology, Mainz University Hospital, Mainz, Germany
| | - Hugo Van Aken
- Department of Anesthesiology, Intensive-Care Medicine and Pain Therapy, Muenster University Hospital, Muenster, Germany
| | - Ulrike Grenzebach
- Department of Ophthalmology, University of Muenster Medical Center, Muenster, Germany
| | - Verena Prokosch
- Department of Ophthalmology, Mainz University Hospital, Mainz, Germany
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Gatson BJ, Pablo L, Plummer CE, Granone TD. Effects of premedication with sustained-release buprenorphine hydrochloride and anesthetic induction with ketamine hydrochloride or propofol in combination with diazepam on intraocular pressure in healthy sheep. Am J Vet Res 2015; 76:771-9. [DOI: 10.2460/ajvr.76.9.771] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Litwack K. Pain management in military trauma. Crit Care Nurs Clin North Am 2015; 27:235-46. [PMID: 25981726 DOI: 10.1016/j.cnc.2015.02.005] [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: 10/23/2022]
Abstract
The wounded warrior requires immediate care, and at times, evacuation from injury. Care may be self-regulated, or may require more advanced care under the direction of medics or advanced practitioners, including physicians and surgeons. While survivability is the immediate priority, pain management has become a military initiative, recognizing that poor management of acute pain may lead to the development of chronic pain and post-traumatic stress disorder. This article reviews current initiatives used in current conflict situations, as well as those in continued care following initial stabilization.
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Affiliation(s)
- Kim Litwack
- University of Wisconsin-Milwaukee College of Nursing, 1921 East Hartford Avenue, Milwaukee, WI 53201, USA; Advanced Pain Management, 34 Schroeder Ct, Madison, WI 53711, USA.
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Wadia S, Bhola R, Lorenz D, Padmanabhan P, Gross J, Stevenson M. Ketamine and Intraocular Pressure in Children. Ann Emerg Med 2014; 64:385-388.e1. [DOI: 10.1016/j.annemergmed.2014.01.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Revised: 01/26/2014] [Accepted: 01/31/2014] [Indexed: 10/25/2022]
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Ferreira TH, Brosnan RJ, Shilo-Benjamini Y, Moore SB, Hollingsworth SR. Effects of ketamine, propofol, or thiopental administration on intraocular pressure and qualities of induction of and recovery from anesthesia in horses. Am J Vet Res 2013; 74:1070-7. [PMID: 23879844 DOI: 10.2460/ajvr.74.8.1070] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To assess the effects of ketamine hydrochloride, propofol, or compounded thiopental sodium administration on intraocular pressure (IOP) and qualities of induction of and recovery from anesthesia in horses. ANIMALS 6 healthy adult horses. PROCEDURES Horses were sedated with xylazine hydrochloride (0.5 mg/kg), and anesthesia was induced with guaifenesin followed by ketamine (2 mg/kg), propofol (3 mg/kg), or thiopental (4 mg/kg) in a crossover study with ≥ 1 week between treatments. For each horse, IOP in the right eye was measured with a handheld applanation tonometer before and after xylazine administration, at the time of recumbency, and every 3 minutes after induction of anesthesia until spontaneous movement was observed. Cardiorespiratory responses and venous blood measurements were recorded during anesthesia. Induction of and recovery from anesthesia were subjectively evaluated by investigators who were unaware of the anesthetic treatment of each horse. Data were analyzed via a repeated-measures ANOVA with Holm-Ŝidák post hoc comparisons. RESULTS Compared with findings after xylazine administration (mean ± SD, 17 ± 3 mm Hg), thiopental decreased IOP by 4 ± 23%, whereas propofol and ketamine increased IOP by 8 ± 11% and 37 ± 16%, respectively. Compared with the effects of ketamine, propofol and thiopental resulted in significantly lower IOP at the time of recumbency and higher heart rates at 3 minutes after induction of anesthesia. No other significant differences among treatments were found. CONCLUSIONS AND CLINICAL RELEVANCE These findings support the use of thiopental or propofol in preference to ketamine for horses in which increases in IOP should be minimized.
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Affiliation(s)
- Tatiana H Ferreira
- Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California-Davis, CA 95616, USA
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Drayna PC, Estrada C, Saville BR, Arnold DH. Ketamine and intraocular pressure. Acad Emerg Med 2013; 20:424. [PMID: 23701354 DOI: 10.1111/acem.12100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Scherzer D, Leder M, Tobias JD. Pro-con debate: etomidate or ketamine for rapid sequence intubation in pediatric patients. J Pediatr Pharmacol Ther 2012; 17:142-9. [PMID: 23118665 DOI: 10.5863/1551-6776-17.2.142] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
When caring for critically ill children, airway management remains a primary determinant of the eventual outcome. Airway control with endotracheal intubation is frequently necessary. Rapid sequence intubation (RSI) is generally used in emergency airway management to protect the airway from passive regurgitation of gastric contents. Along with a rapid acting neuromuscular blocking agent, sedation is an essential element of RSI. A significant safety concern regarding sedatives is the risk of hypotension and cardiovascular collapse, especially in critically ill patients or those with pre-existing comorbid conditions. Ketamine and etomidate, both of which provide effective sedation with limited effects on hemodynamic function, have become increasingly popular as induction agents for RSI. However, experience and clinical investigations have raised safety concerns associated with both etomidate and ketamine. Using a pro-con debate style, the following manuscript discusses the use of ketamine versus etomidate in RSI.
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Affiliation(s)
- Daniel Scherzer
- Division of Emergency Medicine and Department of Pediatrics, Nationwide Children's Hospital and the Ohio State University, Columbus, Ohio
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Halstead SM, Deakyne SJ, Bajaj L, Enzenauer R, Roosevelt GE. The effect of ketamine on intraocular pressure in pediatric patients during procedural sedation. Acad Emerg Med 2012; 19:1145-50. [PMID: 23009160 DOI: 10.1111/j.1553-2712.2012.01450.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Ketamine is one of the most commonly used procedural sedation and analgesia (PSA) agents in pediatric emergency departments (PEDs). It is considered a very safe and reliable agent, with limited respiratory suppression, hemodynamic effects, and adverse outcomes. However, physicians are often reluctant to use ketamine for patients with eye injuries due to a concern that ketamine might increase intraocular pressure (IOP). The objective was to measure IOP in previously healthy children receiving ketamine for PSA for a reason other than eye injury. METHODS This was a prospective noninferiority study of patients seen in an academic tertiary care children's hospital emergency department (ED) who required ketamine for PSA. The authors measured IOP in the right eye as soon as possible after ketamine had been administered and then at 2.5, 5, and 10 minutes after ketamine had been administered. RESULTS Eighty patients were enrolled (28 between 1 and 5 years of age, 26 between 6 and 10 years, 26 between 11 and 15 years); 49 (61%) were male. Procedures requiring PSA included fracture/dislocation reduction (63%), abscess incision and drainage (16%), laceration repair (11%), dental abscess incision and drainage (6%), and other (4%). The mean total ketamine dosage was 1.6 mg/kg (95% confidence interval [CI] = 1.4 to 1.7). The mean initial IOP was 17.5 mm Hg (95% CI = 16.4 to 18.6 mm Hg) and at 2.5 minutes was 18.9 mm Hg (95% CI = 17.9 to 19.9 mm Hg). The mean difference was 1.4 mm Hg (95% CI = 0.4 to 2.4 mm Hg). Using a noninferiority margin of 2.6 mm Hg (15%), noninferiority (no significant elevation in IOP) was demonstrated with 95% confidence between the first and second readings. CONCLUSIONS Ketamine does not significantly increase IOP in pediatric patients without eye injuries receiving typical PSA dosages in the PED. Further study should assess its safety in patients with ocular injury.
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Affiliation(s)
- Sarah M Halstead
- Department of Pediatrics, Section of Pediatric Emergency Medicine, University of Colorado Denver, Children's Hospital Colorado, Denver, CO, USA
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