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Mou J, Liu Z, Gong X, Wang J. Exploring the Micropore Functional Mechanism of N 2O Adsorption by the Eucalyptus Bark-based Porous Carbon. LANGMUIR : THE ACS JOURNAL OF SURFACES AND COLLOIDS 2024; 40:10393-10404. [PMID: 38666366 DOI: 10.1021/acs.langmuir.4c00701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2024]
Abstract
Nitrous oxide (N2O), recognized as a significant greenhouse gas, has received insufficient research attention in the past. In view of their low energy consumption and cost-effectiveness, the application of porous materials in adsorption is increasingly regarded as a potent strategy to reduce N2O pollution. In this study, a series of microporous porous carbons with a preeminent specific surface area (244.54-2018.08 m2 g-1), which are derived from the fast-growing eucalyptus bark, were synthesized by KOH activation at high temperatures. The obtained materials demonstrated a relatively fine N2O capture capability (0.19-0.68 mmol g-1) at normal temperature and pressure. More importantly, the optimal pore size affecting N2O adsorption (0.8 and 1.0 nm) has been detected, which is a meaningful view that has never been put forward in previous studies. The rationality of the N2O adsorption mechanism was also validated by combining the experimental analysis and Grand Canonical Monte Carlo (GCMC) simulation. The calculated results showed that 0.8 and 1.0 nm of the porous carbon were the preferred pore sizes for N2O adsorption, and the interaction force between N2O and the pore wall decreased with the increase of distance. This study provides a significant theoretical basis for the preparation of biomass porous carbon with excellent N2O adsorption performance and practical adsorption application.
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Affiliation(s)
- Jingxian Mou
- School of Resources, Environment and Materials, Guangxi University, Nanning 530004, China
- Education Department of Guangxi Zhuang Autonomous Region, Key Laboratory of Environmental Protection (Guangxi University), Nanning 530004, Guangxi, China
| | - Zheng Liu
- School of Resources, Environment and Materials, Guangxi University, Nanning 530004, China
- Education Department of Guangxi Zhuang Autonomous Region, Key Laboratory of Environmental Protection (Guangxi University), Nanning 530004, Guangxi, China
- State Key Laboratory of Featured Metal Materials and Life-cycle Safety for Composite Structures, Guangxi University, Nanning 530004, China
| | - Xiyue Gong
- School of Resources, Environment and Materials, Guangxi University, Nanning 530004, China
- Education Department of Guangxi Zhuang Autonomous Region, Key Laboratory of Environmental Protection (Guangxi University), Nanning 530004, Guangxi, China
| | - Jiaying Wang
- School of Resources, Environment and Materials, Guangxi University, Nanning 530004, China
- Education Department of Guangxi Zhuang Autonomous Region, Key Laboratory of Environmental Protection (Guangxi University), Nanning 530004, Guangxi, China
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2
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Majeed A, Awan AM. Should pipeline nitrous oxide be discontinued in secondary care: A cost-benefit analysis. Saudi J Anaesth 2024; 18:194-196. [PMID: 38654878 PMCID: PMC11033912 DOI: 10.4103/sja.sja_791_23] [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: 09/23/2023] [Revised: 10/01/2023] [Accepted: 10/03/2023] [Indexed: 04/26/2024] Open
Abstract
Background Nitrous oxide (N2O) has seen a marked decline in its usage in recent years due to its adverse clinical effects. We audited the practice in our department to evaluate the N2O consumption and cost-effectiveness of its supply. Methodology Electronic anesthesia records of all patients anesthetized in our main operating rooms in a typical month were reviewed retrospectively, and utilization of N2O was noted in addition to the patient demographics, surgical procedure, and specialty. Results A total of 950 patients were anesthetized, and 3.1% received N2O. The annual usage was estimated to be 72,871 liters, with a leakage of 3,883,105 liters to the environment, posing a safety hazard and wasting 149,612.50 SAR. Conclusion Notable costs and environmental benefits may be achieved by substituting a piped supply of N2O with portable E-cylinders on demand in operating rooms for rational use.
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Affiliation(s)
- Amer Majeed
- Department of Anesthesia, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Amreen M. Awan
- Department of Anesthesia, McMaster University Medical Centre, Hamilton, Canada
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3
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Kampman JM, Plasmans KYQ, Hermanides J, Hollmann MW, Repping S, Sperna Weiland NH. Influence of nitrous oxide added to general anaesthesia on postoperative mortality and morbidity: a systematic review and meta-analysis. Br J Anaesth 2024:S0007-0912(24)00073-4. [PMID: 38471989 DOI: 10.1016/j.bja.2024.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 02/19/2024] [Accepted: 02/19/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Nitrous oxide (N2O) is a common adjuvant to general anaesthesia. It is also a potent greenhouse gas and causes ozone depletion. We sought to quantify the influence of N2O as an adjuvant to general anaesthesia on postoperative patient outcomes. METHODS We searched Medline, EMBASE, and Cochrane Central for works published from inception to July 6, 2023. RCTs comparing general anaesthesia with or without N2O were included. Risk ratios (RRs) and standardised mean differences (SMDs) were calculated, along with 95% confidence intervals (CIs), using a random-effects model. Outcomes were derived from the Standardised Endpoints for Perioperative Medicine (StEP) outcome set. Primary outcomes were mortality and organ-related morbidity, and secondary outcomes were anaesthetic and surgical morbidity. RESULTS Of 3305 records, 179 full-text articles were assessed, and 71 RCTs, totalling 22 147 patients, were included in the meta-analysis. Addition of N2O to general anaesthesia did not influence postoperative mortality or most morbidity outcomes. N2O increased the incidence of atelectasis (RR 1.62, 95% CI 1.24 to 2.12) and postoperative nausea and vomiting (RR 1.27, 95% CI 1.15 to 1.40), and decreased intraoperative opioid consumption (SMD -0.19, 95% CI -0.35 to -0.04) and time to extubation (MD -2.17 min, 95% CI -3.32 to -1.03 min). CONCLUSIONS N2O did not influence postoperative mortality or most morbidity outcomes. Considering the environmental effects of N2O, these findings confirm that current policy recommendations to limit its use do not affect patient safety. SYSTEMATIC REVIEW PROTOCOL PROSPERO CRD42023443287.
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Affiliation(s)
- Jasper M Kampman
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Amsterdam UMC Centre for Sustainable Healthcare, Amsterdam UMC, Amsterdam, The Netherlands.
| | - Kim Y Q Plasmans
- Department of Anaesthesiology, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Jeroen Hermanides
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Markus W Hollmann
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Sjoerd Repping
- Healthcare Evaluation and Appropriate Use, National Healthcare Institute, Diemen, The Netherlands; Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Nicolaas H Sperna Weiland
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Amsterdam UMC Centre for Sustainable Healthcare, Amsterdam UMC, Amsterdam, The Netherlands
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Lehmann F, Schulz CM, Leicht D, Brady S, Fuhrmann A, Prütting J, Hügel MG, Hörr D, Sander M. Persistent use of nitrous oxide for anaesthesia in European hospitals despite its harmfulness to the climate - how emission taxation can achieve the coupling of cost-effectiveness and climate protection: observational study. BMC Health Serv Res 2023; 23:1392. [PMID: 38082272 PMCID: PMC10714631 DOI: 10.1186/s12913-023-10307-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 11/09/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Health care has the intrinsic obligation to preserve health. This concept is also applicable to planetary health. Nitrous oxide (N2O) lacks clinical indications in modern anaesthesia, while it is a high-potential greenhouse gas. Its seemingly low cost contrasts with the consequential externalised socio-economic costs due to its contribution to the climate crisis, which is approximately €698 per emitted ton of CO2 equivalent. This difference can be internalised through emission taxation. In this study, we aim to evaluate how much N2O - total amount and converted to CO2 equivalent - is used at a German university hospital and compare this amount to that used at European hospitals. Furthermore, how the cost of N2O usage changes under different emission taxation scenarios is calculated. METHODS This trial was a retrospective observational study at a German university hospital with approximately 1,250 beds between 2016 and 2020. Additionally, five European hospitals from the Health Care Without Harm Network were used for comparison from a European perspective. The main outcome parameters were the amount of N2O used, in total and converted to CO2 equivalent, and the total cost at emission taxation of €0, €25, €55 and €698 per ton CO2 equivalent. RESULTS At the peak, 2,104 tCO2 equivalent in N2O was emitted in 2019. The actual cost was €14,040 in this year, while the corresponding socio-economic damage due to the climate crisis was almost €1.5 million. Other European hospitals showed comparable amounts of emissions. CONCLUSIONS The annual peak amount of emitted N2O corresponded to the total annual greenhouse gas emission of 188 people in Germany. To achieve a drastic reduction in use, the abandonment of recommendations by anaesthesiologic societies appears necessary, in addition to an internalisation of future costs via emission taxation, which will cause inadequate cost for a medication without relevant benefit or indication. To that end, the inclusion of health sector emissions within national or international greenhouse gas taxation, for example, the European Union Emissions Trading System, appears necessary and expedient in view of the urgent need to address the ecological transformation. TRIAL REGISTRATION The trial was registered with the German Clinical Trials Register, identifier DRKS00024973 on 12/04/2021.
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Affiliation(s)
- Ferdinand Lehmann
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, UKGM Standort Gießen, Justus-Liebig-Universität, Gießen, Germany.
- Deutsche Allianz für Klima und Gesundheit e.V, Berlin, Germany.
| | | | - Dominik Leicht
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, UKGM Standort Gießen, Justus-Liebig-Universität, Gießen, Germany
| | - Scott Brady
- Health Care Without Harm (HCWH) Europe, Brussels, Belgium
| | - Anna Fuhrmann
- Health Care Without Harm (HCWH) Europe, Brussels, Belgium
| | - Jens Prütting
- Bucerius Law School gGmbH, Hochschule für Rechtswissenschaft, Hamburg, Germany
| | - Max Georg Hügel
- Bucerius Law School gGmbH, Hochschule für Rechtswissenschaft, Hamburg, Germany
| | - Daniel Hörr
- Geschäftsbereich Technik und Bau, UKGM, Standort Gießen, Germany
| | - Michael Sander
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, UKGM Standort Gießen, Justus-Liebig-Universität, Gießen, Germany
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Emont J, Wang M, Wright K. Health system decarbonization on obstetric and newborn units. Semin Perinatol 2023; 47:151844. [PMID: 37852893 DOI: 10.1016/j.semperi.2023.151844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2023]
Abstract
The healthcare industry makes up 4.6 % of greenhouse gas (GHS) emissions worldwide. Although it is not known what proportion of GHGs come from obstetric and newborn units, newborns and pregnant individuals are likely to face some of the largest consequences from climate change. We review the literature in the areas of decarbonization on labor and delivery (L&D) and neonatal units and describe innovations from the fields of surgery and anesthesia. Best practices for L&D include refining disposable equipment packs, decreasing the use of single-use medical devices, adequately triaging waste, and decreasing the use of potent anesthetic gases such as nitrous oxide and desflurane. In neonatal settings, similarly triaging waste and decreasing the use of plastics containing endocrine disrupting chemicals can lower the carbon and environmental footprint and improve neonatal health. Additionally, avoiding unnecessary cesarean deliveries and increasing breastfeeding practices are also likely to improve the carbon footprint of L&D and neonatal units.
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Affiliation(s)
- Jordan Emont
- Department of Obstetrics and Gynecology, Columbia University Medical Center - New York Presbyterian Hospital, 622 W 168th St, New York, NY 10032, USA.
| | - Melissa Wang
- Department of Obstetrics and Gynecology, Columbia University Medical Center - New York Presbyterian Hospital, 622 W 168th St, New York, NY 10032, USA
| | - Kelly Wright
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Agrawal AN, Alagarsamy F, Owen PJ, Klein AA. Is the future of nitrous oxide as volatile as the gas itself? Anaesthesia 2023; 78:1315-1319. [PMID: 37415287 DOI: 10.1111/anae.16086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2023] [Indexed: 07/08/2023]
Affiliation(s)
- A N Agrawal
- Department of Anaesthesia, Addenbrookes Cambridge University Hospitals, Cambridge, UK
| | - F Alagarsamy
- Department of Anaesthesia, Addenbrookes Cambridge University Hospitals, Cambridge, UK
| | - P J Owen
- Department of Trauma and Orthopaedics, Addenbrookes Cambridge University Hospitals, Cambridge, UK
| | - A A Klein
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
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7
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Freeman N, Watson S, Barnes C, Warland J, Rose M, Bradfield Z. A survey of Australian midwives: Experts in nitrous oxide administration within the peripartum setting. Women Birth 2023; 36:520-528. [PMID: 37308354 DOI: 10.1016/j.wombi.2023.06.002] [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: 02/22/2023] [Revised: 05/28/2023] [Accepted: 06/05/2023] [Indexed: 06/14/2023]
Abstract
PROBLEM There is little documented evidence of midwives' perspectives regarding the use of nitrous oxide in the peripartum period. BACKGROUND Nitrous oxide is an inhaled gas used widely in the peripartum period; usually offered and managed by midwives. AIM Explore midwives' knowledge, perceptions, and practices of facilitating women's use of nitrous oxide in the peripartum period. METHODS An exploratory cross-sectional survey design was used. Quantitative data were analysed using descriptive and inferential statistics; open-ended responses underwent template analysis. FINDINGS Midwives (n = 121) working in three Australian settings reported regularly recommending the use of nitrous oxide and high levels of knowledge and confidence supporting its use. There was a significant association between midwifery experience, and perspectives on women's capacity to use nitrous effectively (p = 0.004); and desire for refresher education (p < 0.001). Midwives working in continuity models were more likely to support women using nitrous oxide in any situation (p = 0.039). DISCUSSION Midwives demonstrated expertise in facilitating nitrous oxide use, citing utility to relieve anxiety and distract women from pain or discomfort. Nitrous oxide was identified as an important adjunct to the provision of supportive care requiring midwifery therapeutic presence. CONCLUSION This study provides novel insight into midwives' support of nitrous oxide use in the peripartum setting revealing high levels of knowledge and confidence. Recognition of this unique expertise held by midwives is important to ensure transfer and development of professional knowledge and skills and emphasises the need for midwifery leadership in clinical service provision, planning and policy.
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Affiliation(s)
- Nicole Freeman
- School of Nursing, Midwifery and Paramedicine, Curtin University, Western Australia, Australia; King Edward Memorial Hospital, Western Australia, Australia
| | - Stuart Watson
- School of Nursing, Midwifery and Paramedicine, Curtin University, Western Australia, Australia
| | - Courtney Barnes
- School of Nursing, Midwifery and Paramedicine, Curtin University, Western Australia, Australia
| | - Jane Warland
- School of Nursing, Midwifery and Paramedicine, Curtin University, Western Australia, Australia; King Edward Memorial Hospital, Western Australia, Australia
| | - Monique Rose
- School of Nursing, Midwifery and Paramedicine, Curtin University, Western Australia, Australia
| | - Zoe Bradfield
- School of Nursing, Midwifery and Paramedicine, Curtin University, Western Australia, Australia; King Edward Memorial Hospital, Western Australia, Australia.
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8
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Liu Y, Lee-Archer P, Sheridan NM, Seglenieks R, McGain F, Eley VA. Nitrous Oxide Use in Australian Health Care: Strategies to Reduce the Climate Impact. Anesth Analg 2023; 137:819-829. [PMID: 37471292 DOI: 10.1213/ane.0000000000006620] [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: 07/22/2023]
Abstract
Nitrous oxide is a useful inhaled analgesic. Due to its high global warming potential and ozone-depleting properties, the nitrous oxide emissions related to health care are being increasingly scrutinized. In this narrative review, we will discuss the clinical uses of nitrous oxide relevant to anesthetists, in addition to its contribution as a greenhouse gas. Using available data from Australia, we will explore potential strategies for reducing the impact of those emissions, which are likely to be applicable in other countries. These include destruction of captured nitrous oxide, minimizing nitrous oxide waste and reducing clinical use. Anesthesia clinicians are well placed to raise awareness with colleagues and consumers regarding the environmental impact of nitrous oxide and to promote cleaner alternatives. Reducing use is likely to be the most promising reduction strategy without large-scale changes to infrastructure and subsequent delay in action.
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Affiliation(s)
- Yigang Liu
- From the Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Paul Lee-Archer
- From the Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Department of Anaesthesia and Pain Medicine, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Nicole M Sheridan
- Department of Anaesthesia, Pain and Perioperative Medicine, Western Health, Melbourne, Victoria, Australia
| | - Richard Seglenieks
- Department of Anaesthesia, Pain and Perioperative Medicine, Western Health, Melbourne, Victoria, Australia
- Department of Anaesthesia, Grampians Health, Ballarat, Victoria, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
| | - Forbes McGain
- Department of Anaesthesia, Pain and Perioperative Medicine, Western Health, Melbourne, Victoria, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
- Department of Intensive Care, Western Health, Melbourne, Victoria, Australia
| | - Victoria A Eley
- From the Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Department of Anaesthesia and Perioperative Medicine, The Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
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9
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Pauchard JC, Hafiani EM, Bonnet L, Cabelguenne D, Carenco P, Cassier P, Garnier J, Lallemant F, Pons S, Sautou V, De Jong A, Caillard A. Guidelines for reducing the environmental impact of general anaesthesia. Anaesth Crit Care Pain Med 2023; 42:101291. [PMID: 37562688 DOI: 10.1016/j.accpm.2023.101291] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
OBJECTIVE To provide guidelines for reducing the environmental impact of general anaesthesia. DESIGN A committee of ten experts from SFAR and SF2H and SFPC learned societies was set up. A policy of declaration of competing interests was applied and observed throughout the guideline-writing process. Likewise, it did not benefit from any funding from a company marketing a health product (drug or medical device). The committee followed the GRADE® method (Grading of Recommendations Assessment, Development and Evaluation) to assess the quality of the evidence on which the recommendations were based. METHODS We aimed to formulate recommendations according to the GRADE® methodology for three different fields: anaesthesia vapours and gases; intravenous drugs; medical devices and the working environment. Each question was formulated according to the PICO format (Population, Intervention, Comparator, Outcome). The literature review and recommendations were formulated according to the GRADE® methodology. RESULTS The experts' work on the synthesis and application of the GRADE® method led to the formulation of 17 recommendations. Since the GRADE® method could not be entirely applied to all of the questions, some of the recommendations were formulated as expert opinions. CONCLUSION Based on strong agreement between experts, we produced 17 recommendations designed to guide reducing the environmental impact of general anaesthesia.
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Affiliation(s)
- Jean-Claude Pauchard
- Ramsay Santé, Member of Société Française d'Anesthésie Réanimation (SFAR) Substainable Development Committee, Clinique Aguiléra, Biarritz, France.
| | - El-Madhi Hafiani
- Department of Anaesthesia, Resuscitation and Perioperative Medicine, DMU DREAM - Tenon Hospital, AP-HP Sorbonne University, Paris, France.
| | - Laure Bonnet
- Department of Anesthesia and Intensive Care, Centre Hospitalier Princess Grace, Monaco
| | | | - Philipe Carenco
- Hygiene Department CHU de Nice, Nice, France; CPias PACA, Marseille, France; AFNOR, La Plaine Saint-Denis, France; Comité Européen de Normalisation, Brussels, Belgium; Bureau de Normalisation de l'Industrie Textile et de l'Habillement (BNITH), domaine des textiles en santé, Paris, France
| | - Pierre Cassier
- Institute of Infectious Agents, Hospices Civils de Lyon, Lyon, France; CIRI, Centre International de Recherche en Infectiologie, Université de Lyon, Inserm, U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, ENS de Lyon, Lyon, France
| | - Jérémie Garnier
- Department of Anesthesia and Intensive Care Unit, CHU Amiens-Picardie, 1 Rond-Point du Pr Christian Cabrol, 80054 Amiens Cedex 1, France
| | - Florence Lallemant
- Department of Anesthesia and Intensive Care Unit, CHU Lille, F-59000 Lille, France; CHU Lille, Pôle des Urgences, F-59000 Lille, France
| | - Stéphanie Pons
- DMU DREAM, Department of Anesthesiology and Critical Care, Sorbonne University, GRC 29, AP-HP, Pitié-Salpêtrière, Paris, France
| | - Valérie Sautou
- Clermont Auvergne University, Clermont Auvergne INP, CNRS, CHU Clermont Ferrand, ICCF, F-63000 Clermont-Ferrand, France
| | - Audrey De Jong
- PhyMedExp, Montpellier University, INSERM, CNRS, CHU Montpellier, France; Department of Anesthesia and Intensive Care Unit, St-Eloi Hospital, France
| | - Anaïs Caillard
- Department of Anesthesia and Intensive Care Unit, CHU Brest, Cavale Blanche Hospital, France; ORPHY, EA 4324, France
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Desmidt T, Dujardin PA, Andersson F, Brizard B, Réméniéras JP, Gissot V, Arlicot N, Barantin L, Espitalier F, Belzung C, Tanti A, Robert G, Bulteau S, Gallet Q, Kazour F, Cognet S, Camus V, El-Hage W, Poupin P, Karim HT. Changes in cerebral connectivity and brain tissue pulsations with the antidepressant response to an equimolar mixture of oxygen and nitrous oxide: an MRI and ultrasound study. Mol Psychiatry 2023; 28:3900-3908. [PMID: 37592013 DOI: 10.1038/s41380-023-02217-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 08/01/2023] [Accepted: 08/03/2023] [Indexed: 08/19/2023]
Abstract
Nitrous oxide (N2O) has recently emerged as a potential fast-acting antidepressant but the cerebral mechanisms involved in this effect remain speculative. We hypothesized that the antidepressant response to an Equimolar Mixture of Oxygen and Nitrous Oxide (EMONO) would be associated with changes in cerebral connectivity and brain tissue pulsations (BTP). Thirty participants (20 with a major depressive episode resistant to at least one antidepressant and 10 healthy controls-HC, aged 25-50, only females) were exposed to a 1-h single session of EMONO and followed for 1 week. We defined response as a reduction of at least 50% in the MADRS score 1 week after exposure. Cerebral connectivity of the Anterior Cingulate Cortex (ACC), using ROI-based resting state fMRI, and BTP, using ultrasound Tissue Pulsatility Imaging, were compared before and rapidly after exposure (as well as during exposure for BTP) among HC, non-responders and responders. We conducted analyses to compare group × time, group, and time effects. Nine (45%) depressed participants were considered responders and eleven (55%) non-responders. In responders, we observed a significant reduction in the connectivity of the subgenual ACC with the precuneus. Connectivity of the supracallosal ACC with the mid-cingulate also significantly decreased after exposure in HC and in non-responders. BTP significantly increased in the three groups between baseline and gas exposure, but the increase in BTP within the first 10 min was only significant in responders. We found that a single session of EMONO can rapidly modify the functional connectivity in the subgenual ACC-precuneus, nodes within the default mode network, in depressed participants responders to EMONO. In addition, larger increases in BTP, associated with a significant rise in cerebral blood flow, appear to promote the antidepressant response, possibly by facilitating optimal drug delivery to the brain. Our study identified potential cerebral mechanisms related to the antidepressant response of N2O, as well as potential markers for treatment response with this fast-acting antidepressant.
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Affiliation(s)
- Thomas Desmidt
- UMR 1253, iBrain, Université de Tours, Inserm, Tours, France.
- CHU de Tours, Tours, France.
- CIC 1415, CHU de Tours, Inserm, Tours, France.
| | | | | | - Bruno Brizard
- UMR 1253, iBrain, Université de Tours, Inserm, Tours, France
| | | | | | - Nicolas Arlicot
- UMR 1253, iBrain, Université de Tours, Inserm, Tours, France
- CHU de Tours, Tours, France
| | | | - Fabien Espitalier
- UMR 1253, iBrain, Université de Tours, Inserm, Tours, France
- CHU de Tours, Tours, France
| | | | - Arnaud Tanti
- UMR 1253, iBrain, Université de Tours, Inserm, Tours, France
| | - Gabriel Robert
- Behavior and Basal Ganglia Host Team 4712, University of Rennes 1, Rennes, France Department of Psychiatry, Rennes University Hospital, Guillaume Régnier Hospital Centre, Rennes, France
| | - Samuel Bulteau
- Addictology and Liaison Psychiatry Department, CHU de Nantes, 44000, Nantes, France
| | - Quentin Gallet
- Department of Psychiatry, University Hospital, Angers, France
| | - François Kazour
- Department of Psychiatry, University Hospital, Angers, France
| | | | - Vincent Camus
- UMR 1253, iBrain, Université de Tours, Inserm, Tours, France
- CHU de Tours, Tours, France
| | - Wissam El-Hage
- UMR 1253, iBrain, Université de Tours, Inserm, Tours, France
- CHU de Tours, Tours, France
- CIC 1415, CHU de Tours, Inserm, Tours, France
| | | | - Helmet T Karim
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
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11
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DE Cosmo G, Levantesi L. Lung collapse: which strategy? Minerva Anestesiol 2023; 89:730-732. [PMID: 37676174 DOI: 10.23736/s0375-9393.23.17465-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Affiliation(s)
- Germano DE Cosmo
- Department of Anesthesiology and Intensive Care Medicine, Sacred Heart Catholic University, Rome, Italy -
| | - Laura Levantesi
- Department of Anesthesiology and Intensive Care Medicine, Sacred Heart Catholic University, Rome, Italy
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12
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Azizad O, Joshi GP. Day-surgery adult patients with obesity and obstructive sleep apnea: Current controversies and concerns. Best Pract Res Clin Anaesthesiol 2023; 37:317-330. [PMID: 37938079 DOI: 10.1016/j.bpa.2022.11.004] [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: 10/13/2022] [Accepted: 11/28/2022] [Indexed: 12/02/2022]
Abstract
Obesity and obstructive sleep apnea are considered independent risk factors that can adversely affect perioperative outcomes. A combination of these two conditions in the ambulatory surgery patient can pose significant challenges for the anesthesiologist. Nevertheless, these patients should not routinely be denied access to ambulatory surgery. Instead, patients should be appropriately optimized. Anesthesiologists and surgeons must work together to implement fast-track anesthetic and surgical techniques that will ensure successful ambulatory outcomes.
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Affiliation(s)
- Omaira Azizad
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Girish P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
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13
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Poonai N, Creene C, Dobrowlanski A, Geda R, Hartling L, Ali S, Bhatt M, Trottier ED, Sabhaney V, O'Hearn K, Jain R, Osmond MH. Inhaled nitrous oxide for painful procedures in children and youth: a systematic review and meta-analysis. CAN J EMERG MED 2023:10.1007/s43678-023-00507-0. [PMID: 37171705 DOI: 10.1007/s43678-023-00507-0] [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: 12/19/2022] [Accepted: 04/02/2023] [Indexed: 05/13/2023]
Abstract
OBJECTIVES The objective of this study was to synthesize indication-based evidence for N2O for distress and pain in children. STUDY DESIGN We included trials of N2O in participants 0-21 years, reporting distress or pain for emergency department procedures. The primary outcome was procedural distress. Where meta-analysis was not possible, we used Tricco et al.'s classification of "neutral" (p ≥ 0.05), "favorable," or "unfavorable" (p < 0.05, supporting N2O or comparator, respectively). We used the Cochrane Collaboration's Risk of Bias tool and the Grading of Recommendations Assessment, Development, and Evaluation system to evaluate risk of bias and quality of evidence, respectively. RESULTS We included 30 trials. For pain using the Visual Analog Scale (0-100 mm) during IV insertion, 70% N2O (delta:-16.5; 95%CI:-28.6 to -4.4; p = 0.008; three trials; I2 = 0%) and 50% N2O plus eutectic mixture of local anesthetics (EMLA) (delta:-1.2; 95%CI:-2.1 to -0.3; p = 0.007; two trials; I2 = 43%) were superior to EMLA. 50% N2O was not superior to EMLA (delta:-0.4; 95%CI:-1.2 to 0.3; p = 0.26; two trials; I2 = 15%). For distress and pain during laceration repair, N2O was "favorable" versus each of SC lidocaine, oxygen, and oral midazolam but "neutral" versus IV ketamine (five trials). For distress and pain during fracture reduction (three trials), N2O was "neutral" versus each of IM meperidine plus promethazine, regional anesthesia, and IV ketamine plus midazolam. For distress and pain during lumbar puncture (one trial), N2O was "favorable" versus oxygen. For distress and pain during urethral catheterization (one trial), N2O was "neutral" versus oral midazolam. For pain during intramuscular injection (one trial), N2O plus EMLA was "favorable" versus N2O and EMLA alone. Common adverse effects of N2O included nausea (4.4%), agitation (3.7%), and vomiting (3.6%) AEs were less frequent with N2O alone (278/1147 (24.2%)) versus N2O plus midazolam (48/52 (92.3%)) and N2O plus fentanyl (123/201 (61.2%)). CONCLUSIONS There is sufficient evidence to recommend N2O plus topical anesthetic for IV insertion and laceration repair. Adverse effects are greater when combined with other sedating agents.
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Affiliation(s)
- Naveen Poonai
- Department of Pediatrics, Schulich School of Medicine and Dentistry, London, ON, Canada.
- Division of Emergency Medicine, Western University, London, ON, Canada.
- Children's Health Research Institute, London Health Sciences Centre, London, ON, Canada.
- Division of Pediatric Emergency Medicine, Children's Hospital, London Health Sciences Centre, London, ON, Canada.
| | | | | | - Rishika Geda
- Division of Emergency Medicine, Western University, London, ON, Canada
| | - Lisa Hartling
- Alberta Research Centre for Health Evidence (ARCHE), Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Samina Ali
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
- Women and Children's Health Research Institute, University of Alberta, Edmonton, AB, Canada
| | - Maala Bhatt
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Evelyne D Trottier
- Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Vikram Sabhaney
- BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Katie O'Hearn
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Rini Jain
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Martin H Osmond
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
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14
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Dimic N, Djuric M, Nenadic I, Bojic S, Bobos M, Janicijevic A, Bojanic M, Mijovic M, Stevanovic P. Nitrous Oxide — Application in Modern Anesthesia. CURRENT ANESTHESIOLOGY REPORTS 2023. [DOI: 10.1007/s40140-023-00554-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2023]
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15
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Occupational Exposure to Inhalational Anesthetics and Teratogenic Effects: A Systematic Review. Healthcare (Basel) 2023; 11:healthcare11060883. [PMID: 36981540 PMCID: PMC10048231 DOI: 10.3390/healthcare11060883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 02/27/2023] [Accepted: 03/15/2023] [Indexed: 03/22/2023] Open
Abstract
(1) Background: In the current healthcare environment, there is a large proportion of female staff of childbearing age, so, according to existing conflicting studies, the teratogenic effects that inhalational anesthetics may have on exposed pregnant workers should be assessed. This investigation aims to analyze the teratogenic effects of inhalational anesthetics in conditions of actual use, determining any association with spontaneous abortion or congenital malformations. (2) Methods: A systematic review was carried out according to the PRISMA statement based on PICO (problem of interest–intervention to be considered–intervention compared–outcome) (Do inhalational anesthetics have teratogenic effects in current clinical practice?). The level of evidence of the selected articles was evaluated using the SIGN scale. The databases used were PubMed, Embase, Scopus, Web of Science, Google academic and Opengrey. Primary studies conducted in professionals exposed to inhalational anesthetics that evaluate spontaneous abortions or congenital malformations, conducted in any country and language and published within the last ten years were selected. (3) Results: Of the 541 studies identified, 6 met all inclusion criteria in answering the research question. Since many methodological differences were found in estimating exposure to inhalational anesthetics, a qualitative systematic review was performed. The selected studies have a retrospective cohort design and mostly present a low level of evidence and a low grade of recommendation. Studies with the highest level of evidence do not find an association between the use of inhalational anesthetics and the occurrence of miscarriage or congenital malformations. (4) Conclusions: The administration of inhalational anesthetics, especially with gas extraction systems (scavenging systems) and the adequate ventilation of operating rooms, is not associated with the occurrence of spontaneous abortions or congenital malformations.
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16
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Affiliation(s)
- F Arran Seiler
- From the Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin
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17
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Sood R, Parent T. Peripheral polyneuropathy and acute psychosis from chronic nitrous oxide poisoning: A case report with literature review. Medicine (Baltimore) 2022; 101:e28611. [PMID: 35945749 PMCID: PMC9351869 DOI: 10.1097/md.0000000000028611] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Nitrous oxide (NO) is a commonly used drug in medical practice, restoration, and the automobile industry. Recreational abuse is an emerging public health problem owing to its accessibility and drug properties. PATIENT CONCERNS A 25-year-old male was hospitalized with acute psychosis and lower-extremity sensorimotor proprioceptive ataxia due to nitrous oxide abuse. DIAGNOSIS Laboratory studies confirmed a vitamin B12 deficiency. Magnetic resonance imaging of the spinal cord showed normal findings. Electrophysiological testing confirmed length-dependent sensorimotor polyneuropathy, with a predominant motor component and axonal degeneration. INTERVENTION AND OUTCOMES Abstinence from toxic substances was suggested, and vitamin B12 substitution was introduced. The patient was lost to follow up. LESSONS Nitrous oxide toxicity is multisystemic and is thought to result from vitamin B12 inactivation. Recent case reports postulated direct paranodal lesions resulting from nitrous oxide consumption. Neurological, neuropsychiatric, and hematological toxicities are among those explored in this case report. Correction of the functional vitamin B12 status and nitrous oxide abstinence are essential in the treatment process.
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Affiliation(s)
- Radhika Sood
- Department of Internal Medicine, Hôpitaux Universitaires de Genève, HUG, Geneva, Switzerland
- *Correspondence: Radhika Sood, Department of internal medicine, Hôpitaux universitaires de Genève, HUG, Rue Gabrielle Perret Gentil 4, 1205 Genève, Switzerland (e-mail: )
| | - Thibault Parent
- Department of Internal Medicine, Hôpitaux Universitaires de Genève, HUG, Geneva, Switzerland
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18
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Quantitative nitrous oxide usage by different specialties and current patterns of use in a single hospital. Br J Anaesth 2022; 129:e59-e60. [PMID: 35773029 DOI: 10.1016/j.bja.2022.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 05/22/2022] [Accepted: 05/23/2022] [Indexed: 11/21/2022] Open
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19
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Oulkadi S, Peters B, Vliegen AS. Thromboembolic complications of recreational nitrous oxide (ab)use: a systematic review. J Thromb Thrombolysis 2022; 54:686-695. [PMID: 35759070 DOI: 10.1007/s11239-022-02673-x] [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] [Accepted: 05/31/2022] [Indexed: 10/17/2022]
Abstract
The recreatinal use of nitrous oxide has become more common in recent years, especially in adolescents and young adults. It has been mainly associated with medical conditions like megaloblastic anemia and (myelo)neuropathy. We report on the thromboembolic complications, a less known side effect, associated with recreational inhalation of nitrous oxide. An extensive literature search was performed for publications reporting on the thromboembolic complications associated with recreational nitrous oxide abuse. Data about sex, age, location of thrombosis, laboratory findings, therapy and outcome were collected. A total of 13 case reports or case series were identified comprising a total of 14 patients. The reported thromboembolic side effects included deep venous thrombosis, pulmonary embolism, mesenterial-, portal and splenic vein thrombosis, cerebral sinus thrombosis, cortical vein thrombosis, stroke, acute myocardial infarction and peripheral artery thromboembolism. These side effects are possibly mediated by the interaction of nitrous oxide with vitamin B12, a cofactor of the methionine synthase complex, which eventually results in elevation of plasma levels of homocysteine. Despite being a known risk factor for cardiovascular disease, the exact pathophysiological mechanism remains unclear. Cessation of nitrous oxide inhalation is necessary to prevent recurrent thrombosis. Nitrous oxide abuse may thus result in a wide spectrum of thromboembolic complications. One should be aware of this etiology, especially in a young person with no obvious risk factors for cardiovascular disease. Spreading awareness is important to inform people about the potentially serious side effects associated with nitrous oxide inhalation.
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Affiliation(s)
- Sanad Oulkadi
- Department of Radiology, Resident Radiology, Jessa Hospital, Hasselt, Belgium. .,Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.
| | - Benjamin Peters
- Department of Radiology, Radiologist, Cardiac Imaging, Jessa Hospital, Hasselt, Belgium
| | - Anne-Sophie Vliegen
- Department of Radiology, Radiologist, Thoracic Imaging, Jessa Hospital, Hasselt, Belgium
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20
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Xing Y, Zhou L, Yu J, Wang Z, Ding Z, Xie C, Li Y, Wang F, Tang L. Analgesic efficacy of nitrous oxide in adults in the emergency department: A meta-analysis of randomized controlled trials. Am J Emerg Med 2022; 56:92-99. [DOI: 10.1016/j.ajem.2022.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 03/06/2022] [Accepted: 03/13/2022] [Indexed: 11/24/2022] Open
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21
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Oodit R, Biccard BM, Panieri E, Alvarez AO, Sioson MRS, Maswime S, Thomas V, Kluyts HL, Peden CJ, de Boer HD, Brindle M, Francis NK, Nelson G, Gustafsson UO, Ljungqvist O. Guidelines for Perioperative Care in Elective Abdominal and Pelvic Surgery at Primary and Secondary Hospitals in Low-Middle-Income Countries (LMIC's): Enhanced Recovery After Surgery (ERAS) Society Recommendation. World J Surg 2022; 46:1826-1843. [PMID: 35641574 PMCID: PMC9154207 DOI: 10.1007/s00268-022-06587-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2022] [Indexed: 12/24/2022]
Abstract
Background This is the first Enhanced Recovery After Surgery (ERAS®) Society guideline for primary and secondary hospitals in low–middle-income countries (LMIC’s) for elective abdominal and gynecologic care. Methods The ERAS LMIC Guidelines group was established by the ERAS® Society in collaboration with different representatives of perioperative care from LMIC’s. The group consisted of seven members from the ERAS® Society and eight members from LMIC’s. An updated systematic literature search and evaluation of evidence from previous ERAS® guidelines was performed by the leading authors of the Colorectal (2018) and Gynecologic (2019) surgery guidelines (Gustafsson et al in World J Surg 43:6592–695, Nelson et al in Int J Gynecol Cancer 29(4):651–668). Meta-analyses randomized controlled trials (RCTs), prospective and retrospective cohort studies from both HIC’s and LMIC’s were considered for each perioperative item. The members in the LMIC group then applied the current evidence and adapted the recommendations for each intervention as well as identifying possible new items relevant to LMIC’s. The Grading of Recommendations, Assessment, Development and Evaluation system (GRADE) methodology was used to determine the quality of the published evidence. The strength of the recommendations was based on importance of the problem, quality of evidence, balance between desirable and undesirable effects, acceptability to key stakeholders, cost of implementation and specifically the feasibility of implementing in LMIC’s and determined through discussions and consensus. Results In addition to previously described ERAS® Society interventions, the following items were included, revised or discussed: the Surgical Safety Checklist (SSC), preoperative routine human immunodeficiency virus (HIV) testing in countries with a high prevalence of HIV/AIDS (CD4 and viral load for those patients that are HIV positive), delirium screening and prevention, COVID 19 screening, VTE prophylaxis, immuno-nutrition, prehabilitation, minimally invasive surgery (MIS) and a standardized postoperative monitoring guideline. Conclusions These guidelines are seen as a starting point to address the urgent need to improve perioperative care and to effect data-driven, evidence-based care in LMIC’s.
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Affiliation(s)
- Ravi Oodit
- Division of Global Surgery, University of Cape Town, Anzio Road, Observatory, Cape Town, Western Cape, South Africa
| | - Bruce M Biccard
- Department of Anesthesia and Perioperative Medicine, Groote Schuur Hospital, University of Cape Town, Anzio Road, Observatory, Cape Town, Western Cape, South Africa
| | - Eugenio Panieri
- Division of General Surgery, Groote Schuur Hospital, University of Cape Town, Anzio Road, Observatory, Cape Town, Western Cape, South Africa
| | - Adrian O Alvarez
- Anesthesia Department, Hospital Italiano de Buenos Aires, Teniente General Juan Domingo Peron, 4190, C1199ABB, Beunos Aires, Argentina
| | - Marianna R S Sioson
- Head Section of Medical Nutrition, Department of Medicine and ERAS Team, The Medical City, Ortigas Avenue, Manila, Metro Manila, Philippines
| | - Salome Maswime
- Division of Global Surgery, University of Cape Town, Anzio Road, Observatory, Cape Town, Western Cape, South Africa
| | - Viju Thomas
- Department of Obstetrics and Gynaecology, Tygerberg Hospital and University of Stellenbosch, Francie Van Zyl Drive, Parow, Cape Town, Western Cape, South Africa
| | - Hyla-Louise Kluyts
- Department of Anaesthesiology, Sefako Makgatho Health Sciences University, Medunsa, Molotlegi Street, P.O. Box 60, Ga-Rankuwa, Pretoria, 0204, Gauteng, South Africa
| | - Carol J Peden
- Keck School of Medicine, University of Southern California, 1975 Zonal Ave, Los Angeles, CA, 90033, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Hans D de Boer
- Department of Anesthesiology, Pain Medicine and Procedural Sedation and Analgesia, Martini General Hospital Groningen, Van Swietenplein 1, 9728 NT, Groningen, The Netherlands
| | - Mary Brindle
- Cumming School of Medicine, University of Calgary, London, Canada.,Alberta Children's Hospital, Calgary, Canada.,Safe Systems, Ariadne Labs, Stockholm, USA.,EQuIS Research Platform, Orebro, Canada
| | - Nader K Francis
- Division of Surgery and Interventional Science- UCL, Gower Street, London, WC1E 6BT, UK
| | - Gregg Nelson
- Department of Obstetrics & Gynecology, University of Calgary, 1331 29 St NW, Calgary, AB, T2N 4N2, Canada
| | - Ulf O Gustafsson
- Department of Clinical Sciences, Division of Surgery, Danderyd Hospital, Karolinska Institutet, Entrevägen 2, 19257, Stockholm, Danderyd, Sweden
| | - Olle Ljungqvist
- School of Medical Sciences, Department of Surgery, Örebro University, 701 85, Örebro, Sweden.
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22
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Sharpe EE, Rollins MD. Beyond the epidural: Alternatives to neuraxial labor analgesia. Best Pract Res Clin Anaesthesiol 2022; 36:37-51. [PMID: 35659959 DOI: 10.1016/j.bpa.2022.04.005] [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: 02/28/2022] [Revised: 03/28/2022] [Accepted: 04/12/2022] [Indexed: 11/26/2022]
Abstract
Labor creates an intense pain experienced by women across the world. Although neuraxial analgesia is the most effective treatment of labor pain, in many cases, it may not be undesired, not available, or have contraindications. In addition, satisfaction with labor analgesia is not only determined by the efficacy of analgesia but a woman's sense of agency and involvement in the childbirth experience are also key contributors. Providing safe choices for labor analgesia and support is central to creating a tailored, safe, and effective analgesic treatment plan with high maternal satisfaction. Healthcare provider knowledge of various nonneuraxial analgesic options, including efficacy, contraindications, safe clinical implementation, and side effects of various techniques is needed for optimal patient care and satisfaction. Future rigorous scientific studies addressing all of these labor analgesia options are needed to improve our understanding. This review summarizes the current published literature for commonly available non-neuraxial labor analgesic options.
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Affiliation(s)
- Emily E Sharpe
- Department of Anesthesia and Perioperative Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
| | - Mark D Rollins
- Department of Anesthesia and Perioperative Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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23
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Azizad O, Joshi GP. Ambulatory surgical patients and sleep apnea. Int Anesthesiol Clin 2022; 60:43-49. [PMID: 35180144 DOI: 10.1097/aia.0000000000000356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Omaira Azizad
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
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24
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Gupta N, Gupta A, Narayanan M R V. Current status of nitrous oxide use in pediatric patients. World J Clin Pediatr 2022; 11:93-104. [PMID: 35433304 PMCID: PMC8985494 DOI: 10.5409/wjcp.v11.i2.93] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 07/05/2021] [Accepted: 02/27/2022] [Indexed: 02/06/2023] Open
Abstract
Nitrous oxide is one of the most commonly used inhalational anesthetic agents used in practice. It is a cost-effective, pleasant, safe, and versatile anesthetic agent with many desirable properties like good quality analgesia, decreased awareness, accelerated induction and recovery from anesthesia, and reduced utilization of other expensive inhalational agents with potential cost savings. The use of nitrous oxide has been questioned by a lot of studies and case reports perceiving its adverse systemic, hematological, immune, and neurologic adverse effects. However, the literature in the recent past has tried to resolve the controversies related to its use. The concerns over an increase in cardiovascular complications and mortality following nitrous oxide use have been negated by recent data. However, its use in certain vulnerable populations like children with cobalamin and folate deficiency or defects in their metabolic pathways remains a cause of concern for its toxic effects. In this narrative review, we aim to discuss the pharmacological properties of nitrous oxide, the potential advantages and drawbacks of the use of nitrous oxide in children, address the neurodevelopmental and other systemic effects, and throw light on the evidence regarding the safety of nitrous oxide use and its current role in pediatric procedural sedation and anesthesia practice. The literature related to its use in the pediatric population for painful procedures and surgeries has been summarized.
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Affiliation(s)
- Nishkarsh Gupta
- Department of Onco-Anesthesiology and Palliative Medicine, AIIMS, New Delhi 110029, Delhi, India
| | - Anju Gupta
- Department of Anesthesiology, Pain Medicine and Critical Care, AIIMS, New Delhi 110029, Delhi, India
| | - Vishnu Narayanan M R
- Department of Anesthesiology, Pain Medicine and Critical Care, AIIMS, New Delhi 110029, Delhi, India
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25
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Tunc EM, Burns B, Brennan K, Yoshida H, Burns R. Nitrous Oxide Sedation Asynchronous Curriculum for Pediatric Emergency Medicine Providers. Cureus 2021; 13:e18949. [PMID: 34853733 PMCID: PMC8607845 DOI: 10.7759/cureus.18949] [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] [Accepted: 10/21/2021] [Indexed: 11/23/2022] Open
Abstract
This technical report describes a nitrous oxide sedation training curriculum for pediatric emergency medicine providers. This curriculum was used during the novel coronavirus disease 2019 (COVID-19) pandemic where in-person classroom training was significantly limited. We demonstrate a model for concept and equipment learning with video-guided self-practice in place of in-person training with a facilitator. A similar model can be utilized for other equipment or concept training.
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Affiliation(s)
- Emine M Tunc
- Pediatric Emergency Medicine, University of Washington School of Medicine, Seattle, USA
| | - Brian Burns
- Pediatric Emergency Medicine, Seattle Children's Hospital, Seattle, USA
| | - Kelly Brennan
- Pediatric Emergency Medicine, Seattle Children's Hospital, Seattle, USA
| | - Hiromi Yoshida
- Pediatric Emergency Medicine, University of Washington School of Medicine, Seattle, USA
| | - Rebekah Burns
- Pediatric Emergency Medicine, University of Washington School of Medicine, Seattle, USA
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26
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Rajan N, Joshi GP. Management of postoperative nausea and vomiting in adults: current controversies. Curr Opin Anaesthesiol 2021; 34:695-702. [PMID: 34560688 DOI: 10.1097/aco.0000000000001063] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Postoperative nausea and vomiting (PONV) continue to plague the surgical patient population with an adverse impact on postoperative outcomes. The aim of this review is to critically assess current evidence for PONV management, including studies evaluating baseline risk reduction and antiemetic prophylaxis, to provide a pragmatic approach to prevention and treatment of PONV in routine clinical practice. RECENT FINDINGS Multiple recent reviews and guidelines have been published on this topic with some limitations. In the current ERAS era, all patients irrespective of their PONV risk should receive two to three antiemetics for prophylaxis. Patients at a high risk of PONV [i.e. prior history of PONV, history of motion sickness, high opioid requirements after surgery (e.g. inability to use nonopioid analgesic techniques)] should receive three to four antiemetics for prophylaxis. SUMMARY This review provides a practical approach to PONV prevention based on recent literature.
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Affiliation(s)
- Niraja Rajan
- Department of Anesthesiology and Perioperative Medicine, Penn State Health, Hershey, Pennsylvania
| | - Girish P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, Texas, USA
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27
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Seglenieks R, Wong A, Pearson F, McGain F. Discrepancy between procurement and clinical use of nitrous oxide: waste not, want not. Br J Anaesth 2021; 128:e32-e34. [PMID: 34802695 DOI: 10.1016/j.bja.2021.10.021] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 09/25/2021] [Accepted: 10/17/2021] [Indexed: 11/20/2022] Open
Affiliation(s)
- Richard Seglenieks
- Department of Anaesthesia and Pain Medicine, Western Health, Footscray, Melbourne, Victoria, Australia; Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia.
| | - Angela Wong
- Department of Anaesthesia and Pain Medicine, Western Health, Footscray, Melbourne, Victoria, Australia
| | | | - Forbes McGain
- Department of Anaesthesia and Pain Medicine, Western Health, Footscray, Melbourne, Victoria, Australia; Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia; Department of Intensive Care, Western Health, Footscray, Melbourne, Victoria, Australia
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28
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Joshi GP. General anesthetic techniques for enhanced recovery after surgery: Current controversies. Best Pract Res Clin Anaesthesiol 2021; 35:531-541. [PMID: 34801215 DOI: 10.1016/j.bpa.2020.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 08/11/2020] [Indexed: 10/23/2022]
Abstract
General anesthesia technique can influence not only immediate postoperative outcomes, but also long-term outcomes beyond hospital stay (e.g., readmission after discharge from hospital). There is lack of evidence regarding superiority of total intravenous anesthesia over inhalation anesthesia with regards to postoperative outcomes even in high-risk population including cancer patients. Optimal balanced general anesthetic technique for enhance recovery after elective surgery in adults includes avoidance of routine use preoperative midazolam, avoidance of deep anesthesia, use of opioid-sparing approach, and minimization of neuromuscular blocking agents and appropriate reversal of residual paralysis. Given that the residual effects of drugs used during anesthesia can increase postoperative morbidity and delay recovery, it is prudent to use a minimal number of drug combinations, and the drugs used are shorter-acting and administered at the lowest possible dose. It is imperative that the discerning anesthesiologist consider whether each drug used is really necessary for accomplishing perioperative goals.
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Affiliation(s)
- Girish P Joshi
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9068, USA.
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Puri GD, Meena SC, Sinha V, Hazarika A, Hakkim H, Sharma A, Kajal K, Dogra N. Quantitative Assessment of Nitrous Oxide Levels in Room Air of Operation Theaters and Recovery Area: An Observational Study. Indian J Occup Environ Med 2021; 25:147-151. [PMID: 34759601 PMCID: PMC8559877 DOI: 10.4103/ijoem.ijoem_44_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 03/09/2020] [Accepted: 04/26/2020] [Indexed: 11/19/2022] Open
Abstract
Background: Nitrous oxide has been used during surgical anesthesia for many years. However, information about occupational exposure and related risks due to N2O exposure to the health care personnel in India are still poorly understood. Here, we measured the residual N2O levels during the working time of operation theatre room air in our tertiary care hospital. Material and Methods: The air samples were collected from different anesthesia exposure zones on different days for quantitative analysis of available N2O in the room air in respective areas. Nitrous oxide concentrations in the ambient air were also measured to compare outdoor and indoor levels. Observations and Results: Nitrous oxide mixing ratios were found to be 65.61 ± 0.05 ppm, 281.63 ± 0.43 ppm, and 165.42 ± 0.42 ppm in elective surgical theatres of the hospital on three different days whereas in emergency operation theatres of the same hospital levels of N2O were 166.75 ± 0.07 ppm, 510.19 ± 0.30 ppm and 2443.92 ± 0.64 ppm during same period. In elective pediatric surgical theatres levels of N2O were found to be 1132.55 ± 0.70 ppm and 362.21 ± 0.13 ppm on two days of reading respectively. Outdoor levels of N2O in contrast found 0.32 ± 0.01 ppm and was lower by a factor of 1000. Conclusion: We observed the very high ambient concentration of N2O in the surgical theatre's environment (up to 2443 ppm) and recovery areas (up to 50 ppm). It was 5 to 50 times higher ambient concentration of N2O than REL in OT area and 200-7000 times higher ambient concentration of N2O than outdoor ambient air in all surgical theaters other than CTVS OTs.
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Affiliation(s)
- G D Puri
- Post Graduate Institute Medical Education and Research, Chandigarh, India
| | - Shyam C Meena
- Post Graduate Institute Medical Education and Research, Chandigarh, India
| | - Vinayak Sinha
- Indian Institute of Science Education and Research, Mohali, Punjab, India
| | - Amarjyoti Hazarika
- Post Graduate Institute Medical Education and Research, Chandigarh, India
| | - Haseeb Hakkim
- Indian Institute of Science Education and Research, Mohali, Punjab, India
| | - Ashish Sharma
- Indian Institute of Science Education and Research, Mohali, Punjab, India
| | - Kamal Kajal
- Post Graduate Institute Medical Education and Research, Chandigarh, India
| | - Neeti Dogra
- Post Graduate Institute Medical Education and Research, Chandigarh, India
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Removing CO2 from Xenon anaesthesia circuits using an amino-acid ionic liquid solution in a membrane contactor. Sep Purif Technol 2021. [DOI: 10.1016/j.seppur.2021.119190] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Menon JML, van Luijk JAKR, Swinkels J, Lukas E, Ritskes-Hoitinga M, Roeleveld N, Schlünssen V, Mandrioli D, Hoffmann S, Popa M, Scheepers PTJ. A health-based recommended occupational exposure limit for nitrous oxide using experimental animal data based on a systematic review and dose-response analysis. ENVIRONMENTAL RESEARCH 2021; 201:111575. [PMID: 34174259 DOI: 10.1016/j.envres.2021.111575] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 06/18/2021] [Accepted: 06/20/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Nitrous oxide (N2O) is a common inhalation anaesthetic used in medical, paramedical, and veterinary practice. Since the mid 1950's, concerns have been raised regarding occupational exposure to N2O, leading to many epidemiological and experimental animal studies. Previous evaluations resulted in the classification of N2O as a possible risk factor for adverse reproductive health outcomes based on animal data. Human data were deemed inadequate primarily because of simultaneous co-exposures to other risk factors for adverse reproductive and developmental outcomes, including other anaesthetic gases. Since previous evaluations, controversies regarding N2O use remained and new approaches for dose response modelling have been adopted, calling for an update and re-evaluation of the body of evidence. This review aims to assess available animal evidence on N2O reproductive and developmental outcomes to inform a health-based recommended occupational exposure limit (OEL) for N2O with a benchmark dose-response modelling (BMD) approach. METHODS Comprehensive searches in PubMed, EMBASE, and Web of Science were performed to retrieve all relevant studies addressing reproductive and developmental outcomes related to inhalation of N2O in animals. The articles retrieved were screened based on title-abstract and full text by two independent reviewers. After data extraction, an overview of all studies was created for the different endpoints, namely foetal outcomes (e.g., resorption), female outcomes (e.g. implantations), and male outcomes (e.g. sperm count). A subset of studies reporting on exposure relevant to workplace settings and with a sufficient number of tested doses were included in dose-response modelling using the BMD approach. RESULTS In total, 15.816 articles were retrieved, of which 47 articles were finally included while 4 of those were used for the quantitative data synthesis. The overall risk of bias was judged to be probably high (using OHAT risk of bias tool) and unclear (using SYRCLE's risk of bias tool). From eligible rat studies, three studies provided an acceptable result by fitting a Hill model to the dose-response data. The resulting benchmark dose lower bounds (BMDLs) from three studies converged to an average (±sd) exposure level of 925 ± 2 mg/m3 at an additional risk of one standard deviation of implantation losses above those observed in the control group (i.e. reduced number of live foetuses/mother). For extrapolation from rats to humans, an uncertainty factor of 10 was used and an additional factor of 5 was applied to account for interindividual variability within the population of workers. CONCLUSION With this systematic review, all available evidence for reproductive toxicity and adverse developmental outcomes in animals resulting from inhalation exposure to N2O was used to derive a health-based OEL recommendation of 20 mg/m3 as 8-h time-weighted average.
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Affiliation(s)
- Julia M L Menon
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, the Netherlands
| | - Judith A K R van Luijk
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, the Netherlands
| | - Janne Swinkels
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, the Netherlands
| | - Eva Lukas
- Faculty of Science, Radboud University, Nijmegen, the Netherlands
| | - Merel Ritskes-Hoitinga
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, the Netherlands; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Nel Roeleveld
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, the Netherlands
| | - Vivi Schlünssen
- Department of Public Health, Danish Ramazzini Centre, Aarhus University, Aarhus, Denmark and National Research Center for the Working Environment, Copenhagen, Denmark
| | - Daniele Mandrioli
- Cesare Maltoni Cancer Research Center, Ramazzini Institute, Bologna, Italy
| | - Sebastian Hoffmann
- The Evidence-Based Toxicology Collaboration (EBTC), Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | | | - Paul T J Scheepers
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, the Netherlands.
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Chan CS, Chan MTV. Use of nitrous oxide in contemporary anesthesia-an ongoing tug of war. Can J Anaesth 2021; 68:1597-1600. [PMID: 34448128 DOI: 10.1007/s12630-021-02094-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 08/02/2021] [Accepted: 08/02/2021] [Indexed: 11/25/2022] Open
Affiliation(s)
- Chee Sam Chan
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China
| | - Matthew T V Chan
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China.
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Towards Quantum-Chemical Modeling of the Activity of Anesthetic Compounds. Int J Mol Sci 2021; 22:ijms22179272. [PMID: 34502179 PMCID: PMC8431746 DOI: 10.3390/ijms22179272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 08/16/2021] [Accepted: 08/17/2021] [Indexed: 12/16/2022] Open
Abstract
The modeling of the activity of anesthetics is a real challenge because of their unique electronic and structural characteristics. Microscopic approaches relevant to the typical features of these systems have been developed based on the advancements in the theory of intermolecular interactions. By stressing the quantum chemical point of view, here, we review the advances in the field highlighting differences and similarities among the chemicals within this group. The binding of the anesthetics to their partners has been analyzed by Symmetry-Adapted Perturbation Theory to provide insight into the nature of the interaction and the modeling of the adducts/complexes allows us to rationalize their anesthetic properties. A new approach in the frame of microtubule concept and the importance of lipid rafts and channels in membranes is also discussed.
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The association of nitrous oxide on length of stay in the postanesthesia care unit: a retrospective observational study. Can J Anaesth 2021; 68:1630-1640. [PMID: 34406608 DOI: 10.1007/s12630-021-02067-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 06/04/2021] [Accepted: 06/16/2021] [Indexed: 10/20/2022] Open
Abstract
PURPOSE To assess whether intraoperative use of nitrous oxide (N2O) as an adjunct to general anesthesia is associated with a shorter length of stay in the postanesthesia care unit (PACU). METHODS We analyzed data from adult patients who underwent non-cardiothoracic surgery under general anesthesia between May 2008 and December 2018. We assessed the association between intraoperative low- and high-dose N2O and PACU length of stay. RESULTS A total of 148,284 patients were included in the primary analysis. After adjusting for a priori defined confounders, a high dose of N2O significantly decreased PACU length of stay, with a calculated difference of -9.1 min (95% confidence interval [CI], -10.5 to -7.7; P < 0.001). Patients who received high-dose N2O had a lower incidence of both short- and prolonged-duration of intraoperative hypotension (adjusted odds ratio [aOR], 0.85; 95% CI, 0.83 to 0.88; P < 0.001 and aOR, 0.76; 95% CI, 0.73 to 0.80; P < 0.001, respectively) and received a lower total intraoperative vasopressor dose (-0.04 mg of norepinephrine equivalents; 95% CI, -0.06 to -0.01; P = 0.01). The effect of high-dose N2O on PACU length of stay was modified by surgical complexity (adjusted absolute difference: -26.1 min; 95% CI, -29.2 to -23.1; P < 0.001; P for interaction < 0.001), and most pronounced in patients who underwent complex surgery and received intraoperative antiemetic therapy (adjusted absolute difference: -38.9 min; 95% CI, -43.1 to -34.6; P < 0.001; P for interaction < 0.001). CONCLUSIONS Nitrous oxide was dose-dependently associated with a decreased PACU length of stay. The effect was clinically relevant (> 30 min difference) in patients who underwent complex surgical procedures and received intraoperative antiemetic therapy.
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Nagele P, Palanca BJ, Gott B, Brown F, Barnes L, Nguyen T, Xiong W, Salloum NC, Espejo GD, Lessov-Schlaggar CN, Jain N, Cheng WWL, Komen H, Yee B, Bolzenius JD, Janski A, Gibbons R, Zorumski CF, Conway CR. A phase 2 trial of inhaled nitrous oxide for treatment-resistant major depression. Sci Transl Med 2021; 13:13/597/eabe1376. [PMID: 34108247 DOI: 10.1126/scitranslmed.abe1376] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 11/19/2020] [Accepted: 04/23/2021] [Indexed: 12/26/2022]
Abstract
Nitrous oxide at 50% inhaled concentration has been shown to improve depressive symptoms in patients with treatment-resistant major depression (TRMD). Whether a lower concentration of 25% nitrous oxide provides similar efficacy and persistence of antidepressant effects while reducing the risk of adverse side effects is unknown. In this phase 2 clinical trial (NCT03283670), 24 patients with severe TRMD were randomly assigned in a crossover fashion to three treatments consisting of a single 1-hour inhalation with (i) 50% nitrous oxide, (ii) 25% nitrous oxide, or (iii) placebo (air/oxygen). The primary outcome was the change on the Hamilton Depression Rating Scale (HDRS-21). Whereas nitrous oxide significantly improved depressive symptoms versus placebo (P = 0.01), there was no difference between 25 and 50% nitrous oxide (P = 0.58). The estimated differences between 25% and placebo were -0.75 points on the HDRS-21 at 2 hours (P = 0.73), -1.41 points at 24 hours (P = 0.52), -4.35 points at week 1 (P = 0.05), and -5.19 points at week 2 (P = 0.02), and the estimated differences between 50% and placebo were -0.87 points at 2 hours (P = 0.69), -1.93 points at 24 hours (P = 0.37), -2.44 points at week 1 (P = 0.25), and -7.00 points at week 2 (P = 0.001). Adverse events declined substantially with dose (P < 0.001). These results suggest that 25% nitrous oxide has comparable efficacy to 50% nitrous oxide in improving TRMD but with a markedly lower rate of adverse effects.
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Affiliation(s)
- Peter Nagele
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL 60637, USA.
| | - Ben J Palanca
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Britt Gott
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Frank Brown
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL 60637, USA
| | - Linda Barnes
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Thomas Nguyen
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Willa Xiong
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Naji C Salloum
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Gemma D Espejo
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO 63110, USA
| | | | - Nisha Jain
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL 60637, USA
| | - Wayland W L Cheng
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Helga Komen
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Branden Yee
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Jacob D Bolzenius
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Alvin Janski
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Robert Gibbons
- Center for Health Statistics, University of Chicago, Chicago, IL 60637, USA
| | - Charles F Zorumski
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO 63110, USA.,Taylor Family Institute for Innovative Psychiatric Research, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Charles R Conway
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO 63110, USA.,Taylor Family Institute for Innovative Psychiatric Research, Washington University School of Medicine, St. Louis, MO 63110, USA
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Patel D, Talbot C, Luo W, Mulvaney S, Byrne E. The use of esketamine sedation in the emergency department for manipulation of paediatric forearm fractures: A 5 year study. Injury 2021; 52:1321-1330. [PMID: 33454059 DOI: 10.1016/j.injury.2020.12.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 12/20/2020] [Accepted: 12/27/2020] [Indexed: 02/02/2023]
Abstract
The purpose of this study is to assess the use of esketamine as procedural sedation for the reduction of paediatric forearm fractures in the emergency department (ED). A retrospective analysis was undertaken of forearm fractures between 1st January 2012 to 31st December 2016 which were treated with manipulation in ED using esketamine sedation. Patient demographics and fracture configuration were collected. Patient radiographs were evaluated and cast index calculated. 151 patients (103 male, 48 female) were included (average age of 8.5 [1 to 15]). Four (2.6%) patients were lost to final follow up. 11 (7%) fractures were not accepted after initial manipulation and required formal surgical management under general anaesthetic. At one week follow up, a further 5 (3%) fractures displaced requiring operative management. 100% of patients who slipped at one week had a cast index greater than 0.8 [average 0.86, 95% CI 0.80-0.92]. At final follow up successful reduction was achieved in 89.1% (131/144) of patients. No adverse events occurred following administration of esketamine. This study provides evidence that manipulation of paediatric forearm fractures using esketamine as procedural sedation in the ED is comparable to other methods in achieving acceptable outcomes. This is in addition to the potential for cost savings. However, future studies formally assessing cost effectiveness and patient outcomes are needed.
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Affiliation(s)
- Dhawal Patel
- Department of Orthopaedics, Liverpool University Hospital NHS Foundation Trust, Lower Lane, Liverpool L9 7AL, United Kingdom.
| | - Christopher Talbot
- Department of Orthopaedics, Alder Hey Children's NHS Foundation Trust, East Prescot Road, Liverpool, L14 5AB
| | - Weisang Luo
- Department of Orthopaedics, Liverpool University Hospital NHS Foundation Trust, Lower Lane, Liverpool L9 7AL, United Kingdom
| | - Shirley Mulvaney
- Department of Emergency Medicine, Alder Hey Children's NHS Foundation Trust, East Prescot Road, Liverpool, L14 5AB
| | - Eileen Byrne
- Department of Emergency Medicine, Alder Hey Children's NHS Foundation Trust, East Prescot Road, Liverpool, L14 5AB
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Laghlam D, Naudin C, Coroyer L, Aidan V, Malvy J, Rahoual G, Estagnasié P, Squara P. Virtual reality vs. Kalinox® for management of pain in intensive care unit after cardiac surgery: a randomized study. Ann Intensive Care 2021; 11:74. [PMID: 33983498 PMCID: PMC8119554 DOI: 10.1186/s13613-021-00866-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 05/03/2021] [Indexed: 11/10/2022] Open
Abstract
Introduction The management of pain and anxiety remains a challenge in the intensive care unit. By distracting patients, virtual reality (VR) may have a role in painful procedures. We compared VR vs. an inhaled equimolar mixture of N2O and O2 (Kalinox®) for pain and anxiety management during the removal of chest drains after cardiac surgery. Methods Prospective, non-inferiority, open-label study. Patients were randomized, for Kalinox® or VR session during drain removal. The analgesia/nociception index (ANI) was monitored during the procedure for objective assessment of pain and anxiety. The primary endpoint was the ΔANI (ANImin − ANI0) during the procedure, based on ANIm (average on 4 min). We prespecified VR as non-inferior to Kalinox® with a margin of 3 points. Self-reported pain and anxiety were also analysed using numeric rate scale (NRS). Results 200 patients were included, 99 in the VR group and 101 in the Kalinox® group; 90 patients were analysed in both groups in per-protocol analysis. The median age was 68.0 years [60.0–74.8]. The ΔANI was − 15.1 ± 12.9 in the Kalinox® group and − 15.7 ± 11.6 in the VR group (NS). The mean difference was, therefore, − 0.6 [− 3.6 to 2.4], including the non-inferiority margin of 3. Patients in the VR group had a significantly higher pain NRS scale immediately after the drain removal, 5.0 [3.0–7.0] vs. 3.0 [2.0–6.0], p = 0.009, but no difference 10 min after. NRS of anxiety did not differ between the two groups. Conclusion Based on the ANI, the current study showed that VR did not reach the statistical requirements for a proven non-inferiority vs. Kalinox® in managing pain and anxiety during chest drain removal. Moreover, VR was less effective based on NRS. More studies are needed to determine if VR might have a place in the overall approach to pain and anxiety in intensive care units. Trial registration NCT, NCT03956264. Registered 20 May 2019, https://clinicaltrials.gov/ct2/show/NCT03956264
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Affiliation(s)
- Driss Laghlam
- Department of Cardiology and Critical Care, CERIC, Clinique Ambroise Paré, 27 boulevard Victor Hugo, 92200, Neuilly-sur-Seine, France.
| | - Cecile Naudin
- Department of Clinical Research, Clinique Ambroise Paré, 27 boulevard Victor Hugo, 92200, Neuilly-sur-Seine, France
| | - Lucas Coroyer
- Department of Cardiology and Critical Care, CERIC, Clinique Ambroise Paré, 27 boulevard Victor Hugo, 92200, Neuilly-sur-Seine, France
| | - Vincent Aidan
- Department of Cardiology and Critical Care, CERIC, Clinique Ambroise Paré, 27 boulevard Victor Hugo, 92200, Neuilly-sur-Seine, France
| | - Julien Malvy
- Department of Cardiology and Critical Care, CERIC, Clinique Ambroise Paré, 27 boulevard Victor Hugo, 92200, Neuilly-sur-Seine, France
| | - Ghilas Rahoual
- Department of Cardiology and Critical Care, CERIC, Clinique Ambroise Paré, 27 boulevard Victor Hugo, 92200, Neuilly-sur-Seine, France
| | - Philippe Estagnasié
- Department of Cardiology and Critical Care, CERIC, Clinique Ambroise Paré, 27 boulevard Victor Hugo, 92200, Neuilly-sur-Seine, France
| | - Pierre Squara
- Department of Cardiology and Critical Care, CERIC, Clinique Ambroise Paré, 27 boulevard Victor Hugo, 92200, Neuilly-sur-Seine, France
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Thayabaran D, Burrage D. Nitrous oxide‐induced neurotoxicity: A case report and literature review. Br J Clin Pharmacol 2021; 87:3622-3626. [DOI: 10.1111/bcp.14779] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 12/08/2020] [Accepted: 02/04/2021] [Indexed: 11/27/2022] Open
Affiliation(s)
| | - Daniel Burrage
- Whittington Health NHS Trust Magdala Avenue London N19 5NF UK
- University College London Gower Street London WC1E 6BT UK
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Vogel TM. Unique Pain Management Needs for Pregnant Women with Pre-existing PTSD and Other Mental Health Disorders. CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-020-00430-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
PURPOSE OF REVIEW Implementation of enhanced recovery pathways have allowed migration of complex surgical procedures from inpatient setting to the outpatient setting. These programs improve patient safety and patient-reported outcomes. The present article discusses the principles of enhanced recovery pathways in adults undergoing ambulatory surgery with an aim of improving patient safety and postoperative outcomes. RECENT FINDINGS Procedure and patient selection is one of the key elements that influences perioperative outcomes after ambulatory surgery. Other elements include optimization of comorbid conditions, patient and family education, minimal preoperative fasting and adequate hydration during the fasting period, use of fast-track anesthesia technique, lung-protective mechanical ventilation, maintenance of fluid balance, and multimodal pain, nausea, and vomiting prophylaxis. SUMMARY Implementation of enhanced recovery pathways requires a multidisciplinary approach in which the anesthesiologist should take a lead in collaborating with surgeons and perioperative nurses. Measuring compliance with enhanced recovery pathways through an audit program is essential to evaluate success and need for protocol modification. The metrics to assess the impact of enhanced recovery pathways include complication rates, patient reported outcomes, duration of postoperative stay in the surgical facility, unplanned hospital admission rate, and 7-day and 30-day readmission rates.
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Nakamura M, Jang IS, Yamaga T, Kotani N, Akaike N. Effects of nitrous oxide on glycinergic transmission in rat spinal neurons. Brain Res Bull 2020; 162:191-198. [PMID: 32599127 DOI: 10.1016/j.brainresbull.2020.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 06/16/2020] [Accepted: 06/22/2020] [Indexed: 11/19/2022]
Abstract
We investigated the effects of nitrous oxide (N2O) on glycinergic inhibitory whole-cell and synaptic responses using a "synapse bouton preparation," dissociated mechanically from rat spinal sacral dorsal commissural nucleus (SDCN) neurons. This technique can evaluate pure single- or multi-synaptic responses from native functional nerve endings and enable us to accurately quantify how N2O influences pre- and postsynaptic transmission. We found that 70 % N2O enhanced exogenous glycine-induced whole-cell currents (IGly) at glycine concentrations lower than 3 × 10-5 M, but did not affect IGly at glycine concentrations higher than 10-4 M. N2O did not affect the amplitude and 1/e decay-time of both spontaneous and miniature glycinergic inhibitory postsynaptic currents recorded in the absence and presence of tetrodotoxin (sIPSCs and mIPSCs, respectively). The decrease in frequency induced by N2O was observed in sIPSCs but not in mIPSCs, which was recorded in the presence of both tetrodotoxin and Cd2+, which block voltage-gated Na+ and Ca2+ channels, respectively. N2O also decreased the amplitude and increased the failure rate and paired-pulse ratio of action potential-evoked glycinergic inhibitory postsynaptic currents. N2O slightly decreased the Ba2+ currents mediated by voltage-gated Ca2+ channels in SDCN neurons. We found that N2O suppresses glycinergic responses at synaptic levels with presynaptic effect having much more predominant role. The difference between glycinergic whole-cell and synaptic responses suggests that extrasynaptic responses seriously modulate whole-cell currents. Our results strongly suggest that these responses may thus in part explain analgesic effects of N2O via marked glutamatergic inhibition by glycinergic responses in the spinal cord.
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Affiliation(s)
- Michiko Nakamura
- Department of Pharmacology, School of Dentistry, Kyungpook National University, 2177 Dalgubeol-daero, Jung-gu, Daegu, 700-412, Republic of Korea
| | - Il-Sung Jang
- Department of Pharmacology, School of Dentistry, Kyungpook National University, 2177 Dalgubeol-daero, Jung-gu, Daegu, 700-412, Republic of Korea
| | - Toshitaka Yamaga
- Research Division for Life Science, Kumamoto Health Science University, 325 Izumi-machi, Kita-ku, Kumamoto 861-5598, Japan
| | - Naoki Kotani
- Research Division of Neurophysiology, Kitamoto Hospital, 3-7-6 Kawarasone, Koshigaya, Saitama 343-0821, Japan
| | - Norio Akaike
- Research Division of Neurophysiology, Kitamoto Hospital, 3-7-6 Kawarasone, Koshigaya, Saitama 343-0821, Japan; Research Division for Clinical Pharmacology, Medical Corporation, Juryo Group, Kumamoto Kinoh Hospital, 6-8-1 Yamamuro, Kita-ku, Kumamoto 860-8518, Japan.
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42
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Annequin D. Nitrous oxide (N2O) angel or devil? Paediatr Anaesth 2020; 30:388-389. [PMID: 32323433 DOI: 10.1111/pan.13834] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 01/24/2020] [Accepted: 01/27/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Daniel Annequin
- Centre de la Douleur, de la Migraine de L'enfant et de L'adolescent, Hôpital Trousseau Paris Assistance Publique Hôpitaux de Paris, AP-HP Sorbonne University, Paris, France
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Tung A. Too Early for a Narrative Review? Anesth Analg 2020; 129:333-334. [PMID: 31313671 DOI: 10.1213/ane.0000000000004249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Avery Tung
- From the Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois
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Forster VJ, Bell G, Halsey C. Should nitrous oxide ever be used in oncology patients receiving methotrexate therapy? Paediatr Anaesth 2020; 30:9-16. [PMID: 31667903 DOI: 10.1111/pan.13760] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 10/28/2019] [Accepted: 10/29/2019] [Indexed: 11/27/2022]
Abstract
Nitrous oxide (N2 O) is frequently used for short anesthesia/analgesia in children undergoing painful or repetitive procedures. Children with acute lymphoblastic leukemia (ALL) require repeated lumbar punctures with direct instillation of intrathecal chemotherapy, usually the anti-folate agent methotrexate, during their treatment. These procedures are frequently performed under anesthesia. Concerns have been intermittently raised about a drug interaction between methotrexate and N2 O that may potentiate the undesirable side effects of methotrexate, including neurotoxicity. However, the clinical evidence consists mainly of isolated case reports leading to a lack of consensus among pediatric anesthetists about the relative risk benefits of using N2 O in children with ALL. In this article, we review the biochemical basis and scientific observations that suggest a significant interaction between N2 O and methotrexate due to their dual inhibition of the key enzyme methionine synthase. The possible role of this interaction in potentiating neurotoxicity in children with cancer is discussed, and arguments and counterarguments about the clinical significance of this largely theoretical relationship are explored. Following comprehensive review of all the available data, we make the case for the circumstantial evidence being sufficiently compelling to prompt a review of practice by pediatric anesthetists and call for a precautionary approach by avoiding the use of N2 O in children receiving concurrent methotrexate.
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Affiliation(s)
- Victoria J Forster
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - Graham Bell
- Department of Anaesthetics, Royal Hospital for Children, Glasgow, UK
| | - Christina Halsey
- Institute of Cancer Sciences, College of Medical Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
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Bao L, Li Q, Li Q, Chen H, Zhang R, Shi H, Cui G. Clinical, Electrophysiological and Radiological Features of Nitrous Oxide-Induced Neurological Disorders. Neuropsychiatr Dis Treat 2020; 16:977-984. [PMID: 32346292 PMCID: PMC7167281 DOI: 10.2147/ndt.s236939] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 03/13/2020] [Indexed: 01/20/2023] Open
Abstract
PURPOSE We summarized the clinical manifestations, laboratory and electrodiagnostic characteristics and magnetic resonance imaging (MRI) findings of nitrous oxide (N2O) abuse-induced neurological disorders. PATIENTS AND METHODS We retrospectively reviewed 33 patients with N2O abuse-induced neurological disorders and reported their demographic data, clinical manifestations, laboratory examinations, nerve conduction studies, together with spinal and brain MRI. RESULTS The most frequent clinical manifestations included numbness and weakness in the extremities and unspecified gait disturbance. Low serum vitamin B12 levels were found in 9 patients, and high homocysteine levels were noted in 27 patients. Nerve conduction studies showed a sensory-motor neuropathy. Sixteen patients showed bilateral high-intensity T2 signal within the posterior column on spinal MRI, and four patients showed cerebral white matter lesions on brain MRI. CONCLUSION N2O abuse has become a significant public health problem because of the severe neurological disorders related to chronic abuse. Clinical physicians should be aware of the toxic effects of N2O.
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Affiliation(s)
- Lei Bao
- Department of Neurology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu 221004, People's Republic of China
| | - Qing Li
- Department of Neurology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu 221004, People's Republic of China
| | - Qingjie Li
- Department of Neurology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu 221004, People's Republic of China
| | - Hao Chen
- Department of Neurology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu 221004, People's Republic of China
| | - Ruixue Zhang
- Department of Neurology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu 221004, People's Republic of China
| | - Hongjuan Shi
- Department of Neurology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu 221004, People's Republic of China
| | - Guiyun Cui
- Department of Neurology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu 221004, People's Republic of China
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Granholm A, Alhazzani W, Møller MH. Use of the GRADE approach in systematic reviews and guidelines. Br J Anaesth 2019; 123:554-559. [DOI: 10.1016/j.bja.2019.08.015] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 08/27/2019] [Accepted: 08/27/2019] [Indexed: 12/22/2022] Open
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Environmental impacts of nitrous oxide: no laughing matter! Comment on Br J Anaesth 2019; 122: 587–604. Br J Anaesth 2019; 123:e481-e482. [DOI: 10.1016/j.bja.2019.06.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 06/12/2019] [Accepted: 06/13/2019] [Indexed: 11/21/2022] Open
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Imberger GLL, McGain F. GRADE quality of evidence: a systematic and objective assessment, not an expression of opinion. Comment on Br J Anaesth 2019; 122: 587–604. Br J Anaesth 2019; 123:e479-e480. [DOI: 10.1016/j.bja.2019.06.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 06/11/2019] [Indexed: 11/25/2022] Open
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Pro-Con Debate: Nitrous Oxide for Labor Analgesia. BIOMED RESEARCH INTERNATIONAL 2019; 2019:4618798. [PMID: 31531352 PMCID: PMC6720045 DOI: 10.1155/2019/4618798] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 05/19/2019] [Accepted: 07/19/2019] [Indexed: 02/06/2023]
Abstract
This Pro-Con debate will provide the practitioner with an evidence-based knowledge approach to assist the clinician in determining whether to employ (Pro) or not to employ (Con) this technique in the obstetrical suite for labor analgesia. Nitrous oxide has been used safely in dentistry and medicine for many centuries. However, accumulating preclinical and clinical evidence increasingly suggests previously unrecognized adverse maternal and fetal effects of nitrous oxide, which warrants reconsideration of its use in pregnant women and a more detailed informed consent. Nitrous oxide is associated with metabolic, oxidative, genotoxic, and transgenerational epigenetic effects in animals and humans that may warrant limiting its usefulness in labor. This debate will discuss and review the clinical uses, advantages, and disadvantages of nitrous oxide on occupational effects of nitrous oxide exposure, neuroapoptosis, FDA warning on inhalational anesthetics and the developing brain, research limitations, occupational exposure safety limits, effects on global warming, and potential for diversion.
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