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Zhang H, Wang L, Zheng Z, Han J, Li L, Yao W, Li Z, Luo G, Gao B, Shen J, Dong H, Lei C. The use of transcutaneous electrical acupoint stimulation to reduce opioid consumption in patients undergoing off-pump CABG: a randomized controlled trial. Perioper Med (Lond) 2024; 13:68. [PMID: 38970081 PMCID: PMC11225385 DOI: 10.1186/s13741-024-00427-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 06/22/2024] [Indexed: 07/07/2024] Open
Abstract
BACKGROUND High doses of long-acting opioids were used to facilitate off-pump coronary artery bypass grafting procedure, which may result in opioid-related adverse events after surgery. Transcutaneous electrical acupoint stimulation (TEAS) had been reported to be effective in reducing intraoperative opioids consumption during surgery. The aim of this study is to assess whether TEAS with difference acupoints can reduce the doses of opioid analgesics. METHODS This was a multicenter, randomized, controlled, double-blind trial. Patients underwent off-pump coronary artery bypass grafting under general anesthesia were enrolled. Eligible patients were randomly and equally grouped into sham acupuncture group (n = 105), regional acupoints combination group (n = 105), or distal-proximal acupoints combination group (n = 105) using a centralized computer-generated randomization system. Transcutaneous electrical acupoint stimulation was applied for 30 min before anesthesia induction. The primary outcome was the doses of sufentanil during anesthesia. Secondary outcomes included the highest postoperative vasoactive-inotropic scores within 24 h, intraoperative propofol consumption, length of mechanical ventilation, duration of cardiac care unit and postoperative hospital stay, incidence of postoperative complications, and mortality within 30 days after surgery. RESULTS Of the 315 randomized patients, 313 completed the trial. In the modified intention-to-treat analysis, the doses of sufentanil were 303.9 (10.8) μg in the distal-proximal acupoints group, significantly lower than the sham group, and the mean difference was - 34.9 (- 64.9 to - 4.9) μg, p = 0.023. The consumption of sufentanil was lower in distal-proximal group than regional group (303.9 vs. 339.5), and mean difference was - 35.5 (- 65.6 to - 5.5) μg, p = 0.020. The distal-proximal group showed 10% reduction in opioids consumption comparing to both regional and sham groups. Secondary outcomes were comparable among three groups. CONCLUSION Transcutaneous electrical acupoint stimulation with distal-proximal acupoints combination, compared to regional acupoints combination and sham acupuncture, significantly reduced sufentanil consumption in patients who underwent off-pump coronary artery bypass grafting surgery.
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Affiliation(s)
- Hui Zhang
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, China
| | - Lini Wang
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, China
| | - Ziyu Zheng
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, China
| | - Jiange Han
- Department of Anesthesiology, Tianjin Chest Hospital, Tianjin, China
| | - Lin Li
- Department of Anesthesiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Wenlong Yao
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhijian Li
- Department of Anesthesiology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Gang Luo
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, China
| | - Baobao Gao
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, China
| | - Jie Shen
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, China
| | - Hailong Dong
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, China
| | - Chong Lei
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, China.
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Singh G, Nguyen C, Kuschner W. Pharmacologic Sleep Aids in the Intensive Care Unit: A Systematic Review. J Intensive Care Med 2024:8850666241255345. [PMID: 38881385 DOI: 10.1177/08850666241255345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2024]
Abstract
Background: Patients in the intensive care unit (ICU) often experience poor sleep quality. Pharmacologic sleep aids are frequently used as primary or adjunctive therapy to improve sleep, although their benefits in the ICU remain uncertain. This review aims to provide a comprehensive assessment of the objective and subjective effects of medications used for sleep in the ICU, as well as their adverse effects. Methods: PubMed, Web of Science, Scopus, Embase, and Cochrane Central Register of Controlled Trials were systematically searched from their inception until June 2023 for comparative studies assessing the effects of pharmacologic sleep aids on objective and subjective metrics of sleep. Results: Thirty-four studies with 3498 participants were included. Medications evaluated were melatonin, ramelteon, suvorexant, propofol, and dexmedetomidine. The majority of studies were randomized controlled trials. Melatonin and dexmedetomidine were the best studied agents. Objective sleep metrics included polysomnography (PSG), electroencephalography (EEG), bispectral index, and actigraphy. Subjective outcome measures included patient questionnaires and nursing observations. Evidence for melatonin as a sleep aid in the ICU was mixed but largely not supportive for improving sleep. Evidence for ramelteon, suvorexant, and propofol was too limited to offer definitive recommendations. Both objective and subjective data supported dexmedetomidine as an effective sleep aid in the ICU, with PSG/EEG in 303 ICU patients demonstrating increased sleep duration and efficiency, decreased arousal index, decreased percentage of stage N1 sleep, and increased absolute and percentage of stage N2 sleep. Mild bradycardia and hypotension were reported as side effects of dexmedetomidine, whereas the other medications were reported to be safe. Several ongoing studies have not yet been published, mostly on melatonin and dexmedetomidine. Conclusions: While definitive conclusions cannot be made for most medications, dexmedetomidine improved sleep quantity and quality in the ICU. These benefits need to be balanced with possible hemodynamic side effects.
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Affiliation(s)
- Gaurav Singh
- Pulmonary, Critical Care, and Sleep Medicine Section, Department of Medicine, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - Christopher Nguyen
- Pulmonary, Critical Care, and Sleep Medicine Section, Department of Medicine, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - Ware Kuschner
- Pulmonary, Critical Care, and Sleep Medicine Section, Department of Medicine, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Stanford University, Palo Alto, CA, USA
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Carrascosa AJ, Navarrete F, Saldaña R, García-Gutiérrez MS, Montalbán B, Navarro D, Gómez-Guijarro FM, Gasparyan A, Murcia-Sánchez E, Torregrosa AB, Pérez-Doblado P, Gutiérrez L, Manzanares J. Cannabinoid Analgesia in Postoperative Pain Management: From Molecular Mechanisms to Clinical Reality. Int J Mol Sci 2024; 25:6268. [PMID: 38892456 PMCID: PMC11172912 DOI: 10.3390/ijms25116268] [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: 04/26/2024] [Revised: 05/26/2024] [Accepted: 05/28/2024] [Indexed: 06/21/2024] Open
Abstract
Postoperative pain (POP) is a challenging clinical phenomenon that affects the majority of surgical patients and demands effective management to mitigate adverse outcomes such as persistent pain. The primary goal of POP management is to alleviate suffering and facilitate a seamless return to normal function for the patient. Despite compelling evidence of its drawbacks, opioid analgesia remains the basis of POP treatment. Novel therapeutic approaches rely on multimodal analgesia, integrating different pharmacological strategies to optimize efficacy while minimizing adverse effects. The recognition of the imperative role of the endocannabinoid system in pain regulation has prompted the investigation of cannabinoid compounds as a new therapeutic avenue. Cannabinoids may serve as adjuvants, enhancing the analgesic effects of other drugs and potentially replacing or at least reducing the dependence on other long-term analgesics in pain management. This narrative review succinctly summarizes pertinent information on the molecular mechanisms, clinical therapeutic benefits, and considerations associated with the plausible use of various cannabinoid compounds in treating POP. According to the available evidence, cannabinoid compounds modulate specific molecular mechanisms intimately involved in POP. However, only two of the eleven clinical trials that evaluated the efficacy of different cannabinoid interventions showed positive results.
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Affiliation(s)
- Antonio J. Carrascosa
- Servicio de Anestesiologia y Reanimación, Hospital Universitario 12 de Octubre, Avda. Córdoba s/n, 28041 Madrid, Spain; (A.J.C.); (R.S.); (B.M.); (F.M.G.-G.); (E.M.-S.); (P.P.-D.)
| | - Francisco Navarrete
- Instituto de Neurociencias, Universidad Miguel Hernández-CSIC, Avda de Ramón y Cajal s/n, San Juan de Alicante, 03550 Alicante, Spain; (F.N.); (M.S.G.-G.); (D.N.); (A.G.); (A.B.T.); (L.G.)
- Redes de Investigación Cooperativa Orientada a Resultados en Salud (RICORS), Red de Investigación en Atención Primaria de Adicciones (RIAPAd), Instituto de Salud Carlos III, MICINN and FEDER, 28029 Madrid, Spain
- Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), 03010 Alicante, Spain
| | - Raquel Saldaña
- Servicio de Anestesiologia y Reanimación, Hospital Universitario 12 de Octubre, Avda. Córdoba s/n, 28041 Madrid, Spain; (A.J.C.); (R.S.); (B.M.); (F.M.G.-G.); (E.M.-S.); (P.P.-D.)
| | - María S. García-Gutiérrez
- Instituto de Neurociencias, Universidad Miguel Hernández-CSIC, Avda de Ramón y Cajal s/n, San Juan de Alicante, 03550 Alicante, Spain; (F.N.); (M.S.G.-G.); (D.N.); (A.G.); (A.B.T.); (L.G.)
- Redes de Investigación Cooperativa Orientada a Resultados en Salud (RICORS), Red de Investigación en Atención Primaria de Adicciones (RIAPAd), Instituto de Salud Carlos III, MICINN and FEDER, 28029 Madrid, Spain
- Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), 03010 Alicante, Spain
| | - Belinda Montalbán
- Servicio de Anestesiologia y Reanimación, Hospital Universitario 12 de Octubre, Avda. Córdoba s/n, 28041 Madrid, Spain; (A.J.C.); (R.S.); (B.M.); (F.M.G.-G.); (E.M.-S.); (P.P.-D.)
| | - Daniela Navarro
- Instituto de Neurociencias, Universidad Miguel Hernández-CSIC, Avda de Ramón y Cajal s/n, San Juan de Alicante, 03550 Alicante, Spain; (F.N.); (M.S.G.-G.); (D.N.); (A.G.); (A.B.T.); (L.G.)
- Redes de Investigación Cooperativa Orientada a Resultados en Salud (RICORS), Red de Investigación en Atención Primaria de Adicciones (RIAPAd), Instituto de Salud Carlos III, MICINN and FEDER, 28029 Madrid, Spain
- Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), 03010 Alicante, Spain
| | - Fernando M. Gómez-Guijarro
- Servicio de Anestesiologia y Reanimación, Hospital Universitario 12 de Octubre, Avda. Córdoba s/n, 28041 Madrid, Spain; (A.J.C.); (R.S.); (B.M.); (F.M.G.-G.); (E.M.-S.); (P.P.-D.)
| | - Ani Gasparyan
- Instituto de Neurociencias, Universidad Miguel Hernández-CSIC, Avda de Ramón y Cajal s/n, San Juan de Alicante, 03550 Alicante, Spain; (F.N.); (M.S.G.-G.); (D.N.); (A.G.); (A.B.T.); (L.G.)
- Redes de Investigación Cooperativa Orientada a Resultados en Salud (RICORS), Red de Investigación en Atención Primaria de Adicciones (RIAPAd), Instituto de Salud Carlos III, MICINN and FEDER, 28029 Madrid, Spain
- Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), 03010 Alicante, Spain
| | - Elena Murcia-Sánchez
- Servicio de Anestesiologia y Reanimación, Hospital Universitario 12 de Octubre, Avda. Córdoba s/n, 28041 Madrid, Spain; (A.J.C.); (R.S.); (B.M.); (F.M.G.-G.); (E.M.-S.); (P.P.-D.)
| | - Abraham B. Torregrosa
- Instituto de Neurociencias, Universidad Miguel Hernández-CSIC, Avda de Ramón y Cajal s/n, San Juan de Alicante, 03550 Alicante, Spain; (F.N.); (M.S.G.-G.); (D.N.); (A.G.); (A.B.T.); (L.G.)
- Redes de Investigación Cooperativa Orientada a Resultados en Salud (RICORS), Red de Investigación en Atención Primaria de Adicciones (RIAPAd), Instituto de Salud Carlos III, MICINN and FEDER, 28029 Madrid, Spain
- Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), 03010 Alicante, Spain
| | - Paloma Pérez-Doblado
- Servicio de Anestesiologia y Reanimación, Hospital Universitario 12 de Octubre, Avda. Córdoba s/n, 28041 Madrid, Spain; (A.J.C.); (R.S.); (B.M.); (F.M.G.-G.); (E.M.-S.); (P.P.-D.)
| | - Luisa Gutiérrez
- Instituto de Neurociencias, Universidad Miguel Hernández-CSIC, Avda de Ramón y Cajal s/n, San Juan de Alicante, 03550 Alicante, Spain; (F.N.); (M.S.G.-G.); (D.N.); (A.G.); (A.B.T.); (L.G.)
- Redes de Investigación Cooperativa Orientada a Resultados en Salud (RICORS), Red de Investigación en Atención Primaria de Adicciones (RIAPAd), Instituto de Salud Carlos III, MICINN and FEDER, 28029 Madrid, Spain
- Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), 03010 Alicante, Spain
| | - Jorge Manzanares
- Instituto de Neurociencias, Universidad Miguel Hernández-CSIC, Avda de Ramón y Cajal s/n, San Juan de Alicante, 03550 Alicante, Spain; (F.N.); (M.S.G.-G.); (D.N.); (A.G.); (A.B.T.); (L.G.)
- Redes de Investigación Cooperativa Orientada a Resultados en Salud (RICORS), Red de Investigación en Atención Primaria de Adicciones (RIAPAd), Instituto de Salud Carlos III, MICINN and FEDER, 28029 Madrid, Spain
- Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), 03010 Alicante, Spain
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Liu L, Wang K, Sun Z, Yan P, Hu M, Liu X, Chen M, Wu N, Xiang X. Pharmacokinetics and exposure-safety relationship of ciprofol for sedation in mechanically ventilated patients in the intensive care unit. CPT Pharmacometrics Syst Pharmacol 2024; 13:823-836. [PMID: 38440939 PMCID: PMC11098162 DOI: 10.1002/psp4.13121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 01/30/2024] [Accepted: 02/14/2024] [Indexed: 03/06/2024] Open
Abstract
Ciprofol (HSK3486) is a newly developed, highly selective γ-aminobutyric acid-A (GABAA) receptor potentiator that is recently approved for a new indication of sedation for patients in the intensive care unit (ICU) in China. This analysis aimed to characterize the population pharmacokinetics (PopPKs) of ciprofol and evaluate the relationship of exposure with hypotension in mechanically ventilated patients in the ICU. A total of 462 subjects with 3918 concentration measurements from two clinical trials of mechanically ventilated patients in the ICU, four clinical trials of elective surgical patients, and six clinical trials of healthy subjects were used in the PopPK analysis. Exposure-safety relationship for hypotension was evaluated based on the data gathered from 112 subjects in two clinical trials of mechanically ventilated patients in the ICU. Ciprofol pharmacokinetics (PKs) was adequately described by a three-compartment linear disposition model with first-order elimination. Body weight, age, sex, blood sampling site (vein vs. arterial), study design (long-term infusion vs. short-term infusion), and patient population (ICU vs. non-ICU) were identified as statistically significant covariates on the PKs of ciprofol. Within the exposure range of the mechanically ventilated ICU patient population, no meaningful association was observed between ciprofol exposure and the incidence of hypotension. These results support the dosing regimen currently used in mechanically ventilated patients in the ICU.
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Affiliation(s)
- Lu Liu
- Department of Clinical Pharmacy and Pharmacy Administration, School of PharmacyFudan UniversityShanghaiChina
| | - Kun Wang
- Shanghai Qiangshi Information Technology Co., Ltd.ShanghaiChina
| | - Zhongyi Sun
- Shanghai Qiangshi Information Technology Co., Ltd.ShanghaiChina
| | - Pangke Yan
- Haisco Pharmaceutical Group Co. Ltd.ChengduChina
| | - Mengyue Hu
- Haisco Pharmaceutical Group Co. Ltd.ChengduChina
| | - Xiao Liu
- Haisco Pharmaceutical Group Co. Ltd.ChengduChina
| | - Meixia Chen
- Haisco Pharmaceutical Group Co. Ltd.ChengduChina
| | - Nan Wu
- Haisco Pharmaceutical Group Co. Ltd.ChengduChina
| | - Xiaoqiang Xiang
- Department of Clinical Pharmacy and Pharmacy Administration, School of PharmacyFudan UniversityShanghaiChina
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Leppert J, Küchler J, Wagner A, Hinselmann N, Ditz C. Prospective Observational Study of Volatile Sedation with Sevoflurane After Aneurysmal Subarachnoid Hemorrhage Using the Sedaconda Anesthetic Conserving Device. Neurocrit Care 2024:10.1007/s12028-024-01959-7. [PMID: 38485879 DOI: 10.1007/s12028-024-01959-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 02/09/2024] [Indexed: 06/22/2024]
Abstract
BACKGROUND Volatile sedation is still used with caution in patients with acute brain injury because of safety concerns. We analyzed the effects of sevoflurane sedation on systemic and cerebral parameters measured by multimodal neuromonitoring in patients after aneurysmal subarachnoid hemorrhage (aSAH) with normal baseline intracranial pressure (ICP). METHODS In this prospective observational study, we analyzed a 12-h period before and after the switch from intravenous to volatile sedation with sevoflurane using the Sedaconda Anesthetic Conserving Device with a target Richmond Agitation Sedation Scale score of - 5 to - 4. ICP, cerebral perfusion pressure (CPP), brain tissue oxygenation (PBrO2), metabolic values of cerebral microdialysis, systemic cardiopulmonary parameters, and the administered drugs before and after the sedation switch were analyzed. RESULTS We included 19 patients with a median age of 61 years (range 46-78 years), 74% of whom presented with World Federation of Neurosurgical Societies grade 4 or 5 aSAH. We observed no significant changes in the mean ICP (9.3 ± 4.2 vs. 9.7 ± 4.2 mm Hg), PBrO2 (31.0 ± 13.2 vs. 32.2 ± 12.4 mm Hg), cerebral lactate (5.0 ± 2.2 vs. 5.0 ± 1.9 mmol/L), pyruvate (136.6 ± 55.9 vs. 134.1 ± 53.6 µmol/L), and lactate/pyruvate ratio (37.4 ± 8.7 vs. 39.8 ± 9.2) after the sedation switch to sevoflurane. We found a significant decrease in mean arterial pressure (MAP) (88.6 ± 7.6 vs. 86.3 ± 5.8 mm Hg) and CPP (78.8 ± 8.5 vs. 76.6 ± 6.6 mm Hg) after the initiation of sevoflurane, but the decrease was still within the physiological range requiring no additional hemodynamic support. CONCLUSIONS Sevoflurane appears to be a feasible alternative to intravenous sedation in patients with aSAH without intracranial hypertension, as our study did not show negative effects on ICP, cerebral oxygenation, or brain metabolism. Nevertheless, the risk of a decrease of MAP leading to a consecutive CPP decrease should be considered.
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Affiliation(s)
- Jan Leppert
- Department of Neurosurgery, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Jan Küchler
- Department of Neurosurgery, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Andreas Wagner
- Department of Neurosurgery, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Niclas Hinselmann
- Department of Neurosurgery, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Claudia Ditz
- Department of Neurosurgery, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.
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Zhang J, Ma D, Chen M, Hu Y, Chen X, Chen J, Huang M, Dai H. Prevalence and clinical significance of potential drug-drug interactions among lung transplant patients. Front Pharmacol 2024; 15:1308260. [PMID: 38379901 PMCID: PMC10876870 DOI: 10.3389/fphar.2024.1308260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 01/24/2024] [Indexed: 02/22/2024] Open
Abstract
Background: Drug-drug interactions (DDIs) are a major but preventable cause of adverse drug reactions. There is insufficient information regarding DDIs in lung transplant recipients. Objective: This study aimed to determine the prevalence of potential DDIs (pDDIs) in intensive care unit (ICU) lung transplant recipients, identify the real DDIs and the most frequently implicated medications in this vulnerable population, and determine the risk factors associated with pDDIs. Methods: This retrospective cross-sectional study included lung transplant recipients from January 2018 to December 2021. Pertinent information was retrieved from medical records. All prescribed medications were screened for pDDIs using the Lexicomp® drug interaction software. According to this interaction software, pDDIs were classified as C, D, or X (C = monitor therapy, D = consider therapy modification, X = avoid combination). The Drug Interaction Probability Scale was used to determine the causation of DDIs. All statistical analysis was performed in SPSS version 26.0. Results: 114 patients were qualified for pDDI analysis, and total pDDIs were 4051. The most common type of pDDIs was category C (3323; 82.0%), followed by D (653; 16.1%) and X (75; 1.9%). Voriconazole and posaconazole were the antifungal medicine with the most genuine DDIs. Mean tacrolimus concentration/dose (Tac C/D) before or after co-therapy was considerably lower than the Tac C/D during voriconazole or posaconazole co-therapy (p < 0.001, p = 0.027). Real DDIs caused adverse drug events (ADEs) in 20 patients. Multivariable logistic regression analyses found the number of drugs per patient (OR, 1.095; 95% CI, 1.048-1.145; p < 0.001) and the Acute Physiology and Chronic Health Evaluation II (APACHE Ⅱ) score (OR, 1.097; 95% CI, 1.021-1.179; p = 0.012) as independent risk factors predicting category X pDDIs. Conclusion: This study revealed a high incidence of both potential and real DDIs in ICU lung transplant recipients. Immunosuppressive drugs administered with azole had a high risk of causing clinically significant interactions. The number of co-administered drugs and APACHE Ⅱ score were associated with an increased risk of category × drug interactions. Close monitoring of clinical and laboratory parameters is essential for ensuring successful lung transplantation and preventing adverse drug events associated with DDIs.
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Affiliation(s)
- Jiali Zhang
- Department of Pharmacy, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Danyi Ma
- Department of Pharmacy, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Meng Chen
- Department of Pharmacy, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yanting Hu
- Department of General Intensive Care Unit, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xveying Chen
- Department of Pharmacy, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jingyu Chen
- Department of Lung Transplantation, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Man Huang
- Department of General Intensive Care Unit, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Haibin Dai
- Department of Pharmacy, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Rajamani A, Subramaniam A, Lung B, Masters K, Gresham R, Whitehead C, Lowrey J, Seppelt I, Kumar H, Kumar J, Hassan A, Orde S, Bharadwaj PA, Arvind H, Huang S. Remi-fent 1-A pragmatic randomised controlled study to evaluate the feasibility of using remifentanil or fentanyl as sedation adjuncts in mechanically ventilated patients. CRIT CARE RESUSC 2023; 25:216-222. [PMID: 38234321 PMCID: PMC10790007 DOI: 10.1016/j.ccrj.2023.10.012] [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: 09/26/2023] [Accepted: 10/30/2023] [Indexed: 01/19/2024]
Abstract
Objective To evaluate the feasibility of conducting a prospective randomised controlled trial (pRCT) comparing remifentanil and fentanyl as adjuncts to sedate mechanically ventilated patients. Design Single-center, open-labelled, pRCT with blinded analysis. Setting Australian tertiary intensive care unit (ICU). Participants Consecutive adults between June 2020 and August 2021 expected to receive invasive ventilation beyond the next day and requiring opioid infusion were included. Exclusion criteria were pregnant/lactating women, intubation >12 h, or study-drug hypersensitivity. Interventions Open-label fentanyl and remifentanil infusions per existing ICU protocols. Outcomes Primary outcomes were feasibility of recruiting ≥1 patient/week and >90 % compliance, namely no other opioid infusion used during the study period. Secondary outcomes included complications, ICU-, ventilator- and hospital-free days, and mortality (ICU, hospital). Blinded intention-to-treat analysis was performed concealing the allocation group. Results 208 patients were enrolled (mean 3.7 patients/week). Compliance was 80.6 %. More patients developed complications with fentanyl than remifentanil: bradycardia (n = 44 versus n = 21; p < 0.001); hypotension (n = 78 versus n = 53; p < 0.01); delirium (n = 28 versus n = 15; p = 0.001). No differences were seen in ICU (24.3 % versus 27.6 %,p = 0.60) and hospital mortalities (26.2 % versus 30.5 %; p = 0.50). Ventilator-free days were higher with remifentanil (p = 0.01). Conclusions We demonstrated the feasibility of enrolling patients for a pRCT comparing remifentanil and fentanyl as sedation adjuncts in mechanically ventilated patients. We failed to attain the study-opioid compliance target, likely because of patients with complex sedative/analgesic requirements. Secondary outcomes suggest that remifentanil may reduce mechanical ventilation duration and decrease the incidence of complications. An adequately powered multicentric phase 2 study is required to evaluate these results.
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Affiliation(s)
- Arvind Rajamani
- Nepean Clinical School, University of Sydney, Derby Street, Kingswood, NSW 2747, Australia
- Department of Intensive Care Medicine, Nepean Hospital, Kingswood, NSW 2747, Australia
| | | | - Brian Lung
- Department of Anaesthesia, Nepean Hospital, Kingswood, NSW 2747, Australia
| | - Kristy Masters
- Department of Intensive Care Medicine, Nepean Hospital, Derby Street, Kingswood, NSW 2747, Australia
| | - Rebecca Gresham
- Department of Intensive Care Medicine, Nepean Hospital, Derby Street, Kingswood, NSW 2747, Australia
| | - Christina Whitehead
- Department of Intensive Care Medicine, Nepean Hospital, Derby Street, Kingswood, NSW 2747, Australia
| | - Julie Lowrey
- Department of Intensive Care Medicine, Nepean Hospital, Derby Street, Kingswood, NSW 2747, Australia
| | - Ian Seppelt
- Department of Intensive Care Medicine, Nepean Hospital, Derby Street, Kingswood, NSW 2747, Australia
- Faculty of Medicine, University of Sydney, Australia
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
| | - Hemant Kumar
- Department of Intensive Care Medicine, Nepean Hospital, Derby Street, Kingswood, NSW 2747, Australia
| | - Jayashree Kumar
- Department of Intensive Care Medicine, Nepean Hospital, Derby Street, Kingswood, NSW 2747, Australia
| | - Anwar Hassan
- Department of Intensive Care Medicine, Nepean Hospital, Derby Street, Kingswood, NSW 2747, Australia
| | - Sam Orde
- Department of Intensive Care Medicine, Nepean Hospital, Derby Street, Kingswood, NSW 2747, Australia
| | | | | | - Stephen Huang
- Nepean Clinical School, University of Sydney, Derby Street, Kingswood, NSW 2747, Australia
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8
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Doherty C, Feder S, Gillespie-Heyman S, Akgün KM. Easing Suffering for ICU Patients and Their Families: Evidence and Opportunities for Primary and Specialty Palliative Care in the ICU. J Intensive Care Med 2023:8850666231204305. [PMID: 37822226 DOI: 10.1177/08850666231204305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
Intensive care unit (ICU) admissions are often accompanied by many physical and existential pressure points that can be extraordinarily wearing on patients and their families and surrogate decision makers (SDMs). Multidisciplinary palliative support, including physicians, advanced practice nurses, nutritionists, chaplains and other team members, may alleviate many of these sources of potential suffering. However, the palliative needs of ICU patients undoubtedly exceed the bandwidth of current consultative specialty palliative medicine teams. Informed by standard-of-care palliative medicine domains, we review common ICU symptoms (pain, dyspnea and thirst) and their prevalence, sources and their treatment. We then identify palliative needs and impacts in the domains of communication, SDM support and transitions of care for patients and their families through their journey in the ICU, from discharge and recovery at home to chronic critical illness, post-ICU disability or death. Finally, we examine the evidence for strategies to incorporate specialty palliative medicine and palliative principles into ICU care for the improvement of patient- and family-centered care. While randomized controlled studies have failed to demonstrate measurable improvement in pre-determined outcomes for patient- and family-relevant outcomes, embracing the principles of palliative medicine and assuring their delivery in the ICU is likely to translate to overall improvement in humanistic, person-centered care that supports patients and their SDMs during and following critical illness.
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Affiliation(s)
- Christine Doherty
- Department of Internal Medicine New Haven, Yale New Haven Hospital, New Haven, CT, USA
- Yale School of Medicine, New Haven, CT, USA
| | - Shelli Feder
- Yale University School of Nursing, Orange, CT, USA
| | | | - Kathleen M Akgün
- Yale School of Medicine, New Haven, CT, USA
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, VA-Connecticut and Yale University School of Medicine, New Haven, CT, USA
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Dexmedetomidine Reduces Incidences of Ventricular Arrhythmias in Adult Patients: A Meta-Analysis. Cardiol Res Pract 2022; 2022:5158362. [PMID: 35693451 PMCID: PMC9177331 DOI: 10.1155/2022/5158362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 04/06/2022] [Accepted: 05/05/2022] [Indexed: 11/22/2022] Open
Abstract
Purpose To assess the antiarrhythmic properties of dexmedetomidine in patients in the intensive care unit. Methods A literature review was conducted with Ovid MEDLINE (R), Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Embase, and Scopus. Study Selection. Randomized controlled trials were included, examining the incidence of ventricular arrhythmias, ventricular tachycardia, or ventricular fibrillation with dexmedetomidine compared to placebo or an alternative sedative agent. For each publication that met the selection criteria, the patient demographics, incidence of arrhythmias, mortality, and adverse events were collected. Data extraction was carried out by two authors independently. Results We identified 6 out of 126 studies that met the selection criteria for our meta-analysis, all of which focused on the perioperative cardiac surgery period. Patients receiving dexmedetomidine demonstrated a significant reduction of the overall incidence of ventricular arrhythmias (RR 0.35, 95% CI 0.16, 0.76). In particular, dexmedetomidine significantly decreased the risk of ventricular tachycardia compared with control (RR 0.25, 95% CI 0.08, 0.80, I2 0%). Regarding adverse events, dexmedetomidine significantly increased the frequency of bradycardia (RR 2.78 95% CI 2.00, 3.87). However, there was no significant difference in mortality (RR 0.59 95% CI 0.12, 3.02). Conclusion From this meta-analysis, we report a decreased incidence of ventricular tachycardia with dexmedetomidine in critically ill patients. This result favors the use of dexmedetomidine for its antiarrhythmic properties.
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10
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Marler J, Howland R, Kimmons LA, Mohrien K, Vandigo JE, Jones GM. Safety of Propofol When Used for Rapid Sequence Intubation in Septic Patients: A Multicenter Cohort Study. Hosp Pharm 2022; 57:287-293. [PMID: 35601715 PMCID: PMC9117767 DOI: 10.1177/00185787211029547] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose Septic patients are at risk for hypotension, and this risk may increase during rapid sequence intubation (RSI). Sedatives such as propofol must be used carefully due to its ability to reduce vascular sympathetic tone. Since the safety of propofol for RSI is not well described in sepsis, this was a study evaluating propofol and its effects on hemodynamics when used for RSI in a septic population. Materials and methods We conducted a multicenter, retrospective, cohort study of patients with sepsis or severe sepsis requiring sedation for RSI. Patients receiving a propofol bolus for RSI were compared to patients undergoing RSI without a propofol bolus. The safety profile of propofol was evaluated according to the rates of post-intubation hypotension and vasopressor utilization between groups. Results A total of 179 patients (79 propofol, 100 non-propofol) were evaluated. There were no differences in hypotension (81% vs 78%; P = .62) or vasopressor utilization between the propofol and non-propofol groups (43% vs 49%; P = .43). Patients in the non-propofol group had increased APACHE II scores and healthcare-associated infections. Conclusions In this cohort study, administration of propofol for RSI in patients with sepsis and severe sepsis did not increase incidence of hypotension or vasopressor use, but acute illness may have introduced provider selection bias causing less propofol use in the non-propofol group. Larger prospective studies are needed to better characterize the adverse hemodynamic effects of propofol, before propofol bolus doses for RSI can be considered for safe use in this population.
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Affiliation(s)
- Jacob Marler
- Methodist University Hospital, Memphis, TN, USA
- University of Tennessee Health Sciences Center, Memphis, TN, USA
| | | | - Lauren A. Kimmons
- Methodist University Hospital, Memphis, TN, USA
- University of Tennessee Health Sciences Center, Memphis, TN, USA
| | | | | | - G. Morgan Jones
- Methodist University Hospital, Memphis, TN, USA
- University of Tennessee Health Sciences Center, Memphis, TN, USA
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11
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Abu Y, Vitari N, Yan Y, Roy S. Opioids and Sepsis: Elucidating the Role of the Microbiome and microRNA-146. Int J Mol Sci 2022; 23:1097. [PMID: 35163021 PMCID: PMC8835205 DOI: 10.3390/ijms23031097] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 01/14/2022] [Accepted: 01/17/2022] [Indexed: 02/06/2023] Open
Abstract
Sepsis has recently been defined as life-threatening organ dysfunction caused by the dysregulated host response to an ongoing or suspected infection. To date, sepsis continues to be a leading cause of morbidity and mortality amongst hospitalized patients. Many risk factors contribute to development of sepsis, including pain-relieving drugs like opioids, which are frequently prescribed post-operatively. In light of the opioid crisis, understanding the interactions between opioid use and the development of sepsis has become extremely relevant, as opioid use is associated with increased risk of infection. Given that the intestinal tract is a major site of origin of sepsis-causing microbes, there has been an increasing focus on how alterations in the gut microbiome may predispose towards sepsis and mediate immune dysregulation. MicroRNAs, in particular, have emerged as key modulators of the inflammatory response during sepsis by tempering the immune response, thereby mediating the interaction between host and microbiome. In this review, we elucidate contributing roles of microRNA 146 in modulating sepsis pathogenesis and end with a discussion of therapeutic targeting of the gut microbiome in controlling immune dysregulation in sepsis.
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Affiliation(s)
- Yaa Abu
- Medical Scientist Training Program, Miller School of Medicine, University of Miami, Miami, FL 33136, USA;
- Department of Microbiology and Immunology, Miller School of Medicine, University of Miami, Miami, FL 33136, USA;
| | - Nicolas Vitari
- Department of Microbiology and Immunology, Miller School of Medicine, University of Miami, Miami, FL 33136, USA;
| | - Yan Yan
- Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL 33136, USA;
| | - Sabita Roy
- Department of Microbiology and Immunology, Miller School of Medicine, University of Miami, Miami, FL 33136, USA;
- Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL 33136, USA;
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12
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Taylor SP, Hammer JM, Taylor BT. Weaning Analgosedation in Patients Requiring Prolonged Mechanical Ventilation. J Intensive Care Med 2021; 37:998-1004. [PMID: 34632845 DOI: 10.1177/08850666211048779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Although research supports the minimization of sedation in mechanically ventilated patients, many patients with severe acute respiratory distress syndrome (ARDS) receive prolonged opioid and sedative infusions. ICU teams face the challenge of weaning these medications, balancing the risks of sedation with the potential to precipitate withdrawal symptoms. In this article, we use a clinical case to discuss our approach to weaning analgosedation in patients recovering from long-term mechanical ventilation. We believe that a protocolized, multimodal weaning strategy implemented by a multidisciplinary care team is required to reduce potential harm from both under- and over-sedation. At present, there is no strong randomized clinical trial evidence to support a particular weaning strategy in adult ICU patients, but appraisal of the existing literature in adults and children can guide decision-making to enhance the recovery of these patients.
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Lee H, Choi S, Jang EJ, Lee J, Kim D, Yoo S, Oh SY, Ryu HG. Effect of Sedatives on In-hospital and Long-term Mortality of Critically Ill Patients Requiring Extended Mechanical Ventilation for ≥ 48 Hours. J Korean Med Sci 2021; 36:e221. [PMID: 34463064 PMCID: PMC8405403 DOI: 10.3346/jkms.2021.36.e221] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 07/22/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The purpose of this study was to assess the correlation between sedatives and mortality in critically ill patients who required mechanical ventilation (MV) for ≥ 48 hours from 2008 to 2016. METHODS We conducted a nationwide retrospective cohort study using population-based healthcare reimbursement claims database. Data from adult patients (aged ≥ 18) who underwent MV for ≥ 48 hours between 2008 and 2016 were identified and extracted from the National Health Insurance Service database. The benzodiazepine group consisted of patients who were administered benzodiazepines for sedation during MV. All other patients were assigned to the non-benzodiazepine group. RESULTS A total of 158,712 patients requiring MV for ≥ 48 hours were admitted in 55 centers in Korea from 2008 to 2016. The benzodiazepine group had significantly higher in-hospital and one-year mortality compared to the non-benzodiazepine group (37.0% vs. 34.3%, 55.0% vs. 54.4%, respectively). Benzodiazepine use decreased from 2008 to 2016, after adjusting for age, sex, and mean Elixhauser comorbidity index in the Poisson regression analysis (incidence rate ratio, 0.968; 95% confident interval, 0.954-0.983; P < 0.001). Benzodiazepine use, older age, lower case volume (≤ 500 cases/year), chronic kidney disease, and higher Elixhauser comorbidity index were common significant risk factors for in-hospital and one-year mortality. CONCLUSION In critically ill patients undergoing MV for ≥ 48 hour, the use of benzodiazepines for sedation, older age, and chronic kidney disease were associated with higher in-hospital mortality and one-year mortality. Further studies are needed to evaluate the impact of benzodiazepines on the mortality in elderly patients with chronic kidney disease requiring MV for ≥ 48 hours.
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Affiliation(s)
- Hannah Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Seongmi Choi
- Health Insurance Policy Research Institute, National Health Insurance Service, Wonju, Korea
| | - Eun Jin Jang
- Department of Information Statistics, Andong National University, Andong, Korea
| | - Juhee Lee
- Department of Statistics, Kyungpook National University, Daegu, Korea
| | - Dalho Kim
- Department of Statistics, Kyungpook National University, Daegu, Korea
| | - Seokha Yoo
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Seung-Young Oh
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Ho Geol Ryu
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.
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Long D, Gibbons K, Le Brocque R, Schults JA, Kenardy J, Dow B. Midazolam exposure in the paediatric intensive care unit predicts acute post-traumatic stress symptoms in children. Aust Crit Care 2021; 35:408-414. [PMID: 34373171 DOI: 10.1016/j.aucc.2021.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 06/01/2021] [Accepted: 06/04/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Clinically significant post-traumatic stress symptoms (PTSS) have been reported in up to a quarter of paediatric intensive care unit (PICU) survivors. Ongoing PTSS negatively impacts children's psychological development and physical recovery. However, few data regarding associations between potentially modifiable PICU treatment factors, such as analgosedatives and invasive procedures, and children's PTSS have been reported. OBJECTIVES We sought to investigate the medical treatment factors associated with children's PTSS after PICU discharge. METHODS A prospective longitudinal cohort study was conducted in two Australian tertiary referral PICUs. Children aged 2-16 y admitted to the PICU between June 2008 and January 2011 for >8 h and <28 d were eligible for participation. Biometric and clinical data were obtained from medical records. Parents reported their child's PTSS using the Trauma Symptom Checklist for Young Children at 1, 3, 6, and 12 months after discharge. Logistic regression was used to assess potential associations between medical treatment and PTSS. RESULTS A total of 265 children and their parents participated in the study. In the 12-month period following PICU discharge, 24% of children exhibited clinically elevated PTSS. Median risk of death (Paediatric Index of Mortality 2 [PIM2]) score was significantly higher in the PTSS group (0.31 [IQR 0.14-1.09] v 0.67 [IQR 0.20-1.18]; p = 0.014). Intubation and PICU and hospital length of stay were also significantly associated with PTSS at 1 month, as were midazolam, propofol, and morphine. After controlling for gender, reason for admission, and PIM2 score, only midazolam was significantly and independently associated with PTSS and only at 1 month (adjusted odds ration (aOR) 3.63, 95% CI 1.18, 11.12, p = 0.024). No significant relationship was observed between the use of medications and PTSS after 1 month. CONCLUSIONS Elevated PTSS were evident in one quarter (24%) of children during the 12 months after PICU discharge. One month after discharge, elevated PTSS were most likely to occur in children who had received midazolam therapy.
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Affiliation(s)
- Debbie Long
- Paediatric Intensive Care Unit, Queensland Children's Hospital, Brisbane, Australia; School of Nursing, Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Australia; Child Health Research Centre, The University of Queensland, Brisbane, Australia.
| | - Kristen Gibbons
- Child Health Research Centre, The University of Queensland, Brisbane, Australia
| | - Robyne Le Brocque
- School of Nursing, Midwifery and Social Work, The University of Queensland, Brisbane, Australia
| | - Jessica A Schults
- School of Nursing, Midwifery and Social Work, The University of Queensland, Brisbane, Australia; Menzies Health Institute, Griffith University, Brisbane, Australia; Metro North Hospital and Health Service, Brisbane, Australia
| | - Justin Kenardy
- Child Health Research Centre, The University of Queensland, Brisbane, Australia; School of Psychology, The University of Queensland, Brisbane, Australia
| | - Belinda Dow
- Child Health Research Centre, The University of Queensland, Brisbane, Australia
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Zhang Y, Yan Y, Meng J, Girotra M, Ramakrishnan S, Roy S. Immune modulation mediated by extracellular vesicles of intestinal organoids is disrupted by opioids. Mucosal Immunol 2021; 14:887-898. [PMID: 33854193 PMCID: PMC8225561 DOI: 10.1038/s41385-021-00392-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 02/02/2021] [Accepted: 02/11/2021] [Indexed: 02/06/2023]
Abstract
Extracellular vesicles (EVs) are effective mediators of intercellular communications between enterocytes and immune cells. The current study showed that EVs isolated from mouse and human intestinal organoids modulated inflammatory responses of various immune cells including mouse bone-marrow derived-macrophages, dendritic cells, microglia cells, and human monocytes. EVs suppressed LPS-elicited cytokine production in these cells while morphine abolished EVs' immune modulatory effects. Microarray analysis showed that various microRNAs, especially Let-7, contributed to EV-mediated immune modulation. Using murine models, we showed that injection of EVs derived from intestinal organoids reduced endotoxin-induced systemic inflammation and alleviated the symptoms of DSS-induced colitis. EVs derived from morphine-treated organoids failed to suppress the immune response in both these models. Our study suggests that EVs derived from intestinal crypt cells play crucial roles in maintaining host homeostasis and opioid use is a risk factor for exacerbating inflammation in patients with inflammatory diseases such as sepsis and colitis.
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Affiliation(s)
- Yue Zhang
- Department of Surgery, University of Miami, Miller School of Medicine, Miami, Florida 33101, USA
| | - Yan Yan
- Department of Surgery, University of Miami, Miller School of Medicine, Miami, Florida 33101, USA
| | - Jingjing Meng
- Department of Surgery, University of Miami, Miller School of Medicine, Miami, Florida 33101, USA
| | - Mohit Girotra
- Division of Gastroenterology, University of Miami, Miller School of Medicine
| | - Sundaram Ramakrishnan
- Department of Surgery, University of Miami, Miller School of Medicine, Miami, Florida 33101, USA
| | - Sabita Roy
- Department of Surgery, University of Miami, Miller School of Medicine, Miami, Florida 33101, USA,Correspondence to: Sabita Roy, Department of Surgery, University of Miami, Miller School of Medicine, Miami, Florida 33101, USA, , Phone: +1 (305) 2438452
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16
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Temesgen N, Chekol B, Tamirie T, Eshetie D, Simeneh N, Feleke A. Adult sedation and analgesia in a resource limited intensive care unit - A Systematic Review and evidence based guideline. Ann Med Surg (Lond) 2021; 66:102356. [PMID: 34035907 PMCID: PMC8138481 DOI: 10.1016/j.amsu.2021.102356] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/15/2021] [Accepted: 04/25/2021] [Indexed: 12/04/2022] Open
Abstract
Background Sedation and analgesia are essential in the intensive care unit in order to promote control of pain, anxiety, prevent loss of materials, accidental extubation and improve the synchrony of patients with ventilator. However, excess of these medications leads to an increased morbidity and mortality, and thus demands protocol. Methods Preferred Reporting Items for Systematic Reviews and the Meta-Analysis Protocol have been used to undertake this review. Pub Med, Cochrane Library, and Google Scholar search engines were used to find up-to-date evidence that helps to draw recommendations and conclusions. Results In this Guideline and Systematic Review, we have used 16 Systemic Review and Meta-Analysis, 3 Evidence-Based Guidelines and 10 RCT Meta-Analysis, 6 Systemic Reviews of Non-randomized Studies, 8 Randomized Clinical Trials, 11 Cohort Studies, 5 Cross-Sectional Studies and 1 Case Report with their respective study descriptions. Discussion Analgesia, which as a sedation basement can reduce sedative use, is key aspect of treatment in ICU patients, and we can also conclude that an analgesic sedation regimen can reduce the occurrence of delirium by reducing sedatives. The aim of this guideline and the systematic review is to write up and formulate analgesia-based sedation for limited resource settings. Conclusions Analgesia and sedation are effective in critically ill patients; however, too much sedation is associated with longer periods of mechanical ventilation and longer duration of ICU stay. Poorly managed ICU patients have a delirium rate of up to 80%, increased mortality, longer hospital stays, higher hospital costs and bad long-term outcomes. Critically ill patients shall be awake, alert without pain, anxiety and delirium. Analgesia and sedation in the ICU shall be given as per needed after determined they are in need of. Sedation breaks are paramount important as equal as spontaneous breathing trials. Unnecessary deep sedations will increase hospital and personnel costs by increasing length of ICU stay.
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Affiliation(s)
- Netsanet Temesgen
- Debre Tabor University, College of Health Sciences, School of Medicine, Department of Anesthesia, Ethiopia
| | - Bsazinew Chekol
- Debre Tabor University, College of Health Sciences, School of Medicine, Department of Anesthesia, Ethiopia
| | - Tadesse Tamirie
- Debre Tabor University, College of Health Sciences, School of Medicine, Department of Anesthesia, Ethiopia
| | - Denberu Eshetie
- Debre Tabor University, College of Health Sciences, School of Medicine, Department of Anesthesia, Ethiopia
| | - Nigussie Simeneh
- University of Gondar, College of Medicine and Health Sciences, Department of Anesthesia and Critical Care, Ethiopia
| | - Abatneh Feleke
- University of Gondar, College of Medicine and Health Sciences, Department of Anesthesia and Critical Care, Ethiopia
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Donato M, Carini FC, Meschini MJ, Saubidet IL, Goldberg A, Sarubio MG, Olmos D, Reina R. Consensus for the management of analgesia, sedation and delirium in adults with COVID-19-associated acute respiratory distress syndrome. Rev Bras Ter Intensiva 2021; 33:48-67. [PMID: 33886853 PMCID: PMC8075332 DOI: 10.5935/0103-507x.20210005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 12/29/2020] [Indexed: 01/08/2023] Open
Abstract
Objective To propose agile strategies for a comprehensive approach to analgesia, sedation, delirium, early mobility and family engagement for patients with COVID-19-associated acute respiratory distress syndrome, considering the high risk of infection among health workers, the humanitarian treatment that we must provide to patients and the inclusion of patients’ families, in a context lacking specific therapeutic strategies against the virus globally available to date and a potential lack of health resources. Methods A nonsystematic review of the scientific evidence in the main bibliographic databases was carried out, together with national and international clinical experience and judgment. Finally, a consensus of recommendations was made among the members of the Committee for Analgesia, Sedation and Delirium of the Sociedad Argentina de Terapia Intensiva. Results Recommendations were agreed upon, and tools were developed to ensure a comprehensive approach to analgesia, sedation, delirium, early mobility and family engagement for adult patients with acute respiratory distress syndrome due to COVID-19. Discussion Given the new order generated in intensive therapies due to the advancing COVID-19 pandemic, we propose to not leave aside the usual good practices but to adapt them to the particular context generated. Our consensus is supported by scientific evidence and national and international experience and will be an attractive consultation tool in intensive therapies.
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Affiliation(s)
- Manuel Donato
- Hospital General de Agudos José María Penna - Buenos Aires, Argentina.,Ministerio de Salud de la Nación Argentina - Buenos Aires, Argentina.,Instituto de Efectividad Clínica y Sanitaria - Buenos Aires, Argentina
| | | | | | - Ignacio López Saubidet
- Centro de Educación Médica e Investigaciones Clínicas "Norberto Quirno" - Buenos Aires, Argentina
| | - Adela Goldberg
- Sanatorio de La Trinidad Mitre - Buenos Aires, Argentina
| | | | - Daniela Olmos
- Hospital Municipal Príncipe de Asturias - Córdoba, Argentina
| | - Rosa Reina
- Hospital Interzonal General de Agudos General San Martín - La Plata, Argentina
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Wang X, Meng J. Butorphanol versus Propofol in Patients Undergoing Noninvasive Ventilation: A Prospective Observational Study. Int J Gen Med 2021; 14:983-992. [PMID: 33790627 PMCID: PMC7997559 DOI: 10.2147/ijgm.s297356] [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: 12/14/2020] [Accepted: 02/23/2021] [Indexed: 11/28/2022] Open
Abstract
Background The present study aimed to explore sedation management in agitated patients who suffered from acute respiratory failure (ARF) and were treated with noninvasive ventilation (NIV). Patients and Methods We divided 118 patients undergoing NIV treatment with butorphanol or propofol into two groups: group B (n = 57, butorphanol was initiated at the rate of 0.12 µg/kg/min as a continuous intravenous infusion and then titrated by 0.06 µg/kg/min every half an hour, group P (n = 61, propofol was initiated at the rate of 5 µg/kg/min as a continuous intravenous infusion and then titrated by 1.5 µg/kg/min every half an hour). Score of Sedation Agitation Scale (SAS) in the two groups was maintained between 3 and 4. Medications including sedative, analgesic, and antipsychotic, NIV intolerance score, SAS score, visual analog scale (VAS), medication use and adverse events were recorded repeatedly. Results Patients receiving butorphanol required significantly less total amount of fentanyl than patients receiving propofol during NIV to maintain the target VAS [0 (0–0) µg vs 150 (50–200) µg, P< 0.005]. Hemodynamic stability during NIV showed it was better kept in patients treated with butorphanol. Conclusion Butorphanol not only decreased the requirements of fentanyl but also enhanced hemodynamic stability in agitated patients suffering from ARF receiving NIV. Trial Registration Registered at http://www.chictr.org.cn/ (ChiCTR1800015534).
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Affiliation(s)
- Xiaohong Wang
- Intensive Care Unit, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, 310003, People's Republic of China
| | - Jianbiao Meng
- Intensive Care Unit, Tongde Hospital of Zhejiang Province, Hangzhou, Zhejiang Province, 310012, People's Republic of China
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19
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Abstract
PURPOSES OF REVIEW Critically ill patients frequently require mechanical ventilation as part of their care. Administration of analgesia and sedation to ensure patient comfort and facilitate mechanical ventilation must be balanced against the known negative consequences of excessive sedation. The present review focuses on the current evidence for sedation management during mechanical ventilation, including choice of sedatives, sedation strategies, and special considerations for acute respiratory distress syndrome (ARDS). RECENT FINDINGS The Society of Critical Care Medicine recently published their updated clinical practice guidelines for analgesia, agitation, sedation, delirium, immobility, and sleep in adult patients in the ICU. Deep sedation, especially early in the course of mechanical ventilation, is associated with prolonged time to liberation from mechanical ventilation, longer ICU stays, longer hospital stays, and increased mortality. Dexmedetomidine may prevent ICU delirium when administered nocturnally at low doses; however, it was not shown to improve mortality when used as the primary sedative early in the course of mechanical ventilation, though the majority of patients in the informing study failed to achieve the prescribed light level of sedation. In a follow up to the ACURASYS trial, deep sedation with neuromuscular blockade did not result in improved mortality compared to light sedation in patients with severe ARDS. SUMMARY Light sedation should be targeted early in the course of mechanical ventilation utilizing daily interruptions of sedation and/or nursing protocol-based algorithms, even in severe ARDS.
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20
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Adams CD, Altshuler J, Barlow BL, Dixit D, Droege CA, Effendi MK, Heavner MS, Johnston JP, Kiskaddon AL, Lemieux DG, Lemieux SM, Littlefield AJ, Owusu KA, Rouse GE, Thompson Bastin ML, Berger K. Analgesia and Sedation Strategies in Mechanically Ventilated Adults with COVID‐19. Pharmacotherapy 2020; 40:1180-1191. [DOI: 10.1002/phar.2471] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Christopher D. Adams
- Department of Pharmacy Practice and Administration Ernest Mario School of Pharmacy Piscataway New JerseyUSA
| | - Jerry Altshuler
- Department of Pharmacy Hackensack Meridian JFK Medical Center Edison New JerseyUSA
| | - Brooke L. Barlow
- Department of Pharmacy Services University of Kentucky HealthCare Lexington KentuckyUSA
| | - Deepali Dixit
- Department of Pharmacy Practice and Administration Ernest Mario School of Pharmacy Piscataway New JerseyUSA
| | - Christopher A. Droege
- Department of Pharmacy UC Health – University of Cincinnati Medical Center Cincinnati OhioUSA
| | - Muhammad K. Effendi
- Department of Pharmacy Practice and Administration Ernest Mario School of Pharmacy Piscataway New JerseyUSA
| | - Mojdeh S. Heavner
- Department of Pharmacy Practice University of Maryland School of Pharmacy Baltimore MarylandUSA
| | - Jackie P. Johnston
- Department of Pharmacy Practice and Administration Ernest Mario School of Pharmacy Piscataway New JerseyUSA
| | - Amy L. Kiskaddon
- Department of Pharmacy Johns Hopkins All Children's Hospital St. Petersburg FloridaUSA
| | - Diana G. Lemieux
- Department of Pharmacy Services Yale New Haven Hospital New Haven ConnecticutUSA
| | - Steven M. Lemieux
- Department of Pharmacy Practice and Administration University of Saint Joseph Hartford ConnecticutUSA
| | - Audrey J. Littlefield
- Department of Pharmacy New York‐Presbyterian Hospital/Weill Cornell Medical Center New York New YorkUSA
| | - Kent A Owusu
- Department of Pharmacy Services Yale New Haven Hospital New Haven ConnecticutUSA
| | - Ginger E. Rouse
- Department of Pharmacy Services Yale New Haven Hospital New Haven ConnecticutUSA
| | | | - Karen Berger
- Department of Pharmacy New York‐Presbyterian Hospital/Weill Cornell Medical Center New York New YorkUSA
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21
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Shehabi Y, Al-Bassam W, Pakavakis A, Murfin B, Howe B. Optimal Sedation and Pain Management: A Patient- and Symptom-Oriented Paradigm. Semin Respir Crit Care Med 2020; 42:98-111. [PMID: 32957139 DOI: 10.1055/s-0040-1716736] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In the critically ill patient, optimal pain and sedation management remains the cornerstone of achieving comfort, safety, and to facilitate complex life support interventions. Pain relief, using multimodal analgesia, is an integral component of any orchestrated approach to achieve clinically appropriate goals in critically ill patients. Sedative management, however, remains a significant challenge. Subsequent studies including most recent randomized trials have failed to provide strong evidence in favor of a sedative agent, a mode of sedation or ancillary protocols such as sedative interruption and sedative minimization. In addition, clinical practice guidelines, despite a comprehensive evaluation of relevant literature, have limitations when applied to individual patients. These limitations have been most apparent during the coronavirus disease 2019 pandemic. As such, there is a need for a mindset shift to a practical and achievable sedation strategy, driven by patients' characteristics and individual patient needs, rather than one cocktail for all patients. In this review, we present key principles to achieve patient-and symptom-oriented optimal analgesia and sedation in the critically ill patients. Sedative intensity should be proportionate to care complexity with due consideration to an individual patient's modifiers. The use of multimodal analgesics, sedatives, and antipsychotics agents-that are easily titratable-reduces the overall quantum of sedatives and opioids, and reduces the risk of adverse events while maximizing clinical benefits. In addition, critical considerations regarding the choice of sedative agents should be given to factors such as age, medical versus operative diagnosis, and cardiovascular status. Specific populations such as trauma, neurological injury, and pregnancy should also be taken into account to maximize efficacy and reduce adverse events.
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Affiliation(s)
- Yahya Shehabi
- Monash Health School of Clinical Sciences, Monash University, Clayton, Victoria, Melbourne, Australia.,Prince of Wales Clinical School of Medicine, University of New South Wales, Randwick, New South Wales, Sydney, Australia
| | - Wisam Al-Bassam
- Monash Health School of Clinical Sciences, Monash University, Clayton, Victoria, Melbourne, Australia
| | - Adrian Pakavakis
- Monash Health School of Clinical Sciences, Monash University, Clayton, Victoria, Melbourne, Australia
| | - Brendan Murfin
- Monash Health School of Clinical Sciences, Monash University, Clayton, Victoria, Melbourne, Australia
| | - Belinda Howe
- The Australian and New Zealand Intensive Care Research Centre, Monash University, School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia
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22
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Einhorn OM, Georgiou K, Tompa A. Salivary dysfunction caused by medication usage. Physiol Int 2020; 107:195-208. [PMID: 32750027 DOI: 10.1556/2060.2020.00019] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 05/11/2020] [Indexed: 11/19/2022]
Abstract
A considerable number of patients arriving in dental offices are being treated with ongoing medication for a variety of chronic diseases. As a result, dentists must be familiar with the potential side effects these therapeutic agents may have on the tissues of the oral cavity, and in particular on the salivary gland. Salivary gland function may be altered by a wide range of medications, leading to effects such as xerostomia, hyposalivation, hypersalivation or even swelling of the glands. These disorders can cause a variety of other health complications. This review will focus on the most common groups of drugs responsible for salivary gland dysfunction, including psychoactive drugs, antidepressants, antipsychotics, antihypertensives, and antihistamines.
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Affiliation(s)
- O M Einhorn
- 1Private Dental Office: Dr. Einhorn, 89 Medinat Hayehudim Street, Herzliya, Israel
| | - K Georgiou
- 2Private Dental Office: Dr. Georgiou, 2-4 Makarios Avenue, Nicosia, 1065, Cyprus
| | - A Tompa
- 3Institute of Public Health, Semmelweis University, Budapest, 1089, Hungary
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23
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Besen BAMP, Nassar Júnior AP, Lacerda FH, Silva CMDD, Souza VTD, Martins EVDN, Lopes ATA, Brandão CE, Oliveira LFD. Pain management protocol implementation and opioid consumption in critical care: an interrupted time series analysis. Rev Bras Ter Intensiva 2020; 31:447-455. [PMID: 31967218 PMCID: PMC7009002 DOI: 10.5935/0103-507x.20190085] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Accepted: 09/11/2019] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To evaluate the impact of an opioid-sparing pain management protocol on overall opioid consumption and clinical outcomes. METHODS This was a single-center, quasi-experimental, retrospective, before and after cohort study. We used an interrupted time series to analyze changes in the levels and trends of the utilization of different analgesics. We used bivariate comparisons in the before and after cohorts as well as logistic regression and quantile regression for adjusted estimates. RESULTS We included 988 patients in the preintervention period and 1,838 in the postintervention period. Fentanyl consumption was slightly increasing before the intervention (β = 16; 95%CI 7 - 25; p = 0.002) but substantially decreased in level with the intervention (β = - 128; 95%CI -195 - -62; p = 0.001) and then progressively decreased (β = - 24; 95%CI -35 - -13; p < 0.001). There was an increasing trend in the utilization of dipyrone. The mechanical ventilation duration was significantly lower (median difference: - 1 day; 95%CI -1 - 0; p < 0.001), especially for patients who were mechanically ventilated for a longer time (50th percentile difference: -0.78; 95%CI -1.51 - -0.05; p = 0.036; 75th percentile difference: -2.23; 95%CI -3.47 - -0.98; p < 0.001). CONCLUSION A pain management protocol could reduce the intensive care unit consumption of fentanyl. This strategy was associated with a shorter mechanical ventilation duration.
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Affiliation(s)
- Bruno Adler Maccagnan Pinheiro Besen
- Unidade de Terapia Intensiva, Hospital da Luz - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva Clínica, Disciplina de Emergências Clínicas, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
| | | | - Fábio Holanda Lacerda
- Unidade de Terapia Intensiva, Hospital da Luz - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva Clínica, Disciplina de Emergências Clínicas, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva, Hospital AC Camargo Cancer Center - São Paulo (SP), Brasil
| | - Carla Marchini Dias da Silva
- Unidade de Terapia Intensiva, Hospital da Luz - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva, Hospital AC Camargo Cancer Center - São Paulo (SP), Brasil
| | | | | | | | - Carlos Eduardo Brandão
- Unidade de Terapia Intensiva, Hospital da Luz - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva, Hospital AC Camargo Cancer Center - São Paulo (SP), Brasil
| | - Lucas Fernandes de Oliveira
- Unidade de Terapia Intensiva, Hospital da Luz - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva, Hospital AC Camargo Cancer Center - São Paulo (SP), Brasil
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24
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Naderloo Z, Shayanfar A, Zakeri-Milani P, Valizadeh H. The effect of different factors on partitioning of propofol between aqueous and organic phases of microemulsions. J Mol Liq 2020. [DOI: 10.1016/j.molliq.2020.113003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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25
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Sutt AL, Tronstad O, Barnett AG, Kitchenman S, Fraser JF. Earlier tracheostomy is associated with an earlier return to walking, talking, and eating. Aust Crit Care 2020; 33:213-218. [PMID: 32299649 DOI: 10.1016/j.aucc.2020.02.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 02/25/2020] [Accepted: 02/28/2020] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Conjecture remains regarding the optimal timing for tracheostomy. Most studies examine patient mortality, ventilation duration, intensive care unit (ICU) length of stay, and medical complications. Few studies examine patient-centric outcomes. The aim of this study was to determine whether timing of tracheostomy had an impact on length of stay, morbidity, mortality, and patient-centric outcomes towards their functional recovery. METHODS This prospective observational study included data for all tracheostomised patients over 4 y in a tertiary ICU. The study time period commenced with the insertion of an endotracheal tube. Data collected included patient and disease specifics; mortality up to 4 y; mobility scores; and time to oral intake, talking, and out-of-bed exercises. To assess differences between timing of tracheostomy, a survival analysis was conducted to dynamically compare patients on days before and after tracheostomy tube (TT) placement during their ICU admission. RESULTS TT was placed in 276 patients. After tracheostomy, the patients were able to (on average) verbally communicate 7.4 d earlier (confidence interval [CI] = -9.1 to -4.9), return to oral intake 7.0 d earlier (CI = -10 to -4.6), and perform out-of-bed exercises 6.2 d earlier (CI = -8.4 to -4) than those who did not yet have a TT. In patients with an endotracheal tube, none were able to talk or have oral intake, and the majority (99%) did not participate in out-of-bed exercises/active rehabilitation. After tracheostomy, patients subsequently received significantly less analgesic and sedative drugs and more antipsychotics. No clear differences in ICU and long-term mortality were associated with tracheostomy timing. CONCLUSIONS Earlier tracheostomy is associated with earlier achievement of patient-centric outcomes - patients returning to usual daily activities such as talking, out-of-bed mobility, and eating/drinking significantly earlier, whilst also receiving less sedatives and analgesics.
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Affiliation(s)
- Anna Liisa Sutt
- Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Australia; Northside Medical School, University of Queensland, Brisbane, Australia.
| | - Oystein Tronstad
- Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Australia; Northside Medical School, University of Queensland, Brisbane, Australia; Physiotherapy Department, The Prince Charles Hospital, Brisbane, Australia.
| | - Adrian G Barnett
- Institute of Health and Biomedical Innovation & School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia.
| | - Sarah Kitchenman
- Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Australia.
| | - John F Fraser
- Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Australia; Northside Medical School, University of Queensland, Brisbane, Australia.
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26
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Sutt AL, Hay K, Kinneally T, Fisquet S, Fraser JF. Sedatives, analgesics and antipsychotics in tracheostomised ICU patients - Is less more? Aust Crit Care 2019; 33:407-411. [PMID: 31495639 DOI: 10.1016/j.aucc.2018.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 11/22/2018] [Accepted: 12/11/2018] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Sedation and anaesthesia are used universally to facilitate mechanical ventilation - with larger cumulative doses being used in those with prolonged ventilation. Transitioning from an endotracheal to a tracheostomy tube enables the depth of sedation to be reduced. Early use of speaking valves with tracheostomised patients has become routine in some intensive care units (ICU). The return of verbal communication has been observed to improve ease of patient care and increase patient and family engagement, with a perceived reduction in patient agitation. OBJECTIVES To investigate the potential impact of speaking valve (SV) use on requirements of sedatives, analgesics and antipsychotics in ICU patients with a tracheostomy. METHODS A retrospective data audit was undertaken for all tracheostomised patients in a cardio-respiratory ICU from 2011 to 2014. Use of sedative, analgesic and antipsychotic drugs was captured for endotracheal tube, tracheostomy and SV periods, including patient demographics, disease specifics and severity. Stratified Cox regression analysis was performed to determine the effects of SV on drug dosage. RESULTS Of 257 patients, 144 (56%) received an SV. Use of an SV was associated with reduced risk of being in the upper quartile of daily dosage of analgesics (HR: 0.6; 95% CI: 0.5-0.8; p < 0.001). In the final adjusted multivariable model, analgesic dose was additionally associated with age, and attendance to operating theatre during ICU. Sedative dose was associated with age, gender and SOFA score. Antipsychotic dose was associated with gender (less likely in females: HR 0.6, 95% CI: 0.4-0.8), age and APACHE score. CONCLUSIONS There was significantly less analgesic used in patients with an SV compared to those without. However, SV use in patients with tracheostomy was not found to be associated with reduced dose of sedatives or antipsychotics, despite the clinical impression. Future prospective studies are needed to more adequately investigate the association between drugs and patients' ability to verbally participate in their care.
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Affiliation(s)
- Anna-Liisa Sutt
- Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Australia; Faculty of Medical and Biomedical Sciences, The University of Queensland, Brisbane, Australia; Barts Health NHS Trust, London, United Kingdom.
| | - Karen Hay
- QIMR Berghofer Medical Research Institute, 300 Herston Road, Herston QLD 4006, Brisbane, Australia.
| | - Toni Kinneally
- Faculty of Medical and Biomedical Sciences, The University of Queensland, Brisbane, Australia.
| | - Stephanie Fisquet
- Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Australia; Pharmacy Department, The Prince Charles Hospital, Brisbane, Australia.
| | - John F Fraser
- Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Australia; Faculty of Medical and Biomedical Sciences, The University of Queensland, Brisbane, Australia.
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27
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Shen T, Huh MH, Czer LS, Vaidya A, Esmailian F, Kobashigawa JA, Nurok M. Controversies in the Postoperative Management of the Critically Ill Heart Transplant Patient. Anesth Analg 2019; 129:1023-1033. [PMID: 31162160 DOI: 10.1213/ane.0000000000004220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Heart transplant recipients are susceptible to a number of complications in the immediate postoperative period. Despite advances in surgical techniques, mechanical circulatory support (MCS), and immunosuppression, evidence supporting optimal management strategies of the critically ill transplant patient is lacking on many fronts. This review identifies some of these controversies with the aim of stimulating further discussion and development into these gray areas.
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Affiliation(s)
- Tao Shen
- From the Departments of Anesthesiology.,Surgery, Cedars-Sinai Heart Institute, Los Angeles, California
| | | | - Lawrence S Czer
- Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Ajay Vaidya
- Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, California
| | | | - Jon A Kobashigawa
- Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Michael Nurok
- From the Departments of Anesthesiology.,Surgery, Cedars-Sinai Heart Institute, Los Angeles, California
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28
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Elgebaly AS, Sabry M. Sedation effects by dexmedetomidine versus propofol in decreasing duration of mechanical ventilation after open heart surgery. Ann Card Anaesth 2019; 21:235-242. [PMID: 30052208 PMCID: PMC6078043 DOI: 10.4103/aca.aca_168_17] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective: The objective of this study was to compare the suitability (efficacy and safety) of dexmedetomidine versus propofol for patients admitted to the intensive care unit (ICU) after the cardiovascular surgery for the postoperative sedation before weaning from mechanical ventilation. Background: Sedation is prescribed in patients admitted to the ICU after cardiovascular surgery to reduce the patient discomfort, ventilator asynchrony, to make mechanical ventilation tolerable, prevent accidental device removal, and to reduce metabolic demands during respiratory and hemodynamic instability. Careful drug selection for sedation by the ICU team, postcardiovascular surgery should be done so that patients can be easily weaned from mechanical ventilation after sedation is stopped to achieve a shorter duration of mechanical ventilation and decreased the length of stay in ICU. Methods: A total of 50 patients admitted to the ICU after cardiovascular surgery, aged from 18 to 55 years and requiring mechanical ventilation on arrival to the ICU were enrolled in a prospective and comparative study. They were randomly divided into two groups as follows: Group D patients (n = 25) received dexmedetomidine in a maintenance infusion dose of 0.8 μg/kg/h and Group P patients (n = 25) received propofol in a maintenance infusion dose of 1.5 mg/kg/h. The patients were assessed for 12 h postoperatively, and dosing of the study drug was adjusted based on sedation assessment performed with the Richmond Agitation-Sedation Scale (RASS). The patients were required to be within the RASS target range of −2 to +1 at the time of study drug initiation. At every 4 h, the following information was recorded from each patient such as heart rate (HR), mean arterial pressure (MAP), arterial blood gases (ABG), tidal volume (TV), exhaled TV, maximum inspiratory pressure, respiratory rate and the rapid shallow breathing index, duration of mechanical ventilation, midazolam and fentanyl dose requirements, and financial costs. Results: The study results showed no statistically significant difference between both groups with regard to age and body mass index. Group P patients were more associated with lower MAP and HR than Group D patients. There was no statistically significant difference between groups with regard to ABG findings, oxygenation, ventilation, and respiratory parameters. There was significant difference between both the groups in midazolam and fentanyl dose requirement and financial costs with a value of P < 0.05. Conclusion: Dexmedetomidine is safer and equally effective agent for the sedation of mechanically ventilated patients admitted to the ICU after cardiovascular surgery compared to the patients receiving propofol, with good hemodynamic stability, and equally rapid extubation time.
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Affiliation(s)
- Ahmed Said Elgebaly
- Department of Anesthesia and PSIC, Faculty of Medicine, Tanta University, Tanta, Gharbia 31111, Egypt
| | - Mohab Sabry
- Department of Cardiothoracic Surgery, Faculty of Medicine, Tanta University Hospital, Tanta, Gharbia 31111, Egypt
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29
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Pharmacology in Critical Care. PHYSICIAN ASSISTANT CLINICS 2019. [DOI: 10.1016/j.cpha.2018.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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30
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Lamm W, Nagler B, Hermann A, Robak O, Schellongowski P, Buchtele N, Bojic A, Schmid M, Zauner C, Heinz G, Ullrich R, Staudinger T. Propofol-based sedation does not negatively influence oxygenator running time compared to midazolam in patients with extracorporeal membrane oxygenation. Int J Artif Organs 2019; 42:233-240. [PMID: 30819020 DOI: 10.1177/0391398819833376] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Patients on extracorporeal membrane oxygenation are frequently in need for sedation. Use of propofol has been associated with impaired oxygenator function due to adsorption to the membrane as well as lipid load. The aim of our retrospective analysis was to compare two different sedation regimens containing either propofol or midazolam with respect to oxygenator running time. METHODS Midazolam was used in 73 patients whereas propofol was used in 49 patients, respectively. In the propofol group, veno-arterial-extracorporeal membrane oxygenation was used predominantly (84%), while veno-venous-extracorporeal membrane oxygenation was used more often in the midazolam group (64%). RESULTS Oxygenator running time until first exchange was 7 days in both groups ( p = 0.759). No statistically significant differences could be observed between the subgroup of patients receiving lipid-free (n = 24) and lipid-containing (n = 31) parenteral nutrition, respectively. Laboratory parameters like triglycerides, free hemoglobin, fibrinogen, platelets, and activated partial thromboplastin time were not significantly different between both sedation regimens ( p = 0.462, p = 0.489, p = 0.960, p = 0.134, and p = 0.843) and were not associated with oxygenator running time. CONCLUSION The use of propofol as sedative seems suitable in patients undergoing extracorporeal membrane oxygenation therapy.
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Affiliation(s)
- Wolfgang Lamm
- 1 Department of Medicine I, Intensive Care Unit 13i2, Medical University of Vienna, Vienna, Austria
| | - Bernhard Nagler
- 1 Department of Medicine I, Intensive Care Unit 13i2, Medical University of Vienna, Vienna, Austria
| | - Alexander Hermann
- 1 Department of Medicine I, Intensive Care Unit 13i2, Medical University of Vienna, Vienna, Austria
| | - Oliver Robak
- 1 Department of Medicine I, Intensive Care Unit 13i2, Medical University of Vienna, Vienna, Austria
| | - Peter Schellongowski
- 1 Department of Medicine I, Intensive Care Unit 13i2, Medical University of Vienna, Vienna, Austria
| | - Nina Buchtele
- 1 Department of Medicine I, Intensive Care Unit 13i2, Medical University of Vienna, Vienna, Austria
| | - Andja Bojic
- 1 Department of Medicine I, Intensive Care Unit 13i2, Medical University of Vienna, Vienna, Austria
| | - Monika Schmid
- 2 Department of Medicine III, Intensive Care Unit 13h1, Medical University of Vienna, Vienna, Austria
| | - Christian Zauner
- 2 Department of Medicine III, Intensive Care Unit 13h1, Medical University of Vienna, Vienna, Austria
| | - Gottfried Heinz
- 3 Department of Medicine II, Intensive Care Unit 13h3, Medical University of Vienna, Vienna, Austria
| | - Roman Ullrich
- 4 Department of Anaesthesia, Critical Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Thomas Staudinger
- 1 Department of Medicine I, Intensive Care Unit 13i2, Medical University of Vienna, Vienna, Austria
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31
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Koutsogiannaki S, Shimaoka M, Yuki K. The Use of Volatile Anesthetics as Sedatives for Acute Respiratory Distress Syndrome. ACTA ACUST UNITED AC 2019; 6:27-38. [PMID: 30923729 PMCID: PMC6433148 DOI: 10.31480/2330-4871/084] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Acute respiratory distress syndrome (ARDS) remains to pose a high morbidity and mortality without any targeted therapies. Sedation, usually given intravenously, is an important part of clinical practice in intensive care unit (ICU), and the effect of sedatives on patients’ outcomes has been studied intensively. Although volatile anesthetics are not routine sedatives in ICU, preclinical and clinical studies suggested their potential benefit in pulmonary pathophysiology. This review will summarize the current knowledge of ARDS and the role of volatile anesthetic sedation in this setting from both clinical and mechanistic standpoints. In addition, we will review the infrastructure to use volatile anesthetics.
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Affiliation(s)
- Sophia Koutsogiannaki
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA.,Department of Anesthesiology, Critical Care and Pain Medicine, Cardiac Anesthesia Division, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Motomu Shimaoka
- Department of Molecular Pathobiology and Cell Adhesion Biology, Mie University Graduate School of Medicine, Tsushi, Mie, Japan
| | - Koichi Yuki
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA.,Department of Anesthesiology, Critical Care and Pain Medicine, Cardiac Anesthesia Division, Boston Children's Hospital, Boston, Massachusetts, USA
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32
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Fischer M, Jackson M, Abd-Elsayed A. Pain in the Neurocritical Care Unit. TEXTBOOK OF NEUROANESTHESIA AND NEUROCRITICAL CARE 2019:319-331. [DOI: 10.1007/978-981-13-3390-3_22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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33
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Shafiekhani M, Mirjalili M, Vazin A. Psychotropic drug therapy in patients in the intensive care unit - usage, adverse effects, and drug interactions: a review. Ther Clin Risk Manag 2018; 14:1799-1812. [PMID: 30319262 PMCID: PMC6168070 DOI: 10.2147/tcrm.s176079] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Managing psychological problems in patients admitted to intensive care unit (ICU) is a big challenge, requiring pharmacological interventions. On the other hand, these patients are more prone to side effects and drug interactions associated with psychotropic drugs use. Benzodiazepines (BZDs), antidepressants, and antipsychotics are commonly used in critically ill patients. Therefore, their therapeutic effects and adverse events are discussed in this study. Different studies have shown that non-BZD drugs are preferred to BZDs for agitation and pain management, but antipsychotic agents are not recommended. Also, it is better not to start antidepressants until the patient has fully recovered. However, further investigations are required for the use of psychotropic drugs in ICUs.
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Affiliation(s)
- Mojtaba Shafiekhani
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran,
| | - Mahtabalsadat Mirjalili
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran,
| | - Afsaneh Vazin
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran,
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34
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Characterization of potential drug-drug interactions in patients hospitalized in the intensive care unit of a tertiary hospital in Bogotá. BIOMEDICA 2018; 38:407-416. [PMID: 30335246 DOI: 10.7705/biomedica.v38i4.3884] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 09/20/2017] [Indexed: 11/21/2022]
Abstract
Introduction: Drug-drug interactions occur more frequently in intensive care units than in other services. However, in Colombia, there are few studies on this problem in critically ill patients.
Objectives: To characterize potential drug-drug interactions generated from prescriptions during hospitalization in an intensive care unit and to determine factors associated with their onset.
Materials and methods: A retrospective cohort was assembled with patients hospitalized in an intensive care unit for a seven-month period. The daily prescription was assessed for potential drugdrug interactions using the Lexicomp® program. We calculated the incidence of interactions, classified them by type, severity, and level of documentation, and evaluated the factors associated with their onset using logistic regression.
Results: The proportion of patients with at least one interaction was 84% while 87% had more than one interaction; the median was six interactions per patient. The most frequent was fentanyl and midazolam (23%). Moderate interactions were the most frequent by severity (77.6%) and by documentation (52.6%). The most common index and precipitating drugs were midazolam (12%) and fentanyl (10.6%), respectively. Age (OR=3.1) and the number of drugs (OR=11.8) were associated with the occurrence
of interactions.
Conclusions: Given their high frequency and potential negative impact, the systematic monitoring of prescriptions in intensive care units to detect interactions is important. Such monitoring contributes to the rational use of medicines and to improve the quality of care.
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Abstract
The appropriate use of medications during Emergency Neurological Life Support (ENLS) is essential to optimize patient care. Important considerations when choosing the appropriate agent include the patient's organ function and medication allergies, potential adverse drug effects, drug interactions and critical illness and aging pathophysiologic changes. Critical medications used during ENLS include hyperosmolar therapy, anticonvulsants, antithrombotics, anticoagulant reversal and hemostatic agents, anti-shivering agents, neuromuscular blockers, antihypertensive agents, sedatives, vasopressors and inotropes, and antimicrobials. This article focuses on the important pharmacokinetic and pharmacodynamics characteristics, advantages and disadvantages and clinical pearls of these therapies, providing practitioners with essential drug information to optimize pharmacotherapy in acutely ill neurocritical care patients.
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Affiliation(s)
- Gretchen M Brophy
- Departments of Pharmacotherapy and Outcomes Science and Neurosurgery, Virginia Commonwealth University, Richmond, VA, USA.
| | - Theresa Human
- Department of Clinical Pharmacy, Barnes-Jewish Hospital, Washington University in St. Louis, St. Louis, MO, USA
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Nguyen J, Nacpil N. Effectiveness of dexmedetomidine versus propofol on extubation times, length of stay and mortality rates in adult cardiac surgery patients. ACTA ACUST UNITED AC 2018; 16:1220-1239. [DOI: 10.11124/jbisrir-2017-003488] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Nguyen J, Nacpil N. A comparison between dexmedetomidine and propofol on extubation times in postoperative adult cardiac surgery patients: a systematic review protocol. ACTA ACUST UNITED AC 2018; 14:63-71. [PMID: 27941511 DOI: 10.11124/jbisrir-2016-003195] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
REVIEW QUESTION/OBJECTIVE The objective of this systematic review is to synthesize the best available evidence regarding the effects of dexmedetomidine compared to propofol on time to extubation, intensive care unit (ICU) length of stay (LOS), hospital LOS and mortality in postoperative adult cardiac surgery patients.The specific review question is as follows:What is the effectiveness of dexmedetomidine compared to propofol on times to extubation, ICU LOS, hospital LOS and mortality in postoperative adults undergoing cardiac surgery?
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Affiliation(s)
- John Nguyen
- The Center for Translational Research: a Joanna Briggs Institute Center of Excellence, Forth Worth, USA
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Prescription opioids are associated with higher mortality in patients diagnosed with sepsis: A retrospective cohort study using electronic health records. PLoS One 2018; 13:e0190362. [PMID: 29293575 PMCID: PMC5749778 DOI: 10.1371/journal.pone.0190362] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Accepted: 12/13/2017] [Indexed: 12/21/2022] Open
Abstract
Sepsis continues to be a major problem for hospitalized patients. Opioids are widely used medications for pain management despite recent evidence revealing their adverse effects. The present study evaluates survival differences between opioid-treated patients and non-opioid-treated patients hospitalized with a diagnosis of sepsis. Clinical data was extracted from the University of Minnesota’s Clinical Data Repository, which includes Electronic Health Records (EHRs) of the patients seen at 8 hospitals. Among 5,994 patients diagnosed with sepsis, 4,540 opioid-treated patients and 1,454 non-opioid patients were included based on whether they are exposed to prescription opioids during their hospitalization. Cox proportional hazards regression showed that after adjustments for demographics, clinical comorbidities, severity of illness, and types of infection, opioid-treated patients had a significantly higher risk of death at 28 days.
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Medikamente und toxische Substanzen in der Sterbehilfe. Rechtsmedizin (Berl) 2017. [DOI: 10.1007/s00194-017-0207-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Hauer J, Houtrow AJ, Feudtner C, Klein S, Klick J, Linebarger J, Norwood KW, Adams RC, Brei TJ, Davidson LF, Davis BE, Friedman SL, Hyman SL, Kuo DZ, Noritz GH, Yin L, Murphy NA. Pain Assessment and Treatment in Children With Significant Impairment of the Central Nervous System. Pediatrics 2017; 139:peds.2017-1002. [PMID: 28562301 DOI: 10.1542/peds.2017-1002] [Citation(s) in RCA: 107] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Pain is a frequent and significant problem for children with impairment of the central nervous system, with the highest frequency and severity occurring in children with the greatest impairment. Despite the significance of the problem, this population remains vulnerable to underrecognition and undertreatment of pain. Barriers to treatment may include uncertainty in identifying pain along with limited experience and fear with the use of medications for pain treatment. Behavioral pain-assessment tools are reviewed in this clinical report, along with other strategies for monitoring pain after an intervention. Sources of pain in this population include acute-onset pain attributable to tissue injury or inflammation resulting in nociceptive pain, with pain then expected to resolve after treatment directed at the source. Other sources can result in chronic intermittent pain that, for many, occurs on a weekly to daily basis, commonly attributed to gastroesophageal reflux, spasticity, and hip subluxation. Most challenging are pain sources attributable to the impaired central nervous system, requiring empirical medication trials directed at causes that cannot be identified by diagnostic tests, such as central neuropathic pain. Interventions reviewed include integrative therapies and medications, such as gabapentinoids, tricyclic antidepressants, α-agonists, and opioids. This clinical report aims to address, with evidence-based guidance, the inherent challenges with the goal to improve comfort throughout life in this vulnerable group of children.
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Affiliation(s)
- Julie Hauer
- Complex Care Service, Division of General Pediatrics, Boston Children’s Hospital, Assistant Professor, Harvard Medical School, Boston Massachusetts
- Seven Hills Pediatric Center, Groton, Massachusetts; and
| | - Amy J. Houtrow
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pediatric Rehabilitation Medicine, Rehabilitation Institute, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
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Bodnar J. A Review of Agents for Palliative Sedation/Continuous Deep Sedation: Pharmacology and Practical Applications. J Pain Palliat Care Pharmacother 2017; 31:16-37. [PMID: 28287357 DOI: 10.1080/15360288.2017.1279502] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Continuous deep sedation at the end of life is a specific form of palliative sedation requiring a care plan that essentially places and maintains the patient in an unresponsive state because their symptoms are refractory to any other interventions. Because this application is uncommon, many providers may lack practical experience in this specialized area and resources they can access are outdated, nonspecific, and/or not comprehensive. The purpose of this review is to provide an evidence- and experience-based reference that specifically addresses those medications and regimens and their practical applications for this very narrow, but vital, aspect of hospice care. Patient goals in a hospital and hospice environments are different, so the manner in which widely used sedatives are dosed and applied can differ greatly as well. Parameters applied in end-of-life care that are based on experience and a thorough understanding of the pharmacology of those medications will differ from those applied in an intensive care unit or other medical environments. By recognizing these different goals and applying well-founded regimens geared specifically for end-of-life sedation, we can address our patients' symptoms in a more timely and efficacious manner.
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Effects of propofol on vasopressor use in patients with sepsis and severe sepsis: A pilot study. J Crit Care 2016; 35:155-60. [DOI: 10.1016/j.jcrc.2016.05.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 04/22/2016] [Accepted: 05/14/2016] [Indexed: 12/31/2022]
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Stephens J, Wright M. Pain and Agitation Management in Critically Ill Patients. Nurs Clin North Am 2016; 51:95-106. [PMID: 26897427 DOI: 10.1016/j.cnur.2015.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pain and agitation may be difficult to assess in a critically ill patient. Pain is best assessed by self-reporting pain scales; but in patients who are unable to communicate, behavioral pain scales seem to have benefit. Patients' sedation level should be assessed each shift and preferably by a validated ICU tool, such as the RASS or SAS scale. Pain is most appropriately treated with the use of opiates, and careful consideration should be given to the pharmacokinetic and pharmacodynamic properties of various analgesics to determine the optimal agent for each individual patient. Sedation levels should preferably remain light or with the use of a daily awakening trial. Preferred treatment of agitation is analgosedation with the addition of nonbenzodiazepine sedatives if necessary. There are risks associated with each agent used in the treatment of pain and agitation, and it is important to monitor patients for effectiveness, signs of toxicity, and adverse drug reactions.
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Affiliation(s)
- Julie Stephens
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy, One University Park Drive, Nashville, TN 37204, USA.
| | - Michael Wright
- Department of Pharmacy, Williamson Medical Center, 4321 Carothers Parkway, Franklin, TN 37067, USA
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Reardon DP, Anger KE, Szumita PM. Pathophysiology, assessment, and management of pain in critically ill adults. Am J Health Syst Pharm 2016; 72:1531-43. [PMID: 26346209 DOI: 10.2146/ajhp140541] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
PURPOSE The pathophysiology of pain in critically ill patients, the role of pain assessment in optimal pain management, and pharmacologic and nonpharmacologic strategies for pain prevention and treatment are reviewed. SUMMARY There are many short- and long-term consequences of inadequately treated pain, including hyperglycemia, insulin resistance, an increased risk of infection, decreased patient comfort and satisfaction, and the development of chronic pain. Clinicians should have an understanding of the basic physiology of pain and the patient populations that are affected. Pain should be assessed using validated pain scales that are appropriate for the patient's communication status. Opioids are the cornerstone of pain treatment. The use of opioids, administered via bolus dosing or continuous infusion, should be guided by patient-specific goals of care in order to avoid adverse events. A multimodal approach to pain management, including the use of regional analgesia, may improve patient outcomes and decrease opioid-related adverse events, though there are limited relevant data in adult critically ill patient populations. Nonpharmacologic strategies have been shown to be effective adjuncts to pharmacologic regimens that can improve patient-reported pain intensity and reduce analgesic requirements. Analgesic regimens need to take into account patient-specific factors and be closely monitored for safety and efficacy. CONCLUSION Acute pain management in the critically ill is a largely underassessed and undertreated area of critical care. Opioids are the cornerstone of treatment, though a multimodal approach may improve patient outcomes and decrease opioid-related adverse events.
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Affiliation(s)
- David P Reardon
- David P. Reardon, Pharm.D., BCPS, is Multispecialty Care Clinical Pharmacist, Department of Pharmacy, Yale-New Haven Hospital, New Haven, CT. Kevin E. Anger, Pharm.D., BCPS, is Clinical Pharmacy Specialist-Critical Care; and Paul M. Szumita, Pharm.D., BCPS, is Clinical Pharmacy Practice Manager, Department of Pharmacy, Brigham and Women's Hospital, Boston, MA.
| | - Kevin E Anger
- David P. Reardon, Pharm.D., BCPS, is Multispecialty Care Clinical Pharmacist, Department of Pharmacy, Yale-New Haven Hospital, New Haven, CT. Kevin E. Anger, Pharm.D., BCPS, is Clinical Pharmacy Specialist-Critical Care; and Paul M. Szumita, Pharm.D., BCPS, is Clinical Pharmacy Practice Manager, Department of Pharmacy, Brigham and Women's Hospital, Boston, MA
| | - Paul M Szumita
- David P. Reardon, Pharm.D., BCPS, is Multispecialty Care Clinical Pharmacist, Department of Pharmacy, Yale-New Haven Hospital, New Haven, CT. Kevin E. Anger, Pharm.D., BCPS, is Clinical Pharmacy Specialist-Critical Care; and Paul M. Szumita, Pharm.D., BCPS, is Clinical Pharmacy Practice Manager, Department of Pharmacy, Brigham and Women's Hospital, Boston, MA
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Dai D, Feinstein JA, Morrison W, Zuppa AF, Feudtner C. Epidemiology of Polypharmacy and Potential Drug-Drug Interactions Among Pediatric Patients in ICUs of U.S. Children's Hospitals. Pediatr Crit Care Med 2016; 17:e218-28. [PMID: 26959349 PMCID: PMC5243142 DOI: 10.1097/pcc.0000000000000684] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Polypharmacy is common in hospitalized children in the United States and has been identified as a major risk factor for exposure to potential drug-drug interactions. Little is known about the characteristics and prevalence of exposure of pediatric patients to polypharmacy and potential drug-drug interactions in PICUs. DESIGN Retrospective cohort study using the Pediatric Health Information System database. SETTING Forty-two freestanding children's hospitals throughout the United States. PATIENTS A total of 54,549 patients less than 18 years old cared for in PICUs in 2011. Patients in neonatal ICUs were not included. MEASUREMENTS AND MAIN RESULTS PICU patients were on average exposed to 10 distinct drugs each hospital day and to 20 drugs cumulatively during their hospitalization. Seventy-five percent of patients were exposed to greater than or equal to one potential drug-drug interaction regardless of severity level, 6% to greater than or equal to one contraindicated potential drug-drug interaction, 69% to greater than or equal to one major potential drug-drug interaction, 57% to greater than or equal to one moderate potential drug-drug interaction, 19% to greater than or equal to one minor potential drug-drug interaction. Potential drug-drug interaction exposures were significantly associated with specific diagnoses (p < 0.001), presence of complex chronic conditions (p < 0.001), increasing number of total distinct drugs used (p < 0.001), increasing length of stay in PICU (p < 0.001), and white race (p < 0.001). CONCLUSIONS Many PICU patients are exposed to substantial polypharmacy and potential drug-drug interactions. Future research should identify the risk of adverse drug events following specific potential drug-drug interaction exposures, especially the risk of adverse drug events due to multiple potential drug-drug interaction exposures, and determine the probability and magnitude of the actual harm (if any) for each specific potential drug-drug interaction, especially for multiple potential drug-drug interaction exposures.
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Affiliation(s)
- Dingwei Dai
- Pediatric Advanced Care Team and the Center for Pediatric Clinical
Effectiveness, The Children’s Hospital of Philadelphia; Philadelphia, PA,
USA
| | - James A. Feinstein
- Children’s Outcomes Research Program, Children’s
Hospital Colorado, Aurora, CO, USA,Department of Pediatrics, University of Colorado School of Medicine,
Aurora, CO, USA
| | - Wynne Morrison
- Anesthesiology and Critical Care Medicine, The Children’s
Hospital of Philadelphia; Philadelphia, PA, USA,Department of Pediatrics, The Perelman School of Medicine at the
University of Pennsylvania, Philadelphia, PA, PA
| | - Athena F. Zuppa
- Anesthesiology and Critical Care Medicine, The Children’s
Hospital of Philadelphia; Philadelphia, PA, USA,Center for Clinical Pharmacology, The Children’s Hospital of
Philadelphia; Philadelphia, PA, USA,Department of Pediatrics, The Perelman School of Medicine at the
University of Pennsylvania, Philadelphia, PA, PA
| | - Chris Feudtner
- Pediatric Advanced Care Team and the Center for Pediatric Clinical
Effectiveness, The Children’s Hospital of Philadelphia; Philadelphia, PA,
USA,Department of Pediatrics, The Perelman School of Medicine at the
University of Pennsylvania, Philadelphia, PA, PA,Corresponding author: Chris Feudtner, MD, PhD, MPH, CHOP
North – Room 1523, The Children’s Hospital of Philadelphia, 34th
and Civic Center Blvd, Philadelphia, PA 10194, Phone: 267-426-5032, Fax:
267-426-0380,
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Lebherz-Eichinger D, Tudor B, Krenn CG, Roth GA, Seemann R. Impact of different sedation protocols and perioperative procedures on patients admitted to the intensive care unit after maxillofacial tumor surgery of the lower jaw: A retrospective study. J Craniomaxillofac Surg 2016; 44:506-11. [PMID: 26874556 DOI: 10.1016/j.jcms.2015.12.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Revised: 11/25/2015] [Accepted: 12/30/2015] [Indexed: 10/22/2022] Open
Abstract
Maxillofacial tumor surgery often necessitates prolonged invasive ventilation to prevent blockage of the respiratory tract. To tolerate ventilation, continuously administered sedatives are recommended. Half-time of sedative or analgesic medication is an important characteristic by which narcotic drugs are chosen, due to the fact that weaning period increases with half-time. The aim of our study was to investigate whether a change in sedation regimen would affect the length of invasive ventilation or intensive care unit stay and medical costs. Additionally, the impact of various surgical procedures was analyzed. Data of 157 patients after mandibular surgery were retrospectively analyzed over 5 years in count regression models. Of those patients, 84 received a sedation regimen with sufentanil and midazolam and 73 with remifentanil and propofol. The impact of the surgical procedures (tracheostomy, tumor resection, neck dissection and length of operation) and the patient age and sex were analyzed with respect to length of ventilation and ICU days. Cost savings were calculated. Our data show that patients receiving remifentanil/propofol had fewer ventilation days (2.5 ± 2.5 versus 6.1 ± 4.6 days, P < 0.001) and were discharged earlier from the intensive care unit than patients receiving sufentanil/midazolam (5.1 ± 3.8 versus 9.2 ± 6.2 days, P < 0.001), leading to calculated cost savings of about 8000 Euro per patient. Length of operation negatively influenced length of ICU stay (P < 0.001). In conclusion, short-acting drugs such as remifentanil/propofol, as well as tracheostoma and shortened surgery duration may reduce the postoperative need for invasive ventilation and length of intensive care unit stay.
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Affiliation(s)
- Diana Lebherz-Eichinger
- Department of Anesthesiology, General Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria; RAIC Laboratory 13C1, Medical University of Vienna, Vienna, Austria
| | - Bianca Tudor
- Department of Anesthesiology, General Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria; RAIC Laboratory 13C1, Medical University of Vienna, Vienna, Austria
| | - Claus G Krenn
- Department of Anesthesiology, General Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria; RAIC Laboratory 13C1, Medical University of Vienna, Vienna, Austria
| | - Georg A Roth
- Department of Anesthesiology, General Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria; RAIC Laboratory 13C1, Medical University of Vienna, Vienna, Austria.
| | - Rudolf Seemann
- Department of Cranio-, Maxillofacial and Oral Surgery, Medical University of Vienna, Vienna, Austria
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Kim YS, Lee HJ, Jeon SB. Management of Pain and Agitation for Patients in the Intensive Care Unit. JOURNAL OF NEUROCRITICAL CARE 2015. [DOI: 10.18700/jnc.2015.8.2.53] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Yaffe PB, Butler MB, Green RS, Witter T. Is ICU admission associated with chronic narcotic use? a 4-year follow up of ICU survivors. Intensive Care Med Exp 2015. [PMCID: PMC4798478 DOI: 10.1186/2197-425x-3-s1-a366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Yaffe PB, Green RS, Butler MB, Witter T. Is Admission to the Intensive Care Unit Associated With Chronic Opioid Use? A 4-Year Follow-Up of Intensive Care Unit Survivors. J Intensive Care Med 2015; 32:429-435. [PMID: 26609023 DOI: 10.1177/0885066615618189] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE To describe opioid use before and after intensive care unit (ICU) admission and to identify factors associated with chronic opioid use upto 4 years after ICU discharge. METHODS Retrospective review of adult patients admitted to the ICU at a tertiary care center between January 1, 2005, to December 31, 2008. We defined "nonuser," "intermittent," and "chronic" opioid status by abstinence, use in <70%, and >70% of days for a given time period, respectively. We assessed opioid use at 3 months prior to ICU admission, at discharge, and annually for upto 4 years following ICU discharge. RESULTS A total of 2595 ICU patients were included for surgical (48.6%), medical (38.4%), and undetermined (13%) indications. The study population included both elective (26.9%) and emergent (73.1%) admissions. Three months prior to ICU admission, 76.9% were nonusers, 16.9% used opioids intermittently, and 6.2% used opioids chronically. We found an increase in nonuser patients from 87.8% in the early post-ICU period to 95.6% at 48-month follow-up. Consequently, intermittent and chronic opioid use dropped to 8.6% and 3.6% at discharge and 2.6% and 1.8% at 48-month follow-up, respectively. Prolonged hospital length of stay was associated with chronic opioid use. CONCLUSION Admission to ICU and duration of ICU stay were not associated with chronic opioid use.
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Affiliation(s)
- Paul B Yaffe
- 1 Department of Critical Care Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.,2 Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Robert S Green
- 1 Department of Critical Care Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.,3 Trauma Nova Scotia, Halifax, Nova Scotia, Canada
| | - Michael B Butler
- 1 Department of Critical Care Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.,3 Trauma Nova Scotia, Halifax, Nova Scotia, Canada
| | - Tobias Witter
- 1 Department of Critical Care Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.,4 Department of Anesthesia, Dalhousie University, Halifax, Nova Scotia, Canada
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