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Differential Effects of Gamma-Aminobutyric Acidergic Sedatives on Risk of Post-Extubation Delirium in the ICU: A Retrospective Cohort Study From a New England Health Care Network. Crit Care Med 2022; 50:e434-e444. [PMID: 34982739 DOI: 10.1097/ccm.0000000000005425] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate whether different gamma-aminobutyric acidergic (GABAergic) sedatives such as propofol and benzodiazepines carry differential risks of post-extubation delirium in the ICU. DESIGN Retrospective cohort study. SETTING Seven ICUs in an academic hospital network, Beth Israel Deaconess Medical Center (Boston, MA). PATIENTS Ten thousand five hundred and one adult patients mechanically ventilated for over 24 hours. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We tested the hypothesis that benzodiazepine versus propofol-based sedation is associated with fewer delirium-free days within 14 days after extubation. Further, we hypothesized that the measured sedation level evoked by GABAergic drugs is a better predictor of delirium than the drug dose administered. The proportion of GABAergic drug-induced deep sedation was defined as the ratio of days with a mean Richmond Agitation-Sedation Scale of less than or equal to -3 during mechanical ventilation. Multivariable regression and effect modification analyses were used. Delirium-free days were lower in patients who received a high proportion of deep sedation using benzodiazepine compared with propofol-based sedation (adjusted absolute difference, -1.17 d; 95% CI, -0.64 to -1.69; p < 0.001). This differential effect was magnified in elderly patients (age > 65) and in patients with liver or kidney failure (p-for-interaction < 0.001) but not observed in patients who received a low proportion of deep sedation (p = 0.95). GABAergic-induced deep sedation days during mechanical ventilation was a better predictor of post-extubation delirium than the GABAergic daily average effective dose (area under the curve 0.76 vs 0.69; p < 0.001). CONCLUSIONS Deep sedation during mechanical ventilation with benzodiazepines compared with propofol is associated with increased risk of post-extubation delirium. Our data do not support the view that benzodiazepine-based compared with propofol-based sedation in the ICU is an independent risk factor of delirium, as long as deep sedation can be avoided in these patients.
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Valdes E, Agarwal S, Carroll E, Kvernland A, Bondi S, Snyder T, Kwon P, Frontera J, Gurin L, Czeisler B, Lewis A. Special considerations in the assessment of catastrophic brain injury and determination of brain death in patients with SARS-CoV-2. J Neurol Sci 2020; 417:117087. [PMID: 32798855 PMCID: PMC7414304 DOI: 10.1016/j.jns.2020.117087] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/14/2020] [Accepted: 08/06/2020] [Indexed: 01/08/2023]
Abstract
INTRODUCTION The coronavirus disease 2019 (Covid-19) pandemic has led to challenges in provision of care, clinical assessment and communication with families. The unique considerations associated with evaluation of catastrophic brain injury and death by neurologic criteria in patients with Covid-19 infection have not been examined. METHODS We describe the evaluation of six patients hospitalized at a health network in New York City in April 2020 who had Covid-19, were comatose and had absent brainstem reflexes. RESULTS Four males and two females with a median age of 58.5 (IQR 47-68) were evaluated for catastrophic brain injury due to stroke and/or global anoxic injury at a median of 14 days (IQR 13-18) after admission for acute respiratory failure due to Covid-19. All patients had hypotension requiring vasopressors and had been treated with sedative/narcotic drips for ventilator dyssynchrony. Among these patients, 5 had received paralytics. Apnea testing was performed for 1 patient due to the decision to withdraw treatment (n = 2), concern for inability to tolerate testing (n = 2) and observation of spontaneous respirations (n = 1). The apnea test was aborted due to hypoxia and hypotension. After ancillary testing, death was declared in three patients based on neurologic criteria and in three patients based on cardiopulmonary criteria (after withdrawal of support (n = 2) or cardiopulmonary arrest (n = 1)). A family member was able to visit 5/6 patients prior to cardiopulmonary arrest/discontinuation of organ support. CONCLUSION It is feasible to evaluate patients with catastrophic brain injury and declare brain death despite the Covid-19 pandemic, but this requires unique considerations.
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Affiliation(s)
- Eduard Valdes
- NYU Langone Medical Center, Department of Neurology, New York, NY 10016, United States of America.
| | - Shashank Agarwal
- NYU Langone Medical Center, Department of Neurology, New York, NY 10016, United States of America
| | - Elizabeth Carroll
- NYU Langone Medical Center, Department of Neurology, New York, NY 10016, United States of America
| | - Alexandra Kvernland
- NYU Langone Medical Center, Department of Neurology, New York, NY 10016, United States of America
| | - Steven Bondi
- NYU Langone Medical Center, Department of Neurology, New York, NY 10016, United States of America
| | - Thomas Snyder
- NYU Langone Medical Center, Department of Neurology, New York, NY 10016, United States of America
| | - Patrick Kwon
- NYU Langone Medical Center, Department of Neurology, New York, NY 10016, United States of America
| | - Jennifer Frontera
- NYU Langone Medical Center, Department of Neurology, New York, NY 10016, United States of America; NYU Langone Medical Center, Department of Neurosurgery, New York, NY 10016, United States of America
| | - Lindsey Gurin
- NYU Langone Medical Center, Department of Neurology, New York, NY 10016, United States of America; NYU Langone Medical Center, Department of Psychiatry, New York, NY 10016, United States of America; NYU Langone Medical Center, Department of Rehabilitation Medicine, New York, NY 10016, United States of America
| | - Barry Czeisler
- NYU Langone Medical Center, Department of Neurology, New York, NY 10016, United States of America; NYU Langone Medical Center, Department of Neurosurgery, New York, NY 10016, United States of America
| | - Ariane Lewis
- NYU Langone Medical Center, Department of Neurology, New York, NY 10016, United States of America; NYU Langone Medical Center, Department of Neurosurgery, New York, NY 10016, United States of America
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Diep U, Chudow M, Sunjic KM. Pharmacokinetic Changes in Liver Failure and Impact on Drug Therapy. AACN Adv Crit Care 2018; 28:93-101. [PMID: 28592464 DOI: 10.4037/aacnacc2017948] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Uyen Diep
- Uyen Diep is Critical Care Clinical Pharmacist, Department of Pharmacy Services, Tampa General Hospital, Tampa, FL 33601 . Melissa Chudow is Assistant Professor, Department of Pharmacotherapeutics and Clinical Research, University of South Florida College of Pharmacy, Tampa, Florida. Katlynd M. Sunjic is Assistant Professor, Department of Pharmacotherapeutics and Clinical Research, University of South Florida College of Pharmacy, Tampa, Florida
| | - Melissa Chudow
- Uyen Diep is Critical Care Clinical Pharmacist, Department of Pharmacy Services, Tampa General Hospital, Tampa, FL 33601 . Melissa Chudow is Assistant Professor, Department of Pharmacotherapeutics and Clinical Research, University of South Florida College of Pharmacy, Tampa, Florida. Katlynd M. Sunjic is Assistant Professor, Department of Pharmacotherapeutics and Clinical Research, University of South Florida College of Pharmacy, Tampa, Florida
| | - Katlynd M Sunjic
- Uyen Diep is Critical Care Clinical Pharmacist, Department of Pharmacy Services, Tampa General Hospital, Tampa, FL 33601 . Melissa Chudow is Assistant Professor, Department of Pharmacotherapeutics and Clinical Research, University of South Florida College of Pharmacy, Tampa, Florida. Katlynd M. Sunjic is Assistant Professor, Department of Pharmacotherapeutics and Clinical Research, University of South Florida College of Pharmacy, Tampa, Florida
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Masman AD, Tibboel D, Baar FPM, van Dijk M, Mathot RAA, van Gelder T. Prevalence and Implications of Abnormal Laboratory Results in Patients in the Terminal Phase of Life. J Palliat Med 2018; 19:822-9. [PMID: 27494223 DOI: 10.1089/jpm.2015.0548] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Pathophysiological changes at the end of life may affect pharmacokinetics of drugs. However, caregivers typically do not extensively monitor patients' laboratory parameters at the end of life. OBJECTIVE Our aim was to describe laboratory parameters of hospice patients in the week before death. METHODS A cohort study was conducted on available laboratory results in the week before death, including clinical chemistry and hematology tests. RESULTS Laboratory data of 125 patients in a palliative care center were included, assessed at a median of 3 days before death. Eighty percent of patients had anemia and almost all had hypoalbuminemia (97%). Elevated levels of gamma-glutamyl transferase (gGT) were found in 75%, of alkaline phosphatase (ALP) in 60%, of aspartate aminotransferase (ASAT) in 60%, and of calcium (Ca) in 68%. Alanine aminotransferase (ALAT), bilirubin, sodium (Na), and potassium (K) were abnormal in from 8.8% to 36.0% of patients. A previous unknown poor kidney function was found in 60% of patients. Thirteen patients (22%) with a regular morphine prescription and one patient treated with a non-steroidal anti-inflammatory drug (NSAID) had severe kidney failure. CONCLUSIONS Abnormal laboratory results were expected due to the pathophysiological changes that occur during the last phase of life. Remarkably, however, electrolytes (Na and K) were balanced even shortly before death. Estimated glomerular filtration rate (eGFR), reflecting the kidney function, seems the most clinically relevant laboratory parameter, because it may guide drug choice and dosing.
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Affiliation(s)
- Anniek D Masman
- 1 Palliative Care Centre , Laurens Cadenza, Rotterdam, the Netherlands .,2 Pain Expertise Centre, Erasmus MC-Sophia Children's Hospital , Rotterdam, the Netherlands
| | - Dick Tibboel
- 2 Pain Expertise Centre, Erasmus MC-Sophia Children's Hospital , Rotterdam, the Netherlands .,3 Intensive Care, Department of Paediatric Surgery, Erasmus MC-Sophia Children's Hospital , Rotterdam, the Netherlands
| | - Frans P M Baar
- 1 Palliative Care Centre , Laurens Cadenza, Rotterdam, the Netherlands .,2 Pain Expertise Centre, Erasmus MC-Sophia Children's Hospital , Rotterdam, the Netherlands
| | - Monique van Dijk
- 2 Pain Expertise Centre, Erasmus MC-Sophia Children's Hospital , Rotterdam, the Netherlands .,3 Intensive Care, Department of Paediatric Surgery, Erasmus MC-Sophia Children's Hospital , Rotterdam, the Netherlands
| | - Ron A A Mathot
- 4 Hospital Pharmacy-Clinical Pharmacology , Academic Medical Centre, Amsterdam, the Netherlands
| | - Teun van Gelder
- 5 Department of Hospital Pharmacy, Erasmus Medical Centre , Rotterdam, the Netherlands
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Yogaratnam D, Ditch K, Medeiros K, Miller MA, Smith BS. The Impact of Liver and Renal Dysfunction on the Pharmacokinetics and Pharmacodynamics of Sedative and Analgesic Drugs in Critically Ill Adult Patients. Crit Care Nurs Clin North Am 2016; 28:183-94. [PMID: 27215356 DOI: 10.1016/j.cnc.2016.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The use of sedative and analgesic drug therapy is often necessary for the care of critically ill patients. Renal and hepatic dysfunction, which occurs frequently in this patient population, can significantly alter drugs' pharmacokinetic and pharmacodynamics properties. By anticipating how these medications may be affected by liver or kidney dysfunction, health care practitioners may be able to provide tailored dosing regimens that ensure optimal comfort while minimizing the risk of adverse events.
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Affiliation(s)
- Dinesh Yogaratnam
- Department of Pharmacy Practice, Massachusetts College of Pharmacy and Health Sciences University, 19 Foster Street, Worcester, MA 01608, USA.
| | - Kristen Ditch
- Department of Pharmacy, Neuro-Trauma Burn Intensive Care Unit, UMass Memorial Medical Center, 55 Lake Avenue North, Worcester, MA 01655, USA
| | - Kristin Medeiros
- Department of Pharmacy, UMass Memorial Medical Center, 55 Lake Avenue North, Worcester, MA 01655, USA
| | - Melissa A Miller
- Emergency Medicine, New York-Presbyterian Hospital, 525 East 68th Street, New York, NY 10065, USA
| | - Brian S Smith
- Specialty Pharmacy Services, UMass Memorial Shields Pharmacy, 55 Lake Avenue North, Worcester, MA 01655, USA
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Bϋdingen FV, Gonzalez D, Tucker AN, Derendorf H. Relevance of Liver Failure for Anti-Infective Agents: From Pharmacokinetic Alterations to Dosage Adjustments. Ther Adv Infect Dis 2014; 2:17-42. [PMID: 24949199 DOI: 10.1177/2049936113519089] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The liver is a complex organ with great ability to influence drug pharmacokinetics. Due to its wide array of function, its impairment has the potential to affect bioavailability, enterohepatic circulation, drug distribution, metabolism, clearance, and biliary elimination. These alterations differ widely depending on the cause of the liver failure, if it is acute or chronic in nature, the extent of impairment, and comorbid conditions. In addition, effects on liver functions do not occur in a proportional or predictable manner for escalating degrees of liver impairment. The ability of hepatic alterations to influence PK is also dependent on drug characteristics, such as administration route, chemical properties, protein binding, and extraction ratio, among others. This complexity makes it difficult to predict what these effects have on drugs. Unlike certain classes of agents, efficacy of anti-infectives is most often dependent on fulfilling pharmacokinetic/pharmacodynamic targets, such as Cmax/MIC, AUC/MIC, T>MIC, IC50/EC50, or T>EC95. Loss of efficacy, or conversely, increased risk of toxicity may occur in certain circumstances of liver injury. Although important to consider these potential alterations and their effects on specific anti-infectives, many lack data to constitute specific dosing adjustments, making it important to monitor patients for effectiveness and toxicities of therapy.
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Affiliation(s)
- Fiona V Bϋdingen
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Daniel Gonzalez
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, FL, USA ; Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA ; Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Amelia N Tucker
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Hartmut Derendorf
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, FL, USA
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Voelker M, Foster TG. Nursing Challenges in the Administration of Oral Antidepressant Medications in Gastric Bypass Patients. J Perianesth Nurs 2007; 22:108-21; quiz 122-4. [PMID: 17395078 DOI: 10.1016/j.jopan.2006.11.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
More than half of gastric bypass patients take antidepressants preoperatively, presenting some unique considerations with this patient population. The challenges associated with antidepressant medications are experienced both preoperatively and postoperatively. As the gastric bypass option becomes more readily used in the treatment of obesity, the requirement for understanding the effect of this procedure on any alteration of medications will become more clinically important. The purpose of this paper is to present an overview of the potential challenges in providing optimal patient care for the gastric bypass patient who is taking antidepressant medications.
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Affiliation(s)
- Meg Voelker
- Madigan Army Medical Center, Tacoma, WA, USA.
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