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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; 41:498-510. [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] [MESH Headings] [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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Contreras S, Giménez-Esparza Vich C, Caballero J. Practical approach to inhaled sedation in the critically ill patient. Sedation, analgesia and Delirium Working Group (GTSAD) of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC). Med Intensiva 2024; 48:467-476. [PMID: 38862301 DOI: 10.1016/j.medine.2024.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 04/16/2024] [Indexed: 06/13/2024]
Abstract
The use of sedatives in Intensive Care Units (ICU) is essential for relieving anxiety and stress in mechanically ventilated patients, and it is related to clinical outcomes, duration of mechanical ventilation, and length of stay in the ICU. Inhaled sedatives offer benefits such as faster awakening and extubation, decreased total opioid and neuromuscular blocking agents (NMB) doses, as well as bronchodilator, anticonvulsant, and cardiopulmonary and neurological protective effects. Inhaled sedation is administered using a specific vaporizer. Isoflurane is the recommended agent due to its efficacy and safety profile. Inhaled sedation is recommended for moderate and deep sedation, prolonged sedation, difficult sedation, patients with acute respiratory distress syndrome (ARDS), status asthmaticus, and super-refractory status epilepticus. By offering these significant advantages, the use of inhaled sedatives allows for a personalized and controlled approach to optimize sedation in the ICU.
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Affiliation(s)
- Sofía Contreras
- Servicio de Medicina Intensiva, Hospital Universitario Vall d'Hebron, Barcelona, Spain.
| | | | - Jesús Caballero
- Servicio de Medicina Intensiva, Hospital Universitari Arnau de Vilanova, Institut de Recerca Biomèdica de Lleida (IRBLleida), Lleida, Spain
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García-Montoto F, Paz-Martín D, Pestaña D, Soro M, Marcos Vidal JM, Badenes R, Suárez de la Rica A, Bardi T, Pérez-Carbonell A, García C, Cervantes JA, Martínez MP, Guerrero JL, Lorente JV, Veganzones J, Murcia M, Belda FJ. Guidelines for inhaled sedation in the ICU. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024; 71:90-111. [PMID: 38309642 DOI: 10.1016/j.redare.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 07/29/2023] [Indexed: 02/05/2024]
Abstract
INTRODUCTION AND OBJECTIVES Sedation is used in intensive care units (ICU) to improve comfort and tolerance during mechanical ventilation, invasive interventions, and nursing care. In recent years, the use of inhalation anaesthetics for this purpose has increased. Our objective was to obtain and summarise the best evidence on inhaled sedation in adult patients in the ICU, and use this to help physicians choose the most appropriate approach in terms of the impact of sedation on clinical outcomes and the risk-benefit of the chosen strategy. METHODOLOGY Given the overall lack of literature and scientific evidence on various aspects of inhaled sedation in the ICU, we decided to use a Delphi method to achieve consensus among a group of 17 expert panellists. The processes was conducted over a 12-month period between 2022 and 2023, and followed the recommendations of the CREDES guidelines. RESULTS The results of the Delphi survey form the basis of these 39 recommendations - 23 with a strong consensus and 15 with a weak consensus. CONCLUSION The use of inhaled sedation in the ICU is a reliable and appropriate option in a wide variety of clinical scenarios. However, there are numerous aspects of the technique that require further study.
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Affiliation(s)
- F García-Montoto
- UCI de Anestesia, Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de Cáceres, Cáceres, Spain.
| | - D Paz-Martín
- UCI, Departamento de Anestesia y Cuidados Intensivos, Clínica Universidad de Navarra, Pamplona, Navarra, Spain
| | - D Pestaña
- UCI de Anestesia, Servicio de Anestesiología y Reanimación, Hospital Universitario Ramon y Cajal, Madrid, Spain; Universidad de Alcalá de Henares, Alcalá de Henares, Madrid, Spain
| | - M Soro
- UCI, Servicio de Anestesiología y Cuidados Intensivos, Hospital IMED, Valencia, Spain
| | - J M Marcos Vidal
- Unidad de Reanimación, Servicio de Anestesiología y Reanimación, Complejo Asistencial Universitario de León, León, Spain
| | - R Badenes
- Departamento Cirugía, Facultad de Medicina, Universidad de Valencia, Valencia, Spain; UCI de Anestesia, Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Clínico Universitario de Valencia, Valencia, Spain; INCLIVA Instituto de Investigación Sanitaria, Valencia, Spain
| | - A Suárez de la Rica
- Unidad de Reanimación, Servicio de Anestesiología y Reanimación, Hospital Universitario de La Princesa, Madrid, Spain
| | - T Bardi
- UCI de Anestesia, Servicio de Anestesiología y Reanimación, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - A Pérez-Carbonell
- UCI Quirúrgica, Servicio de Anestesiología, UCI Quirúrgica y Unidad del Dolor, Hospital General Universitario de Elche, Elche, Alicante, Spain
| | - C García
- UCI Quirúrgica, Servicio de Anestesiología y Reanimación, Hospital General Universitario Dr. Balmis, Alicante, Spain
| | - J A Cervantes
- Unidad de Reanimación, Servicio de Anestesiología y Reanimación, Hospital Universitario Torrecárdenas, Almería, Spain
| | - M P Martínez
- Unidad de Reanimación, Servicio de Anestesiología y Reanimación, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - J L Guerrero
- Unidad de Reanimación, Servicio de Anestesiología y Reanimación, Hospital Universitario Virgen de la Victoria, Málaga, Spain; Universidad de Málaga, Málaga, Spain; Instituto Biomédico de Málaga, Málaga, Spain
| | - J V Lorente
- Unidad de Reanimación, Servicio de Anestesiología y Reanimación, Hospital Juan Ramón Jiménez, Huelva, Spain
| | - J Veganzones
- Unidad de Reanimación, Servicio de Anestesiología y Reanimación, Hospital Universitario La Paz, Madrid, Spain
| | - M Murcia
- UCI, Servicio de Anestesiología y Cuidados Intensivos, Hospital IMED, Valencia, Spain
| | - F J Belda
- Departamento Cirugía, Facultad de Medicina, Universidad de Valencia, Valencia, Spain
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Adi O, Apoo FN, Fong CP, Ahmad AH, Roslan NL, Khan FA, Fathil S. Inhaled anaesthetic gas for severe bronchospasm at the emergency department. Am J Emerg Med 2024; 75:179-180. [PMID: 37487778 DOI: 10.1016/j.ajem.2023.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 07/19/2023] [Indexed: 07/26/2023] Open
Affiliation(s)
- Osman Adi
- Resuscitation & Emergency Critical Care Unit (RECCU), Trauma & Emergency Department, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia.
| | - Farah Nuradhwa Apoo
- Resuscitation & Emergency Critical Care Unit (RECCU), Trauma & Emergency Department, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia
| | - Chan Pei Fong
- Resuscitation & Emergency Critical Care Unit (RECCU), Trauma & Emergency Department, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia
| | - Azma Haryaty Ahmad
- Resuscitation & Emergency Critical Care Unit (RECCU), Trauma & Emergency Department, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia
| | - Nurul Liana Roslan
- Resuscitation & Emergency Critical Care Unit (RECCU), Hospital Kuala Lumpur, Malaysia
| | | | - Shahridan Fathil
- Department of Anaesthesia, Gleneagles Hospital Medini Johor, Iskandar Puteri, Johor, Malaysia; Department of anaesthesiology and intensive care, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
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Atraszkiewicz DV. Greener 'Gassers': key challenges in anaesthesia and perioperative medicine related to the evolving climate crisis. Eur J Anaesthesiol 2023; 40:218-221. [PMID: 36722189 DOI: 10.1097/eja.0000000000001790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Martínez Ruíz A, Maroño Boedo MJ, Guereca Gala A, Escontrela Rodríguez BA, Bergese SD. [ Zero Emissions. A shared responsibility. Gas capture and recycling project at the Cruces University Hospital (Spain).]. Rev Esp Salud Publica 2023; 97:e202301001. [PMID: 36625131 PMCID: PMC10540894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 12/20/2022] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE The use of volatile anesthetics plays an important role in the production of greenhouse gases and other environmental pollutants that negatively affect global health. Programs to reduce anesthesia contaminants have been shown to be effective and reduce costs. For this reason, we conducted a study to implementing a Zero Emissions Program for zero carbon dioxide emissions derived from anesthetic gases used in the operating room, as recommended by the Green Deal of the European Union by 2030 and be climate neutral in 2050, maintaining satisfaction and current clinical results. METHODS A Zero Emissions Program was implemented within the Zero safety programs of the Cruces University Hospital in order to produce zero emissions of carbon dioxide derived from the anesthetic gases used in the operating rooms. The contribution of anesthetic gases to carbon dioxide production before and after implementation of program was determined. Data analysis was conducted descriptively to analyze program effectiveness. RESULTS The implementation of a Zero Emissions Program allowed us to achieve a reduction in emissions to zero. CONCLUSIONS Anesthesiologists must understand that minimizing our harmful impact on environmental health sustainability is not only desirable, but ethically necessary. A way to contribute to this ethical responsibility is Zero Emissions Programs which are effective in reducing emissions to zero, probably improving our impact on planet health.
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Affiliation(s)
- Alberto Martínez Ruíz
- Departmento de Anestesia, Reanimación y Terapéutica del Dolor, Hospital Universitario de Cruces. Biocruces Instituto de Investigación Médica. Barakaldo. España
- Facultad de Medicina, Universidad del País Vasco. Leioa. España
| | - María Jesús Maroño Boedo
- Departmento de Anestesia, Reanimación y Terapéutica del Dolor, Hospital Universitario de Cruces. Biocruces Instituto de Investigación Médica. Barakaldo. España
| | - Ane Guereca Gala
- Departmento de Anestesia, Reanimación y Terapéutica del Dolor, Hospital Universitario de Cruces. Biocruces Instituto de Investigación Médica. Barakaldo. España
| | - Blanca Anuncia Escontrela Rodríguez
- Departamento de Anestesia y Reanimación, Hospital Universitario Infanta Leonor. Unidad de Cuidados Intensivos, Hospital de Emergencias Isabel Zendal. Madrid. España
| | - Sergio D Bergese
- Departamento de Anestesiología, Universidad Stony Brook. Nueva York. Estados Unidos
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Colin R, Wild P, Paris C, Boini S. Co-exposures to physical and psychosocial work factors increase the occurrence of workplace injuries among French care workers. Front Public Health 2022; 10:1055846. [PMID: 36582372 PMCID: PMC9792696 DOI: 10.3389/fpubh.2022.1055846] [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: 09/28/2022] [Accepted: 11/21/2022] [Indexed: 12/15/2022] Open
Abstract
Objective The aim of this study was to analyze the effect of co-exposures to physical and psychosocial factors (PSF) regarding the incidence of workplace injuries (WI) among care workers. Additional objective was to identify the work factors associated with the co-exposure combinations leading to the highest rates of WI. Methods The study sample consisted of 4,418 care workers participating to the French Working Conditions Survey both in 2013 and 2016. WI were assessed during the 4-year follow-up by matching the databases of the National Health Insurance Funds' compensation system. We assessed exposure for physical factors and PSF using factorial analyses and hierarchical clustering. We implemented a Poisson regression model with the WI incidence as the outcome and the clusters as independent variables of interest. Logistic regression model allowed identifying the work factors that predicted co-exposure combinations with a WI rate > 40%. Results WI were highly related to both physical and psychosocial exposures. With low exposure to one or the other, there was no increased risk of WI. Physical factors and PSF potentiated each other and their co-exposure significantly increased the risk of WI, with model predicted rates per 1,000 persons-year for those most exposed to physical risk of 14.6 [4.5-24.8] with low PSF and 38.0 [29.8-46.3] with high PSF. Work factors that predicted co-exposure combinations with a rate > 40 WI% were: working as nursing assistant or hospital services officer, lack of predictability and flexibility of schedules, overtime, controlled schedules, work-family imbalance and insufficient preventive measures. Conclusions Our findings highlight the need to take into account psychosocial factors in addition of only considering physical factors when analyzing WI occurrence, as usually done. Prevention actions must be taken to reduce both physical and psychosocial exposure. These results provide keys points for the prevention of WI among care workers.
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Affiliation(s)
- Régis Colin
- Department of Occupational Epidemiology, Occupational Health and Safety Institute (INRS), Vandoeuvre-les-Nancy, France,INSERM U1085 Institut de Recherche en Santé, Environnement et Travail (IRSET), Rennes, France,*Correspondence: Régis Colin
| | - Pascal Wild
- Department of Occupational Epidemiology, Occupational Health and Safety Institute (INRS), Vandoeuvre-les-Nancy, France
| | - Christophe Paris
- INSERM U1085 Institut de Recherche en Santé, Environnement et Travail (IRSET), Rennes, France
| | - Stéphanie Boini
- Department of Occupational Epidemiology, Occupational Health and Safety Institute (INRS), Vandoeuvre-les-Nancy, France
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Kochendörfer IM, Kienbaum P, Großart W, Rossaint R, Snyder-Ramos S, Grüßer L. [Environmentally friendly absorption of anesthetic gases : First experiences with a commercial anesthetic gas capture system]. DIE ANAESTHESIOLOGIE 2022; 71:824-833. [PMID: 36301310 DOI: 10.1007/s00101-022-01210-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/09/2022] [Indexed: 06/16/2023]
Abstract
Anesthetic gases are potent greenhouse gases, which are currently released into the atmosphere where they remain for many years. Strategies to reduce the carbon footprint in anesthesiology without compromising patient safety are urgently needed. Since 2020 several departments of anesthesiology have installed anesthetic gas capture systems with which anesthetic gases can be collected. This article aims to describe the anesthetic gas capture system CONTRAfluran™ and to give an overview of the first experiences in four departments of anesthesiology working with the new device in the daily clinical routine. The CONTRAfluran™ system presents a new concept in the surgical setting that has the potential to reduce the carbon footprint in anesthesiology; however, in order to accurately estimate CO2 equivalent savings, more information concerning the reprocessing and data on the pharmacokinetics of anesthetic gases are needed. Application of the CONTRAfluran™ system in daily clinical routine is feasible when anesthesiologists are aware of specific issues. In order to minimize the carbon footprint, it remains essential to implement the specific recommendations in the position paper of the German Society of Anaesthesiology and Intensive Care medicine (DGAI) and the Professional Association of German Anaesthesiologists (BDA) on ecological sustainability in anesthesiology and intensive care medicine and to support further research.
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Affiliation(s)
| | - Peter Kienbaum
- Klinik für Anästhesiologie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - Wolfgang Großart
- Klinik für Anästhesiologie, interdisziplinäre Intensivmedizin und Notfallmedizin, KRH Klinikum Großburgwedel, Großburgwedel, Deutschland
| | - Rolf Rossaint
- Klinik für Anästhesiologie, Universitätsklinikum RWTH Aachen, Aachen, Deutschland
| | - Stephanie Snyder-Ramos
- Abteilung für Anästhesie und Intensivmedizin, Krankenhaus Salem, Evangelische Stadtmission Heidelberg, Heidelberg, Deutschland
| | - Linda Grüßer
- Klinik für Anästhesiologie, Universitätsklinikum RWTH Aachen, Aachen, Deutschland.
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Kulkarni AP, Bhosale SJ, Kalvit KR, Sahu TK, Mohanty R, Dhas MM, Gondal G, Charie S, Shrivastava A, Divatia JV. Safety and Feasibility of AnaConDa™ to Deliver Inhaled Isoflurane for Sedation in Patients Undergoing Elective Postoperative Mechanical Ventilation: A Prospective, Open-label, Interventional Trial (INSTINCT I Study). Indian J Crit Care Med 2022; 26:906-912. [PMID: 36042768 PMCID: PMC9363797 DOI: 10.5005/jp-journals-10071-24264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Aim Sedation is essential during invasive mechanical ventilation, and conventionally intravenous analgesic and sedative drugs are used. Sedation with inhaled anesthetics using anesthesia conserving device (ACD) is an alternative. There is no data on the safety and ease of use of AnaConDa™ from India. Materials and methods After IEC approval and informed consent, we used AnaConDa™-S for Isoflurane sedation in 50 hemodynamically stable (need for <0.5 µg/kg/min of Noradrenaline infusion), ASA I and II patients aged 18-80 years, undergoing elective mechanical ventilation for up to 24 hours after elective oncosurgeries. Patients with mental obtundation (GCS <14), or if pregnant, were excluded. The primary outcome was time spent between RASS scores of -3 and -4, while secondary outcomes were incidence of delirium, technical problems with AnaConDa™, and adverse systemic effects of isoflurane. Bolus doses of isoflurane 0.2-0.5 mL were given if the Richmond agitation sedation scale (RASS) score was not achieved. Results Fifty patients received isoflurane infusion for a median of 720 (IQR 630-900) minutes, and all remained in the target sedation range. Median time to awakening [19 (IQR, 5-85) minutes], to follow simple verbal commands [20 (IQR 5-180) minutes], and extubation after stopping the infusion of isoflurane was quick [100 (10-470) minutes]. All patients remained hemodynamically stable. None of the patients had delirium. Conclusion Target sedation levels were achieved with initial boluses of isoflurane using AnaConDa™-S. Isoflurane sedation delivery using AnaConDa™-S is safe and feasible. How to cite this article Kulkarni AP, Bhosale SJ, Kalvit KR, Sahu TK, Mohanty R, Dhas MM, et al. Safety and Feasibility of AnaConDa™ to Deliver Inhaled Isoflurane for Sedation in Patients Undergoing Elective Postoperative Mechanical Ventilation: A Prospective, Open-label, Interventional Trial (INSTINCT I Study). Indian J Crit Care Med 2022;26(8):906-912.
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Affiliation(s)
- Atul Prabhakar Kulkarni
- Division of Critical Care Medicine, Department of Anesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India,Atul Prabhakar Kulkarni, Division of Critical Care Medicine, Department of Anesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India, Phone: +91 9869077526, e-mail:
| | - Shilpushp Jagannath Bhosale
- Division of Critical Care Medicine, Department of Anesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Kushal Rajeev Kalvit
- Department of Anesthesiology, Critical Care Medicine and Pain, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Tarun Kumar Sahu
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Rakesh Mohanty
- Division of Critical Care Medicine, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Meshach M Dhas
- Division of Critical Care Medicine, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Gautam Gondal
- Division of Critical Care Medicine, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Swapna Charie
- Division of Critical Care Medicine, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Anjana Shrivastava
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Jigeeshu V Divatia
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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Landoni G, Belloni O, Russo G, Bonaccorso A, Carà G, Jabaudon M. Inhaled Sedation for Invasively Ventilated COVID-19 Patients: A Systematic Review. J Clin Med 2022; 11:jcm11092500. [PMID: 35566625 PMCID: PMC9105857 DOI: 10.3390/jcm11092500] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 04/20/2022] [Accepted: 04/26/2022] [Indexed: 01/22/2023] Open
Abstract
Background: Volatile anesthetics were used as sedative agents in COVID-19 (Coronavirus Disease 2019) invasively ventilated patients for their potentially beneficial pharmacological effects and due to the temporary shortages of intravenous agents during the pandemic crisis. Methods: Online databases (PubMed, EMBASE, The Cochrane Central Register of Controlled Trial) and the “clinicaltrials.gov” website were searched for studies reporting the use of isoflurane, sevoflurane or desflurane. Results: We identified three manuscripts describing the beneficial effects of isoflurane on 41 COVID-19 patients with acute respiratory distress syndrome (ARDS) in Germany (n = 2) and in the USA (n = 1), in terms of reduction in the use of opioids and other sedatives. We also found a case report of two patients with transient nephrogenic diabetes insipidus, which started after 6 and 8 days of sevoflurane sedation. We identified two randomized controlled trials (RCTs; 92 patients overall), two observational studies (238 patients) on the use of volatile anesthetics in COVID-19 patients that were completed but not yet published, and one RCT interrupted for a low recruitment ratio (19 patients) and thus not published. We also identified five ongoing RCTs on the use of inhaled sedation in ARDS, which are also likely to be recruiting COVID-19 patients and which have currently enrolled a total of >1643 patients. Conclusion: Isoflurane was the most frequently used volatile agent in COVID-19 patients and allowed a reduction in the use of other sedative and analgesic drugs. Randomized evidence is building up and will be useful to confirm or challenge these findings.
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Affiliation(s)
- Giovanni Landoni
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (O.B.); (G.R.); (A.B.); (G.C.)
- School of Medicine, Vita-Salute San Raffaele University, 20132 Milan, Italy
- Correspondence:
| | - Olivia Belloni
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (O.B.); (G.R.); (A.B.); (G.C.)
| | - Giada Russo
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (O.B.); (G.R.); (A.B.); (G.C.)
| | - Alessandra Bonaccorso
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (O.B.); (G.R.); (A.B.); (G.C.)
| | - Gianmarco Carà
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (O.B.); (G.R.); (A.B.); (G.C.)
| | - Matthieu Jabaudon
- Department of Perioperative Medicine, CHU Clermont-Ferrand, F-63000 Clermont-Ferrand, France;
- GReD, Université Clermont Auvergne, CNRS, INSERM, F-63000 Clermont-Ferrand, France
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Bellgardt M, Özcelik D, Breuer-Kaiser AFC, Steinfort C, Breuer TGK, Weber TP, Herzog-Niescery J. Extracorporeal membrane oxygenation and inhaled sedation in coronavirus disease 2019-related acute respiratory distress syndrome. World J Crit Care Med 2021; 10:323-333. [PMID: 34888158 PMCID: PMC8613718 DOI: 10.5492/wjccm.v10.i6.323] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/24/2021] [Accepted: 08/23/2021] [Indexed: 02/06/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) related acute respiratory distress syndrome (ARDS) is a severe complication of infection with severe acute respiratory syndrome coronavirus 2, and the primary cause of death in the current pandemic. Critically ill patients often undergo extracorporeal membrane oxygenation (ECMO) therapy as the last resort over an extended period. ECMO therapy requires sedation of the patient, which is usually achieved by intravenous administration of sedatives. The shortage of intravenous sedative drugs due to the ongoing pandemic, and attempts to improve treatment outcome for COVID-19 patients, drove the application of inhaled sedation as a promising alternative for sedation during ECMO therapy. Administration of volatile anesthetics requires an appropriate delivery. Commercially available ones are the anesthetic gas reflection systems AnaConDa® and MIRUSTM, and each should be combined with a gas scavenging system. In this review, we describe respiratory management in COVID-19 patients and the procedures for inhaled sedation during ECMO therapy of COVID-19 related ARDS. We focus particularly on the technical details of administration of volatile anesthetics. Furthermore, we describe the advantages of inhaled sedation and volatile anesthetics, and we discuss the limitations as well as the requirements for safe application in the clinical setting.
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Affiliation(s)
- Martin Bellgardt
- Anesthesia and Intensive Care Medicine, St. Josef-Hospital, University Hospital of Ruhr-University of Bochum, Bochum 44791, Germany
| | - Dennis Özcelik
- Chemistry | Biology | Pharmacy Information Center, ETH Zürich, Zürich 8093, Switzerland
| | | | - Claudia Steinfort
- General and Visceral Surgery, St. Josef-Hospital, University Hospital of Ruhr-University of Bochum, Bochum 44791, Germany
| | - Thomas Georg Karl Breuer
- Internal Medicine/Intensive Care, St. Josef-Hospital, University Hospital of Ruhr-University of Bochum, Bochum 44791, Germany
| | - Thomas Peter Weber
- Anesthesia and Intensive Care Medicine, St. Josef-Hospital, University Hospital of Ruhr-University of Bochum, Bochum 44791, Germany
| | - Jennifer Herzog-Niescery
- Anesthesia and Intensive Care Medicine, St. Josef-Hospital, University Hospital of Ruhr-University of Bochum, Bochum 44791, Germany
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Varughese S, Ahmed R. Environmental and Occupational Considerations of Anesthesia: A Narrative Review and Update. Anesth Analg 2021; 133:826-835. [PMID: 33857027 PMCID: PMC8415729 DOI: 10.1213/ane.0000000000005504] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
With an estimated worldwide volume of 266 million surgeries in 2015, the call for general inhalation anesthesia is considerable. However, widely used volatile anesthetics such as N2O and the highly fluorinated gases sevoflurane, desflurane, and isoflurane are greenhouse gases, ozone-depleting agents, or both. Because these agents undergo minimal metabolism in the body during clinical use and are primarily (≥95%) eliminated unchanged via exhalation, waste anesthetic gases (WAGs) in operating rooms and postanesthesia care units can pose a challenge for overall elimination and occupational exposure. The chemical properties and global warming impacts of these gases vary, with atmospheric lifetimes of 1-5 years for sevoflurane, 3-6 years for isoflurane, 9-21 years for desflurane, and 114 years for N2O. Additionally, the use of N2O as a carrier gas for the inhalation anesthetics and as a supplement to intravenous (IV) anesthetics further contributes to these impacts. At the same time, unscavenged WAGs can result in chronic occupational exposure of health care workers to potential associated adverse health effects. Few adverse effects associated with WAGs have been documented, however, when workplace exposure limits are implemented. Specific measures that can help reduce occupational exposure and the environmental impact of inhaled anesthetics include efficient ventilation and scavenging systems, regular monitoring of airborne concentrations of waste gases to remain below recommended limits, ensuring that anesthesia equipment is well maintained, avoiding desflurane and N2O if possible, and minimizing fresh gas flow rates (eg, use of low-flow anesthesia). One alternative to volatile anesthetics may be total intravenous anesthesia (TIVA). While TIVA is not associated with the risks of occupational exposure or atmospheric pollution that are inherent to volatile anesthetic gases, clinical considerations should be weighed in the choice of agent. Appropriate procedures for the disposal of IV anesthetics must be followed to minimize any potential for negative environmental effects. Overall, although their contributions are relatively low compared with those of other human-produced substances, inhaled anesthetics are intrinsically potent greenhouse gases and pose a risk to operating-room personnel if not properly managed and scavenged. Factors to reduce waste and minimize the future impact of these substances should be considered.
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Affiliation(s)
- Shane Varughese
- From the Global Medical Affairs, AbbVie Inc, North Chicago, Illinois
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Herzog-Niescery J, Vogelsang H, Gude P, Seipp HM, Uhl W, Weber TP, Bellgardt M. Environmental safety: Air pollution while using MIRUS™ for short-term sedation in the ICU. Acta Anaesthesiol Scand 2019; 63:86-92. [PMID: 30088264 DOI: 10.1111/aas.13222] [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] [Received: 03/19/2018] [Revised: 06/16/2018] [Accepted: 06/21/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND MIRUS™ is a device for target-controlled inhalational sedation in the ICU in combination with use of isoflurane, or sevoflurane, or desflurane. The feasibility of this device has recently been proven; however, ICU staff exposure may restrict its application. We investigated ICU ambient room pollution during daily work to estimate ICU personnel exposure while using MIRUS™. METHODS This observational study assessed pollution levels around 15 adult surgical patients who received volatile anaesthetics-based sedation for a median of 11 hours. Measurements were performed by photoacoustic gas monitoring in real-time at different positions near the patient and in the personnel's breathing zone. Additionally, the impact of the Clean Air™ open reservoir scavenging system on volatile agent pollution was evaluated. RESULTS Baseline concentrations [ppm] during intervention and rest periods were isoflurane c ¯ mean = 0.58 ± 0.49, c ¯ max = 5.72; sevoflurane c ¯ mean = 0.22 ± 0.20, c ¯ max = 7.93; and desflurane c ¯ mean = 0.65 ± 0.57, c ¯ max = 6.65. Refilling MIRUS™ with liquid anaesthetic yielded gas concentrations of c ¯ mean = 2.18 ± 1.48 ppm and c ¯ max = 13.03 ± 9.37 ppm in the personnel's breathing zone. Air pollution in the patient's room was approximately five times higher without a scavenging system. CONCLUSION Ambient room pollution was minimal in most cases, and the measured values were within or below the recommended exposure limits. Caution should be taken during refilling of the MIRUS™ system, as this was accompanied by higher pollution levels. The combined use of air-conditioning and gas scavenging systems is strongly recommended.
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Affiliation(s)
| | - Heike Vogelsang
- Department of Anaesthesiology; St. Josef Hospital; Ruhr-University Bochum; Bochum Germany
| | - Philipp Gude
- Department of Anaesthesiology; St. Josef Hospital; Ruhr-University Bochum; Bochum Germany
| | - Hans-Martin Seipp
- Department of Life Science Engineering; University of Applied Sciences; Giessen Germany
| | - Waldemar Uhl
- Department of Surgery; St. Josef Hospital; Ruhr-University Bochum; Bochum Germany
| | - Thomas P. Weber
- Department of Anaesthesiology; St. Josef Hospital; Ruhr-University Bochum; Bochum Germany
| | - Martin Bellgardt
- Department of Anaesthesiology; St. Josef Hospital; Ruhr-University Bochum; Bochum Germany
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14
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An Exploratory Study of Sevoflurane as an Alternative for Difficult Sedation in Critically Ill Children. Pediatr Crit Care Med 2018; 19:e335-e341. [PMID: 29557840 DOI: 10.1097/pcc.0000000000001538] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To analyze the effectiveness of inhaled sevoflurane in critically ill children with challenging sedation. DESIGN Prospective case series. SETTING Two PICUs of university hospitals in Spain. INTERVENTIONS Prospective observational study and exploratory investigation conducted in two PICUs in Madrid, Spain, over a 6-year period. Children treated with inhaled sevoflurane due to difficult sedation were included. Sevoflurane was administered via the anesthetic conserving device (AnaConDa) connected to a Servo-I ventilator (Maquet, Solna, Sweden). A morphine infusion was added to sevoflurane for analgesia. Demographic and clinical data, oral and IV sedatives, Sedation and Analgesic Clinical scores, and Bispectral Index Score monitoring were registered. MEASUREMENTS AND MAIN RESULTS Twenty-three patients with a median age of 6 months old were included. Fifty percentage of the patients had critical heart diseases. Sedative and analgesic drugs used before starting sevoflurane were mainly midazolam (63%) and fentanyl (53%). Six patients (32%) also received muscle relaxants. Sevoflurane was administered for a median of 5 days (interquartile range, 5.5-8.5 d). Median end-tidal sevoflurane concentration was 0.8% (interquartile range, 0.7-0.85%), achieved with an infusion rate of 7.5 mL/hr (5.7-8.6 mL/hr). After 48 hours of treatment, some sedative drugs could be removed in 18 patients (78%). Median Bispectral Index Score value prior to sevoflurane administration was 61 (interquartile range, 49-62), falling to 42 (interquartile range, 41-47; p < 0.05) after 6 hours of treatment. Six patients (26%) presented withdrawal syndrome after sevoflurane suspension, and all of them had received sevoflurane at least for 6 days. The main side effect was moderate hypotension in seven patients (30%). CONCLUSIONS Inhaled sevoflurane appeared to be an effective sedative agent in critically ill children and can be useful in those patients on mechanical ventilation difficult to sedate with conventional drugs. It can be administered easily in the PICU with conventional ventilators using the AnaConDa system. Withdrawal syndrome may occur with prolonged treatment.
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Farrell R, Oomen G, Carey P. A technical review of the history, development and performance of the anaesthetic conserving device "AnaConDa" for delivering volatile anaesthetic in intensive and post-operative critical care. J Clin Monit Comput 2018; 32:595-604. [PMID: 29388094 PMCID: PMC6061082 DOI: 10.1007/s10877-017-0097-9] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 12/21/2017] [Indexed: 12/11/2022]
Abstract
There is a shift in critical care to adopt volatile anaesthetics as sedatives for certain patients using mechanical ventilation. Accompanying this shift is a growing body of literature describing the advantages or disadvantages of using isoflurane or sevoflurane for long term sedation. This practise requires a cost effective, efficient and safe means to deliver these drugs that can simultaneously operate with modern critical care ventilators and ventilation protocols while protecting the care environment and care workers from excessive exposure to the drugs. The anaesthetic conserving device (“AnaConDa”, Sedana Medical) is one device that delivers a safe sedative dose of either isoflurane or sevoflurane to a patient using existing critical care ventilators, common syringe pumps and gas monitors. The device is essentially a small disposable anaesthetic vaporizer and HME filter combined into one airway component. Similar to an HME filter, the device reflects moisture back to the patient, but also reflects 90% of the anaesthetic by adsorbing and releasing the drug using a proprietary carbon filament reflecting medium. This reflection reduces the total amount of anaesthetic needed, reducing that which is exhausted or scavenged upon exhalation. It can be used for 24 h of sedation, and fits into current critical care ventilator circuits almost without modifications. This article will describe the physical characteristics of the device, how it works, its development history and the performance parameters under which it can be used.
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Affiliation(s)
- Ron Farrell
- Sedana Medical, The Village Center, Two Mile House, Naas, Co. Kildare, Ireland.
| | - Glen Oomen
- Sedana Medical, Unit 306, 397 King Street West, Dundas, ON, L9H 1W9, Canada
| | - Pauric Carey
- Sedana Medical, The Village Center, Two Mile House, Naas, Co. Kildare, Ireland
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Herzog-Niescery J, Seipp HM, Weber TP, Bellgardt M. Inhaled anesthetic agent sedation in the ICU and trace gas concentrations: a review. J Clin Monit Comput 2017; 32:667-675. [PMID: 28861655 DOI: 10.1007/s10877-017-0055-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 08/15/2017] [Indexed: 12/12/2022]
Abstract
There is a growing interest in the use of volatile anesthetics for inhalational sedation of adult critically ill patients in the ICU. Its safety and efficacy has been demonstrated in various studies and technical equipment such as the anaesthetic conserving device (AnaConDa™; Sedana Medical, Uppsala, Sweden) or the MIRUS™ system (Pall Medical, Dreieich, Germany) have significantly simplified the application of volatile anesthetics in the ICU. However, the personnel's exposure to waste anesthetic gas during daily work is possibly disadvantageous, because there is still uncertainty about potential health risks. The fact that average threshold limit concentrations for isoflurane, sevoflurane and desflurane either differ significantly between countries or are not even defined at all, leads to raising concerns among ICU staff. In this review, benefits, risks, and technical aspects of inhalational sedation in the ICU are discussed. Further, the potential health effects of occupational long-term low-concentration agent exposure, the staffs' exposure levels in clinical practice, and strategies to minimize the individual gas exposure are reviewed.
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Affiliation(s)
- Jennifer Herzog-Niescery
- Department of Anesthesiology, Ruhr-University Bochum, St. Josef Hospital, Gudrunstraße 56, 44791, Bochum, Germany.
| | - Hans-Martin Seipp
- Department of Life Science Engineering, University of Applied Sciences, Wiesenstr. 14, 35390, Giessen, Germany
| | - Thomas Peter Weber
- Department of Anesthesiology, Ruhr-University Bochum, St. Josef Hospital, Gudrunstraße 56, 44791, Bochum, Germany
| | - Martin Bellgardt
- Department of Anesthesiology, Ruhr-University Bochum, St. Josef Hospital, Gudrunstraße 56, 44791, Bochum, Germany
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Landoni G, Pasin L, Cabrini L, Scandroglio AM, Baiardo Redaelli M, Votta CD, Bellandi M, Borghi G, Zangrillo A. Volatile Agents in Medical and Surgical Intensive Care Units: A Meta-Analysis of Randomized Clinical Trials. J Cardiothorac Vasc Anesth 2016; 30:1005-14. [PMID: 27238433 DOI: 10.1053/j.jvca.2016.02.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To comprehensively assess published randomized peer-reviewed studies related to volatile agents used for sedation in intensive care unit (ICU) settings, with the hypothesis that volatile agents could reduce time to extubation in adult patients. DESIGN Systematic review and meta-analysis of randomized trials. SETTING Intensive care units. PARTICIPANTS Critically ill patients. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The BioMedCentral, PubMed, Embase, and Cochrane Central Register databases of clinical trials were searched systematically for studies on volatile agents used in the ICU setting. Articles were assessed by trained investigators, and divergences were resolved by consensus. Inclusion criteria included random allocation to treatment (volatile agents versus any intravenous comparator, with no restriction on dose or time of administration) in patients requiring mechanical ventilation in the ICU. Twelve studies with 934 patients were included in the meta-analysis. The use of halogenated agents reduced the time to extubation (standardized mean difference = -0.78 [-1.01 to -0.55] hours; p for effect<0.00001; p for heterogeneity = 0.18; I(2) = 32% in 7 studies with 503 patients). Results for time to extubation were confirmed in all subanalyses (eg, medical and surgical patients) and sensitivity analyses. No differences in length of hospital stay, ICU stay, and mortality were recorded. CONCLUSIONS In this meta-analysis of randomized trials, volatile anesthetics reduced time to extubation in medical and surgical ICU patients. The results of this study should be confirmed by large and high-quality randomized controlled studies.
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Affiliation(s)
- Giovanni Landoni
- IRCCS San Raffaele Scientific Institute; Vita-Salute San Raffaele University, Milan, Italy.
| | | | | | | | | | | | | | | | - Alberto Zangrillo
- IRCCS San Raffaele Scientific Institute; Vita-Salute San Raffaele University, Milan, Italy
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Rosenberg H, Pollock N, Schiemann A, Bulger T, Stowell K. Malignant hyperthermia: a review. Orphanet J Rare Dis 2015; 10:93. [PMID: 26238698 PMCID: PMC4524368 DOI: 10.1186/s13023-015-0310-1] [Citation(s) in RCA: 296] [Impact Index Per Article: 32.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Accepted: 07/22/2015] [Indexed: 02/06/2023] Open
Abstract
Malignant hyperthermia (MH) is a pharmacogenetic disorder of skeletal muscle that presents as a hypermetabolic response to potent volatile anesthetic gases such as halothane, sevoflurane, desflurane, isoflurane and the depolarizing muscle relaxant succinylcholine, and rarely, in humans, to stressors such as vigorous exercise and heat. The incidence of MH reactions ranges from 1:10,000 to 1: 250,000 anesthetics. However, the prevalence of the genetic abnormalities may be as great as one in 400 individuals. MH affects humans, certain pig breeds, dogs and horses. The classic signs of MH include hyperthermia, tachycardia, tachypnea, increased carbon dioxide production, increased oxygen consumption, acidosis, hyperkalaemia, muscle rigidity, and rhabdomyolysis, all related to a hypermetabolic response. The syndrome is likely to be fatal if untreated. An increase in end-tidal carbon dioxide despite increased minute ventilation provides an early diagnostic clue. In humans the syndrome is inherited in an autosomal dominant pattern, while in pigs it is autosomal recessive. Uncontrolled rise of myoplasmic calcium, which activates biochemical processes related to muscle activation leads to the pathophysiologic changes. In most cases, the syndrome is caused by a defect in the ryanodine receptor. Over 400 variants have been identified in the RYR1 gene located on chromosome 19q13.1, and at least 34 are causal for MH. Less than 1 % of variants have been found in CACNA1S but not all of these are causal. Diagnostic testing involves the in vitro contracture response of biopsied muscle to halothane, caffeine, and in some centres ryanodine and 4-chloro-m-cresol. Elucidation of the genetic changes has led to the introduction of DNA testing for susceptibility to MH. Dantrolene sodium is a specific antagonist and should be available wherever general anesthesia is administered. Increased understanding of the clinical manifestation and pathophysiology of the syndrome, has lead to the mortality decreasing from 80 % thirty years ago to <5 % in 2006.
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Affiliation(s)
- Henry Rosenberg
- Department of Medical Education and Clinical Research, Saint Barnabas Medical Center, Livingston, NJ, 07039, USA.
| | - Neil Pollock
- Department of Anesthesia and Intensive Care, Palmerston North Hospital, Palmerston North, New Zealand.
| | - Anja Schiemann
- Institute of Fundamental Sciences, Massey University, Palmerston North, New Zealand.
| | - Terasa Bulger
- Department of Anesthesia and Intensive Care, Palmerston North Hospital, Palmerston North, New Zealand.
| | - Kathryn Stowell
- Institute of Fundamental Sciences, Massey University, Palmerston North, New Zealand.
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