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Abdildin Y, Tapinova K, Nemerenova A, Viderman D. The impact of ketamine on outcomes in critically ill patients: a systematic review with meta-analysis and trial sequential analysis of randomized controlled trials. Acute Crit Care 2024; 39:34-46. [PMID: 38476062 PMCID: PMC11002615 DOI: 10.4266/acc.2023.00829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 12/25/2023] [Accepted: 01/03/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND This meta-analysis aims to evaluate the effects of ketamine in critically ill intensive care unit (ICU) patients. METHODS We searched for randomized controlled trials (RCTs) in PubMed, Scopus, and the Cochrane Library; the search was performed initially in January but was repeated in December of 2023. We focused on ICU patients of any age. We included studies that compared ketamine with other traditional agents used in the ICU. We synthesized evidence using RevMan v5.4 and presented the results as forest plots. We also used trial sequential analysis (TSA) software v. 0.9.5.10 Beta and presented results as TSA plots. For synthesizing results, we used a random-effects model and reported differences in outcomes of two groups in terms of mean difference (MD), standardized MD, and risk ratio with 95% confidence interval. We assessed the risk of bias using the Cochrane RoB tool for RCTs. Our outcomes were mortality, pain, opioid and midazolam requirements, delirium rates, and ICU length of stay. RESULTS Twelve RCTs involving 805 ICU patients (ketamine group, n=398; control group, n=407) were included in the meta-analysis. The ketamine group was not superior to the control group in terms of mortality (in five studies with 318 patients), pain (two studies with 129 patients), mean and cumulative opioid consumption (six studies with 494 patients), midazolam consumption (six studies with 304 patients), and ICU length of stay (three studies with 270 patients). However, the model favored the ketamine group over the control group in delirium rate (four studies with 358 patients). This result is significant in terms of conventional boundaries (alpha=5%) but is not robust in sequential analysis. The applicability of the findings is limited by the small number of patients pooled for each outcome. CONCLUSIONS Our meta-analysis did not demonstrate differences between ketamine and control groups regarding any outcome except delirium rate, where the model favored the ketamine group over the control group. However, this result is not robust as sensitivity analysis and trial sequential analysis suggest that more RCTs should be conducted in the future.
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Affiliation(s)
- Yerkin Abdildin
- Department of Mechanical and Aerospace Engineering, School of Engineering and Digital Sciences, Nazarbayev University, Astana, Kazakhstan
| | - Karina Tapinova
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Assel Nemerenova
- Department of Mechanical and Aerospace Engineering, School of Engineering and Digital Sciences, Nazarbayev University, Astana, Kazakhstan
| | - Dmitriy Viderman
- Department of Surgery, School of Medicine, Nazarbayev University, Astana, Kazakhstan
- Department of Anesthesiology, Intensive Care, and Pain Medicine, National Research Oncology Center, Astana, Kazakhstan
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2
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Wittwer ED, Cerhan JH, Schroeder DR, Schaff HV, Mauermann WJ. Impact of ketamine versus propofol for anesthetic induction on cognitive dysfunction, delirium, and acute kidney injury following cardiac surgery in elderly, high-risk patients. Ann Card Anaesth 2023; 26:274-280. [PMID: 37470525 PMCID: PMC10451121 DOI: 10.4103/aca.aca_106_22] [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: 06/11/2022] [Revised: 08/20/2022] [Accepted: 09/02/2022] [Indexed: 07/21/2023] Open
Abstract
Objective Evaluate the effects of ketamine versus propofol when used for induction of anesthesia in elderly, high-risk cardiac surgical patients on postoperative complications including cognitive dysfunction, delirium, and acute kidney injury. Methods Prospective, randomized study performed at a tertiary medical center. A total of 52 patients aged ≥70 and older presenting for complex cardiac surgery were randomized to receive either ketamine or propofol for induction of anesthesia. Patients underwent a battery of cognitive testing preoperatively and postoperatively and the incidence of delirium and acute kidney injury were measured. Norepinephrine (NEE) equivalents following induction were assessed for each group. Results A total of 49 patients were included, 25 in the ketamine group and 24 in the propofol group with 3 patients excluded from the analysis. No difference was found between groups in either postoperative cognitive dysfunction or delirium incidence. Acute kidney injury occurred in 6 (24%) patients in the ketamine group in 12 (50%) patients in the propofol group, but the difference did not meet statistical significance (P = 0.08; Relative Risk = 2.1, 95% CI 0.9-4.7). NEE equivalents were lower in the ketamine group, 9.6 ± 22.2 versus 32.7 ± 46.0, P < 0.03. Conclusions The use of ketamine versus propofol for induction of anesthesia did not impact the incidence of postoperative cognitive dysfunction or delirium. Twice as many patients in the propofol group developed acute kidney injury, although not reaching statistical significance and warranting further investigation. In elderly, high-risk patients, ketamine was associated with a significantly reduced need for vasopressor support following induction.
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Affiliation(s)
- Erica D. Wittwer
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jane H. Cerhan
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Hartzell V. Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - William J. Mauermann
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
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3
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She YJ, Pan J, Peng LM, Ma L, Guo X, Lei DX, Wang HZ. Ketamine modulates neural stem cell differentiation by regulating TRPC3 expression through the GSK3β/β-catenin pathway. Neurotoxicology 2023; 94:1-10. [PMID: 36334642 DOI: 10.1016/j.neuro.2022.10.018] [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: 05/30/2022] [Revised: 10/24/2022] [Accepted: 10/31/2022] [Indexed: 11/06/2022]
Abstract
Ketamine, a popular anesthetic, is often abused by people for its hallucinogenic effect. Thus, the safety of ketamine in pediatric populations has been called into question for potential neurotoxic effects. However, ketamine also has neuroprotective effects in many brain injury models. The differentiation of neural stem cells (NSCs) was influenced significantly by ketamine, but the molecular mechanism is still unclear. NSCs were extracted from the hippocampi of postnatal day 1 rats and treated with ketamine to induce NSCs differentiation. Our results found that ketamine promoted neuronal differentiation of NSCs dose-dependently in a small dose range (P < 0.001). The main types of neurons from NSCs were cholinergic (51 ± 4 %; 95 % CI: 41-61 %) and glutamatergic neurons (34 ± 3 %; 95 % CI: 27-42 %). Furthermore, we performed RNA sequencing to promise a more comprehensive understanding of the molecules regulated by ketamine. Finally, we combined bioimaging and multiple molecular biology techniques to clarify that ketamine influences NSC differentiation by regulating transient receptor potential canonical 3 (TRPC3) expressions. Ketamine dramatically repressed TRPC3 expression (MD [95 % CI]=0.67 [0.40-0.95], P < 0.001) with a significant increase of phosphorylated glycogen synthase kinase 3β (p-GSK3β; MD [95 % CI]=1.00 [0.74-1.27], P < 0.001) and a decrease of β-catenin protein expression (MD [95 % CI]=0.60 [0.32-0.89], P = 0.001), thereby promoting the differentiation of NSCs into neurons and inhibiting their differentiation into astrocytes. These results suggest that TRPC3 is necessary for ketamine to modulate NSC differentiation, which occurs partly via regulation of the GSK3β/β-catenin pathway.
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Affiliation(s)
- Ying-Jun She
- Department of Anesthesiology and Perioperative Medicine, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Junping Pan
- Department of Pharmacology, College of Basic Medicine, Jinan University, Guangzhou, China
| | - Liang-Ming Peng
- Department of Anesthesiology and Perioperative Medicine, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Li Ma
- Department of Cardiac Surgery, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Xinying Guo
- Department of Anesthesiology and Perioperative Medicine, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Dong-Xu Lei
- Department of Anesthesiology and Perioperative Medicine, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Huai-Zhen Wang
- Department of Anesthesiology and Perioperative Medicine, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China.
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4
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Rueda Carrillo L, Garcia KA, Yalcin N, Shah M. Ketamine and Its Emergence in the Field of Neurology. Cureus 2022; 14:e27389. [PMID: 36046286 PMCID: PMC9419113 DOI: 10.7759/cureus.27389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2022] [Indexed: 11/15/2022] Open
Abstract
The quest for a safe and effective anesthetic medication in the mid-20th century led to the discovery of CI-581, which was later named ketamine. Ketamine was labeled a “dissociative anesthetic” due to the state of sensory deprivation that it induces in the subjects receiving it. Although it enjoyed widespread use at the beginning of the Vietnam war, its use rapidly waned due to its psychedelic effect and it became more popular as a recreational drug, and in the field of veterinary medicine. However, as we gained more knowledge about its multiple sites of action, it has reemerged as a useful anesthetic/analgesic agent. In the last decade, the field of neurology has witnessed the growing use of ketamine for the treatment of several neurological conditions including migraine, status epilepticus, stroke, and traumatic brain injury (TBI). Ketamine acts primarily as a non-competitive N-methyl-D-aspartate (NMDA) receptor antagonist. The binding of ketamine to NMDA receptors leads to decreased frequency and duration of Ca+2 channel opening and thus inhibits glutaminergic transmission. This mechanism has proven to be neuroprotective in several neurological conditions. Ketamine does not increase intracranial pressure (ICP), and it maintains cerebral perfusion pressure (CPP) by increasing cerebral blood flow. Ketamine has also been shown to inhibit massive slow waves of neurological depolarizations called cortical spreading depolarizations (CSD), usually seen during acute neurological injury and are responsible for further neurological deterioration. Unlike other anesthetic agents, ketamine does not cause cardiac or respiratory suppression. All these favorable mechanisms and cerebral/hemodynamic actions have led to increased interest among clinicians and researchers regarding the novel uses of ketamine. This review will focus on the use of ketamine for various neurological indications.
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Chan K, Burry LD, Tse C, Wunsch H, De Castro C, Williamson DR. Impact of Ketamine on Analgosedative Consumption in Critically Ill Patients: A Systematic Review and Meta-Analysis. Ann Pharmacother 2022; 56:1139-1158. [PMID: 35081769 PMCID: PMC9393656 DOI: 10.1177/10600280211069617] [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] [Indexed: 11/25/2022] Open
Abstract
Objective: The aim of this study was to synthesize evidence available on continuous
infusion ketamine versus nonketamine regimens for analgosedation in
critically ill patients. Data sources A search of MEDLINE, EMBASE, CINAHL, CDSR, and ClinicalTrials.gov was
performed from database establishment to November 2021 using the following
search terms: critical care, ICU, ketamine, sedation, and
anesthesia. All studies included the primary outcome of
interest: daily opioid and/or sedative consumption. Study selection and data extraction Relevant human studies were considered. Randomized controlled trials (RCT),
quasi-experimental studies, and observational cohort studies were eligible.
Two reviewers independently screened articles, extracted data, and appraised
studies using the Cochrane RoB and ROBINS-I tools. Data synthesis A total of 13 RCTs, 5 retrospective, and 1 prospective cohort study were
included (2255 participants). The primary analysis of six RCTs demonstrated
reduced opioid consumption with ketamine regimens (n = 494 participants,
−13.19 µg kg−1 h−1 morphine equivalents, 95% CI −22.10
to −4.28, P = 0.004). No significant difference was
observed in sedative consumption, duration of mechanical ventilation (MV),
ICU or hospital length of stay (LOS), intracranial pressure, and mortality.
Small sample size of studies may have limited ability to detect true
differences between groups. Relevance to patient care and clinical practice This meta-analysis examining ketamine use in critically ill patients is the
first restricting analysis to RCTs and includes up-to-date publication of
trials. Findings may guide clinicians in consideration and dosing of
ketamine for multimodal analgosedation. Conclusion Results suggest ketamine as an adjunct analgosedative has the potential to
reduce opioid exposure in postoperative and MV patients in the ICU. More
RCTs are required before recommending routine use of ketamine in select
populations.
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Affiliation(s)
- Katalina Chan
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Novo Nordisk Canada Inc, Mississauga, ON, Canada
| | - Lisa D Burry
- Department of Pharmacy and Medicine, Sinai Health System, Toronto, ON, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Christopher Tse
- Department of Pharmacy, Princess Margaret Hospital, Toronto, ON, Canada
| | - Hannah Wunsch
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Charmaine De Castro
- Sidney Liswood Health Sciences Library, Sinai Health System, Toronto, ON, Canada
| | - David R Williamson
- Faculté de Pharmacie, Université de Montréal, Montréal, QC, Canada.,Pharmacy Department and Research Center, CIUSSS du nord-de-l'Île-de-Montréal, Sacré-Cœur Hospital, Montréal, QC, Canada
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6
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Andrew RD, Farkas E, Hartings JA, Brennan KC, Herreras O, Müller M, Kirov SA, Ayata C, Ollen-Bittle N, Reiffurth C, Revah O, Robertson RM, Dawson-Scully KD, Ullah G, Dreier JP. Questioning Glutamate Excitotoxicity in Acute Brain Damage: The Importance of Spreading Depolarization. Neurocrit Care 2022; 37:11-30. [PMID: 35194729 PMCID: PMC9259542 DOI: 10.1007/s12028-021-01429-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 12/20/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Within 2 min of severe ischemia, spreading depolarization (SD) propagates like a wave through compromised gray matter of the higher brain. More SDs arise over hours in adjacent tissue, expanding the neuronal damage. This period represents a therapeutic window to inhibit SD and so reduce impending tissue injury. Yet most neuroscientists assume that the course of early brain injury can be explained by glutamate excitotoxicity, the concept that immediate glutamate release promotes early and downstream brain injury. There are many problems with glutamate release being the unseen culprit, the most practical being that the concept has yielded zero therapeutics over the past 30 years. But the basic science is also flawed, arising from dubious foundational observations beginning in the 1950s METHODS: Literature pertaining to excitotoxicity and to SD over the past 60 years is critiqued. RESULTS Excitotoxicity theory centers on the immediate and excessive release of glutamate with resulting neuronal hyperexcitation. This instigates poststroke cascades with subsequent secondary neuronal injury. By contrast, SD theory argues that although SD evokes some brief glutamate release, acute neuronal damage and the subsequent cascade of injury to neurons are elicited by the metabolic stress of SD, not by excessive glutamate release. The challenge we present here is to find new clinical targets based on more informed basic science. This is motivated by the continuing failure by neuroscientists and by industry to develop drugs that can reduce brain injury following ischemic stroke, traumatic brain injury, or sudden cardiac arrest. One important step is to recognize that SD plays a central role in promoting early neuronal damage. We argue that uncovering the molecular biology of SD initiation and propagation is essential because ischemic neurons are usually not acutely injured unless SD propagates through them. The role of glutamate excitotoxicity theory and how it has shaped SD research is then addressed, followed by a critique of its fading relevance to the study of brain injury. CONCLUSIONS Spreading depolarizations better account for the acute neuronal injury arising from brain ischemia than does the early and excessive release of glutamate.
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Affiliation(s)
| | - Eszter Farkas
- Hungarian Centre of Excellence for Molecular Medicine-University of Szeged, Cerebral Blood Flow and Metabolism Research Group, Department of Cell Biology and Molecular Medicine, University of Szeged, Szeged, Hungary
| | | | | | | | | | | | - Cenk Ayata
- Harvard Medical School, Harvard University, Boston, MA USA
| | | | - Clemens Reiffurth
- Center for Stroke Research Berlin, Berlin, Germany ,Department of Experimental Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Omer Revah
- School of Medicine, Stanford University, Stanford, CA USA
| | | | | | | | - Jens P. Dreier
- Center for Stroke Research Berlin, Berlin, Germany ,Department of Experimental Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany ,Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany ,Department of Neurology, Corporate Member of Freie Universität Berlin, Berlin, Germany ,Department of Neurology, Humboldt-Universität zu Berlin, Berlin, Germany ,Department of Neurology, Berlin Institute of Health, Berlin, Germany ,Bernstein Center for Computational Neuroscience Berlin, Berlin, Germany ,Einstein Center for Neurosciences Berlin, Berlin, Germany
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7
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WANG L, LIU G, SHAO Z, ZHANG Q, YIN L, XU E, LI B, CUI X, TENG H. MicroR-146 protects against rat ischemia-reperfusion injury by targeting NF-κB-mediated PI3K/AKT/mTOR signaling pathway. FOOD SCIENCE AND TECHNOLOGY 2022. [DOI: 10.1590/fst.36820] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Leyuan WANG
- The People's Hospital of Changle County, China
| | - Guofang LIU
- The People's Hospital of Laoling City, China
| | - Zetao SHAO
- The People's Hospital of Changle County, China
| | | | - Lili YIN
- The People's Hospital of Changle County, China
| | - Enbo XU
- The People's Hospital of Changle County, China
| | - Biao LI
- The People's Hospital of Changle County, China
| | | | - Hongtao TENG
- The Fourth People's Hospital of Jinan City, China
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8
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Al-Mufti F, Mayer SA, Kaur G, Bassily D, Li B, Holstein ML, Ani J, Matluck NE, Kamal H, Nuoman R, Bowers CA, S Ali F, Al-Shammari H, El-Ghanem M, Gandhi C, Amuluru K. Neurocritical care management of poor-grade subarachnoid hemorrhage: Unjustified nihilism to reasonable optimism. Neuroradiol J 2021; 34:542-551. [PMID: 34476991 PMCID: PMC8649190 DOI: 10.1177/19714009211024633] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND AND PURPOSE Historically, overall outcomes for patients with high-grade subarachnoid hemorrhage (SAH) have been poor. Generally, between physicians, either reluctance to treat, or selectivity in treating such patients has been the paradigm. Recent studies have shown that early and aggressive care leads to significant improvement in survival rates and favorable outcomes of grade V SAH patients. With advancements in both neurocritical care and end-of-life care, non-treatment or selective treatment of grade V SAH patients is rarely justified. Current paradigm shifts towards early and aggressive care in such cases may lead to improved outcomes for many more patients. MATERIALS AND METHODS We performed a detailed review of the current literature regarding neurointensive management strategies in high-grade SAH, discussing multiple aspects. We discussed the neurointensive care management protocols for grade V SAH patients. RESULTS Acutely, intracranial pressure control is of utmost importance with external ventricular drain placement, sedation, optimization of cerebral perfusion pressure, osmotherapy and hyperventilation, as well as cardiopulmonary support through management of hypotension and hypertension. CONCLUSIONS Advancements of care in SAH patients make it unethical to deny treatment to poor Hunt and Hess grade patients. Early and aggressive treatment results in a significant improvement in survival rate and favorable outcome in such patients.
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Affiliation(s)
- Fawaz Al-Mufti
- Department of Neurology, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
- Department of Neurosurgery, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Stephan A Mayer
- Department of Neurosurgery, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Gurmeen Kaur
- Department of Neurology, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
- Department of Neurosurgery, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Daniel Bassily
- School of Medicine, New York Medical College, New York Medical College, Valhalla, USA
| | - Boyi Li
- School of Medicine, New York Medical College, New York Medical College, Valhalla, USA
| | - Matthew L Holstein
- School of Medicine, New York Medical College, New York Medical College, Valhalla, USA
| | - Jood Ani
- School of Medicine, New York Medical College, New York Medical College, Valhalla, USA
| | - Nicole E Matluck
- School of Medicine, New York Medical College, New York Medical College, Valhalla, USA
| | - Haris Kamal
- Department of Neurosurgery, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Rolla Nuoman
- Department of Neurology, Westchester Medical Center, Maria Fareri Children’s Hospital, Westchester Medical Center, Valhalla, USA
| | | | - Faizan S Ali
- Department of Neurology, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Hussein Al-Shammari
- Department of Neurology, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Mohammad El-Ghanem
- Department of Neurology, Neurosurgery and Medical Imaging, University of Arizona, Tucson, USA
| | - Chirag Gandhi
- Department of Neurosurgery, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Krishna Amuluru
- Goodman Campbell Brain and Spine, Ascension St. Vincent Medical Center, Indianapolis, USA
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9
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Role of Anesthetics and Their Adjuvants in Neurovascular Protection in Secondary Brain Injury after Aneurysmal Subarachnoid Hemorrhage. Int J Mol Sci 2021; 22:ijms22126550. [PMID: 34207292 PMCID: PMC8234913 DOI: 10.3390/ijms22126550] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 06/03/2021] [Accepted: 06/15/2021] [Indexed: 12/13/2022] Open
Abstract
Aneurysmal rupture accounts for the majority of subarachnoid hemorrhage and is responsible for most cerebrovascular deaths with high mortality and morbidity. Initial hemorrhage severity and secondary brain injury due to early brain injury and delayed cerebral ischemia are the major determinants of outcomes after aneurysmal subarachnoid hemorrhage. Several therapies have been explored to prevent these secondary brain injury processes after aneurysmal subarachnoid hemorrhage with limited clinical success. Experimental and clinical studies have shown a neuroprotective role of certain anesthetics in cerebrovascular disorders including aneurysmal subarachnoid hemorrhage. The vast majority of aneurysmal subarachnoid hemorrhage patients require general anesthesia for surgical or endovascular repair of their aneurysm. Given the potential impact certain anesthetics have on secondary brain injury after SAH, appropriate selection of anesthetics may prove impactful on overall outcome of these patients. This narrative review focuses on the available evidence of anesthetics and their adjuvants in neurovascular protection in aneurysmal subarachnoid hemorrhage and discusses current impact on clinical care and future investigative directions.
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10
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Schoknecht K, Kikhia M, Lemale CL, Liotta A, Lublinsky S, Mueller S, Boehm-Sturm P, Friedman A, Dreier JP. The role of spreading depolarizations and electrographic seizures in early injury progression of the rat photothrombosis stroke model. J Cereb Blood Flow Metab 2021; 41:413-430. [PMID: 32241203 PMCID: PMC7812510 DOI: 10.1177/0271678x20915801] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Spreading depolarization (SD) and seizures are pathophysiological events associated with cerebral ischemia. Here, we investigated their role for injury progression in the cerebral cortex. Cerebral ischemia was induced in anesthetized male Wistar rats using the photothrombosis (PT) stroke model. SD and spontaneous neuronal activity were recorded in the presence of either urethane or ketamine/xylazine anesthesia. Blood-brain barrier (BBB) permeability, cerebral perfusion, and cellular damage were assessed through a cranial window and repeated intravenous injection of fluorescein sodium salt and propidium iodide until 4 h after PT. Neuronal injury and early lesion volume were quantified by stereological cell counting and manual and automated assessment of ex vivo T2-weighted magnetic resonance imaging. Onset SDs originated at the thrombotic core and invaded neighboring cortex, whereas delayed SDs often showed opposite propagation patterns. Seizure induction by 4-aminopyridine caused no increase in lesion volume or neuronal injury in urethane-anesthetized animals. Ketamine/xylazine anesthesia was associated with a lower number of onset SDs, reduced lesion volume, and neuronal injury despite a longer duration of seizures. BBB permeability increase inversely correlated with the number of SDs at 3 and 4 h after PT. Our results provide further evidence that ketamine may counteract the early progression of ischemic injury.
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Affiliation(s)
- Karl Schoknecht
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Neuroscience Research Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Institute for Neurophysiology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Carl-Ludwig-Institute for Physiology, Medical Faculty, University of Leipzig, Leipzig, Germany
| | - Majed Kikhia
- Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Einstein Center for Neurosciences Berlin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Coline L Lemale
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Agustin Liotta
- Neuroscience Research Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Institute for Neurophysiology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Anesthesiology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Svetlana Lublinsky
- Departments of Physiology & Cell Biology, Cognitive & Brain Sciences, the Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Susanne Mueller
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,NeuroCure Cluster of Excellence and Charité Core Facility 7T Experimental MRIs, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Philipp Boehm-Sturm
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,NeuroCure Cluster of Excellence and Charité Core Facility 7T Experimental MRIs, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Alon Friedman
- Departments of Physiology & Cell Biology, Cognitive & Brain Sciences, the Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Department of Medical Neuroscience, Dalhousie University, Halifax, Canada
| | - Jens P Dreier
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Einstein Center for Neurosciences Berlin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Bernstein Center for Computational Neuroscience Berlin, Humboldt-Universität zu Berlin, Germany
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11
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Anesthetic management of unruptured intracranial aneurysms: a qualitative systematic review. Neurosurg Rev 2021; 44:2477-2492. [PMID: 33415519 DOI: 10.1007/s10143-020-01441-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 10/31/2020] [Accepted: 11/12/2020] [Indexed: 12/11/2022]
Abstract
Intracranial aneurysms (IA) occur in 3-5% of the general population and may require surgical or endovascular obliteration if the patient is symptomatic or has an increased risk of rupture. These procedures carry an inherent risk of neurological complications, and the outcome can be influenced by the physiological and pharmacological effects of the administered anesthetics. Despite the critical role of anesthetic agents, however, there are no current studies to systematically assess the intraoperative anesthetic risks, benefits, and outcome effects in this population. In this systematic review of the literature, we carefully examine the existing evidence on the risks and benefits of common anesthetic agents during IA obliteration, their physiological and clinical characteristics, and effects on neurological outcome. The initial search strategy captured a total of 287 published studies. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, 28 studies were included in the final report. Our data showed that both volatile and intravenous anesthetics are commonly employed, without evidence that either is superior. Although no specific anesthetic regimens are promoted, their unique neurological, cardiovascular, and physiological properties may be critical to the outcome in vulnerable patients. In particular, patients at risk for perioperative ischemia may benefit from timely administration of anesthetic agents with neuroprotective properties and optimization of their physiological parameters. Further studies are warranted to examine if these anesthetic regimens can reduce the risk of neurological injury and improve the overall outcome in these patients.
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12
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High doses of ketamine to improve neuronal edema in subarachnoid hemorrhage: we should consider other undesirable organ targets. Crit Care 2020; 24:362. [PMID: 32552903 PMCID: PMC7304164 DOI: 10.1186/s13054-020-03004-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 05/19/2020] [Indexed: 01/22/2023] Open
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13
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Abstract
Aneurysmal subarachnoid hemorrhage is an acute neurologic emergency. Prompt definitive treatment of the aneurysm by craniotomy and clipping or endovascular intervention with coils and/or stents is needed to prevent rebleeding. Extracranial manifestations of aneurysmal subarachnoid hemorrhage include cardiac dysfunction, neurogenic pulmonary edema, fluid and electrolyte imbalances, and hyperglycemia. Data on the impact of anesthesia on long-term neurologic outcomes of aneurysmal subarachnoid hemorrhage do not exist. Perioperative management should therefore focus on optimizing systemic physiology, facilitating timely definitive treatment, and selecting an anesthetic technique based on patient characteristics, severity of aneurysmal subarachnoid hemorrhage, and the planned intervention and monitoring. Anesthesiologists should be familiar with evoked potential monitoring, electroencephalographic burst suppression, temporary clipping, management of external ventricular drains, adenosine-induced cardiac standstill, and rapid ventricular pacing to effectively care for these patients.
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14
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Mechanical Ventilation, Sedation and Neuromonitoring of Patients with Aneurysmal Subarachnoid Hemorrhage in Germany: Results of a Nationwide Survey. Neurocrit Care 2020; 34:236-247. [PMID: 32583194 PMCID: PMC7314429 DOI: 10.1007/s12028-020-01029-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objective Current evidence-based guidelines for the management of aneurysmal subarachnoid hemorrhage (aSAH) focus primarily on timing, modality and technique of aneurysm occlusion, and on prevention and treatment of delayed cerebral ischemia. Significant aspects of management in the intensive care unit (ICU) during the later course of aSAH such as ventilation and sedation (VST) remain unaddressed. aSAH patients present unique challenges not accounted for in general ICU recommendations and guidelines, which is why we attempted to further characterize ICU practices in aSAH patients in Germany. Methods We conducted a nationwide survey on ICU practices in aSAH in Germany. Secondarily, we assessed the existence of and compliance with current guidelines regarding ICU practices. The questionnaire was designed in interdisciplinary fashion and distributed online through the kwiksurvey® platform (Bristol, UK). Results A total of 50 responses were received, accounting for a response rate of 49%. Twenty-one were university hospitals (UH), 23 high-volume centers (HVC), 6 low-volume centers (LVC). Half of the participating centers do not take into consideration WFNS at presentation to indicate ventilation. While 42% of centers rely on the P/F ratio to indicate ventilation, 62% of them have a cutoff value of < 200, and 38% of < 100. While most UH and HVC used propofol for the first phase of sedation (95%), LVC employed benzodiazepines (100%). Sedation deepening was done with ketamine in UH (75%) and HVC (60%), whereas LVC used predominantly clonidine (100%). Conclusions Our study clearly demonstrates that attitudes and practices pertaining to ICU management in aSAH are enormously heterogeneous, reflecting the lack of good quality evidence and differing interpretations thereof. Electronic supplementary material The online version of this article (10.1007/s12028-020-01029-8) contains supplementary material, which is available to authorized users.
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15
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Manasco AT, Stephens RJ, Yaeger LH, Roberts BW, Fuller BM. Ketamine sedation in mechanically ventilated patients: A systematic review and meta-analysis. J Crit Care 2020; 56:80-88. [DOI: 10.1016/j.jcrc.2019.12.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 12/04/2019] [Accepted: 12/06/2019] [Indexed: 11/16/2022]
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16
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Neuronal brain injury after cerebral ischemic stroke is ameliorated after subsequent administration of (R)-ketamine, but not (S)-ketamine. Pharmacol Biochem Behav 2020; 191:172904. [DOI: 10.1016/j.pbb.2020.172904] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 03/04/2020] [Accepted: 03/06/2020] [Indexed: 12/22/2022]
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17
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Russo E, Santonastaso DP, Gamberini E, Circelli A, Martino C, Agnoletti V. Ketamine in Neurocritical Care. J Intensive Care Med 2020:885066620912719. [PMID: 32193979 DOI: 10.1177/0885066620912719] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Affiliation(s)
- Emanuele Russo
- Anesthesia and Intensive Care Unit, Azienda Romagna, M. Bufalini Hospital, Cesena, Italy
| | | | - Emiliano Gamberini
- Anesthesia and Intensive Care Unit, Azienda Romagna, M. Bufalini Hospital, Cesena, Italy
| | - Alessandro Circelli
- Anesthesia and Intensive Care Unit, Azienda Romagna, M. Bufalini Hospital, Cesena, Italy
| | - Costanza Martino
- Anesthesia and Intensive Care Unit, Azienda Romagna, M. Bufalini Hospital, Cesena, Italy
| | - Vanni Agnoletti
- Anesthesia and Intensive Care Unit, Azienda Romagna, M. Bufalini Hospital, Cesena, Italy
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18
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Major S, Huo S, Lemale CL, Siebert E, Milakara D, Woitzik J, Gertz K, Dreier JP. Direct electrophysiological evidence that spreading depolarization-induced spreading depression is the pathophysiological correlate of the migraine aura and a review of the spreading depolarization continuum of acute neuronal mass injury. GeroScience 2020; 42:57-80. [PMID: 31820363 PMCID: PMC7031471 DOI: 10.1007/s11357-019-00142-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 11/20/2019] [Indexed: 02/07/2023] Open
Abstract
Spreading depolarization is observed as a large negative shift of the direct current potential, swelling of neuronal somas, and dendritic beading in the brain's gray matter and represents a state of a potentially reversible mass injury. Its hallmark is the abrupt, massive ion translocation between intraneuronal and extracellular compartment that causes water uptake (= cytotoxic edema) and massive glutamate release. Dependent on the tissue's energy status, spreading depolarization can co-occur with different depression or silencing patterns of spontaneous activity. In adequately supplied tissue, spreading depolarization induces spreading depression of activity. In severely ischemic tissue, nonspreading depression of activity precedes spreading depolarization. The depression pattern determines the neurological deficit which is either spreading such as in migraine aura or migraine stroke or nonspreading such as in transient ischemic attack or typical stroke. Although a clinical distinction between spreading and nonspreading focal neurological deficits is useful because they are associated with different probabilities of permanent damage, it is important to note that spreading depolarization, the neuronal injury potential, occurs in all of these conditions. Here, we first review the scientific basis of the continuum of spreading depolarizations. Second, we highlight the transition zone of the continuum from reversibility to irreversibility using clinical cases of aneurysmal subarachnoid hemorrhage and cerebral amyloid angiopathy. These illustrate how modern neuroimaging and neuromonitoring technologies increasingly bridge the gap between basic sciences and clinic. For example, we provide direct electrophysiological evidence for the first time that spreading depolarization-induced spreading depression is the pathophysiological correlate of the migraine aura.
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Affiliation(s)
- Sebastian Major
- Center for Stroke Research, Campus Charité Mitte, Charité University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Department of Experimental Neurology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Neurology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Shufan Huo
- Center for Stroke Research, Campus Charité Mitte, Charité University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Department of Neurology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Coline L Lemale
- Center for Stroke Research, Campus Charité Mitte, Charité University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Department of Experimental Neurology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Eberhard Siebert
- Department of Neuroradiology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Denny Milakara
- Solution Centre for Image Guided Local Therapies (STIMULATE), Otto-von-Guericke-University, Magdeburg, Germany
| | - Johannes Woitzik
- Evangelisches Krankenhaus Oldenburg, University of Oldenburg, Oldenburg, Germany
| | - Karen Gertz
- Center for Stroke Research, Campus Charité Mitte, Charité University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Department of Experimental Neurology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Neurology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Jens P Dreier
- Center for Stroke Research, Campus Charité Mitte, Charité University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany.
- Department of Experimental Neurology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.
- Department of Neurology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.
- Bernstein Center for Computational Neuroscience Berlin, Berlin, Germany.
- Einstein Center for Neurosciences Berlin, Berlin, Germany.
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19
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Zhao H, Yang S, Wang H, Zhang H, An Y. Non-opioid analgesics as adjuvants to opioid for pain management in adult patients in the ICU: A systematic review and meta-analysis. J Crit Care 2019; 54:136-144. [PMID: 31446231 DOI: 10.1016/j.jcrc.2019.08.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 08/12/2019] [Accepted: 08/12/2019] [Indexed: 12/17/2022]
Abstract
PURPOSE To identify the impact of non-opioid analgesics as adjuvants to opioid on opioid consumption and its side effects, as well as the analgesic effectiveness in adult patients in the ICU. METHODS Only randomized clinical trials using non-opioid analgesics for analgesia in the ICU were included. Pooled analyses with 95% CI were determined. RESULTS Twelve studies (mainly surgical and Guillain-Barre syndrome patients) were included. Non-opioid analgesics as adjuvants to opioid were associated with a significant reduction in the consumption of opioids when compared with opioid use alone at Day 1 (MD -15.40; 95% CI -22.41 to -8.39; P < .001) and Day 2 (MD -22.93; 95% CI -27.70 to -18.16; P < .001). Non-opioid analgesics as adjuvants to opioid were associated with a significantly lower incidence of nausea and vomiting when compared with opioid use alone (RR 0.46; 95% CI 0.30 to 0.68; P < .001). Non-opioid analgesics as adjuvants to opioid significantly decreased the pain score at Day 1 (MD -0.68; 95% CI -1.28 to -0.08; P = .03) and Day 2 (MD -1.36; 95% CI -2.47 to -0.24; P = .02). CONCLUSIONS Non-opioid analgesics as adjuvants to opioid reduced the consumption and the side effects of opioids in adult surgical and Guillain-Barre syndrome patients in the ICU. TRIAL REVIEW REGISTRATION PROSPERO international prospective register of systematic reviews on January 23, 2017, registration number CRD42017055768.
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Affiliation(s)
- Huiying Zhao
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, China.
| | - Shuguang Yang
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, China
| | - Huixia Wang
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, China
| | - Hua Zhang
- Epidemiology Center, Peking University Third Hospital, Beijing, China
| | - Youzhong An
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, China.
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20
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Postinterventional Sedation Worsens Functional Outcomes in Patients with Acute Ischemic Stroke Treated with Endovascular Therapy. World Neurosurg 2019; 130:e794-e803. [PMID: 31295591 DOI: 10.1016/j.wneu.2019.06.227] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 06/28/2019] [Accepted: 06/29/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Postinterventional sedation is commonly used in clinical practice to ensure patient safety and comfort. Although sedation or anesthesia during thrombectomy has been well studied, the association between postinterventional sedation and functional outcomes in endovascularly treated patients with acute ischemic stroke (AIS) has yet to be investigated. We describe the association between postinterventional sedation and functional outcomes in patients with AIS treated with endovascular therapy (EVT). METHODS This observational study was based on a prospective registry. Patients with AIS treated with EVT from January 2013 to August 2017 at Xuanwu Hospital, Capital Medical University were included. Patients receiving postinterventional sedation were compared with patients not receiving sedation. The primary outcome was the 3 months modified Rankin Scale score. RESULTS A total of 268 patients were eligible for study: 112 patients (41.8%) receiving postinterventional sedation and 156 patients (58.2%) without sedation. At 3 months follow-up, the median modified Rankin Scale score was 4 (interquartile range, 3-6) in the sedation group and 2 (interquartile range, 1-4) in the nonsedation group (P < 0.001). Multivariable regression analysis suggested that the need for postinterventional sedation was associated with unfavorable outcomes, with an odds ratio of 0.20 for functional independence (95% confidence interval [CI], 0.078-0.487; P < 0.001), 0.06 for freedom from disability (95% CI, 0.017-0.228; P < 0.001), and 8.37 for death (95% CI, 2.196-31.889; P = 0.002). CONCLUSIONS Postinterventional sedation worsens functional outcomes in patients with AIS with large-vessel occlusions treated with EVT. Whether the sedation is a causative factor or a surrogate for poor functional outcomes remains to be determined.
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21
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Gritti P, Lorini FL, Lanterna LA, Bilotta F. Periprocedural management of patients with subarachnoid hemorrhage. Curr Opin Anaesthesiol 2019; 31:511-519. [PMID: 30020154 DOI: 10.1097/aco.0000000000000627] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Anesthesiologists and intensivists may be involved in the management of aneurysmal subarachnoid hemorrhage (aSAH) patients at various stages of care. This article will review the recent advances in the periprocedural management of aSAH patients. RECENT FINDINGS New scoring systems to assess gravity and prognosis of aSAH patients have been evaluated and proposed. Rebleeding still remains, with early aneurysmal treatment, a major challenge in the first hours of aSAH management. In the last decades, the treatment of the aSAH has shifted from clipping to coiling and more recently, the use of flow diversion technique has been introduced in selected patients. Although these improvements allow treatment of more complex aneurysms, they have implications for the anesthesiologist, including requiring the management of anticoagulation with its inherent risks. Even though knowledge, monitoring, and management of postprocedural phase of aSAH patients has improved, vasospasm and cerebral-delayed ischemia still remain the major and devastating complications in the postoperative course of aSAH patients. SUMMARY Despite recent progress in the scoring, diagnosis, and treatment of aSAH patients, the periprocedural management of these patients is still a major challenge for anesthesiologists and intensivists, who are involved from the first phase of the aneurysm rupture through the postoperative phases and vasospasm period.
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Affiliation(s)
- Paolo Gritti
- Department of Anaesthesia and Critical Care Medicine
| | | | - Luigi A Lanterna
- Department of Neurosurgery, Ospedale Papa Giovanni XXIII, Bergamo
| | - Federico Bilotta
- Department of Anaesthesia and Critical Care Medicine, 'Sapienza' University, Rome, Italy
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