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Xiong X, Shao Y, Chen D, Chen B, Lan X, Shi J. Effect of Esketamine on Postoperative Delirium in Patients Undergoing Cardiac Valve Replacement with Cardiopulmonary Bypass: A Randomized Controlled Trial. Anesth Analg 2024; 139:743-753. [PMID: 38446699 DOI: 10.1213/ane.0000000000006925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
BACKGROUND The aim of this study was to investigate the effects of esketamine on the risk of postoperative delirium (POD) in adults undergoing on-pump cardiac valve surgery. METHODS In this randomized, triple-blind, controlled trial, 116 adult patients with an American Society of Anesthesiologists (ASA) grade Ⅱ or Ⅲ and a New York Heart Association (NYHA) grade Ⅱ or Ⅲ who underwent cardiac valve surgery with cardiopulmonary bypass were included. Esketamine (0.25 mg/kg) or normal saline was administered intravenously before anesthesia induction. The primary outcome was POD, defined as a positive delirium assessment according to the 3-minute confusion assessment method (CAM) or the confusion assessment method for the intensive care unit (CAM-ICU) on a twice-daily basis for 7 days after surgery. Delirium duration and the delirium subtype were also recorded. The cognitive status of patients was measured according to the Mini-Mental State Examination at baseline, discharge, 30 days postoperatively and 3 months postoperatively. RESULTS A total of 112 patients (mean age, 52 years; 53.6% female) were enrolled; 56 were assigned to receive esketamine, and 56 were assigned to receive placebo. POD occurred in 13 (23.2%) patients in the esketamine group and in 25 (44.6%) patients in the placebo group (relative risk [RR], 0.52, 95% confidence interval [CI], 0.28-0.91; P = .018). Thirteen patients (23.2%) in the esketamine group and 24 (42.9%) patients in the placebo group had multiple episodes of delirium (RR, 0.54, 95% CI, 0.28-0.92), and 13 (23.2%) vs 22 (39.3%) patients exhibited the hyperactive subtype. CONCLUSIONS A single dose of esketamine (0.25 mg/kg) injected intravenously before anesthesia induction reduced the incidence of delirium in relatively young patients with ASA grade Ⅱ or Ⅲ who underwent on-pump cardiac surgery.
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Affiliation(s)
- Xinglong Xiong
- From the Department of Anesthesiology, The Affiliated Hospital of Guizhou Medical University, Guiyang, P. R. China
| | - Yi Shao
- From the Department of Anesthesiology, The Affiliated Hospital of Guizhou Medical University, Guiyang, P. R. China
| | - Dongxu Chen
- Department of Anesthesiology, West China Second Hospital, Sichuan University, Chengdu, P. R. China
| | - Bo Chen
- From the Department of Anesthesiology, The Affiliated Hospital of Guizhou Medical University, Guiyang, P. R. China
| | - Xin Lan
- From the Department of Anesthesiology, The Affiliated Hospital of Guizhou Medical University, Guiyang, P. R. China
| | - Jing Shi
- From the Department of Anesthesiology, The Affiliated Hospital of Guizhou Medical University, Guiyang, P. R. China
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Waris A, Asim M, Ullah A, Alhumaydhi FA. Various pharmacological agents in the pipeline against intractable epilepsy. Arch Pharm (Weinheim) 2024; 357:e2400229. [PMID: 38767508 DOI: 10.1002/ardp.202400229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 04/25/2024] [Accepted: 04/29/2024] [Indexed: 05/22/2024]
Abstract
Epilepsy is a noncommunicable chronic neurological disorder affecting people of all ages, with the highest prevalence in low and middle-income countries. Despite the pharmacological armamentarium, the plethora of drugs in the market, and other treatment options, 30%-35% of individuals still show resistance to the current medication, termed intractable epilepsy/drug resistance epilepsy, which contributes to 50% of the mortalities due to epilepsy. Therefore, the development of new drugs and agents is needed to manage this devastating epilepsy. We reviewed the pipeline of drugs in "ClinicalTrials. gov," which is the federal registry of clinical trials to identify drugs and other treatment options in various phases against intractable epilepsy. A total of 31 clinical trials were found regarding intractable epilepsy. Among them, 48.4% (15) are about pharmacological agents, of which 26.6% are in Phase 1, 60% are in Phase 2, and 13.3% are in Phase 3. The mechanism of action or targets of the majority of these agents are different and are more diversified than those of the approved drugs. In this article, we summarized various pharmacological agents in clinical trials, their backgrounds, targets, and mechanisms of action for the treatment of intractable epilepsy. Treatment options other than pharmacological ones, such as devices for brain stimulation, ketogenic diets, gene therapy, and others, are also summarized.
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Affiliation(s)
- Abdul Waris
- Department of Biomedical Sciences, City University of Hong Kong, Kowloon Tong, Hong Kong
| | - Muhammad Asim
- Department of Neurosciences, City University of Hong Kong, Kowloon Tong, Hong Kong
- Centre for Regenerative Medicine and Health (CRMH), Hong Kong SAR
| | - Ata Ullah
- Department of Biomedical Sciences, City University of Hong Kong, Kowloon Tong, Hong Kong
| | - Fahad A Alhumaydhi
- Department of Medical Laboratories, College of Applied Medical Sciences, Qassim University, Buraydah, Saudi Arabia
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Wang Y, Ma B, Wang C, Wang Y, Liu A, Hang L. The influence of low-dose s-ketamine on postoperative delirium and cognitive function in older adults undergoing thoracic surgery. J Cardiothorac Surg 2024; 19:324. [PMID: 38849859 PMCID: PMC11157807 DOI: 10.1186/s13019-024-02811-x] [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: 01/01/2024] [Accepted: 05/25/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND Postoperative delirium (POD) and cognitive dysfunction (POCD) are common complications following thoracic surgery, particularly in patients aged 65 years and above. These complications can significantly affect recovery and increase healthcare costs. This study investigates the effects of low-dose S-ketamine on reducing POD and POCD in this patient demographic. METHODS In this retrospective cohort study, medical records of patients aged ≥ 65 years who underwent elective thoracic surgery from January 2019 to August 2023 were reviewed. Patients were categorized into S-ketamine and Control groups based on intraoperative S-ketamine exposure. POD was assessed using the Confusion Assessment Method (CAM), while cognitive function was evaluated using the Montreal Cognitive Assessment (MoCA) at baseline, 1 week, 1 month, and 6 months post-surgery. Intraoperative and postoperative parameters, including hemodynamic stability, blood loss, pain scores, and ICU stay length, were also recorded. RESULTS The study comprised 140 participants, with 70 in each group. The S-ketamine group demonstrated a significantly lower incidence of POD at 7 days post-surgery (12.0% vs. 26.7%, P < 0.001), and reduced POCD at 1 month (18.7% vs. 36.0%, P < 0.05) and 6 months (10.7% vs. 21.3%, P < 0.05). The Ketamine group had a significantly higher median MoCA score compared to the Control group both at 1 month (P = 0.021) and 6 months (P = 0.007). Adverse events, such as infection, bleeding, and respiratory failure, showed no significant differences between the groups, suggesting a safe profile for S-ketamine. CONCLUSION Administering low-dose S-ketamine during thoracic surgery in patients aged 65 years and above significantly reduces the incidence of POD and POCD, highlighting its neuroprotective potential. These findings advocate for the inclusion of S-ketamine in anesthetic protocols to improve postoperative outcomes and reduce healthcare costs in this patient population.
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Affiliation(s)
- Yujia Wang
- Department of Anesthesiology, Kunshan First People's Hospital, Kunshan Hospital Affiliated to Jiangsu University, No.566 Qianjin East Road, Kunshan, 215300, China.
| | - Bingqiang Ma
- Department of Anesthesiology, Kunshan First People's Hospital, Kunshan Hospital Affiliated to Jiangsu University, No.566 Qianjin East Road, Kunshan, 215300, China
| | - Chaochang Wang
- Department of Anesthesiology, Kunshan First People's Hospital, Kunshan Hospital Affiliated to Jiangsu University, No.566 Qianjin East Road, Kunshan, 215300, China
| | - Yingqi Wang
- Department of Anesthesiology, Kunshan First People's Hospital, Kunshan Hospital Affiliated to Jiangsu University, No.566 Qianjin East Road, Kunshan, 215300, China
| | - Aijia Liu
- Department of Anesthesiology, Kunshan First People's Hospital, Kunshan Hospital Affiliated to Jiangsu University, No.566 Qianjin East Road, Kunshan, 215300, China
| | - Lihua Hang
- Department of Anesthesiology, Kunshan First People's Hospital, Kunshan Hospital Affiliated to Jiangsu University, No.566 Qianjin East Road, Kunshan, 215300, China
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Kornilov E, Baker Erdman H, Kahana E, Fireman S, Zarchi O, Israelashvili M, Reiner J, Glik A, Weiss P, Paz R, Bergman H, Tamir I. Interleaved Propofol-Ketamine Maintains DBS Physiology and Hemodynamic Stability: A Double-Blind Randomized Controlled Trial. Mov Disord 2024; 39:694-705. [PMID: 38396358 DOI: 10.1002/mds.29746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 12/18/2023] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND The gold standard anesthesia for deep brain stimulation (DBS) surgery is the "awake" approach, using local anesthesia alone. Although it offers high-quality microelectrode recordings and therapeutic-window assessment, it potentially causes patients extreme stress and might result in suboptimal surgical outcomes. General anesthesia or deep sedation is an alternative, but may reduce physiological testing reliability and lead localization accuracy. OBJECTIVES The aim is to investigate a novel anesthesia regimen of ketamine-induced conscious sedation for the physiological testing phase of DBS surgery. METHODS Parkinson's patients undergoing subthalamic DBS surgery were randomly divided into experimental and control groups. During physiological testing, the groups received 0.25 mg/kg/h ketamine infusion and normal saline, respectively. Both groups had moderate propofol sedation before and after physiological testing. The primary outcome was recording quality. Secondary outcomes included hemodynamic stability, lead accuracy, motor and cognitive outcome, patient satisfaction, and adverse events. RESULTS Thirty patients, 15 from each group, were included. Intraoperatively, the electrophysiological signature and lead localization were similar under ketamine and saline. Tremor amplitude was slightly lower under ketamine. Postoperatively, patients in the ketamine group reported significantly higher satisfaction with anesthesia. The improvement in Unified Parkinson's disease rating scale part-III was similar between the groups. No negative effects of ketamine on hemodynamic stability or cognition were reported perioperatively. CONCLUSIONS Ketamine-induced conscious sedation provided high quality microelectrode recordings comparable with awake conditions. Additionally, it seems to allow superior patient satisfaction and hemodynamic stability, while maintaining similar post-operative outcomes. Therefore, it holds promise as a novel alternative anesthetic regimen for DBS. © 2024 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Evgeniya Kornilov
- Department of Anesthesiology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
- Department of Neurobiology, Weizmann Institute of Science, Rehovot, Israel
| | - Halen Baker Erdman
- Department of Medical Neurobiology, Hebrew University, Jerusalem, Israel
| | - Eilat Kahana
- Department of Anesthesiology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
| | - Shlomo Fireman
- Department of Anesthesiology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
| | - Omer Zarchi
- Intraoperative Neurophysiology Unit, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
| | | | - Johnathan Reiner
- Department of Neurology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
| | - Amir Glik
- Department of Neurology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
- Cognitive Neurology Clinic, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Penina Weiss
- Occupational Therapy Department, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
| | - Rony Paz
- Department of Neurobiology, Weizmann Institute of Science, Rehovot, Israel
| | - Hagai Bergman
- Department of Medical Neurobiology, Hebrew University, Jerusalem, Israel
- Department of Neurosurgery, Hadassah Medical Center, Hebrew University, Jerusalem, Israel
- The Edmond and Lily Safra Center for Brain Sciences, Hebrew University, Jerusalem, Israel
| | - Idit Tamir
- Department of Neurosurgery, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
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Loi MV, Lee JH, Huh JW, Mallory P, Napolitano N, Shults J, Krawiec C, Shenoi A, Polikoff L, Al-Subu A, Sanders R, Toal M, Branca A, Glater-Welt L, Ducharme-Crevier L, Breuer R, Parsons S, Harwayne-Gidansky I, Kelly S, Motomura M, Gladen K, Pinto M, Giuliano J, Bysani G, Berkenbosch J, Biagas K, Rehder K, Kasagi M, Lee A, Jung P, Shetty R, Nadkarni V, Nishisaki A. Ketamine Use in the Intubation of Critically Ill Children with Neurological Indications: A Multicenter Retrospective Analysis. Neurocrit Care 2024; 40:205-214. [PMID: 37160847 DOI: 10.1007/s12028-023-01734-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 04/10/2023] [Indexed: 05/11/2023]
Abstract
BACKGROUND Ketamine has traditionally been avoided for tracheal intubations (TIs) in patients with acute neurological conditions. We evaluate its current usage pattern in these patients and any associated adverse events. METHODS We conducted a retrospective observational cohort study of critically ill children undergoing TI for neurological indications in 53 international pediatric intensive care units and emergency departments. We screened all intubations from 2014 to 2020 entered into the multicenter National Emergency Airway Registry for Children (NEAR4KIDS) registry database. Patients were included if they were under the age of 18 years and underwent TI for a primary neurological indication. Usage patterns and reported periprocedural composite adverse outcomes (hypoxemia < 80%, hypotension/hypertension, cardiac arrest, and dysrhythmia) were noted. RESULTS Of 21,562 TIs, 2,073 (9.6%) were performed for a primary neurological indication, including 190 for traumatic brain injury/trauma. Patients received ketamine in 495 TIs (23.9%), which increased from 10% in 2014 to 41% in 2020 (p < 0.001). Ketamine use was associated with a coindication of respiratory failure, difficult airway history, and use of vagolytic agents, apneic oxygenation, and video laryngoscopy. Composite adverse outcomes were reported in 289 (13.9%) Tis and were more common in the ketamine group (17.0% vs. 13.0%, p = 0.026). After adjusting for location, patient age and codiagnoses, the presence of respiratory failure and shock, difficult airway history, provider demographics, intubating device, and the use of apneic oxygenation, vagolytic agents, and neuromuscular blockade, ketamine use was not significantly associated with increased composite adverse outcomes (adjusted odds ratio 1.34, 95% confidence interval CI 0.99-1.81, p = 0.057). This paucity of association remained even when only neurotrauma intubations were considered (10.6% vs. 7.7%, p = 0.528). CONCLUSIONS This retrospective cohort study did not demonstrate an association between procedural ketamine use and increased risk of peri-intubation hypoxemia and hemodynamic instability in patients intubated for neurological indications.
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Affiliation(s)
- Mervin V Loi
- Department of Pediatric Subspecialties, Children's Intensive Care Unit, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, Singapore.
| | - Jan Hau Lee
- Department of Pediatric Subspecialties, Children's Intensive Care Unit, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, Singapore
| | - Jimmy W Huh
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Palen Mallory
- Department of Pediatric Critical Care Medicine, Duke Children's Hospital and Health Center, Durham, NC, USA
| | - Natalie Napolitano
- Respiratory Therapy Department, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Justine Shults
- Department of Biostatistics, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Conrad Krawiec
- Departments of Pediatric Critical Care Medicine and Pediatrics, Penn State Health Children's Hospital, Hershey, PA, USA
| | - Asha Shenoi
- Department of Pediatrics, University of Kentucky, Lexington, KY, USA
| | - Lee Polikoff
- Department of Pediatric Critical Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Awni Al-Subu
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Wisconsin, School of Medicine and Public Health, Madison, WI, USA
| | - Ronald Sanders
- Division of Critical Care Medicine, Arkansas Children's Hospital, Little Rock, AR, USA
| | - Megan Toal
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | - Aline Branca
- Department of Pediatric Critical Care Medicine, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Lily Glater-Welt
- Department of Pediatric Critical Care Medicine, Cohen Children's Medical Center of New York, New Hyde Park, NY, USA
| | - Laurence Ducharme-Crevier
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Canada
| | - Ryan Breuer
- Division of Critical Care Medicine, Department of Pediatrics, John R. Oishei Children's Hospital, Buffalo, NY, USA
| | - Simon Parsons
- Section of Critical Care Medicine, Alberta Children's Hospital, Calgary, Canada
| | - Ilana Harwayne-Gidansky
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Albany Medical College, Albany, NY, USA
| | - Serena Kelly
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Oregon Health and Science University Doernbecher Children's Hospital, Portland, OR, USA
| | - Makoto Motomura
- Division of Pediatric Critical Care Medicine, Aichi Children's Health and Medical Center, Aichi, Japan
| | - Kelsey Gladen
- Department of Pediatric Critical Care Medicine, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Matthew Pinto
- Department of Pediatrics, New York Medical College, Valhalla, NY, USA
| | - John Giuliano
- Section of Pediatric Critical Care, Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | - Gokul Bysani
- Department of Pediatrics, Medical City Children's Hospital, Dallas, TX, USA
| | - John Berkenbosch
- Department of Pediatric Critical Care, University of Louisville and Norton Children's Hospital, Louisville, KY, USA
| | - Katherine Biagas
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Renaissance School of Medicine at Stony, Brook University, Stony Brook, NY, USA
| | - Kyle Rehder
- Division of Pediatric Critical Care, Duke Children's Hospital, Durham, NC, USA
| | - Mioko Kasagi
- Division of Pediatric Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Anthony Lee
- Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Philipp Jung
- Department of Pediatrics, University Hospital Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - Rakshay Shetty
- Pediatric Intensive Care, Rainbow Children's Hospital, Bengaluru, India
| | - Vinay Nadkarni
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Akira Nishisaki
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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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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Ghazaly HF, Hemaida TS, Zaher ZZ, Elkhodary OM, Hammad SS. A pre-anesthetic bolus of ketamine versus dexmedetomidine for prevention of postoperative delirium in elderly patients undergoing emergency surgery: a randomized, double-blinded, placebo-controlled study. BMC Anesthesiol 2023; 23:407. [PMID: 38082227 PMCID: PMC10712092 DOI: 10.1186/s12871-023-02367-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 11/30/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND We aimed to evaluate whether a single dose of ketamine or dexmedetomidine before induction of general anesthesia could reduce the incidence of postoperative delirium (primary outcome) or cognitive dysfunction (secondary outcome) in elderly patients undergoing emergency surgery. PATIENTS AND METHODS This randomized, double-blinded, placebo-controlled trial included 60 elderly patients who were scheduled for emergency surgery. The patients were randomly assigned into one of three groups (n = 20): group I received 0.9% normal saline, group II received 1 µg/kg dexmedetomidine, and group III received 1 mg/kg ketamine right before anesthesia induction. Patients were observed for three days after surgery and tested for postoperative delirium and cognitive dysfunction using the delirium observation screening scale and the mini-mental state examination score, respectively. RESULTS The dexmedetomidine group had the lowest incidence of delirium (p = 0.001) and cognitive dysfunction (p = 0.006) compared to the ketamine and placebo groups. The multivariate logistic regression model revealed that dexmedetomidine reduced the incidence of postoperative delirium by 32% compared to placebo (reference) (OR = 0.684, 95% CI: 0.240-0.971, p = 0.025), whereas ketamine increased the risk by threefold (OR = 3.012, 95% CI: 1.185-9.681, p = 0.013). Furthermore, dexmedetomidine reduced the incidence of postoperative cognitive dysfunction by 62% (OR = 0.375, 95% CI: 0.091-0.543, p = 0.012), whereas ketamine increased the risk by 4.5 times (OR = 4.501, 95% CI: 1.161-8.817, p = 0.006). CONCLUSION A single pre-anesthetic bolus of dexmedetomidine is a practical choice for preventing postoperative delirium in elderly patients undergoing emergency surgery. TRIAL REGISTRATION This study was approved by the Ethics Committee of Aswan University Hospital (approval number: aswu/548/7/2021; registration date: 06/07/2021) and registered on ClinicalTrials.gov (NCT05341154) (22/04/2022).
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Affiliation(s)
- Huda F Ghazaly
- Anesthesia and Surgical Intensive Care Department, Faculty of Medicine, Aswan University, Aswan, Egypt.
| | - Tarek S Hemaida
- Anesthesia and Surgical Intensive Care Department, Faculty of Medicine, Aswan University, Aswan, Egypt
| | - Zaher Z Zaher
- Anesthesia and Surgical Intensive Care Department, Faculty of Medicine, Aswan University, Aswan, Egypt
| | - Omar M Elkhodary
- Anesthesia and Surgical Intensive Care Department, Faculty of Medicine, Aswan University, Aswan, Egypt
| | - Soudy S Hammad
- Anesthesia and Surgical Intensive Care Department, Faculty of Medicine, Aswan University, Aswan, Egypt
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Domínguez-Oliva A, Hernández-Ávalos I, Olmos-Hernández A, Villegas-Juache J, Verduzco-Mendoza A, Mota-Rojas D. Thermal Response of Laboratory Rats ( Rattus norvegicus) during the Application of Six Methods of Euthanasia Assessed by Infrared Thermography. Animals (Basel) 2023; 13:2820. [PMID: 37760220 PMCID: PMC10526081 DOI: 10.3390/ani13182820] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 08/28/2023] [Accepted: 09/01/2023] [Indexed: 09/29/2023] Open
Abstract
Refinement is one of the principles aiming to promote welfare in research animals. The techniques used during an experimental protocol, including euthanasia selection, must prevent and minimize suffering. Although the current euthanasia methods applied to laboratory rodents are accepted, the controversial findings regarding the potential stress/distress they can cause is a field of research. The objective was to assess the thermal response of Wistar rats during various euthanasia methods using infrared thermography (IRT) to determine the method that prevents or diminishes the stress response and prolonged suffering. Pentobarbital (G1), CO2 (G2), decapitation (G3), isoflurane (G4), ketamine + xylazine (G5), and ketamine + CO2 (G6) were evaluated at five evaluation times with IRT to identify changes in the surface temperature of four anatomical regions: ocular (T°ocu), auricular (T°ear), interscapular (T°dor), and caudal (T°tai). Significant differences (p < 0.05) were found in G2 and G4, registering temperature increases from the administration of the drug to the cessation of respiratory rate and heart rate. Particularly, isoflurane showed a marked thermal response in T°ocu, T°ear, T°dor, and T°tai, suggesting that, in general, inhalant euthanasia methods induce stress in rats and that isoflurane might potentially cause distress, an effect that must be considered when deciding humane euthanasia methods in laboratory rodents.
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Affiliation(s)
- Adriana Domínguez-Oliva
- Master in Science Program “Maestría en Ciencias Agropecuarias”, Xochimilco Campus, Universidad Autónoma Metropolitana, Mexico City 04960, Mexico
- Neurophysiology of Pain, Behavior and Assessment of Welfare in Domestic Animals, DPAA, Xochimilco Campus, Universidad Autónoma Metropolitana (UAM), Mexico City 04960, Mexico
| | - Ismael Hernández-Ávalos
- Clinical Pharmacology and Veterinary Anesthesia, Biological Sciences Department, Facultad de Estudios Superiores Cuautitlán, Universidad Nacional Autónoma de México, Cuautitlán Izcalli 54714, Mexico
| | - Adriana Olmos-Hernández
- Division of Biotechnology—Bioterio and Experimental Surgery, Instituto Nacional de Rehabilitación-Luis Guillermo Ibarra Ibarra (INR-LGII), Mexico City 14389, Mexico
| | - Juan Villegas-Juache
- Bioterio and Experimental Surgery, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City 14080, Mexico
| | - Antonio Verduzco-Mendoza
- Division of Biotechnology—Bioterio and Experimental Surgery, Instituto Nacional de Rehabilitación-Luis Guillermo Ibarra Ibarra (INR-LGII), Mexico City 14389, Mexico
| | - Daniel Mota-Rojas
- Neurophysiology of Pain, Behavior and Assessment of Welfare in Domestic Animals, DPAA, Xochimilco Campus, Universidad Autónoma Metropolitana (UAM), Mexico City 04960, Mexico
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9
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Mazandi VM, Lang SS, Rahman RK, Nishisaki A, Beaulieu F, Zhang B, Griffis H, Tucker AM, Storm PB, Heuer GG, Gajjar AA, Ampah SB, Kirschen MP, Topjian AA, Yuan I, Francoeur C, Kilbaugh TJ, Huh JW. Co-administration of Ketamine in Pediatric Patients with Neurologic Conditions at Risk for Intracranial Hypertension. Neurocrit Care 2022; 38:242-253. [PMID: 36207491 DOI: 10.1007/s12028-022-01611-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 08/15/2022] [Indexed: 10/10/2022]
Abstract
BACKGROUND Ketamine has traditionally been avoided as an induction agent for tracheal intubation in patients with neurologic conditions at risk for intracranial hypertension due to conflicting data in the literature. The objective of this study was to evaluate and compare the effects of ketamine versus other medications as the primary induction agent on peri-intubation neurologic, hemodynamic and respiratory associated events in pediatric patients with neurologic conditions at risk for intracranial hypertension. METHODS This retrospective observational study enrolled patients < 18 years of age at risk for intracranial hypertension who were admitted to a quaternary children's hospital between 2015 and 2020. Associated events included neurologic, hemodynamic and respiratory outcomes comparing primary induction agents of ketamine versus non-ketamine for tracheal intubation. RESULTS Of 143 children, 70 received ketamine as the primary induction agent prior to tracheal intubation. Subsequently after tracheal intubation, all the patients received adjunct analgesic and sedative medications (fentanyl, midazolam, and/or propofol) at doses that were inadequate to induce general anesthesia but would keep them comfortable for further diagnostic workup. There were no significant differences between associated neurologic events in the ketamine versus non-ketamine groups (p = 0.42). This included obtaining an emergent computed tomography scan (p = 0.28), an emergent trip to the operating room within 5 h of tracheal intubation (p = 0.6), and the need for hypertonic saline administration within 15 min of induction drug administration for tracheal intubation (p = 0.51). There were two patients who had clinical and imaging evidence of herniation, which was not more adversely affected by ketamine compared with other medications (p = 0.49). Of the 143 patients, 23 had pre-intubation and post-intubation intracranial pressure values recorded; 11 received ketamine, and 3 of these patients had intracranial hypertension that resolved or improved, whereas the remaining 8 children had intracranial pressure within the normal range that was not exacerbated by ketamine. There were no significant differences in overall associated hemodynamic or respiratory events during tracheal intubation and no 24-h mortality in either group. CONCLUSIONS The administration of ketamine as the primary induction agent prior to tracheal intubation in combination with other agents after tracheal intubation in children at risk for intracranial hypertension was not associated with an increased risk of peri-intubation associated neurologic, hemodynamic or respiratory events compared with those who received other induction agents.
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Affiliation(s)
- Vanessa M Mazandi
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard, 6 Wood Center, Philadelphia, PA, 19104, USA.
| | - Shih-Shan Lang
- Division of Neurosurgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Raphia K Rahman
- Division of Neurosurgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Rowan School of Osteopathic Medicine, Stratford, NJ, USA
| | - Akira Nishisaki
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard, 6 Wood Center, Philadelphia, PA, 19104, USA
| | - Forrest Beaulieu
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard, 6 Wood Center, Philadelphia, PA, 19104, USA.,Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Bingqing Zhang
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Heather Griffis
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alexander M Tucker
- Division of Neurosurgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Phillip B Storm
- Division of Neurosurgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Greg G Heuer
- Division of Neurosurgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Avi A Gajjar
- Division of Neurosurgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Chemistry, Union College, Schenectady, NY, USA
| | - Steve B Ampah
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Matthew P Kirschen
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard, 6 Wood Center, Philadelphia, PA, 19104, USA
| | - Alexis A Topjian
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard, 6 Wood Center, Philadelphia, PA, 19104, USA
| | - Ian Yuan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard, 6 Wood Center, Philadelphia, PA, 19104, USA
| | - Conall Francoeur
- Department of Pediatrics, CHU de Québec-Université Laval Research Center, Quebec City, QC, Canada
| | - Todd J Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard, 6 Wood Center, Philadelphia, PA, 19104, USA
| | - Jimmy W Huh
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard, 6 Wood Center, Philadelphia, PA, 19104, USA
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10
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Ornowska M, Wormsbecker A, Andolfatto G, Leung T, Khan I, Medvedev G. The use of ketamine as a neuroprotective agent following cardiac arrest: A scoping review of current literature. CNS Neurosci Ther 2022; 29:104-110. [PMID: 36184822 PMCID: PMC9804040 DOI: 10.1111/cns.13983] [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: 04/05/2022] [Revised: 09/12/2022] [Accepted: 09/13/2022] [Indexed: 02/06/2023] Open
Abstract
AIMS The objective of this article is to summarize the state of the literature surrounding the use of ketamine as a neuroprotective agent following cardiac arrest. METHODS Five electronic databases were used to search for studies related to the use of ketamine for neuroprotection following cardiac arrest. This search was performed once in May 2020, and an updated search was conducted in May 2021 and March 2022. RESULTS All searches combined retrieved 181 results; no clinical trials were identified. As such, the authors were limited to writing a scoping review of the literature rather than a systematic review. CONCLUSIONS The current state of the literature describes the mechanism of action of ketamine as a neuroprotective agent through its action as an NMDA antagonist. There is evidence of its efficacy as a neuroprotective agent in preclinical models of cardiac arrest. Current published clinical work supports the use of ketamine ameliorating neurologic outcomes in other conditions such as epilepsy, traumatic brain injury, and depression. The current state of the literature is reflective of the notion that the use of ketamine following cardiac arrest may result in improved neurologic outcomes. Future research directions should focus on the use of ketamine as a possible clinical intervention following cardiac arrest.
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Affiliation(s)
- Marlena Ornowska
- Department of Biomedical PhysiologySimon Fraser UniversityBurnabyBritish ColumbiaCanada
| | - Andrew Wormsbecker
- Royal Columbian Hospital, Fraser Health AuthorityNew WestminsterBritish ColumbiaCanada,Division of Critical Care, Department of MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Gary Andolfatto
- Department of Emergency Medicine, Department of MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Tim S. Leung
- Royal Columbian Hospital, Fraser Health AuthorityNew WestminsterBritish ColumbiaCanada,Faculty of Pharmaceutical SciencesUniversity of British ColumbiaVancouverBritish ColumbiaCanada,Lower Mainland Pharmacy ServicesVancouverBritish ColumbiaCanada
| | - Idan Khan
- Royal Columbian Hospital, Fraser Health AuthorityNew WestminsterBritish ColumbiaCanada,Department of Emergency Medicine, Department of MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - George Medvedev
- Royal Columbian Hospital, Fraser Health AuthorityNew WestminsterBritish ColumbiaCanada,Division of Neurology, Department of MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
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11
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Wei W, Zhang A, Liu L, Zheng X, Tang C, Zhou M, Gu Y, Yao Y. Effects of subanaesthetic S-ketamine on postoperative delirium and cognitive function in elderly patients undergoing non-cardiac thoracic surgery: a protocol for a randomised, double-blinded, placebo-controlled and positive-controlled, non-inferiority trial (SKED trial). BMJ Open 2022; 12:e061535. [PMID: 35914911 PMCID: PMC9345033 DOI: 10.1136/bmjopen-2022-061535] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Postoperative delirium (POD) is a common and distressing complication after thoracic surgery. S-ketamine has neuroprotective properties as a dissociative anaesthetic. Emerging literature has indicated that S-ketamine can reduce cognitive impairment in patients with depression. However, the role of S-ketamine in preventing POD remains unknown. Therefore, this study aims to evaluate the effect of intraoperative prophylactic S-ketamine compared with that of dexmedetomidine on the incidence of POD in elderly patients undergoing non-cardiac thoracic surgery. METHODS AND ANALYSIS This will be a randomised, double-blinded, placebo-controlled, positive-controlled, non-inferiority trial that enrolled patients aged 60-90 years undergoing thoracic surgery. The patients will be randomly allocated in a ratio of 1:1:1 to S-ketamine, dexmedetomidine or normal saline placebo groups using computer-generated randomisation with a block size of six. The primary outcome will be the incidence of POD within 4 days after surgery and this will be assessed using a 3-Minute Diagnostic Confusion Assessment Method two times per day. The severity and duration of POD, the incidence of emergence delirium, postoperative pain, quality of sleep, cognitive function, and the plasma concentrations of acetylcholine, brain-derived neurotrophic factor, tumour necrosis factor-α and incidence of adverse events will be evaluated as secondary outcomes. ETHICS AND DISSEMINATION Ethical approval has been obtained from the Institutional Review Board of the Cancer Hospital and the Institute of Guangzhou Medical University (ZN202119). At the end of the trial, we commit to making a public disclosure available, regardless of the outcome. The public disclosure will include a publication in an appropriate journal and an oral presentation at academic meetings. TRIAL REGISTRATION NUMBER ChiCTR2100052750 (NCT05242692).
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Affiliation(s)
- Wei Wei
- Department of Anesthesiology, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Anyu Zhang
- Department of Anesthesiology, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Lv Liu
- Department of Anesthesiology, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Xi Zheng
- Department of Anesthesiology, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Chunlin Tang
- Department of Anesthesiology, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Ming Zhou
- Department of Thoracic Surgery, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Yu Gu
- Department of Anesthesiology, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Yonghua Yao
- Department of Anesthesiology, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou, Guangdong, China
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12
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Erdman HB, Kornilov E, Kahana E, Zarchi O, Reiner J, Socher A, Strauss I, Firman S, Israel Z, Bergman H, Tamir I. Asleep DBS under ketamine sedation: Proof of concept. Neurobiol Dis 2022; 170:105747. [PMID: 35550159 DOI: 10.1016/j.nbd.2022.105747] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 04/28/2022] [Accepted: 05/05/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Deep brain stimulation (DBS) is commonly and safely performed for selective Parkinson's disease patients. Many centers perform DBS lead positioning exclusively under local anesthesia, to optimize brain microelectrode recordings (MER) and testing of stimulation-related therapeutic and side effects. These measures enable physiological identification of the DBS borders and subdomains based on electrophysiological properties like firing rates and patterns, intra-operative evaluation of therapeutic window, and improvement of lead placement accuracy. Nevertheless, due to the challenges of awake surgery, some centers use sedation or general anesthesia, despite the distortion of discharge properties and interference with clinical testing, resulting in potential impact on surgical outcomes. Thus, there is a need for a novel anesthesia regimen that enables sedation without compromising intra-operative monitoring. OBJECTIVE This open-label study investigates the use of low-dose ketamine for conscious sedation during microelectrode recordings and lead positioning in subthalamic nucleus (STN) DBS for Parkinson's disease patients. METHODS Three anesthetic regimens were retrospectively compared in 38 surgeries (74 MER trajectories, 5962 recording sites) across three DBS centers: 1) Interleaved propofol-ketamine (PK), 2) Interleaved propofol-awake (PA), and 3) Fully awake (AA). RESULTS All anesthesia regimens achieved satisfactory MER. Detection of STN borders and subdomains by expert electrophysiologist was similar between the groups. Electrophysiological signature of the STN under ketamine was not inferior to either control group. All patients completed stimulation testing. CONCLUSIONS This study supports a low-dose ketamine anesthesia regimen for DBS which allows microelectrode recordings and stimulation testing that are not inferior to those conducted under awake and propofol-awake regimens and may optimize patient experience. A prospective double-blind study that would also compare patients' satisfaction level and clinical outcome should be performed to confirm these findings.
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Affiliation(s)
- Halen Baker Erdman
- Department of Medical Neurobiology, Hebrew University, Jerusalem, Israel.
| | - Evgeniya Kornilov
- Department of Anesthesiology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel; Department of Neurobiology, Weizmann Institute of Science, Rehovot, Israel
| | - Eilat Kahana
- Department of Anesthesiology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
| | - Omer Zarchi
- Intraoperative Neurophysiology Unit, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
| | - Johnathan Reiner
- Department of Neurology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
| | - Achinoam Socher
- Department of Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ido Strauss
- Department of Neurosurgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Shimon Firman
- Department of Anesthesiology, Critical Care Medicine, and Pain Management, Hadassah Medical Center, Hebrew University, Jerusalem, Israel
| | - Zvi Israel
- Department of Neurosurgery, Hadassah Medical Center, Hebrew University, Jerusalem, Israel
| | - Hagai Bergman
- Department of Medical Neurobiology, Hebrew University, Jerusalem, Israel; Department of Neurosurgery, Hadassah Medical Center, Hebrew University, Jerusalem, Israel; The Edmond and Lily Safra Center for Brain Sciences, Hebrew University, Jerusalem, Israel
| | - Idit Tamir
- Department of Neurosurgery, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel.
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13
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Tagliazucchi E. Language as a Window Into the Altered State of Consciousness Elicited by Psychedelic Drugs. Front Pharmacol 2022; 13:812227. [PMID: 35392561 PMCID: PMC8980225 DOI: 10.3389/fphar.2022.812227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 03/01/2022] [Indexed: 11/22/2022] Open
Abstract
Psychedelics are drugs capable of eliciting profound alterations in the subjective experience of the users, sometimes with long-lasting consequences. Because of this, psychedelic research tends to focus on human subjects, given their capacity to construct detailed narratives about the contents of their consciousness experiences. In spite of its relevance, the interaction between serotonergic psychedelics and language production is comparatively understudied in the recent literature. This review is focused on two aspects of this interaction: how the acute effects of psychedelic drugs impact on speech organization regardless of its semantic content, and how to characterize the subjective effects of psychedelic drugs by analyzing the semantic content of written retrospective reports. We show that the computational characterization of language production is capable of partially predicting the therapeutic outcome of individual experiences, relate the effects elicited by psychedelics with those associated with other altered states of consciousness, draw comparisons between the psychedelic state and the symptomatology of certain psychiatric disorders, and investigate the neurochemical profile and mechanism of action of different psychedelic drugs. We conclude that researchers studying psychedelics can considerably expand the range of their potential scientific conclusions by analyzing brief interviews obtained before, during and after the acute effects. Finally, we list a series of questions and open problems that should be addressed to further consolidate this approach.
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Affiliation(s)
- Enzo Tagliazucchi
- Latin American Brain Health Institute (BrainLat), Universidad Adolfo Ibanez, Santiago, Chile
- Departamento de Física, Universidad de Buenos Aires and Instituto de Física de Buenos Aires (IFIBA, CONICET), Pabellón I, Ciudad Universitaria (1428), Buenos Aires, Argentina
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14
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Augoustides JG. Commentary: Neuroprotection in Hypothermic Circulatory Arrest - is ketamine a magic bullet? Semin Thorac Cardiovasc Surg 2021; 35:259-260. [PMID: 34952156 DOI: 10.1053/j.semtcvs.2021.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 12/13/2021] [Indexed: 11/11/2022]
Affiliation(s)
- John G Augoustides
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania.
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15
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Sorby-Adams AJ, Learoyd AE, Bath PM, Burrows F, Farr TD, Leonard AV, Schiessl I, Allan SM, Turner RJ, Trueman RC. Glyceryl trinitrate for the treatment of ischaemic stroke: Determining efficacy in rodent and ovine species for enhanced clinical translation. J Cereb Blood Flow Metab 2021; 41:3248-3259. [PMID: 34039053 PMCID: PMC8669202 DOI: 10.1177/0271678x211018901] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Hypertension is a leading risk factor for death and dependency after ischaemic stroke. However, administering anti-hypertensive medications post-stroke remains contentious with concerns regarding deleterious effects on cerebral blood flow and infarct expansion. This study sought to determine the effect of glyceryl trinitrate (GTN) treatment in both lissencephalic and gyrencephalic pre-clinical stroke models. Merino sheep underwent middle cerebral artery occlusion (MCAO) followed by GTN or control patch administration (0.2 mg/h). Monitoring of numerous physiologically relevant measures over 24 h showed that GTN administration was associated with decreased intracranial pressure, infarct volume, cerebral oedema and midline shift compared to vehicle treatment (p < 0.05). No significant changes in blood pressure or cerebral perfusion pressure were observed. Using optical imaging spectroscopy and laser speckle imaging, the effect of varying doses of GTN (0.69-50 µg/h) on cerebral blood flow and tissue oxygenation was examined in mice. No consistent effect was found. Additional mice undergoing MCAO followed by GTN administration (doses varying from 0-60 µg/h) also showed no improvement in infarct volume or neurological score within 24 h post-stroke. GTN administration significantly improved numerous stroke-related physiological outcomes in sheep but was ineffective in mice. This suggests that, whilst GTN administration could potentially benefit patients, further research into mechanisms of action are required.
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Affiliation(s)
- Annabel J Sorby-Adams
- Adelaide Medical School and Adelaide Centre for Neuroscience Research, The University of Adelaide, Adelaide, SA, Australia
| | - Annastazia E Learoyd
- School of Life Sciences, University of Nottingham Medical School, Nottingham, UK
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Fiona Burrows
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Tracy D Farr
- School of Life Sciences, University of Nottingham Medical School, Nottingham, UK
| | - Anna V Leonard
- Adelaide Medical School and Adelaide Centre for Neuroscience Research, The University of Adelaide, Adelaide, SA, Australia
| | - Ingo Schiessl
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK.,Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance NHS Group, University of Manchester, Manchester, UK
| | - Stuart M Allan
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK.,Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance NHS Group, University of Manchester, Manchester, UK
| | - Renée J Turner
- Adelaide Medical School and Adelaide Centre for Neuroscience Research, The University of Adelaide, Adelaide, SA, Australia
| | - Rebecca C Trueman
- School of Life Sciences, University of Nottingham Medical School, Nottingham, UK
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16
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Breindahl N, Baekgaard J, Christensen RE, Jensen AH, Creutzburg A, Steinmetz J, Rasmussen LS. Ketamine versus propofol for rapid sequence induction in trauma patients: a retrospective study. Scand J Trauma Resusc Emerg Med 2021; 29:136. [PMID: 34526085 PMCID: PMC8442378 DOI: 10.1186/s13049-021-00948-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 08/31/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Rapid Sequence Induction (RSI) is used for emergency tracheal intubation to minimise the risk of pulmonary aspiration of stomach contents. Ketamine and propofol are two commonly used induction agents for RSI in trauma patients. Yet, no consensus exists on the optimal induction agent for RSI in the trauma population. The aim of this study was to compare 30-day mortality in trauma patients after emergency intubation prehospitally or within 30 min after arrival in the trauma centre using either ketamine or propofol for RSI. METHODS In this investigator-initiated, retrospective study we included adult trauma patients emergently intubated with ketamine or propofol registered in the local trauma registry at Rigshospitalet, a tertiary university hospital that hosts a level-1 trauma centre. The primary outcome was 30-day mortality. Secondary outcomes included hospital and Intensive Care Unit length of stay as well as duration of mechanical ventilation. We analysed outcomes using multivariable logistic regression models adjusting for age, sex, injury severity score, shock (systolic blood pressure < 90 mmHg) and Glasgow Coma Scale score before intubation and present results as odds ratios (ORs) with 95% confidence intervals. RESULTS From January 1st, 2015 through December 31st, 2019 we identified a total of 548 eligible patients. A total of 228 and 320 patients received ketamine and propofol, respectively. The 30-day mortality for patients receiving ketamine and propofol was 20.2% and 22.8% (P = 0.46), respectively. Adjusted OR for 30-day mortality was 0.98 [0.58-1.66], P = 0.93. We found no significant association between type of induction agent and hospital length of stay, Intensive Care Unit length of stay or duration of mechanical ventilation. CONCLUSIONS In this study, trauma patients intubated with ketamine did not have a lower 30-day mortality as compared with propofol.
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Affiliation(s)
- Niklas Breindahl
- Department of Anaesthesia, Section 6011, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Inge Lehmanns Vej 6, Section 6011, 2100, Copenhagen, Denmark.
| | - Josefine Baekgaard
- Department of Anaesthesia, Section 6011, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Inge Lehmanns Vej 6, Section 6011, 2100, Copenhagen, Denmark
| | - Rasmus Ejlersgaard Christensen
- Department of Anaesthesia, Section 6011, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Inge Lehmanns Vej 6, Section 6011, 2100, Copenhagen, Denmark
| | - Alice Herrlin Jensen
- Department of Anaesthesia, Section 6011, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Inge Lehmanns Vej 6, Section 6011, 2100, Copenhagen, Denmark
| | - Andreas Creutzburg
- Department of Anaesthesia, Section 6011, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Inge Lehmanns Vej 6, Section 6011, 2100, Copenhagen, Denmark
| | - Jacob Steinmetz
- Department of Anaesthesia, Section 6011, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Inge Lehmanns Vej 6, Section 6011, 2100, Copenhagen, Denmark.,Danish Air Ambulance, Aarhus, Denmark
| | - Lars S Rasmussen
- Department of Anaesthesia, Section 6011, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Inge Lehmanns Vej 6, Section 6011, 2100, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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17
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Choudhury D, Autry AE, Tolias KF, Krishnan V. Ketamine: Neuroprotective or Neurotoxic? Front Neurosci 2021; 15:672526. [PMID: 34566558 PMCID: PMC8461018 DOI: 10.3389/fnins.2021.672526] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 07/12/2021] [Indexed: 12/20/2022] Open
Abstract
Ketamine, a non-competitive N-methyl-D-aspartate receptor (NMDAR) antagonist, has been employed clinically as an intravenous anesthetic since the 1970s. More recently, ketamine has received attention for its rapid antidepressant effects and is actively being explored as a treatment for a wide range of neuropsychiatric syndromes. In model systems, ketamine appears to display a combination of neurotoxic and neuroprotective properties that are context dependent. At anesthetic doses applied during neurodevelopmental windows, ketamine contributes to inflammation, autophagy, apoptosis, and enhances levels of reactive oxygen species. At the same time, subanesthetic dose ketamine is a powerful activator of multiple parallel neurotrophic signaling cascades with neuroprotective actions that are not always NMDAR-dependent. Here, we summarize results from an array of preclinical studies that highlight a complex landscape of intracellular signaling pathways modulated by ketamine and juxtapose the somewhat contrasting neuroprotective and neurotoxic features of this drug.
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Affiliation(s)
- Divya Choudhury
- Department of BioSciences, Rice University, Houston, TX, United States
| | - Anita E. Autry
- Dominick P. Purpura Department of Neuroscience, Albert Einstein College of Medicine, Bronx, NY, United States
- Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Kimberley F. Tolias
- Department of Neuroscience, Baylor College of Medicine, Houston, TX, United States
| | - Vaishnav Krishnan
- Department of Neuroscience, Baylor College of Medicine, Houston, TX, United States
- Department of Neurology, Baylor College of Medicine, Houston, TX, United States
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States
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18
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Guang J, Baker H, Ben-Yishay Nizri O, Firman S, Werner-Reiss U, Kapuller V, Israel Z, Bergman H. Toward asleep DBS: cortico-basal ganglia spectral and coherence activity during interleaved propofol/ketamine sedation mimics NREM/REM sleep activity. NPJ PARKINSONS DISEASE 2021; 7:67. [PMID: 34341348 PMCID: PMC8329235 DOI: 10.1038/s41531-021-00211-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 07/09/2021] [Indexed: 12/20/2022]
Abstract
Deep brain stimulation (DBS) is currently a standard procedure for advanced Parkinson's disease. Many centers employ awake physiological navigation and stimulation assessment to optimize DBS localization and outcome. To enable DBS under sedation, asleep DBS, we characterized the cortico-basal ganglia neuronal network of two nonhuman primates under propofol, ketamine, and interleaved propofol-ketamine (IPK) sedation. Further, we compared these sedation states in the healthy and Parkinsonian condition to those of healthy sleep. Ketamine increases high-frequency power and synchronization while propofol increases low-frequency power and synchronization in polysomnography and neuronal activity recordings. Thus, ketamine does not mask the low-frequency oscillations used for physiological navigation toward the basal ganglia DBS targets. The brain spectral state under ketamine and propofol mimicked rapid eye movement (REM) and Non-REM (NREM) sleep activity, respectively, and the IPK protocol resembles the NREM-REM sleep cycle. These promising results are a meaningful step toward asleep DBS with nondistorted physiological navigation.
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Affiliation(s)
- Jing Guang
- Edmond and Lily Safra Center for Brain Sciences, The Hebrew University of Jerusalem, Jerusalem, Israel.
| | - Halen Baker
- Department of Medical Neurobiology, The Hebrew University of Jerusalem, Jerusalem, Israel
| | | | - Shimon Firman
- Department of Anesthesiology, Critical Care Medicine, and Pain Management, Hadassah Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Uri Werner-Reiss
- Edmond and Lily Safra Center for Brain Sciences, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Vadim Kapuller
- Department of Pediatric Surgery, Hadassah Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel.,Asuta-Ashdod University Medical Center, Ashdod, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Zvi Israel
- Department of Neurosurgery, Hadassah Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Hagai Bergman
- Edmond and Lily Safra Center for Brain Sciences, The Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Medical Neurobiology, The Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Neurosurgery, Hadassah Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
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19
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Burfeind KG, Tirado Navales AA, Togioka BM, Schenning K. Prevention of postoperative delirium through the avoidance of potentially inappropriate medications in a geriatric surgical patient. BMJ Case Rep 2021; 14:14/4/e240403. [PMID: 33875501 PMCID: PMC8057549 DOI: 10.1136/bcr-2020-240403] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
We demonstrate the utility of risk stratification for postoperative delirium in geriatric patients and show that postoperative delirium can be prevented in high-risk patients when potentially inappropriate medications (PIMs) (medications that are best avoided in older adults) are avoided. In this case, a 65-year-old woman underwent two debridement procedures with similar presurgical risk for postoperative delirium. There was no risk stratification or preoperative cognitive assessment in the first procedure, she received PIMs and developed postoperative delirium. In the second procedure, PIMs were intentionally avoided and postoperative delirium did not occur. This case supports recent recommendations from the European Society of Anaesthesiology, the American Society of Anesthesiologists and the American Geriatrics Society that providers assess a patient's cognitive function and delirium risk profile preoperatively to appropriately guide perioperative management.
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Affiliation(s)
- Kevin G Burfeind
- Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, Oregon, USA.,Medical Scientist Training Program, Oregon Health & Science University, Portland, Oregon, USA
| | - Andrés A Tirado Navales
- Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Brandon Michael Togioka
- Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Katie Schenning
- Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, Oregon, USA
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20
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Kumar A, Kohli A. Comeback of ketamine: resurfacing facts and dispelling myths. Korean J Anesthesiol 2021; 74:103-114. [PMID: 33423410 PMCID: PMC8024210 DOI: 10.4097/kja.20663] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 01/10/2021] [Accepted: 01/10/2021] [Indexed: 11/17/2022] Open
Abstract
Initially known as CI-581, ketamine was first synthesized in 1962 as a replacement from phencyclidine. It has since been used as an anesthetic and analgesic. In addition, it has bronchodilating, sedative, and amnestic properties, preserving airway reflexes and sympathetic nervous system tone. Since the discovery of ketamine, it has been a major topic of discussion due to controversies regarding its usage in particular sets of patients. In the past 50 years, despite its potential benefits, it is not commonly used because of concerns of "emergence phenomenon," its use as a substance of abuse, and its systemic side effects. Since 2012, three World Health Organization reviews on ketamine have addressed its international control. Researchers have been studying this wonder drug for a decade worldwide. Many myths of ketamine regarding emergence phenomenon and its use in traumatic brain injury and open eye injury have been disproved in recent times. It is becoming popular in pre-hospital settings, critical care, emergency medicine, low-dose acute pain services, and adjuvant in regional anesthesia techniques. This review highlights the current consensus on the various applications of ketamine in the literature.
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Affiliation(s)
- Abhijit Kumar
- Department of Anesthesiology, VMMC and Safdarjung Hospital, New Delhi, India
| | - Amit Kohli
- Department of Anesthesiology, Maulana Azad Medical College, New Delhi, India
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21
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Godoy DA, Badenes R, Pelosi P, Robba C. Ketamine in acute phase of severe traumatic brain injury "an old drug for new uses?". CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:19. [PMID: 33407737 PMCID: PMC7788834 DOI: 10.1186/s13054-020-03452-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 12/22/2020] [Indexed: 01/02/2023]
Abstract
Maintaining an adequate level of sedation and analgesia plays a key role in the management of traumatic brain injury (TBI). To date, it is unclear which drug or combination of drugs is most effective in achieving these goals. Ketamine is an agent with attractive pharmacological and pharmacokinetics characteristics. Current evidence shows that ketamine does not increase and may instead decrease intracranial pressure, and its safety profile makes it a reliable tool in the prehospital environment. In this point of view, we discuss different aspects of the use of ketamine in the acute phase of TBI, with its potential benefits and pitfalls.
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Affiliation(s)
- Daniel Agustin Godoy
- Neurointensive Care Unit, Sanatorio Pasteur, Catamarca, Argentina.,Intensive Care Unit, Hospital Carlos Malbran, Catamarca, Argentina
| | - Rafael Badenes
- Anesthesiology and Surgical-Trauma Intensive Care, University Clinic Hospital, Valencia, Spain.,Department of Surgery, University of Valencia, Valencia, Spain.,INCLIVA Research Medical Institute, Valencia, Valencia, Spain
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy. .,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.
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22
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Baekgaard JS, Eskesen TG, Moo Lee J, Ikast Ottosen C, Bennett Gyldenkærne K, Garoussian J, Ejlersgaard Christensen R, Sillesen M, King DR, Velmahos GC, Rasmussen LS, Steinmetz J. Ketamine for rapid sequence intubation in adult trauma patients: A retrospective observational study. Acta Anaesthesiol Scand 2020; 64:1234-1242. [PMID: 32531068 DOI: 10.1111/aas.13651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 05/24/2020] [Accepted: 05/30/2020] [Indexed: 01/20/2023]
Abstract
BACKGROUND In the trauma population, ketamine is commonly used during rapid sequence induction. However, as ketamine has been associated with important side effects, this study sought to compare in-hospital mortality in trauma patients after induction with ketamine versus other induction agents. METHODS We retrospectively identified adult trauma patients intubated in the pre-hospital phase or initially in the trauma bay at two urban level-1 trauma centers during a 2-year period using local trauma registries and medical records. In-hospital mortality was compared for patients intubated with ketamine versus other agents using logistic regression with adjustment for age, gender, Injury Severity Score (ISS), systolic blood pressure (SBP) < 90 mm Hg, and pre-hospital Glasgow Coma Scale (GCS) score. RESULTS A total of 343 trauma patients were included with a median ISS of 25 [17-34]. The most frequently used induction agents were ketamine (36%) and propofol (36%) followed by etomidate (9%) and midazolam (5%). There was no difference in ISS or the presence of SBP <90 mm Hg according to the agent of choice, but the pre-hospital GCS score was higher for patients intubated with ketamine (median 8 vs 5, P = .001). The mortality for patients intubated with ketamine was 18% vs 27% for patients intubated with other agents (P = .14). This remained statistically insignificant in the multivariable logistic regression analysis (odds ratio 0.68 [0.33-1.41], P = .30). CONCLUSIONS We found no statistically significant difference in mortality among patients intubated in the initial phase post-trauma with the use of ketamine compared with other agents (propofol, etomidate, or midazolam).
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Affiliation(s)
- Josefine S. Baekgaard
- Department of Anesthesia Center of Head and Orthopedics, Rigshospitalet University of Copenhagen Copenhagen Denmark
- Department of Trauma Emergency Surgery & Surgical Critical Care Massachusetts General HospitalHarvard University Boston USA
| | - Trine G. Eskesen
- Department of Anesthesia Center of Head and Orthopedics, Rigshospitalet University of Copenhagen Copenhagen Denmark
- Department of Trauma Emergency Surgery & Surgical Critical Care Massachusetts General HospitalHarvard University Boston USA
| | - Jae Moo Lee
- Department of Trauma Emergency Surgery & Surgical Critical Care Massachusetts General HospitalHarvard University Boston USA
| | - Camilla Ikast Ottosen
- Department of Anesthesia Center of Head and Orthopedics, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Katrine Bennett Gyldenkærne
- Department of Anesthesia Center of Head and Orthopedics, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Jasmin Garoussian
- Department of Anesthesia Center of Head and Orthopedics, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | | | - Martin Sillesen
- Department of Surgical Gastroenterology Copenhagen University Hospital Rigshospitalet Denmark
| | - David R. King
- Department of Trauma Emergency Surgery & Surgical Critical Care Massachusetts General HospitalHarvard University Boston USA
| | - George C. Velmahos
- Department of Trauma Emergency Surgery & Surgical Critical Care Massachusetts General HospitalHarvard University Boston USA
| | - Lars S. Rasmussen
- Department of Anesthesia Center of Head and Orthopedics, Rigshospitalet University of Copenhagen Copenhagen Denmark
- Institute of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - Jacob Steinmetz
- Department of Anesthesia Center of Head and Orthopedics, Rigshospitalet University of Copenhagen Copenhagen Denmark
- Institute of Clinical Medicine University of Copenhagen Copenhagen Denmark
- Trauma Center Center of Head and Orthopedics, Rigshospitalet University of Copenhagen Copenhagen Denmark
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23
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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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24
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Pribish A, Wood N, Kalava A. A Review of Nonanesthetic Uses of Ketamine. Anesthesiol Res Pract 2020; 2020:5798285. [PMID: 32308676 PMCID: PMC7152956 DOI: 10.1155/2020/5798285] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 02/07/2020] [Accepted: 03/05/2020] [Indexed: 12/20/2022] Open
Abstract
Ketamine, a nonselective NMDA receptor antagonist, is used widely in medicine as an anesthetic agent. However, ketamine's mechanisms of action lead to widespread physiological effects, some of which are now coming to the forefront of research for the treatment of diverse medical disorders. This paper aims at reviewing recent data on key nonanesthetic uses of ketamine in the current literature. MEDLINE, CINAHL, and Google Scholar databases were queried to find articles related to ketamine in the treatment of depression, pain syndromes including acute pain, chronic pain, and headache, neurologic applications including neuroprotection and seizures, and alcohol and substance use disorders. It can be concluded that ketamine has a potential role in the treatment of all of these conditions. However, research in this area is still in its early stages, and larger studies are required to evaluate ketamine's efficacy for nonanesthetic purposes in the general population.
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Affiliation(s)
- Abby Pribish
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Nicole Wood
- Department of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Arun Kalava
- Department of Anesthesiology, University of Central Florida College of Medicine, Orlando, FL, USA
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25
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Bebarta VS, Mora AG, Bebarta EK, Reeves LK, Maddry JK, Schauer SG, Lairet JR. Prehospital Use of Ketamine in the Combat Setting: A Sub-Analysis of Patients With Head Injuries Evaluated in the Prospective Life Saving Intervention Study. Mil Med 2020; 185:136-142. [DOI: 10.1093/milmed/usz302] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objectives
Ketamine is used as an analgesic for combat injuries. Ketamine may worsen brain injury, but new studies suggest neuroprotection. Our objective was to report the outcomes of combat casualties with traumatic brain injury (TBI) who received prehospital ketamine.
Methods
This was a post hoc, sub-analysis of a larger prospective, multicenter study (the Life Saving Intervention study [LSI]) evaluating prehospital interventions performed in Afghanistan. A DoD Trauma Registry query provided disposition at discharge and outcomes to be linked with the LSI data.
Results
For this study, we enrolled casualties that were suspected to have TBI (n = 160). Most were 26-year-old males (98%) with explosion-related injuries (66%), a median injury severity score of 12, and 5% mortality. Fifty-seven percent (n = 91) received an analgesic, 29% (n = 46) ketamine, 28% (n = 45) other analgesic (OA), and 43% (n = 69) no analgesic (NA). The ketamine group had more pelvic injuries (P = 0.0302) and tourniquets (P = 0.0041) compared to OA. In comparison to NA, the ketamine group was more severely injured and more likely to require LSI procedures, yet, had similar vital signs at admission and disposition at discharge.
Conclusions
We found that combat casualties with suspected TBI that received prehospital ketamine had similar outcomes to those that received OAs or NAs despite injury differences.
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Affiliation(s)
- Vikhyat S Bebarta
- 59th MDW/Chief Scientist Office, USAF En Route Care Research Center, JBSA-Lackland, TX; U.S. Army Institute of Surgical Research, Fort Sam Houston, TX, 1100 Wilford Hall Loop, JBSA-Lackland, TX 78236
- Department of Emergency Medicine, University of Colorado School of Medicine, 12401 E. 17th Avenue, Aurora, CO 80045
| | - Alejandra G Mora
- 59th MDW/Chief Scientist Office, USAF En Route Care Research Center, JBSA-Lackland, TX; U.S. Army Institute of Surgical Research, Fort Sam Houston, TX, 1100 Wilford Hall Loop, JBSA-Lackland, TX 78236
| | - Emma K Bebarta
- Cherry Creek High School, 9300 E Union Ave, Greenwood Village, CO 80111
| | - Lauren K Reeves
- Department of Emergency Medicine, University of Colorado School of Medicine, 12401 E. 17th Avenue, Aurora, CO 80045
| | - Joseph K Maddry
- 59th MDW/Chief Scientist Office, USAF En Route Care Research Center, JBSA-Lackland, TX; U.S. Army Institute of Surgical Research, Fort Sam Houston, TX, 1100 Wilford Hall Loop, JBSA-Lackland, TX 78236
| | - Steve G Schauer
- 59th MDW/Chief Scientist Office, USAF En Route Care Research Center, JBSA-Lackland, TX; U.S. Army Institute of Surgical Research, Fort Sam Houston, TX, 1100 Wilford Hall Loop, JBSA-Lackland, TX 78236
- US Army Institute of Surgical Research, 3698 Chambers Pass, JBSA Fort Sam Houston, Texas Brooke Army Medical Center, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, Texas
| | - Julio R Lairet
- Department of Emergency Medicine, Emory University School of Medicine, 531 Asbury Circle, Annex Building Suite N340, Atlanta, GA 30322
- Headquarters Georgia Air National Guard, 1000 Halsey Avenue Bldg. 447, Marietta, GA 30060
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26
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Association of ketamine use with lower risks of post-intubation hypotension in hemodynamically-unstable patients in the emergency department. Sci Rep 2019; 9:17230. [PMID: 31754159 PMCID: PMC6872717 DOI: 10.1038/s41598-019-53360-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 09/09/2019] [Indexed: 12/16/2022] Open
Abstract
To determine whether ketamine use for tracheal intubation, compared to other sedative use, is associated with a lower risk of post-intubation hypotension in hemodynamically-unstable patients in the emergency department (ED), we analyzed the data of a prospective, multicenter, observational study-the second Japanese Emergency Airway Network (JEAN-2) Study-from February 2012 through November 2017. The current analysis included adult non-cardiac-arrest ED patients with a pre-intubation shock index of ≥0.9. The primary exposure was ketamine use as a sedative for intubation, with midazolam or propofol use as the reference. The primary outcome was post-intubation hypotension. A total of 977 patients was included in the current analysis. Overall, 24% of patients developed post-intubation hypotension. The ketamine group had a lower risk of post-intubation hypotension compared to the reference group (15% vs 29%, unadjusted odds ratio [OR] 0.45 [95% CI 0.31-0.66] p < 0.001). This association remained significant in the multivariable analysis (adjusted OR 0.43 [95% CI 0.28-0.64] p < 0.001). Likewise, in the propensity-score matching analysis, the patients with ketamine use also had a significantly lower risk of post-intubation hypotension (OR 0.47 [95% CI, 0.31-0.71] P < 0.001). Our observations support ketamine use as a safe sedative agent for intubation in hemodynamically-unstable patients in the ED.
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27
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Effects of continuous ketamine infusion on hemodynamics and mortality in critically ill children. PLoS One 2019; 14:e0224035. [PMID: 31626685 PMCID: PMC6799949 DOI: 10.1371/journal.pone.0224035] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 10/03/2019] [Indexed: 11/23/2022] Open
Abstract
We investigated the hemodynamic and mortality effects of continuous ketamine infusion in critically ill pediatric patients. We conducted a retrospective cohort study in a tertiary pediatric intensive care unit (PICU). Patients who used continuous sedative from 2015 to 2017 for 24 hours or more were included. We compared blood pressure, heart and respiratory rates, vasogenic medications, and sedation and pain scores for 12 hours before and after initiation of continuous ketamine. The mortality rates for continuous ketamine and Non-ketamine groups were compared by multivariate logistic regression. A total of 240 patients used continuous sedation, and 82 used continuous ketamine. The median infusion rate of ketamine was 8.1 mcg/kg/min, and the median duration was 6 days. Heart rates (138 vs. 135 beat/minute, P = .033) and respiratory rates (31 vs. 25 respiration/minute, P = .001) decreased, but blood pressure (99.9 vs. 101.1 mm Hg, P = .124) and vasogenic medications did not change after ketamine infusion. Continuous ketamine was not a significant risk factor for mortality (hazard ratio 1.352, confidence interval 0.458–3.996). Continous ketamine could be used in PICU without hemodynamic instability. Further studies in randomized controlled design about the effects of continuous ketamine infusion on hemodynamic changes, sedation, and mortality are required.
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28
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Nowacka A, Borczyk M. Ketamine applications beyond anesthesia - A literature review. Eur J Pharmacol 2019; 860:172547. [PMID: 31348905 DOI: 10.1016/j.ejphar.2019.172547] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 07/09/2019] [Accepted: 07/15/2019] [Indexed: 02/07/2023]
Abstract
Ketamine's clinical use began in the 1970s. Physicians benefited from its safety and ability to induce short-term anesthesia and analgesia. The psychodysleptic effects caused by the drug called its further clinical use into question. Despite these unpleasant effects, ketamine is still applied in veterinary medicine, field medicine, and specialist anesthesia. Recent intensive research brought into light new possible applications of this drug. It began to be used in acute, chronic and cancer pain management. Most interesting reports come from research on the antidepressive and antisuicidal properties of ketamine giving hope for the creation of an effective treatment for major depressive disorder. Other reports highlight the possible use of ketamine in treating addiction, asthma and preventing cancer growth. Besides clinical use, the drug is also applied to in animal model of schizophrenia. It seems that nowadays, with numerous possible applications, the use of ketamine has returned; to its former glory. Nevertheless, the drug must be used with caution because still the mechanisms by which it executes its functions and long-term effects of its use are not fully known. This review aims to discuss the well-known and new promising applications of ketamine.
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Affiliation(s)
- Agata Nowacka
- Laboratory of Molecular Basis of Behavior, Nencki Institute of Experimental Biology, Polish Academy of Sciences, Warsaw, Poland
| | - Malgorzata Borczyk
- Laboratory of Molecular Basis of Behavior, Nencki Institute of Experimental Biology, Polish Academy of Sciences, Warsaw, Poland.
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29
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Sorby-Adams AJ, Leonard AV, Elms LE, Marian OC, Hoving JW, Yassi N, Vink R, Thornton E, Turner RJ. Determining the Temporal Profile of Intracranial Pressure Changes Following Transient Stroke in an Ovine Model. Front Neurosci 2019; 13:587. [PMID: 31338013 PMCID: PMC6629870 DOI: 10.3389/fnins.2019.00587] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 05/23/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND PURPOSE Cerebral edema and elevated intracranial pressure (ICP) are the leading cause of death in the first week following stroke. Despite this, current treatments are limited and fail to address the underlying mechanisms of swelling, highlighting the need for targeted treatments. When screening promising novel agents, it is essential to use clinically relevant large animal models to increase the likelihood of successful clinical translation. As such, we sought to develop a survival model of transient middle cerebral artery occlusion (tMCAO) in the sheep and subsequently characterize the temporal profile of cerebral edema and elevated ICP following stroke in this novel, clinically relevant model. METHODS Merino-sheep (27M;31F) were anesthetized and subject to 2 h tMCAO with reperfusion or sham surgery. Following surgery, animals were allowed to recover and returned to their home pens. At preselected times points ranging from 1 to 7 days post-stroke, animals were re-anesthetized, ICP measured for 4 h, followed by imaging with MRI to determine cerebral edema, midline shift and infarct volume (FLAIR, T2 and DWI). Animals were subsequently euthanized and their brain removed for immunohistochemical analysis. Serum and cerebrospinal fluid samples were also collected and analyzed for substance P (SP) using ELISA. RESULTS Intracranial pressure and MRI scans were normal in sham animals. Following stroke, ICP rose gradually over time and by 5 days was significantly (p < 0.0001) elevated above sham levels. Profound cerebral edema was observed as early as 2 days post-stroke and continued to evolve out to 6 days, resulting in significant midline shift which was most prominent at 5 days post-stroke (p < 0.01), in keeping with increasing ICP. Serum SP levels were significantly elevated (p < 0.01) by 7 days post-tMCAO. CONCLUSION We have successfully developed a survival model of ovine tMCAO and characterized the temporal profile of ICP. Peak ICP elevation, cerebral edema and midline shift occurred at days 5-6 following stroke, accompanied by an elevation in serum SP. Our findings suggest that novel therapeutic agents screened in this model targeting cerebral edema and elevated ICP would most likely be effective when administered prior to 5 days, or as early as possible following stroke onset.
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Affiliation(s)
- Annabel J. Sorby-Adams
- Adelaide Medical School, Adelaide Centre for Neuroscience Research, The University of Adelaide, Adelaide, SA, Australia
| | - Anna V. Leonard
- Adelaide Medical School, Adelaide Centre for Neuroscience Research, The University of Adelaide, Adelaide, SA, Australia
| | - Levi E. Elms
- Adelaide Medical School, Adelaide Centre for Neuroscience Research, The University of Adelaide, Adelaide, SA, Australia
| | - Oana C. Marian
- Adelaide Medical School, Adelaide Centre for Neuroscience Research, The University of Adelaide, Adelaide, SA, Australia
| | - Jan W. Hoving
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
- Department of Radiology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Nawaf Yassi
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
- Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia
| | - Robert Vink
- Division of Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Emma Thornton
- Adelaide Medical School, Adelaide Centre for Neuroscience Research, The University of Adelaide, Adelaide, SA, Australia
| | - Renée J. Turner
- Adelaide Medical School, Adelaide Centre for Neuroscience Research, The University of Adelaide, Adelaide, SA, Australia
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30
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Sorby-Adams AJ, Leonard AV, Hoving JW, Yassi N, Vink R, Wells AJ, Turner RJ. NK1-r Antagonist Treatment Comparable to Decompressive Craniectomy in Reducing Intracranial Pressure Following Stroke. Front Neurosci 2019; 13:681. [PMID: 31333402 PMCID: PMC6624444 DOI: 10.3389/fnins.2019.00681] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 06/13/2019] [Indexed: 12/29/2022] Open
Abstract
Background and Purpose: The morbidity and early mortality associated with stroke is largely attributable to cerebral edema and elevated intracranial pressure (ICP). Existing pharmacotherapies do not target the underlying pathophysiology and are often ineffective in sustainably lowering ICP, whilst decompressive craniectomy (DC) surgery is life-saving yet with surgical/peri-operative risk and increased morbidity in the elderly. Accordingly, there is an urgent need for therapies that directly target the mechanisms of edema genesis. Neurogenic inflammation, mediated by substance P (SP) binding to the tachykinin NK1 receptor (NK1-r), is associated with blood-brain barrier (BBB) disruption, cerebral edema and poor outcome post-stroke. NK1-r antagonist treatment ameliorates BBB dysfunction and cerebral edema in rodent stroke models. However, treatment has not been investigated in a large animal model, an important step toward clinical translation. Consequently, the current study compared the efficacy of NK1-r antagonist treatment to DC surgery in reducing ICP post-stroke in a clinically relevant ovine model. Methods: Anesthetized female Merino sheep (65 ± 6 kg, 18–24 months) underwent sham surgery (n = 4) or permanent middle cerebral artery occlusion (n = 22). Stroke animals were randomized into one of 5 treatments: 1×NK1 bolus (4 h), 2×NK1 bolus (4 h;9 h), 3×NK1 bolus (4 h;9 h;14 h), DC surgery (performed at 4 h) or saline vehicle. ICP, blood pressure and blood gasses were monitored for 24 h post-stroke. At 24 h post-stroke anesthetized animals underwent MRI followed by perfusion and brains removed and processed for histological assessment. Results: 2×NK1, 3×NK1 administration or DC surgery significantly (p < 0.05) reduced ICP compared to vehicle. 1×NK1 was ineffective in sustainably lowering ICP. On MRI, midline shift and cerebral edema were more marked in vehicles compared to NK1-r treatment groups. Conclusion: Two or three boluses of NK1-r antagonist treatment reduced ICP comparable to DC surgery, suggesting it may provide a novel alternative to invasive surgery for the management of elevated ICP.
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Affiliation(s)
- Annabel J Sorby-Adams
- Adelaide Medical School and Adelaide Centre for Neuroscience Research, The University of Adelaide, Adelaide, SA, Australia
| | - Anna V Leonard
- Adelaide Medical School and Adelaide Centre for Neuroscience Research, The University of Adelaide, Adelaide, SA, Australia
| | - Jan W Hoving
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia.,Department of Radiology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Nawaf Yassi
- Florey Institute of Neuroscience and Mental Health, Parkville, VIC, Australia
| | - Robert Vink
- Division of Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Adam J Wells
- Department of Neurosurgery, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Renée J Turner
- Adelaide Medical School and Adelaide Centre for Neuroscience Research, The University of Adelaide, Adelaide, SA, Australia
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31
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Abstract
An aging worldwide population demands that anesthesiologists consider geriatrics a unique subset of patients requiring customization of practice. This article reviews the current literature investigating physiologic changes of the elderly that affect pharmacokinetics and pharmacodynamics. Changes in drug absorption, distribution, metabolism, and excretion are discussed as well as the ultimate effects of medications. Implications for practice regarding specific anesthetic and analgesic drugs are addressed. Despite the immense body of research that contributes to understanding of geriatric pharmacology, elderly patients often are excluded from rigorous research trials, and further scientific investigation to inform best practices for this group of patients is needed.
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Affiliation(s)
- Tate M Andres
- Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, 4648 TVC, Nashville, TN, USA.
| | - Tracy McGrane
- Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, 4648 TVC, Nashville, TN 37232, USA
| | - Matthew D McEvoy
- Perioperative Consult Service, Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, 4648 TVC, Nashville, TN 37232, USA
| | - Brian F S Allen
- Regional and Acute Pain Medicine Fellowship, Regional and Acute Pain Medicine Service, Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, 4648 TVC, Nashville, TN 37232, USA
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32
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Stamenkovic DM, Laycock H, Karanikolas M, Ladjevic NG, Neskovic V, Bantel C. Chronic Pain and Chronic Opioid Use After Intensive Care Discharge - Is It Time to Change Practice? Front Pharmacol 2019; 10:23. [PMID: 30853909 PMCID: PMC6395386 DOI: 10.3389/fphar.2019.00023] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 01/10/2019] [Indexed: 12/12/2022] Open
Abstract
Almost half of patients treated on intensive care unit (ICU) experience moderate to severe pain. Managing pain in the critically ill patient is challenging, as their pain is complex with multiple causes. Pharmacological treatment often focuses on opioids, and over a prolonged admission this can represent high cumulative doses which risk opioid dependence at discharge. Despite analgesia the incidence of chronic pain after treatment on ICU is high ranging from 33-73%. Measures need to be taken to prevent the transition from acute to chronic pain, whilst avoiding opioid overuse. This narrative review discusses preventive measures for the development of chronic pain in ICU patients. It considers a number of strategies that can be employed including non-opioid analgesics, regional analgesia, and non-pharmacological methods. We reason that individualized pain management plans should become the cornerstone for critically ill patients to facilitate physical and psychological well being after discharge from critical care and hospital.
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Affiliation(s)
- Dusica M Stamenkovic
- Department of Anesthesiology and Intensive Care, Military Medical Academy, Belgrade, Serbia.,Medical Faculty, University of Defense, Belgrade, Serbia
| | - Helen Laycock
- Imperial College London, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Menelaos Karanikolas
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, United States
| | - Nebojsa Gojko Ladjevic
- Center for Anesthesia, Clinical Center of Serbia, Belgrade, Serbia.,School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Vojislava Neskovic
- Department of Anesthesiology and Intensive Care, Military Medical Academy, Belgrade, Serbia.,Medical Faculty, University of Defense, Belgrade, Serbia
| | - Carsten Bantel
- Universitätsklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin, und Schmerztherapie, Universität Oldenburg, Klinikum Oldenburg, Oldenburg, Germany.,Imperial College London, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
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33
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Neurochemical models of near-death experiences: A large-scale study based on the semantic similarity of written reports. Conscious Cogn 2019; 69:52-69. [PMID: 30711788 DOI: 10.1016/j.concog.2019.01.011] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 01/16/2019] [Accepted: 01/20/2019] [Indexed: 11/20/2022]
Abstract
The real or perceived proximity to death often results in a non-ordinary state of consciousness characterized by phenomenological features such as the perception of leaving the body boundaries, feelings of peace, bliss and timelessness, life review, the sensation of traveling through a tunnel and an irreversible threshold. Near-death experiences (NDEs) are comparable among individuals of different cultures, suggesting an underlying neurobiological mechanism. Anecdotal accounts of the similarity between NDEs and certain drug-induced altered states of consciousness prompted us to perform a large-scale comparative analysis of these experiences. After assessing the semantic similarity between ≈15,000 reports linked to the use of 165 psychoactive substances and 625 NDE narratives, we determined that the N-methyl-D-aspartate (NMDA) receptor antagonist ketamine consistently resulted in reports most similar to those associated with NDEs. Ketamine was followed by Salvia divinorum (a plant containing a potent and selective κ receptor agonist) and a series of serotonergic psychedelics, including the endogenous serotonin 2A receptor agonist N,N-Dimethyltryptamine (DMT). This similarity was driven by semantic concepts related to consciousness of the self and the environment, but also by those associated with the therapeutic, ceremonial and religious aspects of drug use. Our analysis sheds light on the long-standing link between certain drugs and the experience of "dying", suggests that ketamine could be used as a safe and reversible experimental model for NDE phenomenology, and supports the speculation that endogenous NMDA antagonists with neuroprotective properties may be released in the proximity of death.
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34
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Novel targets for parkinsonism-depression comorbidity. PROGRESS IN MOLECULAR BIOLOGY AND TRANSLATIONAL SCIENCE 2019; 167:1-24. [DOI: 10.1016/bs.pmbts.2019.06.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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35
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Luo Y, Tang H, Li H, Zhao R, Huang Q, Liu J. Recent advances in the development of neuroprotective agents and therapeutic targets in the treatment of cerebral ischemia. Eur J Med Chem 2019; 162:132-146. [DOI: 10.1016/j.ejmech.2018.11.014] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 10/30/2018] [Accepted: 11/06/2018] [Indexed: 11/25/2022]
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36
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Deneyer L, Massie A, Bentea E. Ketamine Does Not Exert Protective Properties on Dopaminergic Neurons in the Lactacystin Mouse Model of Parkinson's Disease. Front Behav Neurosci 2018; 12:219. [PMID: 30283309 PMCID: PMC6156534 DOI: 10.3389/fnbeh.2018.00219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 08/30/2018] [Indexed: 11/18/2022] Open
Abstract
Parkinson’s disease (PD) is an age-related neurodegenerative condition characterized by a progressive loss of dopaminergic neurons in the substantia nigra pars compacta (SNpc). A loss of proteasome function participates to the pathogenesis of PD, leading to the development of rodent models in which a proteasome inhibitor is applied to the nigrostriatal pathway. We recently characterized the intranigral lactacystin (LAC) mouse model, leading to nigrostriatal degeneration, motor dysfunction and alpha-synuclein accumulation. In the present study, we compared the effect of two commonly used anesthetics for generating animal models of PD—i.e., ketamine (KET) and isoflurane (ISO)—on the vulnerability of mouse dopaminergic neurons to proteasome inhibition-induced degeneration. Both anesthetics have the potential to affect the susceptibility of the nigrostriatal pathway for toxin-induced degeneration, and are known to modulate dopamine (DA) homeostasis. Yet, their impact on nigrostriatal degeneration in the proteasome inhibition model has not been evaluated. Unilateral injection with LAC in the SNpc of mice induced motor impairment and significantly reduced the number of dopaminergic cells to ~55%, irrespective of the anesthetic used. However, LAC-induced striatal DA depletion was slightly affected by the choice of anesthetic, resulting in a significant increase in DA turnover in the ISO- but not in KET-treated mice. These results suggest that the extent of nigrostriatal dopaminergic neural loss caused by LAC is not influenced by the choice of anesthetic, and that compared to other PD models, KET is not neuroprotective in the LAC model.
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Affiliation(s)
- Lauren Deneyer
- Center for Neurosciences (C4N), Department of Pharmaceutical Biotechnology and Molecular Biology, Vrije Universiteit Brussel, Brussels, Belgium
| | - Ann Massie
- Center for Neurosciences (C4N), Department of Pharmaceutical Biotechnology and Molecular Biology, Vrije Universiteit Brussel, Brussels, Belgium
| | - Eduard Bentea
- Center for Neurosciences (C4N), Department of Pharmaceutical Biotechnology and Molecular Biology, Vrije Universiteit Brussel, Brussels, Belgium
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37
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Hovaguimian F, Tschopp C, Beck-Schimmer B, Puhan M. Intraoperative ketamine administration to prevent delirium or postoperative cognitive dysfunction: A systematic review and meta-analysis. Acta Anaesthesiol Scand 2018; 62:1182-1193. [PMID: 29947091 DOI: 10.1111/aas.13168] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 05/08/2018] [Accepted: 05/09/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Postoperative cognitive complications are associated with substantial morbidity and mortality. Ketamine has been suggested to have neuroprotective effects in various settings. This systematic review evaluates the effects of intraoperative ketamine administration on postoperative delirium and postoperative cognitive dysfunction (POCD). METHODS Medline, Embase and Central were searched to 4 March 2018 without date or language restrictions. We considered randomised controlled trials (RCTs) comparing intraoperative ketamine administration versus no intervention in adults undergoing surgery under general anaesthesia. Primary outcomes were postoperative delirium and POCD. Non-cognitive adverse events, mortality and length of stay were considered as secondary outcomes. Data were independently extracted. The quality of the evidence (GRADE approach) was assessed following recommendations from the Cochrane collaboration. Risk ratios were calculated for binary outcomes, mean differences for continuous outcomes. We planned to explore the effects of age, specific anaesthesia regimen, depth of anaesthesia and intraoperative haemodynamic events through subgroup analyses. RESULTS Six RCTs were included. The incidence of postoperative delirium did not differ between groups (4 trials, 557 patients, RR 0.83, 95% CI [0.25, 2.80]), but patients receiving ketamine seemed at lower risk of POCD (3 trials, 163 patients, RR 0.34, 95% CI [0.15, 0.73]). However, both analyses presented limitations. Therefore, the quality of the evidence (GRADE) was deemed low (postoperative delirium) and very low (POCD). CONCLUSION The effect of ketamine on postoperative delirium remains unclear but its administration may offer some protection towards POCD. Large, well-designed randomised trials are urgently needed to further clarify the efficacy of ketamine on neurocognitive outcomes.
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Affiliation(s)
- F. Hovaguimian
- Institute of Anaesthesiology; University of Zurich and University Hospital of Zurich; Zurich Switzerland
| | - C. Tschopp
- Institute of Anaesthesiology; University of Zurich and University Hospital of Zurich; Zurich Switzerland
| | - B. Beck-Schimmer
- Institute of Anaesthesiology; University of Zurich and University Hospital of Zurich; Zurich Switzerland
| | - M. Puhan
- Epidemiology, Biostatistics and Prevention Institute; University of Zurich; Zurich Switzerland
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38
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Abstract
There is significant evidence that many older surgical patients experience at least a transient decrease in cognitive function. Although there is still equipoise regarding the degree, duration, and mechanism of cognitive dysfunction, there is a concurrent need to provide best-practice clinical evidence. The two major cognitive disorders seen after surgery are postoperative delirium and postoperative cognitive dysfunction. Delirium is a public health problem; millions of dollars are spent annually on delirium-related medical resource use and prolonged hospital stays. Postoperative cognitive dysfunction is a research construct that historically signifies decline in performance on a neuropsychiatric test or group of tests and begins days to weeks after surgery. This review focuses on the current state of information gathered by several interdisciplinary stakeholder groups. Although there is still a need for high-level evidence to guide clinical practice, there is an emerging literature that can guide practitioners.
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Affiliation(s)
- C Brown
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Sheikh Zayed Tower, 1800 Orleans Street, Baltimore, MD 21287, USA
| | - S Deiner
- Departments of Anesthesiology .,Neurosurgery.,Geriatrics and Palliative Care, Icahn School of Medicine at Mount Sinai, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box #1010, New York, NY 10029-6574, USA
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39
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Abstract
Deciding on proper medication administration for the traumatic brain injury (TBI) patient undergoing intubation can be daunting and confusing. Pretreatment with lidocaine and/or vecuronium is no longer recommended; however, high-dose fentanyl can be utilized to help blunt the sympathetic stimulation of intubation. Induction with etomidate is recommended; however, ketamine can be considered in the proper patient population, such as those with hypotension. Paralysis can be performed with either succinylcholine or rocuronium, with the caveat that rocuronium can lead to delays in proper neurological examinations due to prolonged paralysis. Recommendations for post-intubation continuous sedation medications include a combination propofol and fentanyl in the normotensive/hypertensive patient population. A combination midazolam and fentanyl or ketamine alone can be considered in the hypotensive patient.
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Affiliation(s)
- Nicholas Kramer
- Emergency Medicine, University of Central Florida College of Medicine, Orlando, USA
| | - David Lebowitz
- Office of Faculty and Academic Affairs, University of Central Florida College of Medicine, Orlando, USA
| | - Michael Walsh
- Emergency Medicine, University of Central Florida College of Medicine, Orlando, USA
| | - Latha Ganti
- Clinical Sciences, University of Central Florida College of Medicine, Orlando, USA
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40
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Sorby-Adams AJ, Vink R, Turner RJ. Large animal models of stroke and traumatic brain injury as translational tools. Am J Physiol Regul Integr Comp Physiol 2018. [PMID: 29537289 DOI: 10.1152/ajpregu.00163.2017] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Acute central nervous system injury, encompassing traumatic brain injury (TBI) and stroke, accounts for a significant burden of morbidity and mortality worldwide. Studies in animal models have greatly enhanced our understanding of the complex pathophysiology that underlies TBI and stroke and enabled the preclinical screening of over 1,000 novel therapeutic agents. Despite this, the translation of novel therapeutics from experimental models to clinical therapies has been extremely poor. One potential explanation for this poor clinical translation is the choice of experimental model, given that the majority of preclinical TBI and ischemic stroke studies have been conducted in small animals, such as rodents, which have small lissencephalic brains. However, the use of large animal species such as nonhuman primates, sheep, and pigs, which have large gyrencephalic human-like brains, may provide an avenue to improve clinical translation due to similarities in neuroanatomical structure when compared with widely adopted rodent models. This purpose of this review is to provide an overview of large animal models of TBI and ischemic stroke, including the surgical considerations, key benefits, and limitations of each approach.
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Affiliation(s)
- Annabel J Sorby-Adams
- Adelaide Medical School and Adelaide Centre for Neuroscience Research, The University of Adelaide , Adelaide, South Australia
| | - Robert Vink
- Sansom Institute for Health Research, University of South Australia , Adelaide, South Australia
| | - Renée J Turner
- Adelaide Medical School and Adelaide Centre for Neuroscience Research, The University of Adelaide , Adelaide, South Australia
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41
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Propofol, but not ketamine or midazolam, exerts neuroprotection after ischaemic injury by inhibition of Toll-like receptor 4 and nuclear factor kappa-light-chain-enhancer of activated B-cell signalling: A combined in vitro and animal study. Eur J Anaesthesiol 2018; 33:670-80. [PMID: 26981881 DOI: 10.1097/eja.0000000000000449] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Propofol, midazolam and ketamine are widely used in today's anaesthesia practice. Both neuroprotective and neurotoxic effects have been attributed to all three agents. OBJECTIVE To establish whether propofol, midazolam and ketamine in the same neuronal injury model exert neuroprotective effects on injured neurones in vitro and in vivo by modulation of the Toll-like receptor 4-nuclear factor kappa-light-chain-enhancer of activated B cells (TLR-4-NF-κB) pathway. DESIGN AND SETTING Cell-based laboratory (n = 6 repetitions per experiment) and animal (n = 6 per group) studies using a neuronal cell line (SH-SY5Y cells) and adult Sprague-Dawley rats. INTERVENTIONS Cells were exposed to oxygen-glucose deprivation before or after treatment using escalating, clinically relevant doses of propofol, midazolam and ketamine. In animals, retinal ischaemia (60 min) was induced followed by reperfusion and randomised treatment with saline or propofol. MAIN OUTCOME MEASURES Neuronal cell death was determined using flow-cytometry (mitochondrial membrane potential) and lactate dehydrogenase (LDH) release. Nuclear factor NF-κB and hypoxia-inducible factor 1 α-activity were analysed by DNA-binding ELISA, expression of NF-κB-dependent genes and TLR-4 by luciferase-assay and flow-cytometry, respectively. In animals, retinal ganglion cell density, caspase-3 activation and gene expression (TLR-4, NF-κB) were used to determine in vivo effects of propofol. Results were compared using ANOVA (Analysis of Variance) and t test. A P value less than 0.05 was considered statistically significant. RESULTS Post-treatment with clinically relevant concentrations of propofol (1 to 10 μg ml) preserved the mitochondrial membrane potential in oxygen-glucose deprivation-injured cells by 54% and reduced LDH release by 21%. Propofol diminished TLR-4 surface expression and preserved the DNA-binding activity of the protective hypoxia-inducible factor 1 α transcription factor. DNA-binding and transcriptional NF-κB-activity were inhibited by propofol. Neuronal protection and inhibition of TLR-4-NF-κB signalling were not consistently seen with midazolam or ketamine. In vivo, propofol treatment preserved rat retinal ganglion cell densities (cells mm, saline 1504 ± 251 vs propofol 2088 ± 144, P = 0.0001), which was accompanied by reduced neuronal caspase-3, TLR-4 and NF-κB expression. CONCLUSION Propofol, but neither midazolam nor ketamine, provides neuroprotection to injured neuronal cells via inhibition of TLR-4-NF-κB-dependent signalling.
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42
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Percie du Sert N, Alfieri A, Allan SM, Carswell HV, Deuchar GA, Farr TD, Flecknell P, Gallagher L, Gibson CL, Haley MJ, Macleod MR, McColl BW, McCabe C, Morancho A, Moon LD, O'Neill MJ, Pérez de Puig I, Planas A, Ragan CI, Rosell A, Roy LA, Ryder KO, Simats A, Sena ES, Sutherland BA, Tricklebank MD, Trueman RC, Whitfield L, Wong R, Macrae IM. The IMPROVE Guidelines (Ischaemia Models: Procedural Refinements Of in Vivo Experiments). J Cereb Blood Flow Metab 2017; 37:3488-3517. [PMID: 28797196 PMCID: PMC5669349 DOI: 10.1177/0271678x17709185] [Citation(s) in RCA: 108] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Most in vivo models of ischaemic stroke target the middle cerebral artery and a spectrum of stroke severities, from mild to substantial, can be achieved. This review describes opportunities to improve the in vivo modelling of ischaemic stroke and animal welfare. It provides a number of recommendations to minimise the level of severity in the most common rodent models of middle cerebral artery occlusion, while sustaining or improving the scientific outcomes. The recommendations cover basic requirements pre-surgery, selecting the most appropriate anaesthetic and analgesic regimen, as well as intraoperative and post-operative care. The aim is to provide support for researchers and animal care staff to refine their procedures and practices, and implement small incremental changes to improve the welfare of the animals used and to answer the scientific question under investigation. All recommendations are recapitulated in a summary poster (see supplementary information).
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Affiliation(s)
- Nathalie Percie du Sert
- 1 National Centre for the Replacement, Refinement and Reduction of Animals in Research (NC3Rs), London, UK
| | - Alessio Alfieri
- 2 The Roslin Institute and R(D)SVS, University of Edinburgh, Easter Bush, Midlothian, UK
| | - Stuart M Allan
- 3 Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Hilary Vo Carswell
- 4 Strathclyde Institute of Pharmacy and Biomedical Sciences (SIPBS), University of Strathclyde, Glasgow, UK
| | - Graeme A Deuchar
- 5 Institute of Neuroscience and Psychology, College of Medical, Veterinary and Life Sciences, University of Glasgow/Arum Biosciences, Glasgow, UK
| | - Tracy D Farr
- 6 School of Life Sciences, University of Nottingham Medical School, Nottingham, UK
| | | | - Lindsay Gallagher
- 5 Institute of Neuroscience and Psychology, College of Medical, Veterinary and Life Sciences, University of Glasgow/Arum Biosciences, Glasgow, UK
| | - Claire L Gibson
- 8 Department of Neuroscience, Psychology and Behaviour, University of Leicester, Leicester, UK
| | - Michael J Haley
- 3 Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Malcolm R Macleod
- 9 Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Barry W McColl
- 2 The Roslin Institute and R(D)SVS, University of Edinburgh, Easter Bush, Midlothian, UK
| | - Christopher McCabe
- 5 Institute of Neuroscience and Psychology, College of Medical, Veterinary and Life Sciences, University of Glasgow/Arum Biosciences, Glasgow, UK
| | - Anna Morancho
- 10 Neurovascular Research Laboratory. Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona; Barcelona, Spain
| | - Lawrence Df Moon
- 11 Wolfson Centre for Age-Related Diseases, King's College London, London, UK
| | | | - Isabel Pérez de Puig
- 13 Institut d'Investigacions Biomèdiques de Barcelona (IIBB), Consejo Superior de Investigaciones Científicas (CSIC), IDIBAPS, Barcelona, Spain
| | - Anna Planas
- 13 Institut d'Investigacions Biomèdiques de Barcelona (IIBB), Consejo Superior de Investigaciones Científicas (CSIC), IDIBAPS, Barcelona, Spain
| | | | - Anna Rosell
- 10 Neurovascular Research Laboratory. Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona; Barcelona, Spain
| | - Lisa A Roy
- 5 Institute of Neuroscience and Psychology, College of Medical, Veterinary and Life Sciences, University of Glasgow/Arum Biosciences, Glasgow, UK
| | | | - Alba Simats
- 10 Neurovascular Research Laboratory. Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona; Barcelona, Spain
| | - Emily S Sena
- 9 Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Brad A Sutherland
- 16 Acute Stroke Programme, Radcliffe Department of Medicine, University of Oxford, Oxford, UK.,17 School of Medicine, Faculty of Health, University of Tasmania, Hobart, Australia
| | - Mark D Tricklebank
- 18 Centre for Neuroimaging Sciences, Institute of Psychiatry Psychology and Neuroscience, King's College London, London, UK
| | - Rebecca C Trueman
- 6 School of Life Sciences, University of Nottingham Medical School, Nottingham, UK
| | | | - Raymond Wong
- 3 Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - I Mhairi Macrae
- 5 Institute of Neuroscience and Psychology, College of Medical, Veterinary and Life Sciences, University of Glasgow/Arum Biosciences, Glasgow, UK
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43
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Fan JC, Song JJ, Wang Y, Chen Y, Hong DX. Neuron-protective effect of subanesthestic-dosage ketamine on mice of Parkinson's disease. ASIAN PAC J TROP MED 2017; 10:1007-1010. [PMID: 29111184 DOI: 10.1016/j.apjtm.2017.09.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 08/02/2017] [Accepted: 09/05/2017] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE To discuss the neuron-protective effect and possible mechanism of subanesthestic-dosage ketamine on Parkinson's disease mice induced by 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine. METHODS A total of 30 mice were divided equally into three groups, model control group (MC group), ketamine treatment group (KT group), and blank control group (BC group), respectively. The Parkinson's disease mice of MC group and KT groups were established by 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (20 mg/kg/d), while mice in KT group were treated by intraperitoneal injection of subanesthestic-dosage ketamine (8 mg/kg). Differences on behaviors and the number of nigra dopaminergic neurons of mice in each group were compared through the behavioral test and tyrosine hydroxylase immunohistochemistry experiments after the treatments. Furthermore, Western blot was used to test the expression of autophagy-related gene LC3-Ⅱ, Beclin1, Parkin, PINK1, and mTOR. RESULTS Compared with the BC group, the neuroethology scores were lower and the amount of TH positive cells were less both in MC and MT groups; In KT group, the neuroethology scores were higher and the amount of tyrosine hydroxylase positive cells were significantly more than that in MC group (P < 0.05). Moreover, expression levels of autophagy-related proteins LC3-II, Beclin1, Parkin, and PINK1 were higher, while the mTOR expression level was lower than that in MC group. CONCLUSIONS The subanesthestic-dosage ketamine has some protective effects on the coordinating ability of movement and cognitive ability of Parkinson's disease mice induced by 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine. This is probably due to that the autophagy activity of cells is activated by subanesthestic-dosage ketamine and that the neurons are protected.
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Affiliation(s)
- Jun-Chao Fan
- Department of Anesthesiology, First Affiliated Hospital of Henan University, Kaifeng, Henan, 475000, China
| | - Jun-Jie Song
- Department of Anesthesiology, First Affiliated Hospital of Henan University, Kaifeng, Henan, 475000, China
| | - Ying Wang
- Department of Anesthesiology, First Affiliated Hospital of Henan University, Kaifeng, Henan, 475000, China.
| | - Ying Chen
- Department of Anesthesiology, First Affiliated Hospital of Henan University, Kaifeng, Henan, 475000, China
| | - Dao-Xian Hong
- Department of Anesthesiology, First Affiliated Hospital of Henan University, Kaifeng, Henan, 475000, China
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Avidan MS, Maybrier HR, Abdallah AB, Jacobsohn E, Vlisides PE, Pryor KO, Veselis RA, Grocott HP, Emmert DA, Rogers EM, Downey RJ, Yulico H, Noh GJ, Lee YH, Waszynski CM, Arya VK, Pagel PS, Hudetz JA, Muench MR, Fritz BA, Waberski W, Inouye SK, Mashour GA. Intraoperative ketamine for prevention of postoperative delirium or pain after major surgery in older adults: an international, multicentre, double-blind, randomised clinical trial. Lancet 2017; 390:267-275. [PMID: 28576285 PMCID: PMC5644286 DOI: 10.1016/s0140-6736(17)31467-8] [Citation(s) in RCA: 288] [Impact Index Per Article: 41.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 05/10/2017] [Accepted: 05/11/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND Delirium is a common and serious postoperative complication. Subanaesthetic ketamine is often administered intraoperatively for postoperative analgesia, and some evidence suggests that ketamine prevents delirium. The primary purpose of this trial was to assess the effectiveness of ketamine for prevention of postoperative delirium in older adults. METHODS The Prevention of Delirium and Complications Associated with Surgical Treatments [PODCAST] study is a multicentre, international randomised trial that enrolled adults older than 60 years undergoing major cardiac and non-cardiac surgery under general anaesthesia. Using a computer-generated randomisation sequence we randomly assigned patients to one of three groups in blocks of 15 to receive placebo (normal saline), low-dose ketamine (0·5 mg/kg), or high dose ketamine (1·0 mg/kg) after induction of anaesthesia, before surgical incision. Participants, clinicians, and investigators were blinded to group assignment. Delirium was assessed twice daily in the first 3 postoperative days using the Confusion Assessment Method. We did analyses by intention-to-treat and assessed adverse events. This trial is registered with clinicaltrials.gov, number NCT01690988. FINDINGS Between Feb 6, 2014, and June 26, 2016, 1360 patients were assessed, and 672 were randomly assigned, with 222 in the placebo group, 227 in the 0·5 mg/kg ketamine group, and 223 in the 1·0 mg/kg ketamine group. There was no difference in delirium incidence between patients in the combined ketamine groups and the placebo group (19·45% vs 19·82%, respectively; absolute difference 0·36%, 95% CI -6·07 to 7·38, p=0·92). There were more postoperative hallucinations (p=0·01) and nightmares (p=0·03) with increasing ketamine doses compared with placebo. Adverse events (cardiovascular, renal, infectious, gastrointestinal, and bleeding), whether viewed individually (p value for each >0·40) or collectively (36·9% in placebo, 39·6% in 0·5 mg/kg ketamine, and 40·8% in 1·0 mg/kg ketamine groups, p=0·69), did not differ significantly across groups. INTERPRETATION A single subanaesthetic dose of ketamine did not decrease delirium in older adults after major surgery, and might cause harm by inducing negative experiences. FUNDING National Institutes of Health and Cancer Center Support.
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Affiliation(s)
- Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine, Saint Louis, MO, USA.
| | - Hannah R Maybrier
- Department of Anesthesiology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Arbi Ben Abdallah
- Department of Anesthesiology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Eric Jacobsohn
- Department of Anesthesiology and Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Phillip E Vlisides
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Kane O Pryor
- Department of Anesthesiology, Weill Cornell Medicine, New York City, NY, US
| | - Robert A Veselis
- Department of Neuroanesthesiology, Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - Hilary P Grocott
- Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Daniel A Emmert
- Department of Anesthesiology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Emma M Rogers
- Department of Anesthesiology, Weill Cornell Medicine, New York City, NY, US
| | - Robert J Downey
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - Heidi Yulico
- Department of Anesthesiology, Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - Gyu-Jeong Noh
- Department of Anesthesiology, Asan Medical Center, Seoul, South Korea
| | - Yonghun H Lee
- Department of Anesthesiology, Asan Medical Center, Seoul, South Korea
| | | | - Virendra K Arya
- Department of Anaesthesiology and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Paul S Pagel
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Judith A Hudetz
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Maxwell R Muench
- Department of Anesthesiology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Bradley A Fritz
- Department of Anesthesiology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Witold Waberski
- Department of Anesthesiology, Hartford Hospital, Hartford, Connecticut, USA
| | - Sharon K Inouye
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, and Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - George A Mashour
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
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Abstract
Neurologic deterioration following acute injury to the central nervous system may be amenable to pharmacologic intervention, although, to date, no such therapy exists. Ketamine is an anesthetic and analgesic emerging as a novel therapy for a number of clinical entities in recent years, including refractory pain, depression, and drug-induced hyperalgesia due to newly discovered mechanisms of action and new application of its known pharmacodynamics. In this focused review, the evidence for ketamine as a neuroprotective agent in stroke, neurotrauma, subarachnoid hemorrhage, and status epilepticus is highlighted, with a focus on its applications for excitotoxicity, neuroinflammation, and neuronal hyperexcitability. Preclinical modeling and clinical applications are discussed.
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Affiliation(s)
- Josh D Bell
- From the Department of Anesthesiology, University of Toronto, Toronto, Ontario, Canada
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46
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Hoffmann U, Sheng H, Ayata C, Warner DS. Anesthesia in Experimental Stroke Research. Transl Stroke Res 2016; 7:358-67. [PMID: 27534542 PMCID: PMC5016251 DOI: 10.1007/s12975-016-0491-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 08/03/2016] [Indexed: 10/21/2022]
Abstract
Anesthetics have enabled major advances in development of experimental models of human stroke. Yet, their profound pharmacologic effects on neural function can confound the interpretation of experimental stroke research. Anesthetics have species-, drug-, and dose-specific effects on cerebral blood flow and metabolism, neurovascular coupling, autoregulation, ischemic depolarizations, excitotoxicity, inflammation, neural networks, and numerous molecular pathways relevant for stroke outcome. Both preconditioning and postconditioning properties have been described. Anesthetics also modulate systemic arterial blood pressure, lung ventilation, and thermoregulation, all of which may interact with the ischemic insult as well as the therapeutic interventions. These confounds present a dilemma. Here, we provide an overview of the anesthetic mechanisms of action and molecular and physiologic effects on factors relevant to stroke outcomes that can guide the choice and optimization of the anesthetic regimen in experimental stroke.
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Affiliation(s)
- Ulrike Hoffmann
- Multidisciplinary Neuroprotection Laboratories, Department of Anesthesiology, Duke University Medical Center, Box 3094, Durham, NC, 27710, USA
| | - Huaxin Sheng
- Multidisciplinary Neuroprotection Laboratories, Department of Anesthesiology, Duke University Medical Center, Box 3094, Durham, NC, 27710, USA
| | - Cenk Ayata
- Neurovascular Research Laboratory, Departments of Radiology and Neurology, Massachusetts General Hospital and Harvard Medical School, 149 13th Street, Charlestown, MA, 02129, USA
| | - David S Warner
- Multidisciplinary Neuroprotection Laboratories, Department of Anesthesiology, Duke University Medical Center, Box 3094, Durham, NC, 27710, USA.
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Zhong X, He H, Zhang C, Wang Z, Jiang M, Li Q, Zhang M, Huang X. Mood and neuropsychological effects of different doses of ketamine in electroconvulsive therapy for treatment-resistant depression. J Affect Disord 2016; 201:124-30. [PMID: 27208499 DOI: 10.1016/j.jad.2016.05.011] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 04/10/2016] [Accepted: 05/11/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Treatment-resistant depression (TRD) is a growing clinical challenge. Electroconvulsive therapy (ECT) is an effective tool for TRD treatment. However, there remains a subset of patients who do not respond to this treatment with common anesthetic agent. Ketamine, a noteworthy anesthetic agent, has emerged as an augmentation to enhance the antidepressant efficacy of ECT. Trials of i.v. ketamine in TRD indicated dose-related mood enhancing efficacy. We aimed to explore anesthetic and subanesthetic concentrations of ketamine in ECT for TRD with respect to their impact on mood and neuropsychological effects. METHODS Ninety TRD patients (36 males, 54 females; average age, 30.6 years old) were randomly assigned to receive either ketamine (0.8mg/kg) (n=30), subanesthetic ketamine (0.5mg/kg) plus propofol (0.5mg/kg) (n=30) or propofol (0.8mg/kg) (n=30) as an anesthetic and underwent 8 ECT sessions. The primary outcome measures were the 17-item Hamilton Depression Rating Scale (HDRS-17), cognitive assessments and seizure parameters. RESULTS The ketamine group had an earlier improvement in HDRS-17, longer seizure duration, lower electric quantity, a higher remission rate, and a lower degree of executive cognitive impairment compared to the ketamine+propofol and propofol groups. The ketamine+propofol group showed earlier improvement in the HDRS-17, a longer seizure duration and a different seizure energy index when compared to the propofol group. LIMITATIONS The postoperative dissociative side effect was not assessed. CONCLUSIONS Both anesthetic and subanesthetic concentrations of ketamine have rapid mood enhancing actions in ECT for TRD, while anesthetic concentrations results in larger magnitudes of antidepression and cognitive protection. ECT with ketamine anesthesia might be an optimized therapy for patients with TRD.
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Affiliation(s)
- Xiaomei Zhong
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Hongbo He
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Chunping Zhang
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Zhijie Wang
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Miaoling Jiang
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Qirong Li
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Minling Zhang
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Xiong Huang
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China.
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Zhang Y, Lin H, Yi WB. Evaluation of the effects of ketamine on spinal anesthesia with levobupivacaine or ropivacaine. Exp Ther Med 2016; 12:2290-2296. [PMID: 27698726 DOI: 10.3892/etm.2016.3587] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Accepted: 04/21/2016] [Indexed: 02/07/2023] Open
Abstract
Spinal anesthesia or regional anesthesia is a potent anesthetic procedure. Additional modalities have been sought to increase the duration of block in spinal anesthesia. Ketamine is an N-methyl-D-aspartate (NMDA) receptor blocker that has an anesthetic effect when injected intrathecally and has a synergic effect with bupivacaine. Ketamine also has potent analgesic properties. The present study investigated the effect of intrathecally administered ketamine on spinal anesthesia with levobupivacaine or ropivacaine. Sprague-Dawley rats at post-natal day 21 were exposed to spinal anesthesia with 0.5% levobupivacaine or 0.5% ropivacaine. Separate groups of rats were treated with intrathecal ketamine at a 5 or 10 mg/kg bodyweight dose along with ropivacaine or levobupivacaine. The thermal and mechanical withdrawal latencies of the animals were determined using hot plate and von Frey filaments, respectively. A rotarod apparatus was employed to assess the capacity of the rats to rotate the spindle at 24 h following anesthesia. The gait of the rat pups was also assessed. Intrathecal administration of ketamine resulted in dense blocks and extended the duration of spinal blocks as evidenced by thermal latencies and responses to von Frey filaments. The latency to fall was shorter in rats exposed to ketamine along with ropivacaine or levobupivacaine spinal anesthesia. The gait parameters were also more disturbed upon ketamine administration. In conclusion, ketamine administration with ropivacaine or levobupivacaine increased the intensity and duration of spinal blockade, thereby increasing the anesthetic effects.
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Affiliation(s)
- Yan Zhang
- Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China
| | - Hong Lin
- Department of Anesthesiology, Qianfoshan Hospital of Shandong, Taian, Shandong 271000, P.R. China
| | - Wen-Bo Yi
- Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China
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Ketamine alleviates bradykinin-induced disruption of the mouse cerebrovascular endothelial cell-constructed tight junction barrier via a calcium-mediated redistribution of occludin polymerization. Toxicology 2016; 368-369:142-151. [DOI: 10.1016/j.tox.2016.09.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 09/12/2016] [Accepted: 09/13/2016] [Indexed: 01/17/2023]
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50
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Tizabi Y. Duality of Antidepressants and Neuroprotectants. Neurotox Res 2016; 30:1-13. [PMID: 26613895 PMCID: PMC4884174 DOI: 10.1007/s12640-015-9577-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 11/10/2015] [Accepted: 11/17/2015] [Indexed: 12/14/2022]
Abstract
The co-morbidity of neuropsychiatric disorders, particularly major depressive disorder (MDD) with neurodegenerative diseases, in particular Parkinson's disease (PD) is now well recognized. Indeed, it is suggested that depressive disorders, especially in late life, may be an indication of latent neurodegeneration. Thus, it is not unreasonable to expect that deterrents of MDD may also deter the onset and/or progression of the neurodegenerative diseases including PD. In this review, examples of neuroprotective efficacy of established as well as prospective antidepressants are provided. Conversely, mood-regulating effects of some neuroprotective drugs are also presented. Thus, in addition to currently used antidepressants, ketamine, nicotine, curcumin, and resveratrol are discussed for their dual efficacy. In addition, potential neurobiological substrates for their actions are presented. It is concluded that pharmacological developments of mood-regulating or neuroprotective drugs can have cross benefit in co-morbid conditions of neuropsychiatric and neurodegenerative disorders and that inflammatory and neurotrophic factors play important roles in both conditions.
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Affiliation(s)
- Yousef Tizabi
- Department of Pharmacology, Howard University College of Medicine, Washington, DC, USA.
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