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Hu C, Ou X, Teng Y, Shu S, Wang Y, Zhu X, Kang Y, Miao J. Sedation Effects Produced by a Ciprofol Initial Infusion or Bolus Dose Followed by Continuous Maintenance Infusion in Healthy Subjects: A Phase 1 Trial. Adv Ther 2021; 38:5484-5500. [PMID: 34559359 PMCID: PMC8523013 DOI: 10.1007/s12325-021-01914-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 09/01/2021] [Indexed: 02/05/2023]
Abstract
Introduction The effects of continuous infusions of ciprofol on its pharmacodynamic and pharmacokinetic properties and safety profiles in healthy Chinese subjects were evaluated. Methods In this open-label, randomized, two-way cross-over study, subjects received initial doses of continuous ciprofol/propofol as an infusion for 30 min in part 1 (n = 8) and a bolus dose in part 2 (n = 8) followed by maintenance infusions for a total of 4 h in part 1 and 12 h in part 2. Each subject participated in both parts with a washout time of at least 40 h. Results The safety and tolerability parameters of ciprofol were similar to those of propofol, and all treatment-emergent adverse events were mild. The incidences of injection pain and respiratory depression in subjects given ciprofol were lower than those receiving propofol. The pharmacokinetic parameters Cmax, tmax, t1/2, λz and MRT for ciprofol and propofol were similar, while CL, Vd and Vss were statistically significantly different. Pharmacodynamic parameters including the Richmond Agitation Sedation Scale and bispectral index profiles of ciprofol were similar to those of propofol. Conclusion Ciprofol has potential for clinical application for continuous intravenous infusion to maintain sedation for 12 h with the same safety, tolerability and efficacy as propofol. Supplementary Information The online version contains supplementary material available at 10.1007/s12325-021-01914-4.
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Affiliation(s)
- Chao Hu
- Clinical Trials Center, West China Hospital, Sichuan University, No. 37 Guoxue Lane, Wuhou District, Chengdu, 610041, China
| | - Xiaofeng Ou
- Department of Intensive Care Unit, West China Hospital, Sichuan University, No. 37 Guoxue Lane, Wuhou District, Chengdu, 610041, China
| | - Yi Teng
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Shiqing Shu
- Clinical Trials Center, West China Hospital, Sichuan University, No. 37 Guoxue Lane, Wuhou District, Chengdu, 610041, China
| | - Ying Wang
- Clinical Trials Center, West China Hospital, Sichuan University, No. 37 Guoxue Lane, Wuhou District, Chengdu, 610041, China
| | - Xiaohong Zhu
- Clinical Trials Center, West China Hospital, Sichuan University, No. 37 Guoxue Lane, Wuhou District, Chengdu, 610041, China
| | - Yan Kang
- Department of Intensive Care Unit, West China Hospital, Sichuan University, No. 37 Guoxue Lane, Wuhou District, Chengdu, 610041, China.
| | - Jia Miao
- Clinical Trials Center, West China Hospital, Sichuan University, No. 37 Guoxue Lane, Wuhou District, Chengdu, 610041, China.
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Hewson DW, Hardman JG, Bedforth NM. Patient-maintained propofol sedation for adult patients undergoing surgical or medical procedures: a scoping review of current evidence and technology. Br J Anaesth 2020; 126:139-148. [PMID: 32917377 PMCID: PMC7844373 DOI: 10.1016/j.bja.2020.07.053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 06/04/2020] [Accepted: 07/03/2020] [Indexed: 11/28/2022] Open
Abstract
Patient-maintained propofol sedation (PMPS) is the delivery of procedural propofol sedation by target-controlled infusion with the patient exerting an element of control over their target-site propofol concentration. This scoping review aims to establish the extent and nature of current knowledge regarding PMPS from both a clinical and technological perspective, thereby identifying knowledge gaps to guide future research. We searched MEDLINE, EMBASE, and OpenGrey databases, identifying 17 clinical studies for analysis. PMPS is described in the context of healthy volunteers and in orthopaedic, general surgical, dental, and endoscopic clinical settings. All studies used modifications to existing commercially-available infusion devices to achieve prototype systems capable of PMPS. The current literature precludes rigorous generalisable conclusions regarding the safety or comparative clinical effectiveness of PMPS, however cautious acknowledgement of efficacy in specific clinical settings is appropriate. Based on the existing literature, together with new standardised outcome reporting recommendations for sedation research and frameworks designed to assess novel health technologies research, we have made recommendations for future pharmacological, clinical, behavioural, and health economic research on PMPS. We conclude that high-quality experimental clinical trials with relevant comparator groups assessing the impact of PMPS on standardised patient-orientated outcome measures are urgently required.
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Affiliation(s)
- David W Hewson
- Department of Anaesthesia and Critical Care Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK.
| | - Jonathan G Hardman
- Department of Anaesthesia and Critical Care Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Nigel M Bedforth
- Department of Anaesthesia and Critical Care Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Hewson DW, Worcester F, Sprinks J, Smith MD, Buchanan H, Breedon P, Hardman JG, Bedforth NM. Anaesthetist-controlled versus patient-maintained effect-site targeted propofol sedation during elective primary lower-limb arthroplasty performed under spinal anaesthesia (ACCEPTS): study protocol for a parallel-group randomised comparison trial. Trials 2019; 20:129. [PMID: 30760311 PMCID: PMC6374891 DOI: 10.1186/s13063-019-3228-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 01/29/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The clinical efficacy of effect-site targeted patient-maintained propofol sedation (PMPS) compared to anaesthetist-controlled propofol sedation (ACPS) for patients undergoing awake joint replacement surgery is currently unknown. There is no commercially available medical device capable of delivering PMPS so we have designed and built such a device. We plan a clinical trial to compare PMPS to ACPS and to collect data relating to the safety of our prototype device in delivering sedation. METHODS The trial is an open-label, randomised, controlled superiority trial recruiting adults who are undergoing elective primary lower-limb arthroplasty with sedation by propofol infusion by effect-site targeting into two equal-sized parallel arms: PMPS and ACPS. The primary research objective is to compare the body-weight-normalised rate of propofol consumption when sedation for surgery on adults undergoing elective primary lower-limb arthroplasty under spinal anaesthesia is patient-maintained versus when it is anaesthetist-controlled. The study primary null hypothesis is that there is no difference in the rate of propofol consumption when sedation is patient-maintained versus anaesthetist-controlled. DISCUSSION This is the first trial to test the superiority of effect-site-targeted patient-maintained propofol sedation versus anaesthetist-controlled propofol sedation in terms of total propofol consumption during the sedation period. The results of this trial will help inform clinicians and device manufacturers of the clinical efficacy and safety of patient-maintained propofol sedation applied to a common operative setting. TRIAL REGISTRATION International Standard Randomised Controlled Trial Number Registry, ISRCTN29129799 . Prospectively registered on 12 June 2018.
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Affiliation(s)
- David W Hewson
- Department of Anaesthesia and Critical Care, Nottingham University Hospitals NHS Trust, Nottingham, UK.
| | - Frank Worcester
- Medical Design Research Group, Nottingham Trent University, Nottingham, UK
| | - James Sprinks
- Medical Design Research Group, Nottingham Trent University, Nottingham, UK
| | - Murray D Smith
- Community and Health Research Unit, University of Lincoln, Lincoln, UK
| | - Heather Buchanan
- Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UK
| | - Philip Breedon
- Medical Design Research Group, Nottingham Trent University, Nottingham, UK
| | | | - Nigel M Bedforth
- Department of Anaesthesia and Critical Care, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Network Properties in Transitions of Consciousness during Propofol-induced Sedation. Sci Rep 2017; 7:16791. [PMID: 29196672 PMCID: PMC5711919 DOI: 10.1038/s41598-017-15082-5] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 10/20/2017] [Indexed: 01/10/2023] Open
Abstract
Reliable electroencephalography (EEG) signatures of transitions between consciousness and unconsciousness under anaesthesia have not yet been identified. Herein we examined network changes using graph theoretical analysis of high-density EEG during patient-titrated propofol-induced sedation. Responsiveness was used as a surrogate for consciousness. We divided the data into five states: baseline, transition into unresponsiveness, unresponsiveness, transition into responsiveness, and recovery. Power spectral analysis showed that delta power increased from responsiveness to unresponsiveness. In unresponsiveness, delta waves propagated from frontal to parietal regions as a traveling wave. Local increases in delta connectivity were evident in parietal but not frontal regions. Graph theory analysis showed that increased local efficiency could differentiate the levels of responsiveness. Interestingly, during transitions of responsive states, increased beta connectivity was noted relative to consciousness and unconsciousness, again with increased local efficiency. Abrupt network changes are evident in the transitions in responsiveness, with increased beta band power/connectivity marking transitions between responsive states, while the delta power/connectivity changes were consistent with the fading of consciousness using its surrogate responsiveness. These results provide novel insights into the neural correlates of these behavioural transitions and EEG signatures for monitoring the levels of consciousness under sedation.
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Mason K. Challenges in paediatric procedural sedation: political, economic, and clinical aspects. Br J Anaesth 2014; 113 Suppl 2:ii48-62. [DOI: 10.1093/bja/aeu387] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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O'Brien C, Urquhart CS, Allam S, Anderson KJ, Leitch JA, Macpherson A, Kenny GNC. Reaction time-monitored patient-maintained propofol sedation: a pilot study in oral surgery patients. Anaesthesia 2013; 68:760-4. [PMID: 24044388 DOI: 10.1111/anae.12291] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2013] [Indexed: 11/28/2022]
Abstract
Previous volunteer studies of an effect-site controlled patient-maintained sedation system using propofol have demonstrated a risk of oversedation. We have incorporated a reaction time monitor into the handset to add an individualised patient-feedback mechanism. This pilot study assessed if the reaction time-feedback modification would prove safe and effective in 20 healthy patients receiving sedation while undergoing oral surgery. All patients successfully sedated themselves without reaching any unsafe endpoints. All 20 maintained verbal contact throughout. The mean (SD) lowest peripheral blood oxygen saturation was 98.0 (2.1)% breathing room air. No patient required supplementary oxygen. The mean (SD) maximum effect-site propofol concentration reached was 1.6 (0.5) μg.ml(-1). The present system was found to be safe and effective, allowing oral surgery treatment under conscious sedation, but preventing oversedation.
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Affiliation(s)
- C O'Brien
- University of Glasgow Dental School, Glasgow, UK
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Joo JD, In JH, Kim DW, Jung HS, Kang JH, Yeom JH, Choi JW. The comparison of sedation quality, side effect and recovery profiles on different dosage of remifentanil patient-controlled sedation during breast biopsy surgery. Korean J Anesthesiol 2012. [PMID: 23198037 PMCID: PMC3506853 DOI: 10.4097/kjae.2012.63.5.431] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The patient-controlled sedation (PCS) allows for rapid individualized titration of sedative drugs. Propofol has been the most widely used IV adjuvant, during the monitored anesthesia care (MAC). This study was designed to compare the sedation quality, side effect and recovery of the propofol alone, and propofol-remifentanil combination, using PCS for breast biopsy. METHODS Seventy five outpatients, undergoing breast biopsy procedures with local anesthesia, were randomly assigned to receive propofol alone (group P), propofol-25 ug/ml of remifentanil (group PR25), and propofol-50 ug/ml of remifentanil (group PR50), using PCS. Pain visual analogue scores (VAS) and digit symbol substitution test (DSST), Vital signs, bi-spectral index (BIS) and observer assessment of alertness and sedation (OAA/S) score were recorded. RESULTS Apply/Demand ratio in the group PR50 had a significant increase over the other groups (P < 0.05). The incidence of excessive sedation and dizziness were significantly more frequent in the group PR50 (P < 0.05). BIS and OAA/S score significantly decreased in the group PR25, PR50 at 15 min after the operation, the end of surgery (P < 0.05). At 5 min after the start of PCS, patients in the group PR25 and PR50 gave significantly less correct responses on the DSST than that of the group P (P < 0.05). CONCLUSIONS Compared with the propofol alone, intermittent bolus injection of propofol-remifentanil mixture could be used, appropriately, for the sedation and analgesia during MAC. The group PR25 in a low dose of remifentanil has more advantages in terms of sedation and satisfaction because of the group PR50's side effects.
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Affiliation(s)
- Jin-Deok Joo
- Department of Anesthesiology and Pain Medicine, The Catholic University of Korea, Suwon, Korea
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8
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Anderson KJ, Allam S, Chapman R, Kenny GNC. The effect of propofol on patient reaction time and its relationship with loss of verbal contact before induction of anaesthesia*. Anaesthesia 2012; 68:148-53. [DOI: 10.1111/anae.12035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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9
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Allam S, Anderson KJ, O'Brien C, Macpherson JA, Gambhir S, Leitch JA, Kenny GNC. Patient-maintained propofol sedation using reaction time monitoring: a volunteer safety study. Anaesthesia 2012; 68:154-8. [PMID: 23153106 DOI: 10.1111/anae.12036] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Previous volunteer studies of an effect-site controlled, patient-maintained sedation system using propofol have demonstrated a risk of over-sedation. We have incorporated a reaction-time monitor into the handset of the patient-maintained sedation system to add an individualised patient-feedback mechanism. This study assessed if such reaction-time feedback modification would reduce the risk of over-sedation in 20 healthy volunteers deliberately attempting to over-administer themselves propofol. All the volunteers successfully sedated themselves without reaching any unsafe endpoints. All volunteers maintained verbal contact throughout, in accordance with the definition of conscious sedation. The mean (SD) lowest S(p) O(2) was 97 (1.7) % when breathing room air and no volunteer required supplementary oxygen. The mean (SD) maximum effect-site propofol concentration reached was 1.7 (0.4) μg.ml(-1) . The present system was found to be safer than its predecessors, allowing conscious sedation, but preventing over-sedation.
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Affiliation(s)
- S Allam
- Department of Anaesthesia, Forth Valley Royal Hospital, Larbert, UK.
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10
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Target-controlled infusion of propofol for sedation in patients with non-invasive ventilation failure due to low tolerance: a preliminary study. Intensive Care Med 2010; 36:1675-1680. [DOI: 10.1007/s00134-010-1904-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2009] [Accepted: 04/08/2010] [Indexed: 01/22/2023]
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Edwards JA, Kinsella J, Shaw A, Evans S, Anderson KJ. Sedation for oocyte retrieval using target controlled infusion of propofol and incremental alfentanil delivered by non-anaesthetists. Anaesthesia 2010; 65:453-61. [DOI: 10.1111/j.1365-2044.2010.06264.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Doufas AG, Morioka N, Mahgoub AN, Bjorksten AR, Shafer SL, Sessler DI. Automated Responsiveness Monitor to Titrate Propofol Sedation. Anesth Analg 2009; 109:778-86. [DOI: 10.1213/ane.0b013e3181b0fd0f] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Rigobello MP, Stevanato R, Momo F, Fabris S, Scutari G, Boscolo R, Folda A, Bindoli A. Evaluation of the Antioxidant Properties of Propofol and its Nitrosoderivative. Comparison with Homologue Substituted Phenols. Free Radic Res 2009; 38:315-21. [PMID: 15129739 DOI: 10.1080/03079450310001652031] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Propofol (2,6-diisopropylphenol), some substituted phenols (2,6-dimethylphenol and 2,6-ditertbutylphenol) and their 4-nitrosoderivatives have been compared for their scavenging ability towards 1,1-diphenyl-2-picrylhydrazyl and for their inhibitory action on lipid peroxidation. These products were also compared to the classical antioxidants butylated hydroxytoluene and butylated hydroxyanisole. When measuring the reactivity of the various phenolic derivatives with 1,1-diphenyl-2-picrylhydrazyl the following order of effectiveness was observed: butylated hydroxyanisole > propofol > 2,6-dimethylphenol > 2,6-di-tertbutylphenol > butylated hydroxytoluene. In cumene hydroperoxide-dependent microsomal lipid peroxidation, propofol acts as the most effective antioxidant, while butylated hydroxyanisole, 2,6-di-tertbutylphenol and butylated hydroxytoluene exhibit a rather similar effect, although lower than propofol. In the iron/ascorbate-dependent lipid peroxidation propofol, at concentrations higher than 10 microM, exhibits antioxidant properties comparable to those of butylated hydroxytoluene and butylated hydroxyanisole, 2,6-Dimethylphenol is scarcely effective in both lipoperoxidative systems. The antioxidant properties of the various molecules depend on their hydrophobic characteristics and on the steric and electronic effects of their substituents. However, the introduction of the nitroso group in the 4-position almost completely removes the antioxidant properties of the examined compounds. The nitrosation of the aromatic ring of antioxidant molecules and the consequent loss of antioxidant capacity can be considered a condition potentially occurring in vivo since nitric oxide and its derivatives are continuously formed in biological systems.
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Affiliation(s)
- Maria Pia Rigobello
- Department of Biological Chemistry, University of Padova, Viale G. Colombo 3, 35121 Padova, Italy
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Höhener D, Blumenthal S, Borgeat A. Sedation and regional anaesthesia in the adult patient. Br J Anaesth 2008; 100:8-16. [PMID: 18070783 DOI: 10.1093/bja/aem342] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
This review discusses sedation for regional anaesthesia in the adult population. The first section deals with general aspects of sedation and shows that the majority of patients receiving sedation for regional anaesthesia are satisfied and would choose it again. Methods of assessing the level of sedation are discussed with emphasis on clinical measures. The pharmacology of the drugs involved in sedation is discussed, with propofol and remifentanil appearing to be the combination of choice for sedation in regional anaesthesia. The techniques for administering sedation are discussed and replacement of the traditional repeated boluses or continuous infusion with pharmacokinetic and patient-controlled systems is supported. Patient satisfaction studies suggest that patient-controlled systems are preferred.
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Affiliation(s)
- D Höhener
- Department of Anaesthesiology, Orthopedic University Clinic Balgrist, Forchstrasse 340, 8008 Zurich, Switzerland
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Abstract
Patient-controlled analgesia (PCA) has become the gold standard for acute pain management since it was first introduced 20 years ago, and its merits have been discussed in quite a large number of publications. This review summarizes the more recent developments, such as new application devices and strategies, including intranasal, spinal, and regional PCA; patient-controlled sedation; experience with children and elderly people; and some data from chronic pain situations. Analyzing PCA literature from 2001 onwards confirms the author's long belief that the PCA principle ("WYNIWYG": what you need is what you get) was the most important aspect of a patient-controlled strategy, more or less independent of the type of drug or machine. Discovering this principle has changed the understanding of pain and suffering.
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Affiliation(s)
- Klaus A Lehmann
- Department of Anesthesiology, University of Cologne, Cologne, Germany
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Anderson KJ, Leitch JA, Green JS, Kenny GNC. Effect-site controlled patient maintained propofol sedation: a volunteer safety study. Anaesthesia 2005; 60:235-8. [PMID: 15710007 DOI: 10.1111/j.1365-2044.2004.04071.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Effect-site concentration is a mathematical term related to the clinical effect of a drug. We have designed a patient-maintained sedation system for delivering propofol to the predicted effect-site concentration rather than plasma concentration. To assess its efficacy and safety, 20 healthy volunteers deliberately attempted to over-sedate themselves using the system. The new effect-site concentration driven system delivered sedation successfully, and more rapidly than its predecessor. Fifteen volunteers ended the study when the system automatically reduced the effect-site concentration after 6 min of no button presses despite verbal contact and maintenance of arterial oxygen saturation (at effect-site concentration 1.8-3.8 microg x ml(-1)). Four out of 20 volunteers ended with minor arterial desaturation (lowest 88% at effect-site concentration 2.6-3.4 microg x ml(-1)). One volunteer ended after loss of verbal contact at effect-site concentration 3.4 microg x ml(-1). Further modification of the system's design is necessary before it can be recommended for routine practice.
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Affiliation(s)
- K J Anderson
- University of Glasgow, Department of Anaesthesia, Glasgow Royal Infirmary, 10 Alexandra Parade, Glasgow, UK.
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Leitch JA, Anderson K, Gambhir S, Millar K, Robb ND, McHugh S, Kenny GNC. A partially blinded randomised controlled trial of patient-maintained propofol sedation and operator controlled midazolam sedation in third molar extractions. Anaesthesia 2004; 59:853-60. [PMID: 15310346 DOI: 10.1111/j.1365-2044.2004.03761.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Patient-maintained sedation using propofol has recently been shown to be effective for dental surgery. We compared this new technique to the established technique of operator administered midazolam. The two groups were compared before, during and after sedation. The two primary outcomes were time until discharge and oxygen saturation. Vital signs, anxiety and psychomotor skills were also compared. State anxiety was reduced to a greater extent in the propofol group (mean difference 10 (SD 4) mm; p = 0.010. Propofol patients recovered quicker (mean difference 7 (SD 1.4) min; p = 0.001). Propofol patients had a smaller reduction in arterial oxygen saturation (mean difference 0.8 (SD 0.3)%; p = 0.030), and a reduced increase in heart rate (mean difference 9 (SD 2) beats.min(-1); p < 0.001). Both techniques were well tolerated and safe. Propofol sedation offered superior anxiolysis, quicker recovery, less amnesia and less depression of simple psychomotor function.
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Affiliation(s)
- J A Leitch
- University of Glasgow Dental School, 378 Sauchiehall Street, Glasgow, G2 3JZ, UK.
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Quinart A, Nouette-Gaulain K, Pfeiff R, Revel P, Sztark F. Sédation peropératoire à objectif de concentration avec le propofol : détermination des concentrations au site d'action et évaluation de l'index bispectral. ACTA ACUST UNITED AC 2004; 23:675-80. [PMID: 15324954 DOI: 10.1016/j.annfar.2004.04.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2003] [Accepted: 04/15/2004] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To determine the effect-site concentration (Ce) of propofol, required to achieving adequate sedation. To assess the efficacy and safety of a target-controlled infusion system during monitored anaesthesia care and to evaluate the ability of bispectral index (BIS) to predict sedation level. Study design. - Prospective clinical study. PATIENTS Women scheduled for insertion of tension-free vaginal tape under local anaesthetic infiltration. METHODS After premedication with hydroxyzine, 1% propofol was infused using the Diprifusor system at an initial target plasma concentration (Cc) of 1 microg/ml and then adjusted by steps of 0.2 microg/ml at 5 min intervals. The level of sedation was assessed using the observer's assessment of alertness/sedation (OAA/S) scale; the objective was to obtain an OAA/S level at 4 or 3 (response to verbal stimulation). Ce of propofol and BIS were noted every 5 min. Relation between Ce or BIS and OAA/S scale was analysed by linear regression and probability of prediction (P(K)). RESULTS Fifty patients aged 62 +/- 12 years were studied. Sedation at level 4 or 3 was observed in all patients. Ce of propofol and BIS to maintain this OAA/S score were, respectively, 1.0 +/- 0.2 microg/ml and 87 +/- 7. There was a linear relation between OAA/S scale and BIS or Ce; however, individual values demonstrate wide variability. The average of P(K) values computed for each patient for the BIS and Ce was 0.84 and 0.83, respectively. CONCLUSIONS Target-controlled infusion of propofol provides easy and safe management of intraoperative sedation, allowing a fast and precise adjustment of the propofol concentration to the clinical response of the patient.
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Affiliation(s)
- A Quinart
- Département d'anesthésie-réanimation-I, CHU Pellegrin, 33076 Bordeaux cedex, France
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20
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Abstract
Propofol is an intravenous anaesthetic agent, which presents interesting features for its use in neuro-anaesthesia: it is a powerful hypnotic that does not increase the intracranial pressure. The delay of recovery is short even after several hours of continuous infusion. This is essential for a fast neurologic examination. Continuous infusion should be preferred to bolus in order to prevent hypotension and decrease of the cerebral perfusion pressure. Target-controlled infusion models based on effect site concentrations are now available through several softwares. This technique appears especially useful for awake craniotomy and functional neurosurgery. The level of consciousness is easily fixed between deep anaesthesia and light sedation permitting to ask the patient to move following orders. A sedation controlled by the patient himself is even possible.
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Affiliation(s)
- A M Debailleul
- Département d'anesthésie-réanimation chirurgicale 1, hôpital Roger-Salengro, Lille, France
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Campbell L, Imrie G, Doherty P, Porteous C, Millar K, Kenny GNC, Fletcher G. Patient maintained sedation for colonoscopy using a target controlled infusion of propofol. Anaesthesia 2004; 59:127-32. [PMID: 14725514 DOI: 10.1111/j.1365-2044.2004.03580.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
In this study, we evaluated safety and recovery using a patient maintained, target controlled infusion of propofol for sedation in 20 patients undergoing colonoscopy. Using a handset with a two-minute lockout interval, patients could make 0.2 micro g.ml(-1) increments to an initial target plasma concentration of 1 micro g.ml(-1) up to a maximum 4.5 micro g.ml(-1). Four patients became oversedated but required no airway or circulatory interventions. Subjects had a significant reduction in mean (SD) heart rate: 78.7 (15) vs. 69.8 (13.5) (p < 0.001) and in systolic blood pressure 121.1 (13.2) mmHg vs. 96.5 (8.6) mmHg (p < 0.001). Choice reaction time testing 15 min after colonoscopy showed a significant median (IQR [range]) rise of 162 (- 16, 383.3 [-199-859]) ms (p < 0.05). Six patients had faster reaction times postcolonoscopy. All patients denied unpleasant recall and were satisfied with the system. Although oversedation was a problem in this model, we conclude that patient maintained propofol sedation could be possible for colonoscopy.
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Affiliation(s)
- L Campbell
- Department of Anaesthetics, The Royal Sussex County Hospital, Eastern Road, Brighton, BN2 5BE, UK.
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Hosey MT, Makin A, Jones RM, Gilchrist F, Carruthers M. Propofol intravenous conscious sedation for anxious children in a specialist paediatric dentistry unit. Int J Paediatr Dent 2004; 14:2-8. [PMID: 14706022 DOI: 10.1111/j.1365-263x.2004.00521.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To report on both the use and dosage of propofol, as a new intravenous (IV) conscious sedative agent, for anxious children referred to a specialist paediatric dentistry service. SETTING Paediatric Dentistry Unit, Glasgow Dental Hospital and School. SAMPLE Thirty-four children, 25 females and 9 males, mean age 12 years 10 months, with a mean weight of 54.6 kg (range 30-110 kg). METHODS Report from 34 patients receiving intravenous sedation for the first time in respect of weight dose and amount of treatment completed. RESULTS Thirty-two children successfully accepted operative dental care on their first visit, they received a mean total dose of 146.25 mg of propofol (range 10 mg to 356 mg); in relation to body weight, the mean was 2.5 mg/kg (range 0.2-5.4 mg/kg). The treatment that they received included fissure sealants, amalgam and adhesive restorations, root canal therapy and single and multiple extractions. Their sedation and recovery were uneventful. CONCLUSIONS Sub-anaesthetic doses of propofol used for IV conscious sedation infusion facilitated operative dental treatment in anxious children.
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Affiliation(s)
- M T Hosey
- Glasgow Dental Hospital & School, 378 Sauchiehall Street, Glasgow, Scotland, UK.
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Doufas AG, Bakhshandeh M, Bjorksten AR, Greif R, Sessler DI. A new system to target the effect-site during propofol sedation. Acta Anaesthesiol Scand 2003; 47:944-50. [PMID: 12904185 DOI: 10.1034/j.1399-6576.2003.00161.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND We evaluated a new, integrated, covariate-adjusted, target-controlled infusion system during sedation with propofol combined with 50% nitrous oxide (N2O) and with propofol only (Air). METHODS The protocol consisted of sequential 15-minute cycles in 20 volunteers. After a 15-minute control period, propofol was infused to an initial target effect-site concentration of 0.25 microg x ml-1 (N2O) or 1.5 microg x ml-1 (Air). Subsequently, the target effect-site concentration was increased by 0.25 (N2O) or 0.5 microg x ml-1 (Air) for 15 min This sequence was continued until the volunteers lost consciousness as defined by an Observer's Assessment Alertness/Sedation (OAA/S) score = 2. RESULTS Venous plasma propofol concentrations at the beginning(9 elapsed minutes) and end(15 elapsed minutes) of the pseudo-steady state period differed by only 0.00 +/- 0.16 microg x ml-1 (P = 0.78) during the N2O and 0.00 +/- 0.25 microg x ml-1 (P = 0.91) during the Air trial. OAA/S scores and bispectral index values, as surrogate measures of pharmacodynamic effect, were not different during this time in either trial. The median(25th, 75th percentiles) of the median performance error (%) was -13 (-24, -1) during the N2O and -18 (-26, -9) during the Air trial. The median absolute performance error (%) was 17 (10, 24) in the N2O and 22 (12, 28) in Air trial. The divergence (%/h) was -10 (-26, 4) in the N2O and 14 (-21, 26) in Air trial. The wobble was 7 (5, 10) in the N2O and 6 (4, 8) in the Air trial. CONCLUSIONS When tested with venous blood samples, our TCI system for propofol, using a covariate-adjusted, integrated pharmacokinetic model to target effect-site concentrations, demonstrated a clinically acceptable accuracy and stability during mild to moderate sedation.
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Affiliation(s)
- A G Doufas
- OUTCOMES RESEARCH Institute and Department of Anesthesiology and Pharmacology, University of Louisville, Louisville, KY 40202, USA.
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Glen JB. The Development and Future of Target Controlled Infusion. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2003; 523:123-33. [PMID: 15088846 DOI: 10.1007/978-1-4419-9192-8_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Affiliation(s)
- John B Glen
- Glen Pharma Limited, 35A Bexton Road, Knutsford, Cheshire WA16 0DZ, UK
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Stevanato R, Momo F, Marian M, Rigobello MP, Bindoli A, Bragadin M, Vincenti E, Scutari G. Effects of nitrosopropofol on mitochondrial energy-converting system. Biochem Pharmacol 2002; 64:1133-8. [PMID: 12234616 DOI: 10.1016/s0006-2952(02)01253-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Nitrosopropofol (NOPR) is a relatively stable compound obtained from the reaction between the general anesthetic 2,6 diisopropylphenol (propofol) and nitrosoglutathione (GSNO) and bearing a more acidic phenol group than propofol. It interfered with mitochondrial energetic metabolism in a concentration-dependent manner. Concentrations as high as 100 or 200 microM disrupted both oxidative phosphorylation and electron transport. Low concentrations of NOPR (50 microM) markedly slowed down the electron transport rate which was insensitive both to ADP and uncoupler stimulation and spontaneously gradually stopped. Consequently, both the transmembrane potential production and the ATP synthesis system were affected. In the presence of 10 or 20 microM NOPR, mitochondria respired but showed a worsening of the respiratory control and produced a transmembrane potential useful to respond to a phosphorylation pulse, but were not able to restore it. These results were consistent with ATP synthesis and swelling experiments. NOPR was effective at concentrations lower than those required by the combination of propofol and GSNO, suggesting that mitochondria might be able to catalyze the reaction between GSNO and propofol and that the resulting metabolite was more active on mitochondrial membrane structure than the parent compounds. Although the details of the process are yet unknown, the mechanism presented may be of potential relevance to rationalize the pathophysiological effects of propofol.
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Affiliation(s)
- Roberto Stevanato
- Department of Physical Chemistry, University of Venice, Venice, Italy
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Hosey MT. UK National Clinical Guidelines in Paediatric Dentistry. Managing anxious children: the use of conscious sedation in paediatric dentistry. Int J Paediatr Dent 2002; 12:359-72. [PMID: 12199898 DOI: 10.1046/j.1365-263x.2002.03792.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Henderson F, Absalom AR, Kenny GNC. Patient-maintained propofol sedation: a follow up safety study using a modified system in volunteers. Anaesthesia 2002; 57:387-90. [PMID: 11949642 DOI: 10.1046/j.1365-2044.2002.2410_1.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Patient-maintained sedation is a mode of patient-controlled sedation during which propofol is administered using a target-controlled infusion, with patient demand increasing the target concentration. A system tested previously for safety in our institution resulted in oversedation. Aiming to improve safety, we modified the system by increasing the lockout period to 4 min,reducing the starting concentration to 0.5 microg x ml(-1) and the increments on demand to 0.1 microg x ml(-1). As in the previous study, healthy volunteers attempted to render themselves unconscious by frequently pressing the demand button. To assess effects on memory, volunteers were given keywords to remember every 15 min. The maximum target concentration reached varied between 1.0 and 2.5 microg x ml(-1). No volunteers lost consciousness, however, one volunteer had a brief period of apnoea and oxygen desaturation. The Cp50 for loss of memory for words was 1.26 microg x ml(-1). Although this version represents an improvement, we conclude that the system is not yet completely suitable for use without anaesthetic supervision.
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Affiliation(s)
- F Henderson
- Department of Anaesthesia, Western Infirmary, Glasgow, UK
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Némethy M, Paroli L, Williams-Russo PG, Blanck TJJ. Assessing sedation with regional anesthesia: inter-rater agreement on a modified Wilson sedation scale. Anesth Analg 2002; 94:723-8; table of contents. [PMID: 11867405 DOI: 10.1097/00000539-200203000-00045] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
UNLABELLED A valid and reliable means for measuring sedation during regional anesthesia would be valuable for both research and practice. Current methods of monitoring sedation include machine-, patient-, and observer-based assessment. The reliability of machine-based methods is limited at lower levels of sedation, whereas patient-based methods are impractical at higher levels. Observer-based methods offer the best alternative for assessing sedation during regional anesthesia; however, their reliability has not been adequately documented. We examined the interrater reliability of the Wilson sedation scale. Sedation was assessed by pairs of anesthesia care providers in 100 patients undergoing surgical procedures with regional anesthesia. On the basis of the findings, the scale was modified, and 50 additional patients were assessed. The study protocol called for a series of standardized stimuli administered by a research assistant. Raters were blinded to each other's ratings. Interrater reliability was assessed by using the kappa statistic, a measure of actual agreement beyond agreement by chance. When continuing checks on its operationalization and reliability are included, the modified Wilson scale provides a simple and reliable means by which to assess and monitor intraoperative sedation. IMPLICATIONS We evaluated the interrater reliability of the Wilson scale for measuring sedation during regional anesthesia. Paired anesthesia care providers' ratings of patient sedation indicated very good interrater reliability in both the original scale and a modified version. The modified Wilson scale provides a quick noninvasive means of monitoring sedation during regional anesthesia.
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Affiliation(s)
- Mária Némethy
- Department of Medicine, Hospital for Special Surgery, Cornell University Medical College, New York, New York, USA
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Schraag S. Theoretical basis of target controlled anaesthesia: history, concept and clinical perspectives. Best Pract Res Clin Anaesthesiol 2001. [DOI: 10.1053/bean.2001.0132] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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