1
|
Lu K, Li X, Wu J. Sirtuin 3 is required for the dexmedetomidine-mediated alleviation of inflammation and oxidative stress in nephritis. Immun Inflamm Dis 2024; 12:e1135. [PMID: 38270316 PMCID: PMC10777884 DOI: 10.1002/iid3.1135] [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: 03/29/2023] [Revised: 11/23/2023] [Accepted: 12/17/2023] [Indexed: 01/26/2024] Open
Abstract
INTRODUCTION Although sirtuin 3 (SIRT3) is known to be involved in dexmedetomidine (DEX)-mediated alleviation of renal ischemia and reperfusion injury, the influence of the association between DEX and SIRT3 on nephritis development remains unclear. In this study, the role of SIRT3 in DEX-mediated amelioration of inflammation and oxidative stress in nephritis as well as the possible underlying mechanism were explored in vivo and in vitro. METHODS An animal model of glomerulonephritis was generated by injecting mice with interferon-alpha (IFNα)-expressing adenoviruses, and periodic acid-Schiff staining was then used to reveal pathogenicity-related changes in the renal tissue. Additionally, human embryonic kidney cells (HEK293) and renal mesangial cells (RMCs) were treated with IFNα to establish cell models of inflammation in vitro. RESULTS DEX administration alleviated glomerulonephritis in the animal model and upregulated SIRT3 expression in the renal tissue. SIRT3 knockdown inhibited the renoprotective effects of DEX against nephritis. IFNα induced inflammation, oxidative stress, and apoptosis in the RMCs and HEK293 cells and reduced their growth, as evidenced by the evaluation of cytokine levels (enzyme-linked immunosorbent assay), reactive oxygen species generation, catalase and superoxide dismutase activities, nuclear factor-erythroid factor 2-related factor 2/heme oxygenase-1 signal transduction, apoptotic cell proportion, and cell viability. In addition to promoting SIRT3 expression, DEX inhibited IFNα-induced inflammation, oxidative stress, and apoptosis in these cells and promoted their viability. SIRT3 knockdown partially reversed the beneficial effects of DEX on RMCs and HEK293 cells. CONCLUSIONS Our results suggest that DEX exhibits renoprotective activity during nephritis progression, protecting renal cells against inflammatory injury by promoting SIRT3 expression.
Collapse
Affiliation(s)
- Kai Lu
- Department of Anesthesiology, Sir Run Run Shaw Hospital, School of MedicineZhejiang UniversityHangzhouChina
| | - Xinlong Li
- Department of Anesthesiology, Sir Run Run Shaw Hospital, School of MedicineZhejiang UniversityHangzhouChina
| | - Jie Wu
- Department of Anesthesiology, Sir Run Run Shaw Hospital, School of MedicineZhejiang UniversityHangzhouChina
| |
Collapse
|
2
|
Lankadeva YR, Shehabi Y, Deane AM, Plummer MP, Bellomo R, May CN. Emerging benefits and drawbacks of α 2 -adrenoceptor agonists in the management of sepsis and critical illness. Br J Pharmacol 2021; 178:1407-1425. [PMID: 33450087 DOI: 10.1111/bph.15363] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 12/21/2020] [Accepted: 12/29/2020] [Indexed: 12/29/2022] Open
Abstract
Agonists of α2 -adrenoceptors are increasingly being used for the provision of comfort, sedation and the management of delirium in critically ill patients, with and without sepsis. In this context, increased sympathetic and inflammatory activity are common pathophysiological features linked to multi-organ dysfunction, particularly in patients with sepsis or those undergoing cardiac surgery requiring cardiopulmonary bypass. Experimental and clinical studies support the notion that the α2 -adrenoceptor agonists, dexmedetomidine and clonidine, mitigate sympathetic and inflammatory overactivity in sepsis and cardiac surgery requiring cardiopulmonary bypass. These effects can protect vital organs, including the cardiovascular system, kidneys, heart and brain. We review the pharmacodynamic mechanisms by which α2 -adrenoceptor agonists might mitigate multi-organ dysfunction arising from pathophysiological conditions associated with excessive inflammatory and adrenergic stress in experimental studies. We also outline recent clinical trials that have examined the use of dexmedetomidine in critically ill patients with and without sepsis and in patients undergoing cardiac surgery.
Collapse
Affiliation(s)
- Yugeesh R Lankadeva
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia.,Centre for Integrated Critical Care, School of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Yahya Shehabi
- Department of Intensive Care Medicine, Monash Health, School of Clinical Sciences, Monash University, Melbourne, Prince of Wales Clinical School of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Adam M Deane
- Centre for Integrated Critical Care, School of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Department of Intensive Care Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Mark P Plummer
- Centre for Integrated Critical Care, School of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Department of Intensive Care Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Centre for Integrated Critical Care, School of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Clive N May
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia.,Centre for Integrated Critical Care, School of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| |
Collapse
|
3
|
Heming N, Mazeraud A, Azabou E, Moine P, Annane D. Vasopressor Therapy and the Brain: Dark Side of the Moon. Front Med (Lausanne) 2020; 6:317. [PMID: 31998736 PMCID: PMC6966606 DOI: 10.3389/fmed.2019.00317] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 12/13/2019] [Indexed: 12/14/2022] Open
Abstract
Sepsis, a leading cause of morbidity and mortality, is caused by a deregulated host response to pathogens, and subsequent life-threatening organ dysfunctions. All major systems, including the cardiovascular, respiratory, renal, hepatic, hematological, and the neurological system may be affected by sepsis. Sepsis associated neurological dysfunction is triggered by multiple factors including neuro-inflammation, excitotoxicity, and ischemia. Ischemia results from reduced cerebral blood flow, caused by extreme variations of blood pressure, occlusion of cerebral vessels, or more subtle defects of the microcirculation. International guidelines comprehensively describe the initial hemodynamic management of sepsis, revolving around the normalization of systemic hemodynamics and of arterial lactate. By contrast, the management of sepsis patients suffering from brain dysfunction is poorly detailed, the only salient point being mentioned is that sedation and analgesia should be optimized. However, sepsis and the hemodynamic consequences thereof as well as vasopressors may have severe untoward neurological consequences. The current review describes the general neurological complications, as well as the consequences of vasopressor therapy on the brain and its circulation and addresses methods for cerebral monitoring during sepsis.
Collapse
Affiliation(s)
- Nicholas Heming
- General Intensive Care Unit, Raymond Poincaré Hospital, Garches, France.,U1173 Lab Inflammation and Infection, University of Versailles SQY-Paris Saclay - INSERM, Montigny-le-Bretonneux, France
| | - Aurélien Mazeraud
- Department of Neuro-Anesthesiology and Intensive Care Medicine, Sainte-Anne Teaching Hospital, Paris-Descartes University, Paris, France
| | - Eric Azabou
- U1173 Lab Inflammation and Infection, University of Versailles SQY-Paris Saclay - INSERM, Montigny-le-Bretonneux, France.,Department of Physiology, Assistance Publique-Hôpitaux de Paris, Raymond-Poincaré Hospital, Garches, France
| | - Pierre Moine
- General Intensive Care Unit, Raymond Poincaré Hospital, Garches, France.,U1173 Lab Inflammation and Infection, University of Versailles SQY-Paris Saclay - INSERM, Montigny-le-Bretonneux, France
| | - Djillali Annane
- General Intensive Care Unit, Raymond Poincaré Hospital, Garches, France.,U1173 Lab Inflammation and Infection, University of Versailles SQY-Paris Saclay - INSERM, Montigny-le-Bretonneux, France
| |
Collapse
|
4
|
Algebaly H, ElSherbini S, Galal A, Hamdi R, Baz A, Elbeleidy A. Transcranial Doppler Can Predict Development and Outcome of Sepsis-Associated Encephalopathy in Pediatrics With Severe Sepsis or Septic Shock. Front Pediatr 2020; 8:450. [PMID: 32974238 PMCID: PMC7468380 DOI: 10.3389/fped.2020.00450] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 06/29/2020] [Indexed: 12/04/2022] Open
Abstract
Background and Aim: Sepsis is a common cause of pediatric intensive care unit (ICU) admission. Sepsis-associated encephalopathy (SAE) may occur owing to brain dysfunction in those patients and may be related to impaired cerebral microcirculation. Transcranial Doppler (TCD) can be used to detect this impairment. In this study, we aimed to assess the role of TCD in prediction of SAE and mortality in patients with severe sepsis or septic shock admitted to PICU. Patients and Methods: This prospective study included 75 children admitted to PICU owing to severe sepsis or septic shock. Upon admission, all patients were subjected to careful history taking, thorough clinical examination, and standard laboratory workup. Severity of clinical illness was assessed using the Pediatric Risk of Mortality (PRISM) III score. TCD was performed on the first day of admission after the normalization of systolic blood pressure with or without vasopressors. The primary study outcome was differences in the measurement of TCD in SAE, and the secondary outcome was discharge from ICU or mortality. Results: The study comprised 45 children with SAE and 30 age- and sex-matched children without SAE. In this study, SAE patients had significantly higher pulsatility index [PI; median interquartile range (IQR): 1.15 (0.98-1.48) vs. 1.0 (0.95-1.06), p = 0.002] and resistive index [RI; median (IQR): 0.68 (0.61-0.77) vs. 0.62 (0.59-0.64), p = 0.001] than had non-SAE patients. PI and RI showed good performance as predictors of subsequent SAE development [area under the curve (AUC): 0.72 and 0.73, respectively]. Non-survivors in SAE patients had significantly higher PRISM III. Receiver operating characteristic (ROC) curve analysis showed good performance of PI and RI as predictors of mortality at the end of follow-up. Conclusions: In children with SAE, cerebrovascular resistance is high and is associated with increased mortality.
Collapse
Affiliation(s)
- HebatAllah Algebaly
- Pediatric Critical Care Unit, Department of Pediatrics, Cairo University, Cairo, Egypt
| | - Seham ElSherbini
- Pediatric Critical Care Unit, Department of Pediatrics, Cairo University, Cairo, Egypt
| | - Ahmed Galal
- Pediatric Critical Care Unit, Children's Cancer Hospital, Cairo University, Cairo, Egypt
| | - Rania Hamdi
- Pediatric Imaging Unit, Department of Radiology, Cairo University, Cairo, Egypt
| | - Ahmed Baz
- Pediatric Imaging Unit, Department of Radiology, Cairo University, Cairo, Egypt
| | - Ahmed Elbeleidy
- Pediatric Critical Care Unit, Department of Pediatrics, Cairo University, Cairo, Egypt
| |
Collapse
|
5
|
The relative effects of dexmedetomidine and propofol on cerebral blood flow velocity and regional brain oxygenation: A randomised noninferiority trial. Eur J Anaesthesiol 2018; 34:732-739. [PMID: 28891839 DOI: 10.1097/eja.0000000000000662] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Dexmedetomidine constricts cerebral blood vessels without a concomitant reduction in cerebral metabolic oxygen consumption. Its safety as a sedative in patients with neurological diseases thus remains uncertain. OBJECTIVE Our primary objective was to test the hypothesis that dexmedetomidine is noninferior to propofol as regards cerebral blood flow (CBF) velocity and brain oxygenation. DESIGN Unblinded randomised trial. SETTING Cleveland Clinic Hospital, Cleveland, from November 2010 to July 2013. PATIENTS Forty-four patients scheduled for insertion of a deep-brain stimulating electrodes. INTERVENTIONS Patients were randomised to receive either dexmedetomidine or propofol sedation during deep-brain stimulating electrode insertion. MAIN OUTCOME MEASURES Intraoperative CBF velocity was measured with transcranial Doppler, and brain oxygenation was assessed with near-infrared spectroscopy. Noninferiority of dexmedetomidine to propofol was defined as a less than 20% difference in means. RESULTS Twenty-three patients were given dexmedetomidine and 21 propofol. Baseline characteristics and operative management were similar in each group. Dexmedetomidine was noninferior to propofol on both CBF and brain oxygenation, confirming our primary hypothesis. For cerebral flood flow, the estimated ratio of means (dexmedetomidine/propofol) was 0.94 [90% CI: 0.84 to 1.05], P = 0.011 for noninferiority. For brain oxygenation, the estimated ratio of means was 0.99 [90% CI: 0.96 to 1.02], P < 0.001 for noninferiority. Superiority was not found for either primary outcome. Dexmedetomidine provided deeper sedation than propofol, with a difference of medians of 1 [90% CI: 0 to 2], P < 0.001 on the Observer's Assessment of Alertness/Sedation scale. No significant differences were observed in pulsatility index, cerebral perfusion pressure, number of hypertensive or apnoeic episodes. CONCLUSION Regional brain oxygenation and CBF velocity are comparably preserved during dexmedetomidine and propofol sedation. Thus, the use of dexmedetomidine in patients with movement disorders appears reasonable. TRIAL REGISTRATION The trial was registered at ClinicalTrials.gov (NCT 01200433).
Collapse
|
6
|
Guo F, Ding Y, Yu X, Cai X. Effect of dexmedetomidine, midazolam, and propofol on lipopolysaccharide-stimulated dendritic cells. Exp Ther Med 2018; 15:5487-5494. [PMID: 29904429 DOI: 10.3892/etm.2018.6094] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 03/09/2018] [Indexed: 12/17/2022] Open
Abstract
Dexmedetomidine, midazolam and propofol are common sedative drugs used in the intensive care unit. Lipopolysaccharides (LPS) are a potent inducer of human dendritic cells (DCs) maturation and survival, which induces cytokine production. The present study aimed to investigate the effect and mechanisms of sedative drugs on LPS-induced cytokine production in DCs. The mouse bone marrow-derived dendritic DC2.4 cell line was used in the present study. The Cell Counting Kit-8 assay was used to measure the viability of cells. Tumor necrosis factor (TNF)-α, interleukin (IL)-1β, IL-6, and IL-10 mRNA expression levels and contents were measured using reverse transcription-quantitative polymerase chain reaction and ELISA, respectively. The expression levels of proteins associated with nuclear factor-κB (NF-κB) and mitogen activated protein kinase signaling pathways were assessed by western blotting. The three sedatives had different roles on TNF-α, IL-1β, IL-6, and IL-10 mRNA expression levels and content in DCs. Dexmedetomidine promoted inflammatory cytokine production at high clinical concentrations (10, 1 and 0.1 µM), however suppressed them at the lowest clinical concentration (0.001 µM), which was associated with NF-κB and c-Jun N-terminal kinase (JNK)-mitogen-activated protein kinase (MAPK) signaling. Midazolam inhibited inflammatory cytokine production via suppression of the NF-κB and JNK signaling pathways. Propofol partly inhibited inflammatory cytokine production, including IL-1β and IL-6, and the anti-inflammatory effect may result from inhibition of JNK-MAPK, and enhanced NF-κB and extracellular signal-regulated kinase-MAPK signaling at clinical concentrations. The present study helped to elucidate the function of sedatives in LPS-induced cytokine production in DCs, which will facilitate rational implementation of these sedatives in patients undergoing tracheal intubation with sepsis or multiple organ dysfunction syndrome.
Collapse
Affiliation(s)
- Feng Guo
- Department of Intensive Care Unit, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, P.R. China
| | - Ying Ding
- Department of Intensive Care Unit, Sir Run Run Shaw Hospital Xiasha Campus, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, P.R. China
| | - Xue Yu
- Department of Medicine, Tengzhou Central People's Hospital, Zaozhuang, Shandong 277500, P.R. China
| | - Xiujun Cai
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, P.R. China
| |
Collapse
|
7
|
de Azevedo DS, Salinet ASM, de Lima Oliveira M, Teixeira MJ, Bor-Seng-Shu E, de Carvalho Nogueira R. Cerebral hemodynamics in sepsis assessed by transcranial Doppler: a systematic review and meta-analysis. J Clin Monit Comput 2016; 31:1123-1132. [PMID: 27757739 DOI: 10.1007/s10877-016-9945-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 10/11/2016] [Indexed: 12/14/2022]
Abstract
Cerebral microcirculation is gradually compromised during sepsis, with significant reductions in the function of capillaries and blood perfusion in small vessels. Transcranial Doppler ultrasound (TCD) has been used to assess cerebral circulation in a typical clinical setting. This study was to systematically review TCD studies, assess their methodological quality, and identify trends that can be associated with the temporal evolution of sepsis and its clinical outcome. A meta-analysis of systematic reviews was conducted according to the PRISMA statement. Articles were searched from 1982 until the conclusion of this review in December 2015. Twelve prospective and observational studies were selected. Evaluations of cerebral blood flow, cerebral autoregulation, and carbon dioxide (CO2) vasoreactivity were summarized. A temporal pattern of the evolution of the illness was found. In early sepsis, the median blood flow velocity (Vm) and pulsatility index (PI) increased, and the cerebral autoregulation (CA) remained unchanged. In contrast, Vm normalization, PI reduction and CA impairment were found in later sepsis (patients with severe sepsis or septic shock). Cerebral haemodynamic is impaired in sepsis. Modifications in cerebral blood flow may be consequence to the endothelial dysfunction of the microvasculature induced by the release of inflammatory mediators. A better understanding of cerebral hemodynamics may improve the clinical management of patients with sepsis and, consequently, improve clinical outcomes.
Collapse
Affiliation(s)
- Daniel Silva de Azevedo
- Neurology Department, School of Medicine, Hospital das Clinicas, University of São Paulo, Avenida Doutor Arnaldo, 455, Cerqueira César, São Paulo, SP, CEP 01246-904, Brazil
| | - Angela Salomao Macedo Salinet
- Neurology Department, School of Medicine, Hospital das Clinicas, University of São Paulo, Avenida Doutor Arnaldo, 455, Cerqueira César, São Paulo, SP, CEP 01246-904, Brazil
| | - Marcelo de Lima Oliveira
- Neurology Department, School of Medicine, Hospital das Clinicas, University of São Paulo, Avenida Doutor Arnaldo, 455, Cerqueira César, São Paulo, SP, CEP 01246-904, Brazil
| | - Manoel Jacobsen Teixeira
- Neurology Department, School of Medicine, Hospital das Clinicas, University of São Paulo, Avenida Doutor Arnaldo, 455, Cerqueira César, São Paulo, SP, CEP 01246-904, Brazil
| | - Edson Bor-Seng-Shu
- Neurology Department, School of Medicine, Hospital das Clinicas, University of São Paulo, Avenida Doutor Arnaldo, 455, Cerqueira César, São Paulo, SP, CEP 01246-904, Brazil.
| | - Ricardo de Carvalho Nogueira
- Neurology Department, School of Medicine, Hospital das Clinicas, University of São Paulo, Avenida Doutor Arnaldo, 455, Cerqueira César, São Paulo, SP, CEP 01246-904, Brazil
| |
Collapse
|
8
|
Zamani MM, Keshavarz-Fathi M, Fakhri-Bafghi MS, Hirbod-Mobarakeh A, Rezaei N, Bahrami A, Nader ND. Survival benefits of dexmedetomidine used for sedating septic patients in intensive care setting: A systematic review. J Crit Care 2016; 32:93-100. [DOI: 10.1016/j.jcrc.2015.11.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 11/08/2015] [Accepted: 11/10/2015] [Indexed: 12/15/2022]
|
9
|
Chen K, Lu Z, Xin YC, Cai Y, Chen Y, Pan SM. Alpha-2 agonists for long-term sedation during mechanical ventilation in critically ill patients. Cochrane Database Syst Rev 2015; 1:CD010269. [PMID: 25879090 PMCID: PMC6353054 DOI: 10.1002/14651858.cd010269.pub2] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Sedation reduces patient levels of anxiety and stress, facilitates the delivery of care and ensures safety. Alpha-2 agonists have a range of effects including sedation, analgesia and antianxiety. They sedate, but allow staff to interact with patients and do not suppress respiration. They are attractive alternatives for long-term sedation during mechanical ventilation in critically ill patients. OBJECTIVES To assess the safety and efficacy of alpha-2 agonists for sedation of more than 24 hours, compared with traditional sedatives, in mechanically-ventilated critically ill patients. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 10, 2014), MEDLINE (1946 to 9 October 2014), EMBASE (1980 to 9 October 2014), CINAHL (1982 to 9 October 2014), Latin American and Caribbean Health Sciences Literature (1982 to 9 October 2014), ISI Web of Science (1987 to 9 October 2014), Chinese Biological Medical Database (1978 to 9 October 2014) and China National Knowledge Infrastructure (1979 to 9 October 2014), the World Health Organization international clinical trials registry platform (to 9 October 2014), Current Controlled Trials metaRegister of controlled trials active registers (to 9 October 2014), the ClinicalTrials.gov database (to 9 October 2014), the conference proceedings citation index (to 9 October 2014) and the reference lists of included studies and previously published meta-analyses and systematic reviews for relevant studies. We imposed no language restriction. SELECTION CRITERIA We included all randomized and quasi-randomized controlled trials comparing alpha-2 agonists (clonidine or dexmedetomidine) versus alternative sedatives for long-term sedation (more than 24 hours) during mechanical ventilation in critically ill patients. DATA COLLECTION AND ANALYSIS Two review authors independently assessed study quality and extracted data. We contacted study authors for additional information. We performed meta-analyses when more than three studies were included, and selected a random-effects model due to expected clinical heterogeneity. We calculated the geometric mean difference for continuous outcomes and the risk ratio for dichotomous outcomes. We described the effects by values and 95% confidence intervals (CIs). We considered two-sided P < 0.05 to be statistically significant. MAIN RESULTS Seven studies, covering 1624 participants, met the inclusion criteria. All included studies investigated adults and compared dexmedetomidine with traditional sedatives, including propofol, midazolam and lorazepam. Compared with traditional sedatives, dexmedetomidine reduced the geometric mean duration of mechanical ventilation by 22% (95% CI 10% to 33%; four studies, 1120 participants, low quality evidence), and consequently the length of stay in the intensive care unit (ICU) by 14% (95% CI 1% to 24%; five studies, 1223 participants, very low quality evidence). There was no evidence that dexmedetomidine decreased the risk of delirium (RR 0.85; 95% CI 0.63 to 1.14; seven studies, 1624 participants, very low quality evidence) as results were consistent with both no effect and appreciable benefit. Only one study assessed the risk of coma, but lacked methodological reliability (RR 0.69; 95% CI 0.55 to 0.86, very low quality evidence). Of all the adverse events included, the most commonly reported one was bradycardia, and we observed a doubled (111%) increase in the incidence of bradycardia (RR 2.11; 95% CI 1.39 to 3.20; six studies, 1587 participants, very low quality evidence). Our meta-analysis provided no evidence that dexmedetomidine had any impact on mortality (RR 0.99; 95% CI 0.79 to 1.24; six studies, 1584 participants, very low quality evidence). We observed high levels of heterogeneity in risk of delirium (I² = 70%), but due to the limited number of studies we were unable to determine the source of heterogeneity through subgroup analyses or meta-regression. We judged six of the seven studies to be at high risk of bias. AUTHORS' CONCLUSIONS In this review, we found no eligible studies for children or for clonidine. Compared with traditional sedatives, long-term sedation using dexmedetomidine in critically ill adults reduced the duration of mechanical ventilation and ICU length of stay. There was no evidence for a beneficial effect on risk of delirium and the heterogeneity was high. The evidence for risk of coma was inadequate. The most common adverse event was bradycardia. No evidence indicated that dexmedetomidine changed mortality. The general quality of evidence ranged from very low to low, due to high risks of bias, serious inconsistency and imprecision, and strongly suspected publication bias. Future studies could pay more attention to children and to using clonidine
Collapse
Affiliation(s)
- Ken Chen
- Rui Jin Hospital Lu Wan Branch, Shanghai Jiao Tong University School of MedicineDepartment of AnesthesiologySouth Chong Qing Road, Number 149ShanghaiChina200020
| | - Zhijun Lu
- Rui Jin Hospital, Shanghai Jiao Tong University School of MedicineDepartment of Anesthesiology197 Rui Jin 2nd Road,ShanghaiChina200025
| | - Yi Chun Xin
- Rui Jin Hospital Lu Wan Branch, Shanghai Jiao Tong University School of MedicineDepartment of AnesthesiologySouth Chong Qing Road, Number 149ShanghaiChina200020
| | - Yong Cai
- School of Public Health, Shanghai Jiao Tong UniversityDepartment of Preventative Medicine227 South Chongqing RoadShanghaiChina200025
| | - Yi Chen
- Shanghai Institute of Materia Medica, Chinese Academy of SciencesDivision of Anti‐tumor Pharmacology555 Zuchongzhi RoadShanghaiChina201203
| | - Shu Ming Pan
- Xinhua Hospital, Shanghai Jiao Tong University School of MedicineEmergency Department1665 Kong Jiang RoadShanghaiChina200092
| | | |
Collapse
|
10
|
MacLaren R, Krisl JC, Cochrane RE, Mueller SW. A case-based approach to the practical application of dexmedetomidine in critically ill adults. Pharmacotherapy 2013; 33:165-86. [PMID: 23386596 DOI: 10.1002/phar.1175] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Dexmedetomidine is a selective α(2) -adrenoceptor agonist that offers unique sedation because patients are readily awakened while administration continues and the drug does not suppress the respiratory center. Limitations of use include higher acquisition cost, inability to produce deep sedation, and bradycardia and hypotension. Using a case-based approach, the purpose of this review was to qualitatively assess the role of dexmedetomidine in the care of the critically ill and in the management of alcohol withdrawal, and to formulate recommendations regarding its clinical application. Sixty-six studies were identified that investigated dexmedetomidine for the provision of sedation. These studies were heterogeneous in design and patient populations; most investigated patients did not require heavy sedation, and few used propofol as the comparator. In general, though, the aggregate results of all studies demonstrate that dexmedetomidine provides comfort, possibly shortens the duration of mechanical ventilation to facilitate extubation, reduces the occurrence of acute brain dysfunction, and facilitates communication, but the drug is associated with hemodynamic instability and requires the supplemental use of traditional sedative and analgesic agents. These outcomes need to be substantiated in additional studies that include assessments of cost-effectiveness. Dexmedetomidine should be considered when patients require mild to moderate levels of sedation of short to intermediate time frames, and they qualify for daily awakenings with traditional sedative therapies. The data for dexmedetomidine in relation to alcohol withdrawal are limited to 12 retrospective reports representing a total of 127 patients. Its role for this indication requires further study, but it may be considered as adjunctive therapy when clinicians are concerned about respiratory suppression associated with escalating doses of γ-aminobutyric acid agonists. Regardless of the indication for dexmedetomidine, the practitioner must closely monitor patient comfort and the occurrence of hemodynamic deviations with the realization that as-needed administration of traditional sedatives and analgesics will be required and some degree of bradycardia and hypotension expected but intervention rarely required.
Collapse
Affiliation(s)
- Robert MacLaren
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado 80045, USA.
| | | | | | | |
Collapse
|
11
|
Hsing CH, Lin CF, So E, Sun DP, Chen TC, Li CF, Yeh CH. α2-Adrenoceptor agonist dexmedetomidine protects septic acute kidney injury through increasing BMP-7 and inhibiting HDAC2 and HDAC5. Am J Physiol Renal Physiol 2012; 303:F1443-53. [DOI: 10.1152/ajprenal.00143.2012] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Bone morphogenetic protein (BMP)-7 protects sepsis-induced acute kidney injury (AKI). Dexmedetomidine (DEX), an α2-adrenoceptor (α2-AR) agonist, has anti-inflammatory effects. We investigated the protective effects of DEX on sepsis-induced AKI and the expression of BMP-7 and histone deacetylases (HDACs). In vitro , the effects of DEX or trichostatin A (TSA, an HDAC inhibitor) on TNF-α, monocyte chemotactic protein (MCP-1), BMP-7, and HDAC mRNA expression in LPS-stimulated rat renal tubular epithelial NRK52E cells, was determined using real-time PCR. In vivo, mice were intraperitoneally injected with DEX (25 μg/kg) or saline immediately and 12 h after cecal ligation and puncture (CLP) surgery. Twenty-four hours after CLP, we examined kidney injury and renal TNF-α, MCP-1, BMP-7, and HDAC expression. Survival was monitored for 120 h. LPS increased HDAC2, HDAC5, TNF-α, and MCP-1 expression, but decreased BMP-7 expression in NRK52E cells. DEX treatment decreased the HDAC2, HDAC5, TNF-α, and MCP-1 expression, but increased BMP-7 and acetyl histone H3 expression, whose effects were blocked by yohimbine, an α2-AR antagonist. With DEX treatment, the LPS-induced TNF-α expression and cell death were attenuated in scRNAi-NRK52E but not BMP-7 RNAi-NRK52E cells. In CLP mice, DEX treatment increased survival and attenuated AKI. The expression of HDAC2, HDAC5, TNF-α, and MCP-1 mRNA in the kidneys of CLP mice was increased, but BMP-7 was decreased. However, DEX treatment reduced those changes. DEX reduces sepsis-induced AKI by decreasing TNF-α and MCP-1 and increasing BMP-7, which is associated with decreasing HDAC2 and HDAC5, as well as increasing acetyl histone H3.
Collapse
Affiliation(s)
- Chung-Hsi Hsing
- Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan
- Department of Anesthesiology, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chiou-Feng Lin
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Edmund So
- Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan
| | - Ding-Ping Sun
- Department of Surgery, Chi Mei Medical Center, Tainan, Taiwan
| | - Tai-Chi Chen
- Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan
| | - Chien-Feng Li
- Department of Pathology, Chi Mei Medical Center, Tainan, Taiwan
| | - Ching-Hua Yeh
- Institute of Medical Science, College of Health Science, Chang Jung Christian University, Tainan, Taiwan; and
| |
Collapse
|
12
|
He L, Xu JM, Dai RP. Dexmedetomidine reduces the incidence of fentanyl-induced cough: a double-blind, randomized, and placebo-controlled study. Ups J Med Sci 2012; 117:18-21. [PMID: 22335390 PMCID: PMC3282237 DOI: 10.3109/03009734.2011.629749] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES The incidence of fentanyl-induced cough (FIC) during induction of general anesthesia varies around 40% and is undesirable. It increases intracranial, intraocular, and intra-abdominal pressures. This prospective, randomized, double-blind, placebo-controlled study evaluated the effect of dexmedetomidine (DEX) pretreatment on the incidence and severity of FIC. METHODS Altogether 300 patients undergoing elective surgical procedures were randomly allocated into three groups (I, II, III; n = 100) and administered intravenously, over 10 min, 10 mL isotonic saline, DEX 0.5 μg/kg in 10 mL isotonic saline, or DEX 1 μg/kg in 10 mL isotonic saline, respectively. All groups subsequently received a fentanyl (4.0 μg/kg) intravenous push. The incidence and severity of cough were recorded for 1 min after fentanyl administration. RESULTS The incidence of FIC was 61%, 40%, and 18% in groups I, II, and III, respectively (P < 0.05 for treatment groups II and III versus control group I). There was no significant difference in the severity or onset time of cough, or hemodynamic variables, among the three groups. CONCLUSIONS . Intravenous DEX (0.5 μg/kg or 1 μg/kg) immediately before the administration of intravenous fentanyl (4.0 μg/kg) significantly reduced the incidence of FIC.
Collapse
Affiliation(s)
- Liang He
- Department of Anesthesia, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Jun-Mei Xu
- Department of Anesthesia, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Ru-Ping Dai
- Department of Anesthesia, The Second Xiangya Hospital of Central South University, Changsha, China
| |
Collapse
|
13
|
Kato J, Ogawa Y, Kojima W, Aoki K, Ogawa S, Iwasaki K. Cardiovascular reflex responses to temporal reduction in arterial pressure during dexmedetomidine infusion: a double-blind, randomized, and placebo-controlled study. Br J Anaesth 2009; 103:561-5. [DOI: 10.1093/bja/aep210] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
14
|
Liu YC, Chan JY, Tsai YC. Influence of Propofol on Blood Pressure Spectrum in Sepsis and the Role of Inducible Nitric Oxide Synthase. ACTA ACUST UNITED AC 2009; 47:62-70. [DOI: 10.1016/s1875-4597(09)60026-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
15
|
Differential protection against oxidative stress and nitric oxide overproduction in cardiovascular and pulmonary systems by propofol during endotoxemia. J Biomed Sci 2009; 16:8. [PMID: 19272174 PMCID: PMC2653513 DOI: 10.1186/1423-0127-16-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2008] [Accepted: 01/15/2009] [Indexed: 12/16/2022] Open
Abstract
Background Both overproduction of nitric oxide (NO) and oxidative injury of cardiovascular and pulmonary systems contribute to fatal cardiovascular depression during endotoxemia. We investigated in the present study the relative contribution of oxidative stress and NO to cardiovascular depression during different stages of endotoxemia, and delineated their roles in cardiovascular protective effects of a commonly used anesthetic propofol during endotoxemia. Methods Experimental endotoxemia was induced by systemic injection of E. coli lipopolysaccharide (LPS, 15 mg/kg) to Sprague-Dawley rats that were maintained under propofol (15 or 30 mg/kg/h, i.v.) anesthesia. Mean systemic arterial pressure (MSAP) and heart rate (HR) were monitored for 6 h after the endotoxin. Tissue level of NO was measured by chemical reduction-linked chemiluminescence and oxidative burst activity was determined using dihydroethidium method. Expression of NO synthase (NOS) was determined by immunoblotting. The Scheffé multiple range test was used for post hoc statistical analysis. Results Systemic injection of LPS (15 mg/kg) induced biphasic decreases in MSAP and HR. In the heart, lung and aorta, an abrupt increase in lipid peroxidation, our experimental index of oxidative tissue injury, was detected in early stage and sustained during late stage cardiovascular depression. LPS injection, on the other hand, induced a gradual increase in tissue nitrite and nitrate levels in the same organs that peaked during late stage endotoxemia. Propofol infusion (15 or 30 mg/kg/h, i.v.) significantly attenuated lipid peroxidation in the heart, lung and aorta during early and late stage endotoxemia. High dose (30 mg/kg/h, i.v.) propofol also reversed the LPS-induced inducible NO synthase (iNOS) upregulation and NO production in the aorta, alongside a significant amelioration of late stage cardiovascular depression and increase in survival time during endotoxemia. Conclusion Together these results suggest that oxidative injury and NO may play a differential role in LPS-induced cardiovascular depression. Oxidative tissue injury is associated with both early and late stage; whereas NO is engaged primarily in late stage cardiovascular depression. Moreover, propofol anesthesia may protect against fatal cardiovascular depression during endotoxemia by attenuating the late stage NO surge in the aorta, possibly via inhibition of iNOS upregulation by the endotoxin.
Collapse
|
16
|
Evaluation of cerebrovascular carbon dioxide reactivity in patients with diabetes mellitus under sedative doses of propofol. J Anesth 2008; 22:429-34. [PMID: 19011782 DOI: 10.1007/s00540-008-0660-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2008] [Accepted: 06/25/2008] [Indexed: 10/21/2022]
Abstract
The present study compared cerebrovascular CO2 reactivity in diabetic patients on different treatment modalities under sedative doses of propofol. Fifteen patients with diabetes mellitus (on three different antidiabetic treatment modalities) who required mechanical ventilation during intensive care therapy were studied, sedation during mechanical ventilation being maintained using propofol. As controls, 6 patients without diabetes were monitored. A 2.5-MHz pulsed transcranial Doppler probe was attached to the head of the patient at the right temporal window for continuous measurement of mean blood flow velocity in the middle cerebral artery (Vmca). After establishing baseline values of Vmca and cardiovascular hemodynamics, end-tidal CO2 was decreased by increasing ventilatory frequency by 5-8 breaths.min(-1). Values for absolute and relative CO2 reactivity in insulintreated patients were lower than those in the other three groups (absolute CO2 reactivity [means +/- SD]: control, 3.1 +/- 0.6 cm.s(-1).mmHg(-1), diet, 3.8 +/- 1.4 cm.s(-1) x mmHg(-1); oral antidiabetic drug 3.2 +/- 0.9 cm x s(-1) x mmHg(-1); insulin, 1.1 +/- 0.6 cm x s(-1) x mmHg(-1); P = 0.002).The present study shows that insulin-treated diabetic patients probably have lower cerebrovascular CO2 reactivity under propofol anesthesia than control patients or diabetics treated with dietary therapy or oral hypoglycemics.
Collapse
|