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Del Pilar Zarazaga M, Tinti MG, Litterio NJ, Himelfarb MA, Andrés-Larrea MIS, Rubio-Langre S, Serrano-Rodríguez JM, Lorenzutti AM. Dose regimen optimization of cephalothin for surgical prophylaxis against Staphylococcus aureus and coagulase negative staphylococci in dogs by pharmacokinetic/pharmacodynamic modeling. Res Vet Sci 2024; 171:105202. [PMID: 38492279 DOI: 10.1016/j.rvsc.2024.105202] [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: 10/17/2023] [Revised: 02/13/2024] [Accepted: 02/26/2024] [Indexed: 03/18/2024]
Abstract
First generation cephalosporins such cephalothin of cefazolin are indicated for antimicrobial prophylaxis for clean and clean contaminated surgical procedures because its antimicrobial spectrum, relative low toxicity and cost. Anesthesia and surgery could alter the pharmacokinetic behavior of different drugs administered perioperative by many mechanisms that affect distribution, metabolism or excretion processes. Intravenous administration of the antimicrobial within 30 and 60 min before incision is recommended in order to reach therapeutic serum and tissue concentrations and redosing is recommended if the duration of the procedure exceeds two half-life of the antimicrobial. To the author's knowledge there are no pharmacokinetic studies of cephalothin in dogs under anesthesia/surgery conditions. The aim of this study was (1) to evaluate the pharmacokinetics of cephalothin in anesthetized dogs undergoing ovariohysterectomy by a nonlinear mixed-effects model and to determine the effect of anesthesia/surgery and other individual covariates on its pharmacokinetic behavior; (2) to determine the MIC and conduct a pharmacodynamic modeling of time kill curves assay of cephalothin against isolates of Staphylococcus spp. isolated from the skin of dogs; (3) to conduct a PK/PD analysis by integration of the obtained nonlinear mixed-effects models in order to evaluate the antimicrobial effect of changing concentrations on simulated bacterial count; and (4) to determine the PK/PD endpoints and PK/PDco values in order to predict the optimal dose regimen of cephalothin for antimicrobial prophylaxis in dogs. Anesthesia/surgery significantly reduced cephalothin clearance by 18.78%. Based on the results of this study, a cephalothin dose regimen of 25 mg/kg q6h by intravenous administration showed to be effective against Staphylococcus spp. isolates with MIC values ≤2 μg/mL and could be recommended for antimicrobial prophylaxis for clean surgery in healthy dogs.
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Affiliation(s)
- María Del Pilar Zarazaga
- Facultad de Ciencias Agropecuarias, IRNASUS CONICET-Universidad Católica de Córdoba, Argentina; Farmacología Clínica y Toxicología, Carrera de Veterinaria, Instituto Académico y Pedagógico de Ciencias Básicas y Aplicadas, Universidad Nacional de Villa María, Argentina.
| | - Mariano Guillermo Tinti
- Facultad de Ciencias Agropecuarias, IRNASUS CONICET-Universidad Católica de Córdoba, Argentina.
| | - Nicolás Javier Litterio
- Facultad de Ciencias Agropecuarias, IRNASUS CONICET-Universidad Católica de Córdoba, Argentina.
| | | | | | - Sonia Rubio-Langre
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, Universidad Complutense de Madrid, Spain.
| | - Juan Manuel Serrano-Rodríguez
- Pharmacology Area, Department of Nursing, Pharmacology and Physiotherapy, Faculty of Veterinary Medicine, University of Córdoba, Spain.
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Vellinga R, Introna M, van Amsterdam K, Zhou XYT, De Smet T, Weber Jensen E, Struys MMRF, van den Berg JP. Implementation of a Bayesian based advisory tool for target-controlled infusion of propofol using qCON as control variable. J Clin Monit Comput 2024; 38:519-529. [PMID: 38112878 DOI: 10.1007/s10877-023-01106-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 11/09/2023] [Indexed: 12/21/2023]
Abstract
This single blinded randomized controlled trial aims to assess whether the application of a Bayesian-adjusted CePROP (effect-site of propofol) advisory tool leads towards a more stringent control of the cerebral drug effect during anaesthesia, using qCON as control variable. 100 patients scheduled for elective surgery were included and randomized into a control or intervention group (1:1 ratio). In the intervention group the advisory screen was made available to the clinician, whereas it was blinded in the control group. The settings of the target-controlled infusion pumps could be adjusted at any time by the clinician. Cerebral drug effect was quantified using processed EEG (CONOX monitor, Fresenius Kabi, Bad Homburg, Germany). The time of qCON between the desired range (35-55) during anaesthesia maintenance was defined as our primary end point. Induction parameters and recovery times were considered secondary end points and coefficient of variance of qCON and CePROP was calculated in order to survey the extent of control towards the mean of the population. The desired range of qCON between 35 and 55 was maintained in 84% vs. 90% (p = 0.15) of the case time in the control versus intervention group, respectively. Secondary endpoints showed similar results in both groups. The coefficient of variation for CePROP was higher in the intervention group. The application of the Bayesian-based CePROP advisory system in this trial did not result in a different time of qCON between 35 and 55 (84 [21] vs. 90 [18] percent of the case time). Significant differences between groups were hard to establish, most likely due to a very high performance level in the control group. More extensive control efforts were found in the intervention group. We believe that this advisory tool could be a useful educational tool for novices to titrate propofol effect-site concentrations.
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Affiliation(s)
- Remco Vellinga
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Michele Introna
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- NeuroAnesthesia and NeuroIntensive Care, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria, 11, 20133, Milan, Italy
| | - Kai van Amsterdam
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - X Y Tommy Zhou
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Erik Weber Jensen
- Centre for Biomedical Research (CREB), UPC-Barcelonatech, Barcelona, Spain
| | - Michel M R F Struys
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium
| | - Johannes P van den Berg
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
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Withey SL, Pizzagalli DA, Bergman J. Translational In Vivo Assays in Behavioral Biology. Annu Rev Pharmacol Toxicol 2024; 64:435-453. [PMID: 37708432 DOI: 10.1146/annurev-pharmtox-051921-093711] [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] [Indexed: 09/16/2023]
Abstract
The failure of preclinical research to advance successful candidate medications in psychiatry has created a paradigmatic crisis in psychiatry. The Research Domain Criteria (RDoC) initiative was designed to remedy this situation with a neuroscience-based approach that employs multimodal and cross-species in vivo methodology to increase the probability of translational findings and, consequently, drug discovery. The present review underscores the feasibility of this methodological approach by briefly reviewing, first, the use of multidimensional and cross-species methodologies in traditional behavioral pharmacology and, subsequently, the utility of this approach in contemporary neuroimaging and electrophysiology research-with a focus on the value of functionally homologous studies in nonhuman and human subjects. The final section provides a brief review of the RDoC, with a focus on the potential strengths and weaknesses of its domain-based underpinnings. Optimistically, this mechanistic and multidimensional approach in neuropsychiatric research will lead to novel therapeutics for the management of neuropsychiatric disorders.
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Affiliation(s)
- Sarah L Withey
- Preclinical Behavioral Biology Program, McLean Hospital, Belmont, Massachusetts, USA;
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
- McLean Imaging Center, McLean Hospital, Belmont, Massachusetts, USA
| | - Diego A Pizzagalli
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
- McLean Imaging Center, McLean Hospital, Belmont, Massachusetts, USA
- Center for Depression, Anxiety and Stress Research, McLean Hospital, Belmont, Massachusetts, USA
| | - Jack Bergman
- Preclinical Behavioral Biology Program, McLean Hospital, Belmont, Massachusetts, USA;
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
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Vellinga R, Eleveld DJ, Struys MMRF, van den Berg JP. General purpose models for intravenous anesthetics, the next generation for target-controlled infusion and total intravenous anesthesia? Curr Opin Anaesthesiol 2023; 36:602-607. [PMID: 37678184 DOI: 10.1097/aco.0000000000001300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
PURPOSE OF REVIEW There are various pharmacokinetic-dynamic models available, which describe the time course of drug concentration and effect and which can be incorporated into target-controlled infusion (TCI) systems. For anesthesia and sedation, most of these models are derived from narrow patient populations, which restricts applicability for the overall population, including (small) children, elderly, and obese patients. This forces clinicians to select specific models for specific populations. RECENT FINDINGS Recently, general purpose models have been developed for propofol and remifentanil using data from multiple studies and broad, diverse patient groups. General-purpose models might reduce the risks associated with extrapolation, incorrect usage, and unfamiliarity with a specific TCI-model, as they offer less restrictive boundaries (i.e., the patient "doesn't fit in the selected model") compared with the earlier, simpler models. Extrapolation of a model can lead to delayed recovery or inadequate anesthesia. If multiple models for the same drug are implemented in the pump, it is possible to select the wrong model for that specific case; this can be overcome with one general purpose model implemented in the pump. SUMMARY This article examines the usability of these general-purpose models in relation to the more traditional models.
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Affiliation(s)
- Remco Vellinga
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Douglas J Eleveld
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Michel M R F Struys
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium
| | - Johannes P van den Berg
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Bong CL, Balanza GA, Khoo CEH, Tan JSK, Desel T, Purdon PL. A Narrative Review Illustrating the Clinical Utility of Electroencephalogram-Guided Anesthesia Care in Children. Anesth Analg 2023; 137:108-123. [PMID: 36729437 DOI: 10.1213/ane.0000000000006267] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The major therapeutic end points of general anesthesia include hypnosis, amnesia, and immobility. There is a complex relationship between general anesthesia, responsiveness, hemodynamic stability, and reaction to noxious stimuli. This complexity is compounded in pediatric anesthesia, where clinicians manage children from a wide range of ages, developmental stages, and body sizes, with their concomitant differences in physiology and pharmacology. This renders anesthetic requirements difficult to predict based solely on a child's age, body weight, and vital signs. Electroencephalogram (EEG) monitoring provides a window into children's brain states and may be useful in guiding clinical anesthesia management. However, many clinicians are unfamiliar with EEG monitoring in children. Young children's EEGs differ substantially from those of older children and adults, and there is a lack of evidence-based guidance on how and when to use the EEG for anesthesia care in children. This narrative review begins by summarizing what is known about EEG monitoring in pediatric anesthesia care. A key knowledge gap in the literature relates to a lack of practical information illustrating the utility of the EEG in clinical management. To address this gap, this narrative review illustrates how the EEG spectrogram can be used to visualize, in real time, brain responses to anesthetic drugs in relation to hemodynamic stability, surgical stimulation, and other interventions such as cardiopulmonary bypass. This review discusses anesthetic management principles in a variety of clinical scenarios, including infants, children with altered conscious levels, children with atypical neurodevelopment, children with hemodynamic instability, children undergoing total intravenous anesthesia, and those undergoing cardiopulmonary bypass. Each scenario is accompanied by practical illustrations of how the EEG can be visualized to help titrate anesthetic dosage to avoid undersedation or oversedation when patients experience hypotension or other physiological challenges, when surgical stimulation increases, and when a child's anesthetic requirements are otherwise less predictable. Overall, this review illustrates how well-established clinical management principles in children can be significantly complemented by the addition of EEG monitoring, thus enabling personalized anesthesia care to enhance patient safety and experience.
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Affiliation(s)
- Choon Looi Bong
- From the Department of Pediatric Anesthesia, KK Women's and Children's Hospital, Duke-NUS Medical School, Singapore
| | - Gustavo A Balanza
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Charis Ern-Hui Khoo
- From the Department of Pediatric Anesthesia, KK Women's and Children's Hospital, Duke-NUS Medical School, Singapore
| | - Josephine Swee-Kim Tan
- From the Department of Pediatric Anesthesia, KK Women's and Children's Hospital, Duke-NUS Medical School, Singapore
| | - Tenzin Desel
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Patrick Lee Purdon
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Rai GS, Rozario CJ. Mechanisms of drug interactions II: pharmacokinetics and pharmacodynamics. ANAESTHESIA & INTENSIVE CARE MEDICINE 2023. [DOI: 10.1016/j.mpaic.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
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Guo F, Sun DF, Feng Y, Yang L, Li JL, Sun ZL. Efficacy and safety of propofol target-controlled infusion combined with butorphanol for sedated colonoscopy. World J Clin Cases 2023; 11:610-620. [PMID: 36793626 PMCID: PMC9923854 DOI: 10.12998/wjcc.v11.i3.610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 12/19/2022] [Accepted: 01/05/2023] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Propofol is a short-acting, rapid-recovering anesthetic widely used in sedated colonoscopy for the early detection, diagnosis and treatment of colon diseases. However, the use of propofol alone may require high doses to achieve the induction of anesthesia in sedated colonoscopy, which has been associated with anesthesia-related adverse events (AEs), including hypoxemia, sinus bradycardia, and hypotension. Therefore, propofol co-administrated with other anesthetics has been proposed to reduce the required dose of propofol, enhance the efficacy, and improve the satisfaction of patients receiving colonoscopy under sedation.
AIM To evaluate the efficacy and safety of propofol target-controlled infusion (TCI) in combination with butorphanol for sedation during colonoscopy.
METHODS In this controlled clinical trial, a total of 106 patients, who were scheduled for sedated colonoscopy, were prospectively recruited and assigned into three groups to receive different doses of butorphanol before propofol TCI: Low-dose butorphanol group (5 μg/kg, group B1), high-dose butorphanol group (10 μg/kg, group B2), and control group (normal saline, group C). Anesthesia was achieved by propofol TCI. The primary outcome was the median effective concentration (EC50) of propofol TCI, which was measured using the up-and-down sequential method. The secondary outcomes included AEs in perianesthesia and recovery characteristics.
RESULTS The EC50 of propofol for TCI was 3.03 μg/mL [95% confidence interval (CI): 2.83-3.23 μg/mL] in group B2, 3.41 μg/mL (95%CI: 3.20-3.62 μg/mL) in group B1, and 4.05 μg/mL (95%CI: 3.78-4.34 μg/mL) in group C. The amount of propofol necessary for anesthesia was 132 mg [interquartile range (IQR), 125-144.75 mg] in group B2 and 142 mg (IQR, 135-154 mg) in group B1. Furthermore, the awakening concentration was 1.1 μg/mL (IQR, 0.9-1.2 μg/mL) in group B2 and 1.2 μg/mL (IQR, 1.025-1.5 μg/mL) in group B1. Notably, the propofol TCI plus butorphanol groups (groups B1 and B2) had a lower incidence of anesthesia AEs, when compared to group C. Furthermore, no significant differences were observed in the rates of AEs in perianesthesia, including hypoxemia, sinus bradycardia, hypotension, nausea and vomiting, and vertigo, among group C, group B1 and group B2.
CONCLUSION The combined use with butorphanol reduces the EC50 of propofol TCI for anesthesia. The decrease in propofol might contribute to the reduced anesthesia-related AEs in patients undergoing sedated colonoscopy.
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Affiliation(s)
- Feng Guo
- Department of Anesthesiology, No. 967 Hospital, Joint Logistics Support Force of Chinese People’s Liberation Army, Dalian 116011, Liaoning Province, China
| | - De-Feng Sun
- Department of Anesthesiology, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, Liaoning Province, China
| | - Yan Feng
- Department of Anesthesiology, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, Liaoning Province, China
| | - Lin Yang
- Department of Neuroelectrophysiology, The First Affiliated Hospital of Dalian Medical University, Dalian 11601, Liaoning Province, China
| | - Jing-Lin Li
- Department of Anesthesiology, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, Liaoning Province, China
| | - Zhong-Liang Sun
- Department of Anesthesiology, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, Liaoning Province, China
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van den Berg J, Elgersma H, Zeillemaker-Hoekstra M. Anorexia nervosa: practical implications for the anaesthetist. BJA Educ 2023; 23:17-23. [PMID: 36601024 PMCID: PMC9805935 DOI: 10.1016/j.bjae.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
- J.P. van den Berg
- University of Groningen, University Medical Center Groningen, the Netherlands
| | - H.J. Elgersma
- Accare, Groningen, the Netherlands
- University of Groningen, the Netherlands
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Chen HY, Deng F, Tang SH, Liu W, Yang H, Song JC. Effect of different doses of dexmedetomidine on the median effective concentration of propofol during gastrointestinal endoscopy: a randomized controlled trial. Br J Clin Pharmacol 2022; 89:1799-1808. [PMID: 36527308 DOI: 10.1111/bcp.15647] [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: 06/21/2022] [Revised: 12/06/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022] Open
Abstract
AIMS Dexmedetomidine could be an ideal adjuvant to propofol during gastrointestinal endoscopy because it provides both analgesia and sedation without respiratory depression. This study investigates the effect of different doses of dexmedetomidine on the median effective concentration of propofol during gastrointestinal endoscopy. METHODS Ninety adult patients were randomly assigned to Group Control, Group DEX0.5 (0.5 μg/kg dexmedetomidine) or Group DEX1.0 (1.0 μg/kg dexmedetomidine). Anaesthesia during endoscopy was implemented by plasma target-controlled infusion (TCI) of propofol with different doses of dexmedetomidine. TCI concentration of the first patient for each group was 2.5 μg/mL and the consecutive adjacent concentration gradient was 0.5 μg/mL. Median effective concentration (EC50 ) of propofol by TCI for gastrointestinal endoscopy was determined by using the modified Dixon's up-and-down method. Cardiovascular variables were also measured. RESULTS EC50 of propofol by TCI and 95% confidence interval (CI) for gastrointestinal endoscopy were 3.77 (3.48-4.09), 2.51 (2.27-2.78) and 2.10 (1.90-2.33) μg/mL in Group Control, Group DEX0.5 and Group DEX1.0, respectively. The average percent change from heart rate (HR) baseline was 2.8 (8.9), -7.4 (7.7) and -10.5 (8.8) (P < .001), and the average percent change from mean arterial pressure (MAP) baseline was -10.6 [-24.7; 3.5], -9.5 [-29.2; 11.4] and -4.0 [-27.3; 15.5] (P = .034) in Group Control, Group DEX0.5 and Group DEX1.0, respectively. CONCLUSIONS Dexmedetomidine reduced the EC50 of propofol by TCI. A 0.5-1 μg/kg dose of dexmedetomidine caused a decrease in HR without bradycardia. The decrease in dosage of propofol with increasing doses of dexmedetomidine caused more stable MAP. Dexmedetomidine is an ideal adjuvant drug to propofol during gastrointestinal endoscopy.
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Affiliation(s)
- Hai-Yan Chen
- Department of Anesthesiology, Shidong Hospital Affiliated to University of Shanghai for Science and Technology, Shanghai, China
| | - Fang Deng
- Department of Anesthesiology, Shidong Hospital Affiliated to University of Shanghai for Science and Technology, Shanghai, China
| | - Shu-Heng Tang
- Department of Anesthesiology, Shidong Hospital Affiliated to University of Shanghai for Science and Technology, Shanghai, China
| | - Wen Liu
- Department of Anesthesiology, Shidong Hospital Affiliated to University of Shanghai for Science and Technology, Shanghai, China
| | - Hua Yang
- Department of Anesthesiology, Shidong Hospital Affiliated to University of Shanghai for Science and Technology, Shanghai, China
| | - Jin-Chao Song
- Department of Anesthesiology, Shidong Hospital Affiliated to University of Shanghai for Science and Technology, Shanghai, China
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Singariya G, Malhotra N, Kamal M, Jaju R, Aggarwal S, Bihani P. Comparison of nebulized dexmedetomidine and ketamine for premedication in pediatric patients undergoing hernia repair surgery: a randomized comparative trial. Anesth Pain Med (Seoul) 2022; 17:173-181. [PMID: 35378572 PMCID: PMC9091671 DOI: 10.17085/apm.21081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 01/03/2022] [Indexed: 11/17/2022] Open
Abstract
Background Allaying anxiety and providing calm children in the operating room is a challenging task for anesthesiologists. This study was designed to compare the use of nebulized dexmedetomidine and ketamine for premedication in pediatric patients under general anesthesia. Methods Seventy patients, aged 2 to 8 years of both sexes, with American Society of Anesthesiologists physical status I/II scheduled for hernia repair surgery under general anesthesia, were randomized to two equal groups using a computer-generated random number table. Patients in group D received dexmedetomidine (2 µg/kg), and patients in group K received ketamine (2 mg/kg) by a jet nebulizer before the induction of anesthesia. The study's primary objective was comparing the level of sedation, which was achieved at 30 min after a study drug administration using the Ramsay sedation scale, between the two groups. The secondary objectives were the two-group comparison of parental separation anxiety scale, acceptance of the mask, hemodynamic variables, recovery time, incidence of emergence agitation, and adverse events. Results The median Ramsay sedation scale at 30 min was 3 (1–4) in group D and 3 (1–3) in group K (P = 0.002). Patients in group D had a more acceptable parental separation anxiety scale (P = 0.001) and a satisfactory mask acceptance scale (P = 0.042). Conclusions Nebulized dexmedetomidine (2 µg/kg) provided better sedation along with smooth parental separation and satisfactory mask acceptance during induction of anesthesia with a similar emergence agitation profile and adverse reactions compared to nebulized ketamine in pediatric patients.
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Affiliation(s)
- Geeta Singariya
- Department of Anesthesiology & Critical Care, Dr S N Medical College, Jodhpur, India
- Corresponding Author Geeta Singariya, M.D. Department of Anesthesiology & Critical Care, Dr S N Medical College, Jodhpur 123, Vaishali Avenue, Jhanwar Road, Jodhpur 342008, Rajasthan, India E-mail: Tel: 91-0291-2705705, Fax: 91-0291-2434376
| | - Namita Malhotra
- Department of Anesthesiology & Critical Care, Dr S N Medical College, Jodhpur, India
| | - Manoj Kamal
- Department of Anesthesiology & Critical Care, All India Institute of Medical Sciences, Jodhpur, India
| | - Rishabh Jaju
- Department of Anesthesiology & Critical Care, Andaman Nicobar Island Institute of Medical Sciences, Port Blair, India
| | - Shruti Aggarwal
- Department of Anesthesiology & Critical Care, Dr S N Medical College, Jodhpur, India
| | - Pooja Bihani
- Department of Anesthesiology & Critical Care, Dr S N Medical College, Jodhpur, India
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Strand H, Elshaug AC, Bernersen Ø, Ballangrud R. Effectiveness of the advisory display SmartPilot® view in the assessment of anesthetic depth in low risk gynecological surgery patients: a randomized controlled trial. BMC Anesthesiol 2022; 22:57. [PMID: 35227197 PMCID: PMC8883615 DOI: 10.1186/s12871-022-01593-w] [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: 07/06/2021] [Accepted: 02/18/2022] [Indexed: 11/12/2022] Open
Abstract
Background Assessment of appropriate anesthetic depth is crucial to prevent harm to patients. Unnecessary deep anesthesia can be harmful, potentially causing acute renal failure, myocardial injury, delirium, and an increased mortality rate. Conversely, too light anesthesia combined with muscle relaxants can result in intraoperative patient awareness and lead to serious psychological trauma. This trial aimed to ascertain the effectiveness of the advisory display SmartPilot® View (SPV), as a supplemental measure in the assessment of anesthetic depth in low risk gynecological surgery patients. The hypothesis was that the use of the SPV would increase the precision of assessment, and result in a higher mean arterial pressure. Methods This trial used a randomized, controlled, single-blind design with a homogeneous sample. Patients undergoing minor, low risk gynecological surgery were randomly assigned to two groups: a test group wherein current standards were supplemented with the advisory display SPV and a control group assessed using only the current standards. Female patients aged between 18 and 75 years with American Society of Anesthesiologists Physical Status Classification System scores of 1–3 undergoing planned general anesthesia using the total intravenous anesthetic method, combining propofol and remifentanil, were included. The exclusion criteria included a body mass index ≥ 35 kg/m2, a history of alcoholism, drug intake affecting propofol and remifentanil dynamics, and inability to consent. The independent sample t-test and chi-square test or Fisher’s exact test were used to assess the statistical significance of differences between the two groups. Results A total of 114 patients were included in the analysis (test group n = 58, control group n = 56). No significant differences in the mean arterial pressure, heart rate, bispectral index, extubation delay, or post-anesthesia care unit stay were found between groups. Conclusions The addition of the advisory display SmartPilot® View to current standards in the evaluation of anesthetic depth had no significant effect on the outcome. Trial registration The trial was registered on January 16th 2019 with ClinicalTrials.gov (ref: NCT03807271). Supplementary Information The online version contains supplementary material available at 10.1186/s12871-022-01593-w.
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Affiliation(s)
- Hilde Strand
- Department of Anesthesiology, Innlandet Hospital Trust, Sykehuset Lillehammer, Anders Sandvigs gate 17, 2609, Lillehammer, Norway.
| | - Ann Charlott Elshaug
- Department of Anesthesiology, Østfold Hospital Trust, Sykehuset Østfold Kalnes, Kalnesveien 300, 1714, Grålum, Norway
| | - Øyvind Bernersen
- Department of Emergency, Anesthesiology and Intensive Care Unit, Innlandet Hospital Trust, Sykehuset Lillehammer, Anders Sandvigs gate 17, 2609, Lillehammer, Norway
| | - Randi Ballangrud
- Department of Health Science Gjøvik, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Teknologiveien 22, 2815, Gjøvik, Norway
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Optimization of Propofol Dose Estimated During Anesthesia Through Artificial Intelligence by Genetic Algorithm: Design and Clinical Assessment. Neural Process Lett 2022. [DOI: 10.1007/s11063-022-10751-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Vazquez PM, Jensen EW. Different perspectives for monitoring nociception during general anesthesia. Korean J Anesthesiol 2022; 75:112-123. [PMID: 35172074 PMCID: PMC8980281 DOI: 10.4097/kja.22002] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 02/15/2022] [Indexed: 11/30/2022] Open
Abstract
Safe anesthesia is achieved using objective methods that estimate the patient’s state during different phases of surgery. A patient’s state under anesthesia is characterized by three major aspects, which are linked to the main effects produced by each of the families of anesthetic agents administered: hypnosis, analgesia, and muscular relaxation. While quantification techniques designed to assess muscular relaxation under neuromuscular blocking agents have a relatively long history with a high degree of standardization and understanding (e.g., the train-of-four), the knowledge and techniques used to the depth of hypnosis assessment suffer from a lesser degree in both standardization and interpretation due to brain complexity. The problem of standardization and interpretation in the analgesia and nociception assessment increases since it involves more systems, the central nervous system, and the autonomic nervous system. This helps to explain why there are multiple a priori valid approaches to develop nociception monitoring from different interpretations and physiological bases of noxious stimuli processing. Thus, in this review, the current monitoring technologies clinically available for estimating a patient’s nociception under general anesthesia are described.
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Affiliation(s)
- Pablo Martinez Vazquez
- Deutsches Primaten Zentrum (DPZ), 37077 Goettingen, Germany.,R&D of Quantium Medical/Fresenius Kabi. Barcelona, Spain
| | - Erik Weber Jensen
- R&D of Quantium Medical/Fresenius Kabi. Barcelona, Spain.,Automatic Control and Information (ESAII) Department, CREB. UPC-Barcelonatech, Barcelona, Spain
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14
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Choi GJ, Ahn EJ, Lee OH, Kang H. Effects of a BMI1008 mixture on postoperative pain in a rat model of incisional pain. PLoS One 2021; 16:e0257267. [PMID: 34570780 PMCID: PMC8476004 DOI: 10.1371/journal.pone.0257267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 08/31/2021] [Indexed: 11/23/2022] Open
Abstract
Background The purpose of this study was to evaluate the analgesic effect of BMI1008 (a new drug containing lidocaine, methylene blue, dexamethasone and vitamin B complex) and to investigate the analgesic effect of lidocaine and BMI-L (other components of BMI1008 except lidocaine) at different concentrations in a rat model of incisional pain. Methods Male Sprague-Dawley rats (250–300 g) were used for the incisional pain model simulating postoperative pain. After the operation, normal saline, various concentrations of BMI1008, lidocaine with a fixed concentration of BMI-L, and BMI-L with a fixed concentration of lidocaine were injected at the incision site. The preventive analgesic effect was evaluated using BMI1008 administered 30 min before and immediately after the operation. In addition, BMI1008 was compared with positive controls using intraperitoneal ketorolac 30 mg/kg and fentanyl 0.5 μg/kg. The mechanical withdrawal threshold was measured with a von Frey filament. Results The analgesic effect according to the concentration of BMI1008, lidocaine with a fixed concentration of BMI-L, and BMI-L with a fixed concentration of lidocaine showed a concentration-dependent response and statistically significant difference among the groups (P <0.001, P <0.001, and P <0.001, respectively). The analgesic effect according to the time point of administration (before and after the operation) showed no evidence of a statistically significant difference between the groups (P = 0.170). Compared with the positive control groups, the results showed a statistically significant difference between the groups (P = 0.024). Conclusion BMI1008 showed its analgesic effect in a rat model of incisional pain in a concentration-dependent manner. Moreover, BMI-L showed an additive effect on the analgesic effect of lidocaine.
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Affiliation(s)
- Geun Joo Choi
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chung-Ang University, Seoul, Korea
| | - Eun Jin Ahn
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chung-Ang University, Seoul, Korea
| | - Oh Haeng Lee
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chung-Ang University, Seoul, Korea
| | - Hyun Kang
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chung-Ang University, Seoul, Korea
- * E-mail:
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15
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Evaluating the role of Smartpilot® view assisted target-controlled infusion anesthesia during intracranial mass surgery: A comparative retrospective study with bispectral index-guided standard anesthesia. JOURNAL OF SURGERY AND MEDICINE 2021. [DOI: 10.28982/josam.987346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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16
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Gonzalez D, Sinha J. Pediatric Drug-Drug Interaction Evaluation: Drug, Patient Population, and Methodological Considerations. J Clin Pharmacol 2021; 61 Suppl 1:S175-S187. [PMID: 34185913 PMCID: PMC8500325 DOI: 10.1002/jcph.1881] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Accepted: 04/18/2021] [Indexed: 12/27/2022]
Abstract
Hospitalized pediatric patients and those with complex or chronic conditions treated on an outpatient basis are commonly prescribed multiple drugs, resulting in increased risk for drug-drug interactions (DDIs). Although dedicated DDI evaluations are routinely performed in healthy adult volunteers during drug development, they are rarely performed in pediatric patients because of ethical, logistical, and methodological challenges. In the absence of pediatric DDI evaluations, adult DDI data are often extrapolated to pediatric patients. However, the magnitude of a DDI in pediatric patients may differ from adults because of age-dependent physiological changes that can impact drug disposition or response and because of other factors related to the drug (eg, dose, formulation) and the patient population (eg, disease state, obesity). Therefore, the DDI magnitude needs to be assessed in children separately from adults, although a lack of clinical DDI data in pediatric populations makes this evaluation challenging. As a result, pediatric DDI assessment relies on the predictive performance of the pharmacometric approaches used, such as population and physiologically based pharmacokinetic modeling. Therefore, careful consideration needs to be given to adequately account for the age-dependent physiological changes in these models to build high confidence for such untested DDI scenarios. This review article summarizes the key considerations related to the drug, patient population, and methodology, and how they can impact DDI evaluation in the pediatric population.
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Affiliation(s)
- Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina, Chapel Hill, North Carolina, USA
| | - Jaydeep Sinha
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina, Chapel Hill, North Carolina, USA
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17
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Influence of general anaesthesia on the intravenous acetaminophen pharmacokinetics in Beagle dogs. Vet Anaesth Analg 2021; 48:637-644. [PMID: 34281773 DOI: 10.1016/j.vaa.2021.02.007] [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: 03/23/2020] [Revised: 12/23/2020] [Accepted: 02/22/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To determine if general anaesthesia influences the intravenous (IV) pharmacokinetics (PK) of acetaminophen in dogs. STUDY DESIGN Prospective, crossover, randomized experimental study. ANIMALS A group of nine healthy Beagle dogs. METHODS Acetaminophen PK were determined in conscious and anaesthetized dogs on two separate occasions. Blood samples were collected before, and at 5, 10, 15, 30, 45, 60 and 90 minutes and 2, 3, 4, 6, 8, 12 and 24 hours after 20 mg kg-1 IV acetaminophen administration. Haematocrit, total proteins, albumin, alanine aminotransferase, aspartate aminotransferase, urea and creatinine were determined at baseline and 24 hours after acetaminophen. The anaesthetized group underwent general anaesthesia (90 minutes) for dental cleaning. After the administration of dexmedetomidine (3 μg kg-1) intramuscularly, anaesthesia was induced with propofol (2-3 mg kg-1) IV, followed by acetaminophen administration. Anaesthesia was maintained with isoflurane in 50% oxygen (Fe'Iso 1.3-1.5%). Dogs were mechanically ventilated. Plasma concentrations were analysed with high-performance liquid chromatography. PK analysis was undertaken using compartmental modelling. A Wilcoxon test was used to compare PK data between groups, and clinical laboratory values between groups, and before versus 24 hours after acetaminophen administration. Data are presented as median and range (p < 0.05). RESULTS A two-compartmental model best described time-concentration profiles of acetaminophen. No significant differences were found for volume of distribution values 1.41 (0.94-3.65) and 1.72 (0.89-2.60) L kg-1, clearance values 1.52 (0.71-2.30) and 1.60 (0.91-1.78) L kg-1 hour-1 or terminal elimination half-life values 2.45 (1.45-8.71) and 3.57 (1.96-6.35) hours between conscious and anaesthetized dogs, respectively. Clinical laboratory variables were within normal range. No adverse effects were recorded. CONCLUSIONS AND CLINICAL RELEVANCE IV acetaminophen PK in healthy Beagle dogs were unaffected by general anaesthesia under the study conditions. Further studies are necessary to evaluate the PK in different clinical contexts.
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18
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[An analysis of medication errors in patients admitted to surgery rooms and post-anesthetic recovery at a high-complexity hospital in Bogota, Colombia]. Salud Colect 2021; 17:e3155. [PMID: 34105334 DOI: 10.18294/sc.2021.3155] [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: 09/08/2020] [Accepted: 03/01/2021] [Indexed: 11/24/2022] Open
Abstract
Medication errors represent one of the main causes of incidents and adverse events during the perioperative period. Therefore, this study analyzes errors before, during, and after the administration of general anesthesia for abdominal surgery at a high-complexity hospital in Bogota, Colombia. A descriptive cross-sectional study was conducted with 390 patients between January and September 2019. Of the 3,677 medication administrations, some type of error was made in 60% of cases, mostly in emergency surgeries. The pharmacological group with the most errors was general anesthetics, with 32%. All identified errors constituted situations with harm potential, indicating the need to promote the standardization of activities involving the use of medications and a culture of healthcare safety in order to avoid adverse events.
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19
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Jooma Z. Drug interactions. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2020. [DOI: 10.36303/sajaa.2020.26.6.s3.2543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Administration of multiple drugs within a short period of time is inevitable in anaesthesia practice, increasing the likelihood of drug interactions with each drug or with patients’ chronic medication. Drug interactions can be described as the pharmacological effect of one drug on another drug when administered simultaneously. The principles of these interactions may be divided into pharmaceutical, which relates to the physicochemical structure or pharmaceutical preparation of a drug; pharmacokinetic (PK), which relates to changes in drug handling in the body; or pharmacodynamic (PD) where drug activity is affected.
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Affiliation(s)
- Z Jooma
- University of the Witwatersrand
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20
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The role of dexmedetomidine in neurosurgery. Best Pract Res Clin Anaesthesiol 2020; 35:221-229. [PMID: 34030806 DOI: 10.1016/j.bpa.2020.10.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 09/28/2020] [Accepted: 10/13/2020] [Indexed: 01/14/2023]
Abstract
Dexmedetomidine can be used for sedation and analgesia and has been approved for this use by the European Medicines Agency since 2017. It causes an arousable state of sedation, which is beneficial during neurosurgical procedures that require the patient to cooperate with neurological tests (i.e. tumor surgery or implantation of deep brain stimulators). During procedures where monitoring of somatosensory evoked potentials and/or motor evoked potentials is required, dexmedetomidine can be used as an adjunct to general anesthesia with GABAergic drugs to decrease the dose of the latter when these drugs impair the monitoring signals. The use of dexmedetomidine has also been associated with neuroprotective effects and a decreased incidence of delirium, but studies confirming these effects in the peri-operative (neuro-)surgical setting are lacking. Although dexmedetomidine does not cause respiratory depression, its hemodynamic effects are complex and careful patient selection, choice of dose, and monitoring must be performed.
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21
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Resistance to state transitions in responsiveness is differentially modulated by different volatile anaesthetics in male mice. Br J Anaesth 2020; 125:308-320. [PMID: 32660718 DOI: 10.1016/j.bja.2020.05.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 04/07/2020] [Accepted: 05/03/2020] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Recent studies point to a fundamental distinction between population-based and individual-based anaesthetic pharmacology. At the population level, anaesthetic potency is defined as the relationship between drug concentration and the likelihood of response to a stimulus. At the individual level, even when the anaesthetic concentration is held constant, fluctuations between the responsive and unresponsive states are observed. Notably, these spontaneous fluctuations exhibit resistance to state transitions Rst. Therefore, the response probability in each individual depends not just upon the drug concentration, but also upon responses to previous stimuli. Here, we hypothesise that Rst is distinct from drug potency and is differentially modulated by different anaesthetics. METHODS Adult (14-24 weeks old) C57BL/6J male mice (n=60) were subjected to repeated righting reflex (RR) assays at equipotent steady-state concentrations of isoflurane (0.6 vol%), sevoflurane (1.0 vol%), and halothane (0.4 vol%). RESULTS Fluctuations in RR were observed for all tested anaesthetics. Analysis of these fluctuations revealed that Rst was differentially modulated by different anaesthetics (F[2, 56.01]=49.59; P<0.0001). Fluctuations in RR were modelled using a stochastic dynamical system. This analysis confirmed that the amount of noise that drives behavioural state transitions depends on the anaesthetic agent (F[2, 42.86]=16.72; P<0.0001). CONCLUSIONS Whilst equipotent doses of distinct anaesthetics produce comparable population response probabilities, they engage dramatically different dynamics in each individual animal. This manifests as a differential aggregate propensity to exhibit state transitions. Thus, resistance to state transitions is a fundamentally distinct, novel measure of individualised anaesthetic pharmacology.
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22
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Van Hese L, Theys T, Absalom A, Rex S, Cuypers E. Comparison of predicted and real propofol and remifentanil concentrations in plasma and brain tissue during target‐controlled infusion: a prospective observational study. Anaesthesia 2020; 75:1626-1634. [DOI: 10.1111/anae.15125] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2020] [Indexed: 12/14/2022]
Affiliation(s)
- L. Van Hese
- Department of Anaesthesiology University Hospitals Leuven KU Leuven 3000 Leuven Belgium
- Maastricht MultiModal Molecular Imaging (M4I) institute Division of Imaging Mass Spectrometry Maastricht University Maastricht The Netherlands
| | - T. Theys
- Neurosurgery Department University Hospitals Leuven Laboratory for Experimental Neurosurgery and Neuroanatomy Department of Neurosciences KU Leuven 3000 Leuven Belgium
| | - A.R. Absalom
- Neurosurgery Department University Hospitals Leuven Laboratory for Experimental Neurosurgery and Neuroanatomy Department of Neurosciences KU Leuven 3000 Leuven Belgium
| | - S. Rex
- Department of Anaesthesiology University Medical Center Groningen University of Groningen The Netherlands
| | - E. Cuypers
- Toxicology and Pharmacology Department KU Leuven 3000 Leuven Belgium
- Maastricht MultiModal Molecular Imaging (M4I) institute Division of Imaging Mass Spectrometry Maastricht University Maastricht The Netherlands
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23
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van den Berg JP, Absalom AR, Venema AM, Kalmar AF, Van Amsterdam K, Hannivoort LN, Proost JH, Meier S, Scheeren TWL, Struys MMRF, Vereecke HEM. Comparison of haemodynamic- and electroencephalographic-monitored effects evoked by four combinations of effect-site concentrations of propofol and remifentanil, yielding a predicted tolerance to laryngoscopy of 90. J Clin Monit Comput 2020; 35:815-825. [PMID: 32488680 PMCID: PMC8286956 DOI: 10.1007/s10877-020-00540-9] [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: 02/25/2020] [Accepted: 05/26/2020] [Indexed: 11/05/2022]
Abstract
This prospective study evaluates haemodynamic and electroencephalographic effects observed when administering four combinations of effect-site concentrations of propofol (CePROP) and remifentanil (CeREMI), all yielding a single predicted probability of tolerance of laryngoscopy of 90% (PTOL = 90%) according to the Bouillon interaction model. We aimed to identify combinations of CePROP and CeREMI along a single isobole of PTOL that result in favourable hypnotic and haemodynamic conditions. This knowledge could be of advantage in the development of drug advisory monitoring technology. 80 patients (18–90 years of age, ASA I–III) were randomized into four groups and titrated towards CePROP (Schnider model, ug⋅ml−1) and CeREMI (Minto model, ng⋅ml−1) of respectively 8.6 and 1, 5.9 and 2, 3.6 and 4 and 2.0 and 8. After eleven minutes of equilibration, baseline measurements of haemodynamic endpoints and bispectral index were compared with three minutes of responsiveness measurements after laryngoscopy. Before laryngoscopy, bispectral index differed significantly (p < 0.0001) between groups in concordance with CePROP. Heart rate decreased with increasing CeREMI (p = 0.001). The haemodynamic and arousal responses evoked by laryngoscopy were not significantly different between groups, but CePROP = 3.6 μg⋅ml−1 and CeREMI = 4 ng⋅ml−1 evoked the lowest median value for ∆HR and ∆SAP after laryngoscopy. This study provides clinical insight on the haemodynamic and hypnotic consequences, when a model based predicted PTOL is used as a target for combined effect-site controlled target- controlled infusion of propofol and remifentanil. Heart rate and bispectral index were significantly different between groups despite a theoretical equipotency for PTOL, suggesting that each component of the anaesthetic state (immobility, analgesia, and hypnotic drug effect) should be considered as independent neurophysiological and pharmacological phenomena. However, claims of (in)accuracy of the predicted PTOL must be considered preliminary because larger numbers of observations are required for that goal.
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Affiliation(s)
- J P van den Berg
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.
| | - A R Absalom
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - A M Venema
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - A F Kalmar
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - K Van Amsterdam
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - L N Hannivoort
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - J H Proost
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - S Meier
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - T W L Scheeren
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - M M R F Struys
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.,Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium
| | - H E M Vereecke
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.,Department of Anaesthesia and Reanimation, AZ Sint-Jan Brugge-Oostende AV, Brugge, Belgium
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24
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Neckebroek M, Boldingh JWHL, De Smet T, Struys MMRF. Influence of Remifentanil on the Control Performance of the Bispectral Index Controlled Bayesian-Based Closed-Loop System for Propofol Administration. Anesth Analg 2020; 130:1661-1669. [DOI: 10.1213/ane.0000000000004208] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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25
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Li Y, Zhang W, Yin T, Wang C, Wang F, Sun J, Liu L, Zhang Q, Zhang C. Inhibition of UDP-glucuronosyltransferases by different furoquinoline alkaloids. Xenobiotica 2020; 50:1170-1179. [PMID: 32367776 DOI: 10.1080/00498254.2020.1760400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Herbs are often administered in combination with therapeutic drugs, raising the possibility for herb-drug interactions (HDIs). Furoquinoline alkaloids are found in Rutaceae plants, which are structurally similar and have many medicinal properties. This study aims to investigate the inhibition of four furoquinoline alkaloids on the activity of UDP-glucuronosyltransferases (UGTs).The recombinant UGTs-catalyzed glucuronidation metabolism of 4-methylumbelliferone (4-MU) was utilized to investigate the inhibition potential. Inhibition type and parameters were determined, and in silico docking was employed to elucidate the inhibition difference of furoquinoline alkaloids towards UGTs.Dictamine, haplopine, γ-fagarine and skimmianine strongly inhibited UGT1A3, UGT1A7, UGT1A9 and UGT2B4, respectively. Among them, dictamnine inhibited more than 70% of the four UGTs. Inhibition kinetics determination showed that they all exerted competitive inhibition, and the inhibition kinetic constant (Ki) was determined to be 8.3, 7.2, 3.7 and 33.9 μM, respectively. In vitro-in vivo extrapolation (IVIVE) was employed to demonstrate the inhibition possibility for four alkaloids. Skimmianine was proved to be more suitable for clinical application. In silico docking study indicated that the hydrophobic interactions played a key role in the inhibition of furoquinoline alkaloids towards three of the four UGTs. In conclusion, monitoring the interactions between furoquinoline alkaloids and drugs mainly undergoing UGTs-catalyzed metabolism is necessary.
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Affiliation(s)
- Yixuan Li
- School of integrative medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China.,Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, China
| | - Weihua Zhang
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, China
| | - Tingting Yin
- School of integrative medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China.,Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, China
| | - Ce Wang
- Basic Medical College, Hebei North University, Hebei, China
| | - Feige Wang
- School of integrative medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Jing Sun
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, China
| | - Lina Liu
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, China
| | - Qinghuai Zhang
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, China
| | - Chunze Zhang
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, China.,State Key Laboratory of Medicinal Chemical Biology, NanKai University, Tianjin, China
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26
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Anderson BJ, Morse JD, Hannam JA, Cortinez LI. Pharmacokinetic and pharmacodynamic considerations of general anesthesia in pediatric subjects. Expert Opin Drug Metab Toxicol 2020; 16:279-295. [PMID: 32148110 DOI: 10.1080/17425255.2020.1739648] [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] [Indexed: 01/06/2023]
Abstract
Introduction: The target concentration strategy uses PKPD information for dose determination. Models have also quantified exposure-response relationships, improved understanding of developmental pharmacokinetics, rationalized dose prescription, provided insight into the importance of covariate information, explained drug interactions and driven decision-making and learning during drug development.Areas covered: The prime PKPD consideration is parameter estimation and quantification of variability. The main sources of variability in children are age (maturation) and weight (size). Model use is mostly confined to pharmacokinetics, partly because anesthesia effect models in the young are imprecise. Exploration of PK and PD covariates and their variability hold potential to better individualize treatment.Expert opinion: The ability to model drugs using computer-based technology is hindered because covariate data required to individualize treatment using these programs remain lacking. Target concentration intervention strategies remain incomplete because covariate information that might better predict individualization of dose is absent. Pharmacogenomics appear a valuable area for investigation for pharmacodynamics and pharmacodynamics. Effect measures in the very young are imprecise. Assessment of the analgesic component of anesthesia is crude. While neuromuscular monitoring is satisfactory, depth of anaesthesia EEG interpretation is inadequate. Closed loop anesthesia is possible with better understanding of EEG changes.
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Affiliation(s)
- Brian J Anderson
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - James D Morse
- Department of Pharmacology & Clinical Pharmacology, University of Auckland, Auckland, New Zealand
| | - Jacqueline A Hannam
- Department of Pharmacology & Clinical Pharmacology, University of Auckland, Auckland, New Zealand
| | - L Ignacio Cortinez
- División Anestesiología, Pontificia Universidad Católica De Chile, Santiago De Chile, Chile
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27
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Neckebroek M, Ghita M, Ghita M, Copot D, Ionescu CM. Pain Detection with Bioimpedance Methodology from 3-Dimensional Exploration of Nociception in a Postoperative Observational Trial. J Clin Med 2020; 9:E684. [PMID: 32143327 PMCID: PMC7141233 DOI: 10.3390/jcm9030684] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 02/13/2020] [Accepted: 02/29/2020] [Indexed: 12/21/2022] Open
Abstract
Although the measurement of dielectric properties of the skin is a long-known tool for assessing the changes caused by nociception, the frequency modulated response has not been considered yet. However, for a rigorous characterization of the biological tissue during noxious stimulation, the bioimpedance needs to be analyzed over time as well as over frequency. The 3-dimensional analysis of nociception, including bioimpedance, time, and frequency changes, is provided by ANSPEC-PRO device. The objective of this observational trial is the validation of the new pain monitor, named as ANSPEC-PRO. After ethics committee approval and informed consent, 26 patients were monitored during the postoperative recovery period: 13 patients with the in-house developed prototype ANSPEC-PRO and 13 with the commercial device MEDSTORM. At every 7 min, the pain intensity was measured using the index of Anspec-pro or Medstorm and the 0-10 numeric rating scale (NRS), pre-surgery for 14 min and post-anesthesia for 140 min. Non-significant differences were reported for specificity-sensitivity analysis between ANSPEC-PRO (AUC = 0.49) and MEDSTORM (AUC = 0.52) measured indexes. A statistically significant positive linear relationship was observed between Anspec-pro index and NRS (r2 = 0.15, p < 0.01). Hence, we have obtained a validation of the prototype Anspec-pro which performs equally well as the commercial device under similar conditions.
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Affiliation(s)
- Martine Neckebroek
- Department of Anesthesia, Ghent University Hospital, Corneel Heymanslaan 10, 9000 Ghent, Belgium;
| | - Mihaela Ghita
- Research group of Dynamical Systems and Control, Ghent University, Tech Lane Science Park 125, 9052 Ghent, Belgium (D.C.); (C.M.I.)
- EEDT—Core Lab on Decision and Control, Flanders Make Consortium, Tech Lane Science Park 131, 9052 Ghent, Belgium
| | - Maria Ghita
- Research group of Dynamical Systems and Control, Ghent University, Tech Lane Science Park 125, 9052 Ghent, Belgium (D.C.); (C.M.I.)
- EEDT—Core Lab on Decision and Control, Flanders Make Consortium, Tech Lane Science Park 131, 9052 Ghent, Belgium
| | - Dana Copot
- Research group of Dynamical Systems and Control, Ghent University, Tech Lane Science Park 125, 9052 Ghent, Belgium (D.C.); (C.M.I.)
- EEDT—Core Lab on Decision and Control, Flanders Make Consortium, Tech Lane Science Park 131, 9052 Ghent, Belgium
| | - Clara M. Ionescu
- Research group of Dynamical Systems and Control, Ghent University, Tech Lane Science Park 125, 9052 Ghent, Belgium (D.C.); (C.M.I.)
- EEDT—Core Lab on Decision and Control, Flanders Make Consortium, Tech Lane Science Park 131, 9052 Ghent, Belgium
- Department of Automatic Control, Technical University of Cluj Napoca, Memorandumului 28, 400114 Cluj-Napoca, Romania
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Dholakia U, Seddighi R, Cox SK, Sun X, Pypendop BH. Pharmacokinetics of midazolam in sevoflurane-anesthetized cats. Vet Anaesth Analg 2019; 47:200-209. [PMID: 31983556 DOI: 10.1016/j.vaa.2019.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 11/20/2019] [Accepted: 11/23/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To estimate the pharmacokinetics of midazolam and 1-hydroxymidazolam after midazolam administration as an intravenous bolus in sevoflurane-anesthetized cats. STUDY DESIGN Prospective pharmacokinetic study. ANIMALS A group of six healthy adult, female domestic cats. METHODS Anesthesia was induced and maintained with sevoflurane. After 30 minutes of anesthetic equilibration, cats were administered midazolam (0.3 mg kg-1) over 15 seconds. Venous blood was collected at 0, 1, 2, 4, 8, 15, 30, 45, 90, 180 and 360 minutes after administration. Plasma concentrations for midazolam and 1-hydroxymidazolam were measured using high-pressure liquid chromatography. The heart rate (HR), respiratory rate (fR), rectal temperature, noninvasive mean arterial pressure (MAP) and end-tidal carbon dioxide (Pe'CO2) were recorded at 5 minute intervals. Population compartment models were fitted to the time-plasma midazolam and 1-hydroxymidazolam concentrations using nonlinear mixed effect modeling. RESULTS The pharmacokinetic model was fitted to the data from five cats, as 1-hydroxymidazolam was not detected in one cat. A five-compartment model best fitted the data. Typical values (% interindividual variability where estimated) for the volumes of distribution for midazolam (three compartments) and hydroxymidazolam (two compartments) were 117 (14), 286 (10), 705 (14), 53 (36) and 334 mL kg-1, respectively. Midazolam clearance to 1-hydroxymidazolam, midazolam fast and slow intercompartmental clearances, 1-hydroxymidazolam clearance and 1-hydroxymidazolam intercompartment clearance were 18.3, 63.5 (15), 22.1 (8), 1.7 (67) and 3.8 mL minute-1 kg-1, respectively. No significant changes in HR, MAP, fR or Pe'CO2 were observed following midazolam administration. CONCLUSION AND CLINICAL RELEVANCE In sevoflurane-anesthetized cats, a five-compartment model best fitted the midazolam pharamacokinetic profile. There was a high interindividual variability in the plasma 1-hydroxymidazolam concentrations, and this metabolite had a low clearance and persisted in the plasma for longer than the parent drug. Midazolam administration did not result in clinically significant changes in physiologic variables.
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Affiliation(s)
- Urshulaa Dholakia
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Tennessee, Knoxville, TN, USA
| | - Reza Seddighi
- Department of Large Animal Clinical Sciences, College of Veterinary Medicine, University of Tennessee, Knoxville, TN, USA.
| | - Sherry K Cox
- Department of Biological and Diagnostic Services, College of Veterinary Medicine, University of Tennessee, Knoxville, TN, USA
| | - Xiaocun Sun
- Office of Information and Technology, University of Tennessee, Knoxville, TN, USA
| | - Bruno H Pypendop
- Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, CA, USA
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29
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Aytuluk HG, Simsek T, Yilmaz M, Turan AZ, Saracoglu KT. Can Propofol Lead to an Increase in Seizure Threshold Over the Course of Electroconvulsive Therapy? CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE 2019; 17:523-530. [PMID: 31671490 PMCID: PMC6852674 DOI: 10.9758/cpn.2019.17.4.523] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 04/22/2019] [Accepted: 07/29/2019] [Indexed: 01/08/2023]
Abstract
Objective To evaluate the effects of 2 different dose regimens of propofol (low dose: < 1 mg/kg, high dose: ≥ 1 mg/kg) on the duration of the seizures, the required energy for the seizures, and the seizure threshold over the course of electroconvulsive therapy (ECT). Methods The electronic medical records of 165 patients receiving 971 sessions of ECT were analyzed retrospectively. Patients were evaluated in two groups according to the according to propofol doses that they had received for ECT. Group LP (n = 91): patients who received low dose propofol (< 1 mg/kg). Group HP (n = 74): patients who received high dose propofol (≥1 mg/kg). Results The required energy for seizures in Group HP were significantly higher than the Group LP in the 3rd, 4th, 5th, 6th, 7th, 8th, and 9th sessions (p < 0.05). The duration of seizures in the Group HP were significantly lower than the Group LP in the 1st, 2nd, 4th, 5th, 7th, and 8th sessions (p < 0.05). Higher electrical stimulus was needed to acquire a minimum length of seizure (> 25 sn) during the course of ECT in higher propofol doses. Although there was an increase in the seizure threshold over the course of ECT in both groups, this increase was found to be much more pronounced in the high-dose propofol group according to the low-dose propofol group. Longer duration of seizures was observed in the low-dose propofol group. Conclusion Higher doses of propofol in induction of anesthesia can lead to a more progressive rise in seizure threshold than lower doses of propofol.
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Affiliation(s)
- Hande Gurbuz Aytuluk
- Department of Anesthesiology and Reanimation, University of Health Sciences Derince Training and Research Hospital, Kocaeli, Turkey
| | - Tahsin Simsek
- Department of Anesthesiology and Reanimation, University of Health Sciences Derince Training and Research Hospital, Kocaeli, Turkey
| | - Mehmet Yilmaz
- Department of Anesthesiology and Reanimation, University of Health Sciences Derince Training and Research Hospital, Kocaeli, Turkey
| | - Ayse Zeynep Turan
- Department of Anesthesiology and Reanimation, University of Health Sciences Derince Training and Research Hospital, Kocaeli, Turkey
| | - Kemal Tolga Saracoglu
- Department of Anesthesiology and Reanimation, University of Health Sciences Derince Training and Research Hospital, Kocaeli, Turkey
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30
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Schiller RM, Allegaert K, Hunfeld M, van den Bosch GE, van den Anker J, Tibboel D. Analgesics and Sedatives in Critically Ill Newborns and Infants: The Impact on Long-Term Neurodevelopment. J Clin Pharmacol 2019; 58 Suppl 10:S140-S150. [PMID: 30248203 DOI: 10.1002/jcph.1139] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 03/23/2018] [Indexed: 12/12/2022]
Abstract
Inadequate pain and/or stress management in preterm- and term-born infants has been associated with increased morbidity and even mortality. However, exposure to analgosedatives during early infancy may also be one of the risk factors for subsequent neurodevelopmental impairment, at least in animal studies. Because infants admitted to neonatal or pediatric intensive care units may receive high amounts of these drugs for prolonged periods of time and the majority of these infants nowadays survive to discharge, this is of major concern. A balanced approach that incorporates the assessment and quantification of both wanted effects as well as unwanted side effects is therefore needed. In this article, the optimal dose determination of commonly used analgosedative drugs as well as their potential long-term effects on the developing human brain and neuropsychological functioning are reviewed.
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Affiliation(s)
- R M Schiller
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - K Allegaert
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Maayke Hunfeld
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - G E van den Bosch
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - John van den Anker
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands.,Division of Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, Switzerland.,Division of Clinical Pharmacology, Children's National Health System, Washington, DC, USA
| | - D Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
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31
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Dholakia U, Seddighi R, Odunayo A, Cox SK, Jones EH, Pypendop BH. Prolonged Anesthetic Recovery after Continuous Infusion of Midazolam in 2 Domestic Cats ( Felis catus). Comp Med 2019; 69:321-326. [PMID: 31182185 DOI: 10.30802/aalas-cm-18-000145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Two healthy research cats involved in a randomized, blinded prospective pharmacodynamics study evaluating midazolam continuous-rate infusion as a means to decrease sevoflurane concentrations experienced unexpectedly prolonged recoveries. Midazolam loading doses, infusion rates, and the targeted plasma midazolam concentrations at steady-state were determined by pharmacokinetic modeling based on the results of a preliminary pharmacokinetic study using a single dose of midazolam. In the pharmacodynamics study, cats remained oversedated after recovery from anesthesia, and plasma concentrations of midazolam and its primary metabolite (1-hydroxymidazolam) remained elevated. The use of flumazenil was unsuccessful in timely treatment of oversedation. Administration of intravenous lipid emulsion was used in one of the cats to facilitate recovery and appeared to be effective in both reducing the depth of midazolam-induced oversedation and significantly reducing the plasma concentration of 1-hydroxymidazolam. The effects after the administration of both treatment modalities on clinical signs and plasma drug concentrations in cats are discussed. The observations suggest that cats may eliminate 1-hydroxymidazolam more slowly than expected; consequently dose adjustments may be required when continuous infusion of midazolam is intended. In addition, intravenous lipid emulsion may facilitate recovery from midazolam oversedation, particularly in cases unresponsive to traditional treatment modalities. However, further investigations are warranted to delineate the efficacy of this modality in the treatment of midazolam oversedation.
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32
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Pharmacokinetic–pharmacodynamic population modelling in paediatric anaesthesia and its clinical translation. Curr Opin Anaesthesiol 2019; 32:353-362. [DOI: 10.1097/aco.0000000000000725] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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33
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Emergence times and airway reactions during general anaesthesia with remifentanil and a laryngeal mask airway: A multicentre randomised controlled trial. Eur J Anaesthesiol 2019; 35:588-597. [PMID: 29916859 PMCID: PMC6072370 DOI: 10.1097/eja.0000000000000852] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Avoidance of airway complications and rapid emergence from anaesthesia are indispensable for the use of a laryngeal mask airway (LMA). Evidence from adequately powered randomised studies with a low risk of bias for the optimal anaesthetic in this context is limited. OBJECTIVE We tested the hypothesis that when using remifentanil-based intra-operative analgesia, desflurane would be the most suitable anaesthetic: with noninferiority in the occurrence of upper airway complications and superiority in emergence times compared with sevoflurane or propofol. DESIGN A randomised, multicentre, partially double-blinded, three-arm, parallel-group study. SETTING Two university and two regional German hospitals, from February to October 2015. PATIENTS A total of 352 patients (age 18 to 75 years, ASA physical status I to III, BMI less than 35 kg m−2 and fluent in German) were enrolled in this study. All surgery was elective with a duration of 0.5 to 2 h, and general anaesthesia with a LMA was feasible. INTERVENTION The patients were randomised to receive desflurane, sevoflurane or propofol anaesthesia. MAIN OUTCOME MEASURES This study was powered for the primary outcome ‘time to state date of birth’ and the secondary outcome ‘intra-operative cough’. Time to emergence from anaesthesia and the incidence of upper airway complications were assessed on the day of surgery. RESULTS The primary outcome was analysed for 343 patients: desflurane (n=114), sevoflurane (n=111) and propofol (n=118). The desflurane group had the fastest emergence. The mean (± SD) times to state the date of birth following desflurane, sevoflurane and propofol were 8.1 ± 3.6, 10.1 ± 4.0 and 9.8 ± 5.1 min, respectively (P < 0.01). There was no difference in upper airway complications (cough and laryngospasm) across the groups, but these complications were less frequent than in previous studies. CONCLUSION When using a remifentanil infusion for intra-operative analgesia in association with a LMA, desflurane was associated with a significantly faster emergence and noninferiority in the incidence of intra-operative cough than either sevoflurane or Propofol. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02322502; EudraCT identifier: 2014-003810-96.
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34
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van den Berg JP, Eleveld DJ, De Smet T, van den Heerik AVM, van Amsterdam K, Lichtenbelt BJ, Scheeren TWL, Absalom AR, Struys MMRF. Influence of Bayesian optimization on the performance of propofol target-controlled infusion. Br J Anaesth 2019; 119:918-927. [PMID: 29028925 DOI: 10.1093/bja/aex243] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2017] [Indexed: 11/12/2022] Open
Abstract
Background Target controlled infusion (TCI) systems use population-based pharmacokinetic (PK) models that do not take into account inter-individual residual variation. This study compares the bias and inaccuracy of a population-based vs a personalized TCI propofol titration using Bayesian adaptation. Haemodynamic and hypnotic stability, and the prediction probability of alternative PK models, was studied. Methods A double-blinded, prospective randomized controlled trial of 120 subjects undergoing cardiac surgery was conducted. Blood samples were obtained at 10, 35, 50, 65, 75 and 120 min and analysed using a point-of-care propofol blood analyser. Bayesian adaptation of the PK model was applied at 60 min in the intervention group. Median (Absolute) Performance Error (Md(A)PE) was used to evaluate the difference between bias and inaccuracy of the models. Haemodynamic (mean arterial pressure [MAP], heart rate) and hypnotic (bispectral index [BIS]) stability was studied. The predictive performance of four alternative propofol PK models was studied. Results MdPE and MdAPE did not differ between groups during the pre-adjustment period (control group: 6.3% and 16%; intervention group: 5.4% and 18%). MdPE differed in the post-adjustment period (12% vs. -0.3%), but MdAPE did not (18% vs. 15%). No difference in heart rate, MAP or BIS was found. Compared with the other models, the Eleveld propofol PK model (patients) showed the best prediction performance. Conclusions When an accurate population-based PK model was used for propofol TCI, Bayesian adaption of the model improved bias but not precision. Clinical trial registration Dutch Trial Registry NTR4518.
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Affiliation(s)
- J P van den Berg
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - D J Eleveld
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | - A V M van den Heerik
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - K van Amsterdam
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - B J Lichtenbelt
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - T W L Scheeren
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - A R Absalom
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - M M R F Struys
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department of Anaesthesia and Peri-Operative Medicine, Ghent University, Ghent, Belgium
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35
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Tams C, Syroid N, Vasilopoulos T, Johnson K. Optimizing intraoperative administration of propofol, remifentanil, and fentanyl through pharmacokinetic and pharmacodynamic simulations to increase the postoperative duration of analgesia. J Clin Monit Comput 2019; 33:959-971. [PMID: 30864076 DOI: 10.1007/s10877-019-00298-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 03/05/2019] [Indexed: 12/14/2022]
Abstract
Titrating an intraoperative anesthetic to achieve the postoperative goals of rapid emergence and prolonged analgesia can be difficult because of inter-patient variability and the need to provide intraoperative sedation and analgesia. Modeling pharmacokinetics and pharmacodynamics of anesthetic administrations estimates drug concentrations and predicted responses to stimuli during anesthesia. With utility of these PK/PD models we created an algorithm to optimize the intraoperative dosing regimen. We hypothesized the optimization algorithm would find a dosing regimen that would increase the postoperative duration of analgesia, not increase the time to emergence, and meet the intraoperative requirements of sedation and analgesia. To evaluate these hypotheses we performed a simulation study on previously collected anesthesia data. We developed an algorithm to recommend different intraoperative dosing regimens for improved post-operative results. To test the post-operative results of the algorithm we tested it on previously collected anesthesia data. An anesthetic dataset of 21 patients was obtained from a previous study from an anesthetic database at the University of Utah. Using the anesthetic records from these surgeries we modeled 21 patients using the same patient demographics and anesthetic requirements as the dataset. The anesthetic was simulated for each of the 21 patients with three different dosing regimens. The three dosing regimens are: from the anesthesiologist as recorded in the dataset (control group), from the algorithm in the clinical scenario one (test group), and from the algorithm in the clinical scenario two (test group). We created two clinical scenarios for the optimization algorithm to perform; one with normal general anesthesia constraints and goals, and a second condition where a delayed time to emergence is allowed to further maximize the duration of analgesia. The algorithm was evaluated by comparing the post-operative results of the control group to each of the test groups. Comparing results between the clinical scenario 1 dosing to the actual dosing showed a median increase in the duration of analgesia by 6 min and the time to emergence by 0.3 min. This was achieved by decreasing the intraoperative remifentanil infusion rate, increased the fentanyl dosing regimen, and not changing the propofol infusion rate. Comparing results between the clinical scenario 2 dosing to the actual dosing showed a median increase in the duration of analgesia by 26 min and emergence by 1.5 min. To dosing regimen from clinical scenario 2 greatly increased the fentanyl dosing regimen and greatly decreased the remifentanil infusion rate with no change to the propofol infusion rate. The results from this preliminary analysis of the optimization algorithm appear to imply that it can operate as intended. However a clinical study is warranted to determine to what extent the optimization algorithm determined optimal dosing regimens can maximize the postoperative duration of analgesia without delaying the time to emergence in a clinical setting.
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Affiliation(s)
- Carl Tams
- Department of Anesthesiology, University of Utah, 30 N 1900 E, Salt Lake City, UT, 84132, USA.
| | - Noah Syroid
- Department of Anesthesiology, University of Utah, 30 N 1900 E, Salt Lake City, UT, 84132, USA.,MedVis, 2050 E 1700 S, Salt Lake City, UT, 84108, USA
| | - Terrie Vasilopoulos
- Department of Anesthesiology, University of Florida, P.O. Box 100524, Gainesville, FL, 32610-0254, USA
| | - Ken Johnson
- Department of Anesthesiology, University of Utah, 30 N 1900 E, Salt Lake City, UT, 84132, USA
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36
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Padmanabhan R, Meskin N, Ionescu CM, Haddad WM. A nonovershooting tracking controller for simultaneous infusion of anesthetics and analgesics. Biomed Signal Process Control 2019. [DOI: 10.1016/j.bspc.2018.09.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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37
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Padmanabhan R, Meskin N, Haddad WM. Optimal adaptive control of drug dosing using integral reinforcement learning. Math Biosci 2019; 309:131-142. [PMID: 30735696 DOI: 10.1016/j.mbs.2019.01.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Revised: 01/24/2019] [Accepted: 01/31/2019] [Indexed: 12/13/2022]
Abstract
In this paper, a reinforcement learning (RL)-based optimal adaptive control approach is proposed for the continuous infusion of a sedative drug to maintain a required level of sedation. To illustrate the proposed method, we use the common anesthetic drug propofol used in intensive care units (ICUs). The proposed online integral reinforcement learning (IRL) algorithm is designed to provide optimal drug dosing for a given performance measure that iteratively updates the control solution with respect to the pharmacology of the patient while guaranteeing convergence to the optimal solution. Numerical results are presented using 10 simulated patients that demonstrate the efficacy of the proposed IRL-based controller.
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Affiliation(s)
| | - Nader Meskin
- Department of Electrical Engineering, Qatar University, Qatar.
| | - Wassim M Haddad
- School of Aerospace Engineering, Georgia Institute of Technology, Atlanta, GA 30332-0150, USA.
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38
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Sahinovic MM, Eleveld DJ, Miyabe-Nishiwaki T, Struys MMRF, Absalom AR. Pharmacokinetics and pharmacodynamics of propofol: changes in patients with frontal brain tumours. Br J Anaesth 2018; 118:901-909. [PMID: 28549082 DOI: 10.1093/bja/aex134] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2017] [Indexed: 11/14/2022] Open
Abstract
Background Models of propofol pharmacokinetics and pharmacodynamics developed in patients without brain pathology are widely used for target-controlled infusion (TCI) during brain tumour excision operations. The goal of this study was to determine if the presence of a frontal brain tumour influences propofol pharmacokinetics and pharmacodynamics and existing PK-PD model performance. Methods Twenty patients with a frontal brain tumour and 20 control patients received a propofol infusion to achieve an induction-emergence-induction anaesthetic sequence. Propofol plasma concentration was measured every 4 min and at each transition of the conscious state. Bispectral index (BIS) values were continuously recorded. We used non-linear mixed-effects modelling to analyse the effects of the presence of a brain tumour on the pharmacokinetics and pharmacodynamics of propofol. Subsequently we calculated the predictive performance of Marsh, Schnider, and Eleveld models in terms of median prediction error (MdPE) and median absolute prediction error (MdAPE). Results Patients with brain tumours showed 40% higher propofol clearance than control patients. Performance of the Schnider model (MdPEpk -20.0%, MdAPEpk 23.4%) and Eleveld volunteer model (MdPEpk -8.58%, MdAPEpk 21.6%) were good. The Marsh model performed less well (MdPEpk -14.3%, MdAPEpk 41.4%), as did the Eleveld patient model (MdPEpk -30.8%, MdAPEpk 32.1%). Conclusions Brain tumours might alter the pharmacokinetics of propofol. Caution should be exerted when using propofol TCI in patients with frontal brain tumours due to higher clearance. Trial registry number NCT01060631.
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Affiliation(s)
- M M Sahinovic
- Department of Anaesthesia, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - D J Eleveld
- Department of Anaesthesia, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | - M M R F Struys
- Department of Anaesthesia, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department of Anaesthesia, Ghent University, Belgium
| | - A R Absalom
- Department of Anaesthesia, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Abstract
Propofol is an intravenous hypnotic drug that is used for induction and maintenance of sedation and general anaesthesia. It exerts its effects through potentiation of the inhibitory neurotransmitter γ-aminobutyric acid (GABA) at the GABAA receptor, and has gained widespread use due to its favourable drug effect profile. The main adverse effects are disturbances in cardiopulmonary physiology. Due to its narrow therapeutic margin, propofol should only be administered by practitioners trained and experienced in providing general anaesthesia. Many pharmacokinetic (PK) and pharmacodynamic (PD) models for propofol exist. Some are used to inform drug dosing guidelines, and some are also implemented in so-called target-controlled infusion devices, to calculate the infusion rates required for user-defined target plasma or effect-site concentrations. Most of the models were designed for use in a specific and well-defined patient category. However, models applicable in a more general population have recently been developed and published. The most recent example is the general purpose propofol model developed by Eleveld and colleagues. Retrospective predictive performance evaluations show that this model performs as well as, or even better than, PK models developed for specific populations, such as adults, children or the obese; however, prospective evaluation of the model is still required. Propofol undergoes extensive PK and PD interactions with both other hypnotic drugs and opioids. PD interactions are the most clinically significant, and, with other hypnotics, tend to be additive, whereas interactions with opioids tend to be highly synergistic. Response surface modelling provides a tool to gain understanding and explore these complex interactions. Visual displays illustrating the effect of these interactions in real time can aid clinicians in optimal drug dosing while minimizing adverse effects. In this review, we provide an overview of the PK and PD of propofol in order to refresh readers' knowledge of its clinical applications, while discussing the main avenues of research where significant recent advances have been made.
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Affiliation(s)
- Marko M. Sahinovic
- Department of Anaesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
- University Medical Center Groningen, Hanzeplein 1, PO Box 30.001, 9700 RB Groningen, The Netherlands
| | - Michel M. R. F. Struys
- Department of Anaesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
- Department of Anaesthesia and Peri-Operative Medicine, Ghent University, Ghent, Belgium
| | - Anthony R. Absalom
- Department of Anaesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
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40
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Kuck K, Egan T. Getting the dose right: anaesthetic drug delivery and the posological sweet spot. Br J Anaesth 2017; 119:862-864. [DOI: 10.1093/bja/aex320] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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