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Annborn M, Ceric A, Borgquist O, During J, Moseby-Knappe M, Lybeck A. Hypothermia versus Normothermia after Out-of-Hospital Cardiac Arrest; The effect on post-intervention serum concentrations of sedatives and analgesics and time to awakening. Resuscitation 2023; 188:109831. [PMID: 37178902 DOI: 10.1016/j.resuscitation.2023.109831] [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: 03/09/2023] [Revised: 04/19/2023] [Accepted: 05/07/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND This study investigated the association of two levels of targeted temperature management (TTM) after out-of-hospital cardiac arrest (OHCA) with administered doses of sedative and analgesic drugs, serum concentrations, and the effect on time to awakening. METHODS This substudy of the TTM2-trial was conducted at three centers in Sweden, with patients randomized to either hypothermia or normothermia. Deep sedation was mandatory during the 40-hour intervention. Blood samples were collected at the end of TTM and end of protocolized fever prevention (72 hours). Samples were analysed for concentrations of propofol, midazolam, clonidine, dexmedetomidine, morphine, oxycodone, ketamine and esketamine. Cumulative doses of administered sedative and analgesic drugs were recorded. RESULTS Seventy-one patients were alive at 40 hours and had received the TTM-intervention according to protocol. 33 patients were treated at hypothermia and 38 at normothermia. There were no differences between cumulative doses and concentration and of sedatives/analgesics between the intervention groups at any timepoint. Time until awakening was 53 hours in the hypothermia group compared to 46 hours in the normothermia group (p=0.09). CONCLUSION This study of OHCA patients treated at normothermia versus hypothermia found no significant differences in dosing or concentration of sedatives or analgesic drugs in blood samples drawn at the end of the TTM intervention, or at end of protocolized fever prevention, nor the time to awakening.
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Affiliation(s)
- Martin Annborn
- Anesthesia & Intensive Care, Department of Clinical Sciences Lund, Lund University, Helsingborg Hospital, Helsingborg, Sweden
| | - Ameldina Ceric
- Anesthesia & Intensive Care, Department of Clinical Sciences, Lund University, Skane University Hospital, Malmö, Sweden.
| | - Ola Borgquist
- Anesthesia & Intensive Care, Department of Clinical Sciences Lund, Lund University, Skane University Hospital, Lund, Sweden
| | - Joachim During
- Anesthesia & Intensive Care, Department of Clinical Sciences, Lund University, Skane University Hospital, Malmö, Sweden
| | - Marion Moseby-Knappe
- Neurology, Department of Clinical Sciences Lund, Lund University, Skane University Hospital, Lund, Sweden
| | - Anna Lybeck
- Anesthesia & Intensive Care, Department of Clinical Sciences Lund, Lund University, Skane University Hospital, Lund, Sweden
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Scherrer V, Lamoureux F, Chaventre C, Thill C, Demailly Z, Selim J, Bauer F, Imbert L, Wurtz V, Compère V, Clavier T, Besnier E. Reliability of the Minto model for target-controlled infusion of remifentanil during cardiac surgery with cardiopulmonary bypass. Br J Anaesth 2022; 129:163-171. [PMID: 35750514 DOI: 10.1016/j.bja.2022.05.003] [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: 07/05/2021] [Revised: 05/03/2022] [Accepted: 05/06/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The Minto pharmacokinetic model is used for target-controlled infusion of remifentanil. The reliability of this model has never been evaluated during normothermic cardiac surgery with cardiopulmonary bypass (CPB). The aim of this study was to assess the predictive performance of the model during CPB to determine its reliability during cardiac surgery. METHODS This was a single-centre observational study. Arterial blood samples were drawn at five time points: T1, after tracheal intubation; T2, immediately before CPB; T3, 10 min after starting CPB; T4, 45 min after starting CPB; T5, 10 min after weaning off CPB. Prediction error (PE) and absolute prediction error (APE) were calculated for each sample and used to determine median prediction error (MDPE) and median absolute prediction error (MDAPE) per patient. Risk factors for APE >30% were assessed using multivariable analysis. Results are presented as medians with inter-quartile ranges. RESULTS Fifty-eight patients with 283 blood samples (110 during CPB) were included. In the pre-CPB period, MDPE and MDAPE were -17.3 [-32.9 to 2.3] and 24.6 [12-37.7]%, whereas during CPB, they were -1.8 [-15.6 to 11.1] and 14.0 [6.74-27.1]%, respectively. There was no statistically significant difference between measured and predicted remifentanil plasma concentrations during CPB. Age, preoperative albumin concentrations, temperature, and haemodilution were not independently associated with MDAPE >30%. CONCLUSIONS The Minto model accurately predicts plasma remifentanil concentrations during cardiac surgery with CPB. CLINICAL TRIAL REGISTRATION 2017-A03153-50.
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Affiliation(s)
- Vincent Scherrer
- Rouen University Hospital, Department of Anaesthesiology and Critical Care, Rouen, France
| | - Fabien Lamoureux
- Rouen University Hospital, Department of Pharmacology, Rouen, France; Normandie Univ, UNIROUEN, Inserm U1096, EnVi, Rouen, France
| | - Céline Chaventre
- Rouen University Hospital, Department of Anaesthesiology and Critical Care, Rouen, France
| | - Caroline Thill
- Rouen University Hospital, Department of Biostatistics, Rouen, France
| | - Zoe Demailly
- Rouen University Hospital, Department of Anaesthesiology and Critical Care, Rouen, France; Normandie Univ, UNIROUEN, Inserm U1096, EnVi, Rouen, France
| | - Jean Selim
- Rouen University Hospital, Department of Anaesthesiology and Critical Care, Rouen, France; Normandie Univ, UNIROUEN, Inserm U1096, EnVi, Rouen, France
| | - Fabrice Bauer
- Normandie Univ, UNIROUEN, Inserm U1096, EnVi, Rouen, France; Rouen University Hospital, Department of Cardiac Surgery, Rouen, France
| | - Laurent Imbert
- Rouen University Hospital, Department of Pharmacology, Rouen, France
| | - Véronique Wurtz
- Rouen University Hospital, Department of Anaesthesiology and Critical Care, Rouen, France
| | - Vincent Compère
- Rouen University Hospital, Department of Anaesthesiology and Critical Care, Rouen, France; Normandie Univ, UNIROUEN, INSERM U1239, Rouen, France
| | - Thomas Clavier
- Rouen University Hospital, Department of Anaesthesiology and Critical Care, Rouen, France; Normandie Univ, UNIROUEN, Inserm U1096, EnVi, Rouen, France
| | - Emmanuel Besnier
- Rouen University Hospital, Department of Anaesthesiology and Critical Care, Rouen, France; Normandie Univ, UNIROUEN, Inserm U1096, EnVi, Rouen, France.
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3
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Jung KT, Bapat A, Kim YK, Hucker WJ, Lee K. Therapeutic hypothermia for acute myocardial infarction: a narrative review of evidence from animal and clinical studies. Korean J Anesthesiol 2022; 75:216-230. [PMID: 35350095 PMCID: PMC9171548 DOI: 10.4097/kja.22156] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 03/27/2022] [Accepted: 03/29/2022] [Indexed: 11/21/2022] Open
Abstract
Myocardial infarction (MI) is the leading cause of death from coronary heart disease and requires immediate reperfusion therapy with thrombolysis, primary percutaneous coronary intervention, or coronary artery bypass grafting. However, myocardial reperfusion therapy is often accompanied by cardiac ischemia/reperfusion (I/R) injury, which leads to myocardial injury with detrimental consequences. The causes of I/R injury are unclear, but are multifactorial, including free radicals, reactive oxygen species, calcium overload, mitochondria dysfunction, inflammation, and neutrophil-mediated vascular injury. Mild hypothermia has been introduced as one of the potential inhibitors of myocardial I/R injury. Although animal studies have demonstrated that mild hypothermia significantly reduces or delays I/R myocardium damage, human trials have not shown clinical benefits in acute MI (AMI). In addition, the practice of hypothermia treatment is increasing in various fields such as surgical anesthesia and intensive care units. Adequate sedation for anesthetic procedures and protection from body shivering has become essential during therapeutic hypothermia. Therefore, anesthesiologists should be aware of the effects of therapeutic hypothermia on the metabolism of anesthetic drugs. In this paper, we review the existing data on the use of therapeutic hypothermia for AMI in animal models and human clinical trials to better understand the discrepancy between perceived benefits in preclinical animal models and the absence thereof in clinical trials thus far.
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Affiliation(s)
- Ki Tae Jung
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Anesthesiology and Pain Medicine, College of Medicine and Medical School, Chosun University, Gwangju, Korea
| | - Aneesh Bapat
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, MA, USA
| | - Young-Kug Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - William J. Hucker
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, MA, USA
| | - Kichang Lee
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, MA, USA
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Wahba A, Milojevic M, Boer C, De Somer FMJJ, Gudbjartsson T, van den Goor J, Jones TJ, Lomivorotov V, Merkle F, Ranucci M, Kunst G, Puis L. 2019 EACTS/EACTA/EBCP guidelines on cardiopulmonary bypass in adult cardiac surgery. Eur J Cardiothorac Surg 2021; 57:210-251. [PMID: 31576396 DOI: 10.1093/ejcts/ezz267] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Alexander Wahba
- Department of Cardio-Thoracic Surgery, St Olav's University Hospital, Trondheim, Norway.,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Milan Milojevic
- Department of Cardiovascular Anaesthesia and Intensive Care Unit, Dedinje Cardiovascular Institute, Belgrade, Serbia.,Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Christa Boer
- Department of Anaesthesiology, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | | | - Tomas Gudbjartsson
- Department of Cardiothoracic Surgery, Faculty of Medicine, Landspitali University Hospital, University of Iceland, Reykjavik, Iceland
| | - Jenny van den Goor
- Department of Cardiothoracic Surgery, Academic Medical Centre of the University of Amsterdam, Amsterdam, Netherlands
| | - Timothy J Jones
- Department of Paediatric Cardiac Surgery, Birmingham Women's and Children's Hospital, Birmingham, UK
| | - Vladimir Lomivorotov
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk State University, Novosibirsk, Russia
| | - Frank Merkle
- Academy for Perfusion, Deutsches Herzzentrum, Berlin, Germany
| | - Marco Ranucci
- Department of Cardiovascular Anaesthesia and Intensive Care Unit, IRCCS Policlinico San Donato, Milan, Italy
| | - Gudrun Kunst
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust and School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Excellence, London, UK
| | - Luc Puis
- Department of Perfusion, University Hospital Brussels, Jette, Belgium
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5
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Wolstencroft P, Arnold P, Anderson BJ. Dose estimation for bivalirudin during pediatric cardiopulmonary bypass. Paediatr Anaesth 2021; 31:637-643. [PMID: 33423355 DOI: 10.1111/pan.14125] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 12/15/2020] [Accepted: 01/05/2021] [Indexed: 01/19/2023]
Abstract
AIM A typical adult-based bivalirudin regimen during cardiopulmonary bypass uses a loading dose of 1 mg kg-1 and a circuit prime (volume L × 13 mg) with a subsequent intravenous infusion 2.5 mg h-1 kg-1 . Dose in children remains unknown. We wished to determine a practical bivalirudin dosing schedule for children undergoing surgery with cardiopulmonary bypass. METHODS Published pharmacokinetic parameters in children who were anticoagulated for cardiac catheterization using bivalirudin were compared to adult by scaling for size using allometry. An infusion regimen suitable for children was determined using a bivalirudin target concentration (13 mg L-1 ) common in adults for effect during cardiopulmonary bypass. Predicted bivalirudin infusion rates in children were compared to regimens published as case reports. RESULTS Current pediatric bivalirudin infusion rates are based on those used in adults with titration during cardiopulmonary bypass to achieve activated clotting times longer than 400 s. Bivalirudin clearance (mL min-1 kg-1 ) can be estimated in children by scaling adult parameters using allometry. Clearance decreases through childhood and higher infusion rates in children would achieve target concentration rapidly without the need to titrate initial infusion rate. An infusion rate of 4.5 mg h-1 kg-1 in a 10 kg infant, 4 mg h-1 kg-1 in a 20 kg child and 3.5 mg h-1 kg-1 in a child 30-40 kg will target an activated clotting time slower than 400 s. Adult regimens could be used in those children heavier than 50 kg. CONCLUSION Bivalirudin infusion in children should be started after loading dose at rates greater than those used in adults. Dose in neonates remains uncertain because neither pharmacokinetics nor coagulation pharmacodynamics have been adequately characterized.
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Affiliation(s)
- Philip Wolstencroft
- Department of Paediatric Anaesthesia, Starship Children's Hospital, Auckland, New Zealand
| | - Philip Arnold
- Jackson Rees Department of Paediatric Anaesthesia, Alder Hey Children's Hospital, Liverpool, UK
| | - Brian J Anderson
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
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6
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Puis L, Milojevic M, Boer C, De Somer FMJJ, Gudbjartsson T, van den Goor J, Jones TJ, Lomivorotov V, Merkle F, Ranucci M, Kunst G, Wahba A. 2019 EACTS/EACTA/EBCP guidelines on cardiopulmonary bypass in adult cardiac surgery. Interact Cardiovasc Thorac Surg 2020; 30:161-202. [PMID: 31576402 PMCID: PMC10634377 DOI: 10.1093/icvts/ivz251] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Luc Puis
- Department of Perfusion, University Hospital Brussels, Jette, Belgium
| | - Milan Milojevic
- Department of Cardiovascular Anaesthesia and Intensive Care Unit, Dedinje Cardiovascular Institute, Belgrade, Serbia
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Christa Boer
- Department of Anaesthesiology, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | | | - Tomas Gudbjartsson
- Department of Cardiothoracic Surgery, Faculty of Medicine, Landspitali University Hospital, University of Iceland, Reykjavik, Iceland
| | - Jenny van den Goor
- Department of Cardiothoracic Surgery, Academic Medical Centre of the University of Amsterdam, Amsterdam, Netherlands
| | - Timothy J Jones
- Department of Paediatric Cardiac Surgery, Birmingham Women’s and Children’s Hospital, Birmingham, UK
| | - Vladimir Lomivorotov
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk State University, Novosibirsk, Russia
| | - Frank Merkle
- Academy for Perfusion, Deutsches Herzzentrum, Berlin, Germany
| | - Marco Ranucci
- Department of Cardiovascular Anaesthesia and Intensive Care Unit, IRCCS Policlinico San Donato, Milan, Italy
| | - Gudrun Kunst
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust and School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Excellence, London, UK
| | - Alexander Wahba
- Department of Cardio-Thoracic Surgery, St Olav s University Hospital, Trondheim, Norway
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
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7
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Kunst G, Milojevic M, Boer C, De Somer FM, Gudbjartsson T, van den Goor J, Jones TJ, Lomivorotov V, Merkle F, Ranucci M, Puis L, Wahba A, Alston P, Fitzgerald D, Nikolic A, Onorati F, Rasmussen BS, Svenmarker S. 2019 EACTS/EACTA/EBCP guidelines on cardiopulmonary bypass in adult cardiac surgery. Br J Anaesth 2019; 123:713-757. [DOI: 10.1016/j.bja.2019.09.012] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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8
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Adiraju SKS, Shekar K, Fraser JF, Smith MT, Ghassabian S. Effect of cardiopulmonary bypass on cytochrome P450 enzyme activity: implications for pharmacotherapy. Drug Metab Rev 2017; 50:109-124. [PMID: 29254370 DOI: 10.1080/03602532.2017.1417423] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
For patients undergoing cardiopulmonary bypass (CPB) during cardiac surgery, there are well-documented changes in the pharmacokinetics (PK) of commonly administered drugs. Although multiple factors potentially underpin these changes, there has been scant research attention on the impact of CPB to alter the activities of cytochrome P450 (CYP) isoenzymes. PK changes during cardiac surgery with CPB have the potential to adversely affect the safety and efficacy of pharmacotherapy and increase the risk of drug-drug interactions. Clinically significant changes in drug PK during CPB are likely to be prominent for drugs where CYP metabolism is a major clearance (CL) mechanism. However, clinical data from patients undergoing CPB surgery in support of this hypothesis are lacking, leaving a significant knowledge gap. In this review, we address the effects of CPB on the release of pro-inflammatory cytokines, in surgeries with and without CPB, both pre and post initiation of surgery. We reviewed literature to explore the relationship between the release of pro-inflammatory cytokines, and the expression and activities of CYP enzymes. Through this approach, we provide new insight on the effects of CPB on the PK of drugs administered to patients in the clinical setting. Future research to address this knowledge gap will have considerable impact to assist clinicians with optimizing pharmacotherapy in this patient population.
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Affiliation(s)
- Santosh Kumar Sreevatsav Adiraju
- a Centre for Integrated Preclinical Drug Development, Centre for Clinical Research, Faculty of Medicine , The University of Queensland , Brisbane , QLD , Australia
| | - Kiran Shekar
- b Critical Care Research Group , The Prince Charles Hospital and The University of Queensland , Brisbane , QLD , Australia
| | - John F Fraser
- b Critical Care Research Group , The Prince Charles Hospital and The University of Queensland , Brisbane , QLD , Australia
| | - Maree T Smith
- a Centre for Integrated Preclinical Drug Development, Centre for Clinical Research, Faculty of Medicine , The University of Queensland , Brisbane , QLD , Australia.,c School of Pharmacy, Faculty of Health and Behavioral Sciences , The University of Queensland , Brisbane , QLD , Australia
| | - Sussan Ghassabian
- a Centre for Integrated Preclinical Drug Development, Centre for Clinical Research, Faculty of Medicine , The University of Queensland , Brisbane , QLD , Australia
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9
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Yang S, Noh H, Hahn J, Jin BH, Min KL, Bae SK, Kim J, Park MS, Hong T, Wi J, Chang MJ. Population pharmacokinetics of remifentanil in critically ill patients receiving extracorporeal membrane oxygenation. Sci Rep 2017; 7:16276. [PMID: 29176598 PMCID: PMC5701170 DOI: 10.1038/s41598-017-16358-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 11/10/2017] [Indexed: 11/09/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is associated with pharmacokinetic (PK) changes of drugs. It presents considerable challenges to providing optimal dosing regimens for patients receiving ECMO. We aimed to describe the population PK of remifentanil in critically ill adult patients receiving venoartrial extracorporeal membrane oxygenation (VA-ECMO) and to identify determinants associated with altered remifentanil concentrations. The population PK model of remifentanil was developed using nonlinear mixed effects modelling (NONMEM). Fifteen adult patients who received a continuous infusion of remifentanil during VA-ECMO participated in the study. The PK of remifentanil was best described by a one-compartment model with additive and proportional residual errors. Remifentanil concentrations were affected by sex and ECMO pump speed. The final PK model included the effect of sex and ECMO pump speed on clearance is developed as followed: clearance (L/h) = 366 × 0.502sex × (ECMO pump speed/2350)2.04 and volume (L) = 41. Remifentanil volume and clearance were increased in adult patients on VA-ECMO compared with previously reported patients not on ECMO. We suggest that clinicians should consider an increased remifentanil dosing to achieve the desired level of sedation and provide a dosing regimen according to sex and ECMO pump speed.
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Affiliation(s)
- Seungwon Yang
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, College of Pharmacy, Yonsei University, Incheon, Republic of Korea
| | - Hayeon Noh
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, College of Pharmacy, Yonsei University, Incheon, Republic of Korea
| | - Jongsung Hahn
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, College of Pharmacy, Yonsei University, Incheon, Republic of Korea
| | - Byung Hak Jin
- Department of Pharmaceutical Medicine and Regulatory Sciences, Colleges of Medicine and Pharmacy, Yonsei University, Incheon, Republic of Korea
- Deparment of Clinical Pharmacology, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kyoung Lok Min
- Department of Pharmaceutical Medicine and Regulatory Sciences, Colleges of Medicine and Pharmacy, Yonsei University, Incheon, Republic of Korea
| | - Soo Kyung Bae
- College of Pharmacy, The Catholic University of Korea, Bucheon, Kyunggido, Republic of Korea
| | - Jiseon Kim
- College of Pharmacy, The Catholic University of Korea, Bucheon, Kyunggido, Republic of Korea
| | - Min Soo Park
- Department of Pharmaceutical Medicine and Regulatory Sciences, Colleges of Medicine and Pharmacy, Yonsei University, Incheon, Republic of Korea
- Deparment of Clinical Pharmacology, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Taegon Hong
- Deparment of Clinical Pharmacology, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jin Wi
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Min Jung Chang
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, College of Pharmacy, Yonsei University, Incheon, Republic of Korea.
- Department of Pharmaceutical Medicine and Regulatory Sciences, Colleges of Medicine and Pharmacy, Yonsei University, Incheon, Republic of Korea.
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10
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Cho YJ, Jo WY, Oh H, Koo CH, Oh J, Cho JY, Yu KS, Jeon Y, Kim TK. Performance of the Minto model for the target-controlled infusion of remifentanil during cardiopulmonary bypass. Anaesthesia 2017; 72:1196-1205. [PMID: 28891056 DOI: 10.1111/anae.14019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2017] [Indexed: 02/05/2023]
Abstract
We studied the predictive performance of the Minto pharmacokinetic model during cardiopulmonary bypass in patients undergoing cardiac surgery. Patients received remifentanil target-controlled infusion using the Minto model during total intravenous anaesthesia with propofol. From 56 patients, 275 arterial blood samples were drawn before, during and after bypass to determine the plasma concentration of remifentanil, and the predicted concentrations were recorded at each time. For pooled data, the median prediction error and median absolute prediction error were 21.3% and 21.8%, respectively, and 22.1% and 22.3% during bypass. Both were 148.4% during hypothermic circulatory arrest and measured concentrations were more than three times greater than predicted (26.9 (17.0) vs. 7.1 (1.6) ng.ml-1 ). The Minto model showed considerable bias but overall acceptable precision during bypass. The target concentration of remifentanil should be reduced when using the Minto model during hypothermic circulatory arrest.
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Affiliation(s)
- Y J Cho
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea
| | - W Y Jo
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea
| | - H Oh
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea
| | - C-H Koo
- CHA Bundang Medical Centre, Department of Anaesthesiology and Pain Medicine, Seongnam-si, South Korea
| | - J Oh
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, South Korea
| | - J-Y Cho
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, South Korea
| | - K-S Yu
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, South Korea
| | - Y Jeon
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea
| | - T K Kim
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea
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Abstract
Hypothermia, along with acidosis and coagulopathy, is part of the lethal triad that worsen the prognosis of severe trauma patients. While accidental hypothermia is easy to identify by a simple measurement, it is no less pernicious if it is not detected or treated in the initial phase of patient care. It is a multifactorial process and is a factor of mortality in severe trauma cases. The consequences of hypothermia are many: it modifies myocardial contractions and may induce arrhythmias; it contributes to trauma-induced coagulopathy; from an immunological point of view, it diminishes inflammatory response and increases the chance of pneumonia in the patient; it inhibits the elimination of anaesthetic drugs and can complicate the calculation of dosing requirements; and it leads to an over-estimation of coagulation factor activities. This review will detail the pathophysiological consequences of hypothermia, as well as the most recent principle recommendations in dealing with it.
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Affiliation(s)
- Fanny Vardon
- Équipe d'accueil « Modélisation de l'agression tissulaire et nociceptive », Toulouse University Teaching Hospital, Université Toulouse III Paul-Sabatier, Hôpital Pierre-Paul-Riquet, CHU de Toulouse, place du Dr-Baylac, 31059 Toulouse cedex 09, France
| | - Ségolène Mrozek
- Équipe d'accueil « Modélisation de l'agression tissulaire et nociceptive », Toulouse University Teaching Hospital, Université Toulouse III Paul-Sabatier, Hôpital Pierre-Paul-Riquet, CHU de Toulouse, place du Dr-Baylac, 31059 Toulouse cedex 09, France
| | - Thomas Geeraerts
- Équipe d'accueil « Modélisation de l'agression tissulaire et nociceptive », Toulouse University Teaching Hospital, Université Toulouse III Paul-Sabatier, Hôpital Pierre-Paul-Riquet, CHU de Toulouse, place du Dr-Baylac, 31059 Toulouse cedex 09, France.
| | - Olivier Fourcade
- Équipe d'accueil « Modélisation de l'agression tissulaire et nociceptive », Toulouse University Teaching Hospital, Université Toulouse III Paul-Sabatier, Hôpital Pierre-Paul-Riquet, CHU de Toulouse, place du Dr-Baylac, 31059 Toulouse cedex 09, France
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12
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Schraag S. The Current Role of Total Intravenous Anesthesia in Cardiac Surgery: Total Intravenous Anesthesia and Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2015; 29 Suppl 1:S27-30. [DOI: 10.1053/j.jvca.2015.01.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Indexed: 11/11/2022]
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13
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Abstract
Therapeutic hypothermia is the only treatment currently recommended for moderate or severe encephalopathy of hypoxic‒ischaemic origin in term neonates. Though the effects of hypothermia on human physiology have been explored for many decades, much of the data comes from animal or adult studies; the latter originally after accidental hypothermia, followed by application of controlled hypothermia after cardiac arrest or trauma, or during cardiopulmonary bypass. Though this work is informative, the effects of hypothermia on neonatal physiology after perinatal asphyxia must be considered in the context of a prolonged hypoxic insult that has already induced a number of significant physiological sequelae. This article reviews the effects of therapeutic hypothermia on respiratory, cardiovascular, and metabolic parameters, including glycaemic control and feeding requirements. The potential pitfalls of blood‒gas analysis and overtreatment of physiological changes in cardiovascular parameters are also discussed. Finally, the effects of hypothermia on drug metabolism are covered, focusing on how the pharmacokinetics, pharmacodynamics, and dosing requirements of drugs frequently used in neonatal intensive care may change during therapeutic hypothermia.
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Hemmati N, Zokaei AH. Comparison of the Effect of Anesthesia With Midazolam-Fentanyl Versus Propofol-Remifentanil on Bispectral Index in Patients Undergoing Coronary Artery Bypass Graft. Glob J Health Sci 2015; 7:233-8. [PMID: 26156911 PMCID: PMC4803899 DOI: 10.5539/gjhs.v7n5p233] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 12/11/2014] [Indexed: 12/05/2022] Open
Abstract
The aim of this study was to compare the effect of anesthesia with midazolam-fentanyl versus propofol-remifentanil on the BIS (bispectral index) in patients undergoing coronary artery bypass grafting (CABG). Sixty-four patients undergoing CABG were randomly assigned to one of two study groups: midazolam-fentanyl (MF, N= 32) or propofol-remifentanil (PR, N= 32). The BIS was measured before induction of anesthesia, five minutes after induction of anesthesia, at skin incision, sternotomy, pericardiotomy, aorta cannulation, onset of cardiopulmonary bypass, during rewarming, five minutes after separation from cardiopulmonary bypass, at thorax closure, and at the end of the surgery. There were no significant differences between the two groups with regard to age and gender. The difference in mean BIS between the two groups was significant (P < 0.05) at all times, except before induction, five minutes after induction, at skin incision and on rewarming. Changes in the BIS were lower in the PR group than in the MF group. Both techniques can provide adequate anesthesia in patients undergoing CABG. However, the probability of awareness during anesthesia is lower with propofol-remifentanil than with midazolam-fentanyl.
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Affiliation(s)
| | - Abdol Hamid Zokaei
- School of Medicine, Kermanshah University of Medical Sciences, Kermanshah.
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BJELLAND TW, KLEPSTAD P, HAUGEN BO, NILSEN T, SALVESEN Ø, DALE O. Concentrations of remifentanil, propofol, fentanyl, and midazolam during rewarming from therapeutic hypothermia. Acta Anaesthesiol Scand 2014; 58:709-15. [PMID: 24611449 DOI: 10.1111/aas.12300] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND The clearance of sedatives and analgesics may be reduced by therapeutic hypothermia. However, little is known about the concentrations of such drugs during rewarming. The aim of this study was to describe the serum concentrations of sedatives and analgesics during rewarming from therapeutic hypothermia. METHODS Blood samples were collected for quantification of drug concentrations in 22 patients given analgesia/sedation with either remifentanil/propofol or fentanyl/midazolam during rewarming from therapeutic hypothermia (33-34°C) after cardiac arrest. Samples for were drawn before (-2 h) and during rewarming (0-8 h). Linear mixed effects models were used to describe serum concentrations and adjust for rates of infusion during rewarming from therapeutic hypothermia. RESULTS Subjects with samples analyzed were remifentanil (n = 8), propofol (n = 14), fentanyl (n = 8), and midazolam (n = 8). Age, body mass index, and simplified acute physiology score II [mean (standard deviation)] were 64 (14.2) years, 27.3 (3.7) kg/m(2), and 69 (13.2), respectively. While the concentration of fentanyl was not significantly affected by temperature, concentrations of remifentanil, propofol, and midazolam decreased with core temperature by 16%, 12%, and 11% (mean values) from 33°C to 37°C after adjusting for rates of infusion, respectively. CONCLUSION Concentrations of remifentanil, propofol, and midazolam decreased during rewarming from therapeutic hypothermia when adjusting for rates of infusion. No changes were demonstrated for fentanyl.
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Affiliation(s)
- T. W. BJELLAND
- Department of Circulation and Medical Imaging; Faculty of Medicine; Norwegian University of Science and Technology (NTNU); Trondheim Norway
| | - P. KLEPSTAD
- Department of Circulation and Medical Imaging; Faculty of Medicine; Norwegian University of Science and Technology (NTNU); Trondheim Norway
- Clinic of Anaesthesia and Intensive Care; St. Olav's University Hospital; Trondheim Norway
| | - B. O. HAUGEN
- Department of Circulation and Medical Imaging; Faculty of Medicine; Norwegian University of Science and Technology (NTNU); Trondheim Norway
- Clinic of Cardiology; St. Olav's University Hospital; Trondheim Norway
| | - T. NILSEN
- Department of Circulation and Medical Imaging; Faculty of Medicine; Norwegian University of Science and Technology (NTNU); Trondheim Norway
| | - Ø. SALVESEN
- Unit for Applied Clinical Research; Faculty of Medicine; Norwegian University of Science and Technology (NTNU); Trondheim Norway
| | - O. DALE
- Department of Circulation and Medical Imaging; Faculty of Medicine; Norwegian University of Science and Technology (NTNU); Trondheim Norway
- Clinic of Anaesthesia and Intensive Care; St. Olav's University Hospital; Trondheim Norway
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Sappenfield JW, Hong CM, Galvagno SM. Perioperative temperature measurement and management: moving beyond the Surgical Care Improvement Project. ACTA ACUST UNITED AC 2013. [DOI: 10.7243/2049-9752-2-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Özarslan NG, Ayhan B, Kanbak M, Çelebioğlu B, Demircin M, Ince C, Aypar Ü. Comparison of the Effects of Sevoflurane, Isoflurane, and Desflurane on Microcirculation in Coronary Artery Bypass Graft Surgery. J Cardiothorac Vasc Anesth 2012; 26:791-8. [DOI: 10.1053/j.jvca.2012.03.019] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2011] [Indexed: 11/11/2022]
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Djafarzadeh S, Vuda M, Takala J, Jakob SM. Effect of remifentanil on mitochondrial oxygen consumption of cultured human hepatocytes. PLoS One 2012; 7:e45195. [PMID: 23028840 PMCID: PMC3441687 DOI: 10.1371/journal.pone.0045195] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2011] [Accepted: 08/17/2012] [Indexed: 11/19/2022] Open
Abstract
During sepsis, liver dysfunction is common, and failure of mitochondria to effectively couple oxygen consumption with energy production has been described. In addition to sepsis, pharmacological agents used to treat septic patients may contribute to mitochondrial dysfunction. This study addressed the hypothesis that remifentanil interacts with hepatic mitochondrial oxygen consumption. The human hepatoma cell line HepG2 and their isolated mitochondria were exposed to remifentanil, with or without further exposure to tumor necrosis factor-α (TNF-α). Mitochondrial oxygen consumption was measured by high-resolution respirometry, Caspase-3 protein levels by Western blotting, and cytokine levels by ELISA. Inhibitory κBα (IκBα) phosphorylation, measurement of the cellular ATP content and mitochondrial membrane potential in intact cells were analysed using commercial ELISA kits. Maximal cellular respiration increased after one hour of incubation with remifentanil, and phosphorylation of IκBα occurred, denoting stimulation of nuclear factor κB (NF-κB). The effect on cellular respiration was not present at 2, 4, 8 or 16 hours of incubation. Remifentanil increased the isolated mitochondrial respiratory control ratio of complex-I-dependent respiration without interfering with maximal respiration. Preincubation with the opioid receptor antagonist naloxone prevented a remifentanil-induced increase in cellular respiration. Remifentanil at 10× higher concentrations than therapeutic reduced mitochondrial membrane potential and ATP content without uncoupling oxygen consumption and basal respiration levels. TNF-α exposure reduced respiration of complex-I, -II and -IV, an effect which was prevented by prior remifentanil incubation. Furthermore, prior remifentanil incubation prevented TNF-α-induced IL-6 release of HepG2 cells, and attenuated fragmentation of pro-caspase-3 into cleaved active caspase 3 (an early marker of apoptosis). Our data suggest that remifentanil increases cellular respiration of human hepatocytes and prevents TNF-α-induced mitochondrial dysfunction. The results were not explained by uncoupling of mitochondrial respiration.
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Affiliation(s)
- Siamak Djafarzadeh
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Madhusudanarao Vuda
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Jukka Takala
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Stephan M. Jakob
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
- * E-mail:
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Bjelland TW, Dale O, Kaisen K, Haugen BO, Lydersen S, Strand K, Klepstad P. Propofol and remifentanil versus midazolam and fentanyl for sedation during therapeutic hypothermia after cardiac arrest: a randomised trial. Intensive Care Med 2012; 38:959-67. [DOI: 10.1007/s00134-012-2540-1] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2011] [Accepted: 01/12/2012] [Indexed: 10/28/2022]
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Ziegeler S, Buchinger H, Wilhelm W, Larsen R, Kreuer S. Impact of deep hypothermic circulatory arrest on the BIS index. J Clin Anesth 2010; 22:340-5. [DOI: 10.1016/j.jclinane.2009.09.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2008] [Revised: 09/04/2009] [Accepted: 09/26/2009] [Indexed: 11/24/2022]
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Are there still limitations for the use of target-controlled infusion in children? Curr Opin Anaesthesiol 2010; 23:356-62. [DOI: 10.1097/aco.0b013e32833938db] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Hostler D, Zhou J, Tortorici MA, Bies RR, Rittenberger JC, Empey PE, Kochanek PM, Callaway CW, Poloyac SM. Mild hypothermia alters midazolam pharmacokinetics in normal healthy volunteers. Drug Metab Dispos 2010; 38:781-8. [PMID: 20164112 DOI: 10.1124/dmd.109.031377] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The clinical use of therapeutic hypothermia has been rapidly expanding due to evidence of neuroprotection. However, the effect of hypothermia on specific pathways of drug elimination in humans is relatively unknown. To gain insight into the potential effects of hypothermia on drug metabolism and disposition, we evaluated the pharmacokinetics of midazolam as a probe for CYP3A4/5 activity during mild hypothermia in human volunteers. A second objective of this work was to determine whether benzodiazepines and magnesium administered intravenously would facilitate the induction of hypothermia. Subjects were enrolled in a randomized crossover study, which included two mild hypothermia groups (4 degrees C saline infusions and 4 degrees C saline + magnesium) and two normothermia groups (37 degrees C saline infusions and 37 degrees C saline + magnesium). The lowest temperatures achieved in the 4 degrees C saline + magnesium and 4 degrees C saline infusions were 35.4 +/- 0.4 and 35.8 +/- 0.3 degrees C, respectively. A significant decrease in the formation clearance of the major metabolite 1'-hydroxymidazolam was observed during the 4 degrees C saline + magnesium compared with that in the 37 degrees C saline group (p < 0.05). Population pharmacokinetic modeling identified a significant relationship between temperature and clearance and intercompartmental clearance for midazolam. This model predicted that midazolam clearance decreases 11.1% for each degree Celsius reduction in core temperature from 36.5 degrees C. Midazolam with magnesium facilitated the induction of hypothermia, but shivering was minimally suppressed. These data provided proof of concept that even mild and short-duration changes in body temperature significantly affect midazolam metabolism. Future studies in patients who receive lower levels and a longer duration of hypothermia are warranted.
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Affiliation(s)
- David Hostler
- Department of Emergency Medicine, Emergency Responder Human Performance Laboratory, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Standing JF, Hammer GB, Sam WJ, Drover DR. Pharmacokinetic-pharmacodynamic modeling of the hypotensive effect of remifentanil in infants undergoing cranioplasty. Paediatr Anaesth 2010; 20:7-18. [PMID: 19825011 DOI: 10.1111/j.1460-9592.2009.03174.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Although remifentanil has been used to induce hypotension during surgery in infants, no pharmacokinetic-pharmacodynamic (PKPD) model exists for its quantitative analysis. Our aim was to determine the quantitative relationship between whole blood remifentanil concentration and its hypotensive effect during surgery in infants. METHODS/MATERIALS We studied seven infants (age 0.3-1 year) who underwent cranioplasty surgery and received remifentanil delivered by a computer-controlled infusion pump during the maintenance of anesthesia. Arterial blood samples to determine remifentanil concentration and mean arterial blood pressure (MAP) measurements were collected. A simultaneous PKPD mixed-effects model was built in NONMEM. RESULTS A total of 77 remifentanil concentrations and 185 MAP measurements were collected. Remifentanil pharmacokinetics was described with a two-compartment model, parameter estimates were 2.99 l x min(-1) x 70 kg(-1) for clearance and 16.23 l x 70 kg(-1) for steady state volume of distribution. Mean baseline MAP was 69.7 mmHg and was decreased as per clinical requirements. A sigmoidal E(max) model driven by an effect compartment described the decrease in MAP, with an estimated concentration to decrease MAP by half (EC(50)) being 17.1 ng x ml(-1). CONCLUSIONS Remifentanil is effective in causing hypotension. The final model predicts that a steady state remifentanil concentration of 14 ng.ml(-1) would typically achieve a 30% decrease in MAP.
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Affiliation(s)
- Joseph F Standing
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
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Sam WJ, Hammer GB, Drover DR. Population pharmacokinetics of remifentanil in infants and children undergoing cardiac surgery. BMC Anesthesiol 2009; 9:5. [PMID: 19635151 PMCID: PMC2723094 DOI: 10.1186/1471-2253-9-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2008] [Accepted: 07/27/2009] [Indexed: 11/10/2022] Open
Abstract
Background The aim of this study was to provide a model-based analysis of the pharmacokinetics of remifentanil in infants and children undergoing cardiac surgery with cardiopulmonary bypass (CPB). Methods We studied nine patients aged 0.5 to 4 years who received a continuous remifentanil infusion via a computer-controlled infusion pump during cardiac surgery with mildly hypothermic CPB were studied. Arterial blood samples taken prior to, during and after CPB were analyzed for remifentanil concentrations using a validated gas-chromatographic mass-spectrophotometric assay. We used population mixed-effects modeling to characterize remifentanil pharmacokinetics. The final model was evaluated by its predictive performance. Results The pharmacokinetics of remifentanil was described by a 1-compartment model with adjustments for CPB. Population mean parameter estimates were 1.41 L for volume of distribution (V) and 0.244 L/min for clearance. V was increased during CPB and post-CPB to 2.41 times the pre-CPB value. The median prediction error and the median of individual median absolute prediction error were 2.44% and 21.6%, respectively. Conclusion Remifentanil dosage adjustments are required during and after CPB due to marked changes in the V of the drug. Simulations indicate that a targeted blood concentration of 14 ng/mL is achieved and maintained in 50% of typical patients by administration of an initial dose of 18 μg remifentanil followed by an infusion of 3.7 μg/min before, during and post-CPB, supplemented with a bolus dose of 25 μg given at the start of CPB.
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Affiliation(s)
- Wai Johnn Sam
- Department of Anesthesia, Stanford University, Stanford, California USA.
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Kim TH, Park HG, Kang DU, Lee SS, Yoo BH, Kim KM, Yon JH. Factors that influence awakening in coronary artery bypass graft using propofol and remifentanil. Korean J Anesthesiol 2009; 56:502-506. [PMID: 30625779 DOI: 10.4097/kjae.2009.56.5.502] [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: 11/10/2022] Open
Abstract
BACKGROUND The development of total intravenous anesthesia in coronary artery bypass graft (CABG) surgery has led to increased interest in the use of combination of propofol and remifentanil. Early extubation in post-cardiac surgery reduces the length of stay in intensive care unit and hospital and costs. The purpose of this study is to evaluate which anesthetic factors affect awakening time after anesthesia. METHODS We enrolled twenty patients of ASA physical status II or III, scheduled for CABG in this study. All patients received a standardized propofol/remifentanil anesthesia as an effect site target controlled infusion. We recorded times to awakening and tracheal extubation, duration of cardiopulmonary bypass (CPB) period, total time of anesthesia and operation. Also, we recorded dose of propofol, remifentanil, fentanyl and minimum body temperature during CPB. To predict the factors that affect awakening time as a dependent variable, we considered all measured parameters as independent variables, and analyzed multiple linear regressions. RESULTS The mean time responded to verbal command was 216.5 +/- 124.8 minutes after end of surgery. Among several parameters, minimum body temperature during CPB (P = 0.001) and total time of anesthesia (P = 0.003) were considered as significant factors that influence awakening time after CABG. CONCLUSIONS Minimum body temperature during CPB and the duration of anesthesia influence awakening time after CABG, significantly.
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Affiliation(s)
- Tae Hun Kim
- Department of Anesthesiology and Pain Medicine, Sanggye Paik Hospital, Collage of Medicine, Inje University, Seoul, Korea.
| | - Hae Gyun Park
- Department of Anesthesiology and Pain Medicine, Sanggye Paik Hospital, Collage of Medicine, Inje University, Seoul, Korea.
| | - Dong Uk Kang
- Department of Anesthesiology and Pain Medicine, Sanggye Paik Hospital, Collage of Medicine, Inje University, Seoul, Korea.
| | - Sang Seok Lee
- Department of Anesthesiology and Pain Medicine, Sanggye Paik Hospital, Collage of Medicine, Inje University, Seoul, Korea.
| | - Byung Hoon Yoo
- Department of Anesthesiology and Pain Medicine, Sanggye Paik Hospital, Collage of Medicine, Inje University, Seoul, Korea.
| | - Kye Min Kim
- Department of Anesthesiology and Pain Medicine, Sanggye Paik Hospital, Collage of Medicine, Inje University, Seoul, Korea.
| | - Jun Heum Yon
- Department of Anesthesiology and Pain Medicine, Sanggye Paik Hospital, Collage of Medicine, Inje University, Seoul, Korea.
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Pea F, Pavan F, Furlanut M. Clinical relevance of pharmacokinetics and pharmacodynamics in cardiac critical care patients. Clin Pharmacokinet 2008; 47:449-62. [PMID: 18563954 DOI: 10.2165/00003088-200847070-00002] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Pharmacokinetics is a discipline aimed at predicting the best dosage and dosing regimen for each single drug in order to ensure and maintain therapeutically effective concentrations at the action sites. In cardiac critical care patients, various pathophysiological conditions may significantly alter the pharmacokinetic behaviour of drugs. Gastrointestinal drug absorption may be erratic and unpredictable in the early postoperative period, and so patients may be unresponsive to oral therapy; thus the intravenous route should be preferred for life-saving drugs whenever feasible. Variations in the extracellular fluid content as a response to the trauma of surgery and the fluid load or significant drug loss through thoracic drainages may significantly lower plasma concentrations of extracellularly distributed hydrophilic antimicrobials (beta-lactams, aminoglycosides and glycopeptides). Drug metabolism may be altered by the systemic inflammatory response and/or multiple organ failure and/or drug-drug pharmacokinetic interactions that can potentially occur during polytherapy, especially in immunosuppressed cardiac transplant patients. Instability of renal function may promote significant changes in body fluid concentrations of renally eliminated drugs, even in a brief period of hours. Finally, the application of extracorporeal circulation by means of cardiopulmonary bypass may significantly alter the disposition of several drugs during the operation because of acute haemodilution, hypoalbuminaemia, hypothermia and/or adsorption to the bypass equipment. Accordingly, to avoid either overexposure and the consequent increased risk of toxicity or underexposure and the consequent risk of therapeutic failure in critically ill cardiac patients, the dosing regimens of several drugs are expected to be significantly different from those suggested for clinically stable patients. Additionally, therapeutic drug monitoring may be helpful in the management of drug therapy and should be routinely used to guide individualized dose adjustments for (i) immunosuppressants whenever cytochrome P450 3A4 isoenzyme inhibitors (e.g. macrolide antibacterials, azole antifungals) or inducers (e.g. rifampicin [rifampin]) are added to or withdrawn from the regimen; and (ii) glycopeptide and aminoglycoside antibacterials whenever haemodynamically active agents (such as dopamine, dobutamine and furosemide [frusemide]) are added to or withdrawn from the regimen, and also whenever significant changes of haemodynamics and/or of renal function occur.
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Affiliation(s)
- Federico Pea
- Institute of Clinical Pharmacology & Toxicology, Department of Experimental and Clinical Pathology and Medicine, Medical School, University of Udine, Udine, Italy.
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Pypendop BH, Brosnan RJ, Siao KT, Stanley SD. Pharmacokinetics of remifentanil in conscious cats and cats anesthetized with isoflurane. Am J Vet Res 2008; 69:531-6. [DOI: 10.2460/ajvr.69.4.531] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Róka A, Melinda KT, Vásárhelyi B, Machay T, Azzopardi D, Szabó M. Elevated morphine concentrations in neonates treated with morphine and prolonged hypothermia for hypoxic ischemic encephalopathy. Pediatrics 2008; 121:e844-9. [PMID: 18381513 DOI: 10.1542/peds.2007-1987] [Citation(s) in RCA: 110] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Asphyxia and hypothermia may modify drug pharmacokinetics. We investigated whether analgesia with morphine in neonates with hypoxic ischemic encephalopathy undergoing prolonged moderate systemic hypothermia resulted in elevated serum morphine concentrations compared with normothermic infants. PATIENTS AND METHODS Infants from 1 center participating in a multicenter randomized study of moderate whole-body hypothermia after perinatal asphyxia (the Total Body Hypothermia Study) were randomly selected for treatment with hypothermia (n = 10) or for standard care on normothermia (n = 6). Hypothermia (33 degrees C to 34 degrees C) was started before 6 hours of age and maintained for 72 hours. All of the infants were treated with a continuous infusion of morphine-hydrochloride, with the rate adjusted according to clinical status. Serum morphine concentrations were determined at 6, 12, 24, 48, and 72 hours after birth. RESULTS Serum morphine concentrations at 24 to 72 hours after birth were (median [range]) 292 ng/mL (137-767 ng/mL) in the hypothermia-treated infants and 206 ng/mL (88-327 ng/mL) in the infants on normothermia, despite similar morphine infusion rates and cumulative doses. Morphine concentrations correlated with morphine infusion rate, cumulative dose, and treatment with hypothermia. Serum morphine concentrations reached a steady state after 24 hours in the normothermic infants but continued to increase throughout the assessment period in the hypothermia group. Morphine clearance was low in both groups: (median [range]) morphine clearance estimated from area under the curve was 0.69 mL/min per kg (0.58-1.21 mL/min per kg) in hypothermic group and 0.89 mL/min per kg (0.65-1.33 mL/min per kg) in infants on normothermia. Serum morphine concentrations >300 nL/mL occurred more often in the hypothermia group and when the morphine infusion rate was >10 microg/kg per h. CONCLUSIONS Infants with hypoxic ischemic encephalopathy have reduced morphine clearance and elevated serum morphine concentrations when morphine infusion rates are based on clinical state. Potentially toxic serum concentrations of morphine may occur with moderate hypothermia and infusion rates >10 microg/kg per h.
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Affiliation(s)
- Anikó Róka
- First Department of Paediatrics, Semmelweis University, 1083 Budapest Bókay Str 53, Hungary.
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Abstract
BACKGROUND AND AIM Remifentanil is an ultra-short-acting opioid, increasingly used today in neuroanesthesia and neurointensive care. Its characteristics make remifentanil a potentially ideal agent, but previous data have cast a shadow on this opioid, supporting potentially toxic effects on the ischemic brain. The aim of the present concise review is to survey available up-to-date information on the effects of remifentanil on the central nervous system. METHOD A MEDLINE search within the past seven years for available up-to-date information on remifentanil and brain was performed. RESULTS Concise up-to-date information on the effects of remifentanil on the central nervous system was reported, with a particular emphasis on the following topics: cerebral metabolism, electroencephalogram, electrocorticography, motor-evoked potentials, regional cerebral blood flow, cerebral blood flow velocity, arterial hypotension and hypertension, intracranial pressure, cerebral perfusion pressure, cerebral autoregulation, cerebrovascular CO(2) reactivity, cerebrospinal fluid, painful stimulation, analgesia and hyperalgesia, neuroprotection, neurotoxicity and hypothermia. CONCLUSION The knowledge of the influence of remifentanil on brain functions is crucial before routine use in neuroanesthesia to improve anesthesia performance and patient safety as well as outcome.
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Affiliation(s)
- V Fodale
- Department of Neuroscience, Psychiatric and Anesthesiological Sciences, University of Messina, Messina, Italy.
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Abstract
Growth and development can be investigated using readily observable demographic factors such as weight and age. Size is the primary covariate and can be referenced to a 70-kg person with allometry using a coefficient of 0.75 for clearance and 1 for volume. The use of these coefficients is supported by fractal geometric concepts and observations from diverse areas in biology. Fat free mass (FFM) might be expected to do better than total body weight when there are wide variations in fat affecting body composition. Clearance pathways develop in the fetus before birth. The use of postnatal age as a descriptor of maturation is unsatisfactory because birth may occur prematurely; therefore postmenstrual age is a superior predictor of elimination function. A sigmoid E(max) model (Hill equation) describes gradual maturation of clearance in early life leading to a mature adult clearance achieved at a later age.
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Affiliation(s)
- B J Anderson
- Department of Anaesthesiology, University of Auckland School of Medicine, Auckland, New Zealand.
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Tortorici MA, Kochanek PM, Poloyac SM. Effects of hypothermia on drug disposition, metabolism, and response: A focus of hypothermia-mediated alterations on the cytochrome P450 enzyme system. Crit Care Med 2007; 35:2196-204. [PMID: 17855837 DOI: 10.1097/01.ccm.0000281517.97507.6e] [Citation(s) in RCA: 291] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Therapeutic hypothermia has been shown to decrease neurologic damage in patients experiencing out-of-hospital cardiac arrest. In addition to being treated with hypothermia, critically ill patients are treated with an extensive pharmacotherapeutic regimen. The effects of hypothermia on drug disposition increase the probability for unanticipated toxicity, which could limit its putative benefit. This review examines the effects of therapeutic hypothermia on the disposition, metabolism, and response of drugs commonly used in the intensive care unit, with a focus on the cytochrome P450 enzyme system. DATA SOURCES AND STUDY SELECTION A MEDLINE/PubMed search from 1965 to June 2006 was conducted using the search terms hypothermia, drug metabolism, P450, critical care, cardiac arrest, traumatic brain injury, and pharmacokinetics. DATA EXTRACTION AND SYNTHESIS Twenty-one studies were included in this review. The effects of therapeutic hypothermia on drug disposition include both the effects during cooling and the effects after rewarming on drug metabolism and response. The studies cited in this review demonstrate that the addition of mild to moderate hypothermia decreases the systemic clearance of cytochrome P450 metabolized drugs between approximately 7% and 22% per degree Celsius below 37degreesC during cooling. The addition of hypothermia decreases the potency and efficacy of certain drugs. CONCLUSIONS This review provides evidence that the therapeutic index of drugs is narrowed during hypothermia. The magnitude of these alterations indicates that intensivists must be aware of these alterations in order to maximize the therapeutic efficacy of this modality. In addition to increased clinical attention, future research efforts are essential to delineate precise dosing guidelines and mechanisms of the effect of hypothermia on drug disposition and response.
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Affiliation(s)
- Michael A Tortorici
- University of Pittsburgh School of Pharmacy, Department of Pharmaceutical Sciences, Pittsburgh, PA, USA
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Lison S, Schill M, Conzen P. Fast-Track Cardiac Anesthesia: Efficacy and Safety of Remifentanil Versus Sufentanil. J Cardiothorac Vasc Anesth 2007; 21:35-40. [PMID: 17289477 DOI: 10.1053/j.jvca.2006.03.011] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2005] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The purpose of this study was to compare the safety and efficacy of fast-track cardiac anesthesia with remifentanil (group R) versus sufentanil (group S). DESIGN Prospective, single-blinded, randomized study. SETTING University hospital. PARTICIPANTS One hundred twenty patients undergoing coronary artery bypass graft surgery and/or cardiac valve surgery. INTERVENTIONS After routine standardized anesthesia induction, anesthesia was maintained with isoflurane (0.4-0.8 vol%) together with either remifentanil (group R) (1 microg/kg/min) or sufentanil (group S) (1 microg/kg for induction, 0.5 microg/kg for skin incision, and then 0.02 microg/kg/min). After surgery, which included cardiopulmonary bypass in all cases, postoperative sedation was achieved in both groups with propofol until the patient was deemed ready for extubation. Additionally, patients in group R received remifentanil, 0.25 microg/kg/min. MEASUREMENTS AND MAIN RESULTS Recovery profile in group R patients was faster (p < 0.05), with a median time interval between end of surgery and eligibility for extubation of 295 minutes versus 375 minutes. Time from end of surgery to being eligible for discharge from intensive care unit was similar in both groups, with 22.9 hours in group R versus 26.3 hour in group S. Remifentanil provided a better protection against intraoperative stimuli at skin incision and maximal sternal spread (p < 0.05). The incidence of adverse events was comparable in both groups. Postoperative pain scores during the first hour of weaning were higher in group R (p < 0.05). CONCLUSIONS Remifentanil for fast-track cardiac anesthesia provided safe and stable operating conditions and facilitated earlier tracheal extubation. However, postoperative pain management should be planned carefully.
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Affiliation(s)
- Susanne Lison
- Department of Anesthesiology, Ludwig-Maximilians-University, Munich, Germany
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Tortorici MA, Kochanek PM, Bies RR, Poloyac SM. Therapeutic hypothermia-induced pharmacokinetic alterations on CYP2E1 chlorzoxazone-mediated metabolism in a cardiac arrest rat model*. Crit Care Med 2006; 34:785-91. [PMID: 16521272 DOI: 10.1097/01.ccm.0000201899.52739.4f] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Therapeutic hypothermia has demonstrated considerable benefit in patients experiencing cardiac arrest. Despite increasing clinical use, there is a paucity of information regarding the effect of hypothermia on the disposition of medications, specifically cytochrome P450-mediated drug metabolism. The objective was to determine the effect of hypothermia after cardiac arrest on the in vivo kinetics of a cytochrome P450 (CYP2E1) probe drug, chlorzoxazone, and to investigate the mechanism of these alterations. DESIGN Laboratory investigation. SETTING University pharmacy school and animal research facility. SUBJECTS Sixteen male Sprague-Dawley rats. INTERVENTIONS An asphyxial arrest rat model was used and moderate hypothermia was induced immediately postinsult via surface cooling. Chlorzoxazone was administered as an intravenous bolus, and plasma concentrations were analyzed using high-performance liquid chromatography methods. Protein binding was analyzed using rat control plasma, and Michaelis-Menten enzyme kinetic analysis was performed at 37 degrees C and 30 degrees C using control rat microsomes at varying concentrations of chlorzoxazone. MEASUREMENTS AND MAIN RESULTS Moderate hypothermia after cardiac arrest in rats markedly decreased the systemic clearance of the CYP2E1 substrate, chlorzoxazone, when compared with normothermia after cardiac arrest, 1.26+/-0.34 mL/min vs. 0.580+/-0.37 mL/min (p<.001). No changes in chlorzoxazone protein binding were observed at 37 degrees C and 30 degrees C, and CYP2E1 enzyme capacity (maximum velocity) was not altered at these different incubation temperatures. However, Michaelis-Menten constant was significantly increased at 30 degrees C (551+/-150 microM) compared with incubations at 37 degrees C (255+/-52 microM, p<.01). CONCLUSIONS Moderate hypothermia markedly reduces the systemic clearance of chlorzoxazone in cardiac arrest rats. This results from hypothermia-induced decreases in the CYP2E1 enzyme affinity for the substrate chlorzoxazone. This is the first systematic mechanistic investigation of the effect of hypothermia on CYP2E1-mediated metabolism.
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Affiliation(s)
- Michael A Tortorici
- University of Pittsburgh School of Pharmacy, Department of Pharmaceutical Sciences, and Department of Paediatrics, the Children't Hospital of Pittsburgh, PA, USA
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Steinlechner B, Koinig H, Grubhofer G, Ponschab M, Eislmeir S, Dworschak M, Rajek A. Postoperative Analgesia with Remifentanil in Patients Undergoing Cardiac Surgery. Anesth Analg 2005; 100:1230-1235. [PMID: 15845659 DOI: 10.1213/01.ane.0000147703.85557.09] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Remifentanil, a short-acting opioid, is commonly used in cardiac anesthesia. In this study we sought to demonstrate the feasibility of pain treatment and to determine the remifentanil dose necessary for adequate analgesia in tracheally extubated patients after cardiac surgery. Thirty patients undergoing elective cardiac surgery were included in this study. After surgery, the intraoperatively administered remifentanil was initially continued at 0.05 microg . kg(-1) . min(-1). Before tracheal extubation, a nonsteroidal antiinflammatory drug was administered and remifentanil was reduced to 0.035 microg . kg(-1) . min(-1). Pain assessment using a visual analog scale (VAS) was performed after tracheal extubation, in 2-min intervals for 10 min, every 10 min until the end of the first hour and every 30 min during the ensuing 5 h. A VAS score > or =30 or a respiratory rate <10 breaths/min was followed by an increase or decrease in the remifentanil dose by 0.005 microg . kg(-1) . min(-1), respectively. For rapid dose adaptation during the first 10 min, remifentanil was increased twice by 0.005 microg. kg(-1) . min(-1) and then 3 times by 0.01 microg . kg(-1) . min(-1). With a mean remifentanil dose of 0.051 microg . kg(-1) . min(-1) VAS decreased to 26 +/- 14 after 30 min. Sufficient analgesia was achieved with remifentanil doses ranging from 0.03 to 0.09 microg. kg(-1) . min(-1). A maximum mean remifentanil dose of 0.057microg. kg(-1) . min(-1) was reached after 4 h. The combination of remifentanil with a nonsteroidal antiinflammatory drug provided adequate analgesia in 73% of patients 30 min after tracheal extubation. Rapid dose titration was necessary during the first 10 min in 50% of patients. Increasing the initial remifentanil dose could shorten the titration period but may be associated with respiratory complications.
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Affiliation(s)
- Barbara Steinlechner
- Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, University Hospital of Vienna, Austria
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Lena P, Balarac N, Arnulf JJ, Bigeon JY, Tapia M, Bonnet F. Fast-track coronary artery bypass grafting surgery under general anesthesia with remifentanil and spinal analgesia with morphine and clonidine. J Cardiothorac Vasc Anesth 2005; 19:49-53. [PMID: 15747269 DOI: 10.1053/j.jvca.2004.11.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Effective postoperative analgesia is a critical part of fast-track cardiac surgery. This study compared the postoperative analgesic effect of fast-track anesthesia with remifentanil and spinal morphine and clonidine with that of sufentanil anesthesia followed by patient-controlled administration of intravenous morphine. DESIGN Prospective, blinded, randomized study. SETTING Single private institution. PARTICIPANTS Forty patients selected for coronary artery bypass graft surgery allocated randomly into 2 groups. INTERVENTIONS General anesthesia was performed with etomidate, isoflurane, cisatracurium, and either remifentanil (0.10-0.25 microg/kg/min) or sufentanil (up to 3.5 microg/kg). In the remifentanil group, patients received spinal morphine (4 microg/kg) and clonidine (1 microg/kg) before induction. Postoperatively, patients in both groups were connected to an intravenous patient-controlled analgesia (PCA) morphine pump that delivered a 1-g bolus with a 7-minute lockout interval. MEASUREMENTS AND MAIN RESULTS Patients were evaluated for pain on a visual analog scale (VAS), at rest and on deep breathing, and for intravenous PCA morphine consumption during 24 hours. The intravenous PCA morphine 24-hour cumulative dose was lower in the fast-track than in the control group (15.8+/-12.6 v 32.7+/-22.3 mg, p<0.05). Before extubation, VAS scores were higher in the fast-track group, but after they were lower both at rest and during deep breathing. Extubation delay was shorter in the fast-track group (156.5+/-46.1 v 272+/-116.4 minutes, p<0.05). CONCLUSION The combination of anesthesia with remifentanil and spinal analgesia with morphine and clonidine produces effective analgesia after coronary artery surgery and a rapid extubation time.
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Affiliation(s)
- Pierre Lena
- Institut Arnault Tzanck, Saint-Laurent du Var, France
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Abstract
The anilidopiperidine opioid remifentanil has pharmacodynamic properties similar to all opioids; however, its pharmacokinetic characteristics are unique. Favourable pharmacokinetic properties, minimally altered by extremes of age or renal or hepatic dysfunction, enable easy titration and rapid dissipation of clinical effect of this agent, even after prolonged infusion. Remifentanil is metabolised by esterases that are widespread throughout the plasma, red blood cells, and interstitial tissues, whereas other anilidopiperidine opioids (e.g. fentanyl, alfentanil and sufentanil) depend upon hepatic biotransformation and renal excretion for elimination. Consequently, remifentanil is cleared considerably more rapidly than other anilidopiperidine opioids. In addition, its pKa (the pH at which the drug is 50% ionised) is less than physiological pH; thus, remifentanil circulates primarily in the non-ionised moiety, which quickly penetrates the lipid blood-brain barrier and rapidly equilibrates across the plasma/effect site interface. By virtue of these distinctive pharmacokinetic properties, the context-sensitive half-time (i.e. the time required for the drug's plasma concentration to decrease by 50% after cessation of an infusion) of remifentanil remains consistently short (3.2 minutes), even following an infusion of long duration (> or =8 hours). Remifentanil, a clinically versatile opioid, is useful for intravenous analgesia and sedation in spontaneously breathing patients undergoing painful procedures. Profound analgesia may be achieved with minimal effect on cognitive function. Remifentanil may also provide sedation and analgesia during placement of regional anaesthetic blocks, and in conjunction with topical anaesthesia and airway nerve blocks, it may be useful for blunting reflex responses and facilitating 'awake' fibreoptic intubation. Compared with fentanyl and alfentanil in a day-surgery setting, remifentanil supplementation of general anaesthesia may improve intraoperative haemodynamic control. Both emergence time and the incidence of respiratory depression during post-anaesthetic recovery may be reduced. However, outcomes such as home discharge time, post-emergence adverse effect profile, and patient and provider satisfaction are not significantly improved, and the incidence of intraoperative hypotension and bradycardia is greater. In addition, drug acquisition costs for remifentanil are higher and clinicians may need extra time to familiarise themselves with the drug's unique pharmacokinetics.Ironically, the quick dissipation of opioid analgesic effect following remifentanil discontinuation may be a significant clinical disadvantage. Unless little or no postoperative pain is anticipated, the clinician may wish to treat prospectively using local or regional anaesthesia, non-opioid analgesics, or longer-acting opioid analgesics.
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Affiliation(s)
- Richard Beers
- Department of Anesthesiology, SUNY Upstate Medical University, Syracuse, New York 13210, USA.
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Abstract
Remifentanil is a synthetic opioid that was developed in the early 1990s and introduced into clinical use in 1996. It is a methyl ester and is metabolised by nonspecific tissue and plasma esterases. Consequently, it is a drug that undergoes rapid elimination and has a reported terminal elimination half-life of between 10 and 35 minutes. Because there is no drug accumulation, the context-sensitive half-time remains constant; thus the pharmacokinetics of the drug do not change regardless of the duration of infusion. The organ-independent elimination of remifentanil, coupled with the fact that its clearance is greater in infants and neonates compared with older age groups, make its pharmacokinetic profile different from any other opioid. In addition, its unique metabolism confers predictability in its clinical use. Like other opioid mu receptor agonists, remifentanil provides dose-dependent analgesia, while the adverse effects of this drug, e.g. respiratory depression, are also thought to be dose related. The incidence of nausea and vomiting appear similar to other opioids. Its rapid and consistent metabolism regardless of duration of infusion has made remifentanil an attractive analgesic/anaesthetic option for paediatric care providers.
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Affiliation(s)
- Peter J Davis
- Department of Anesthesiology, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, 3705 Fifth Avenue, Pittsburgh, PA 15213, USA.
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Abstract
Remifentanil (Ultiva), a fentanyl derivative, is an ultra-short acting, nonspecific esterase-metabolised, selective mu-opioid receptor agonist, with a pharmacodynamic profile typical of opioid analgesic agents. Notably, the esterase linkage in remifentanil results in a unique and favourable pharmacokinetic profile for this class of agent. Adjunctive intravenous remifentanil during general anaesthesia is an effective and generally well tolerated opioid analgesic in a broad spectrum of patients, including adults and paediatric patients, undergoing several types of surgical procedures in both the inpatient and outpatient setting. Remifentanil is efficacious in combination with intravenous or volatile hypnotic agents, with these regimens generally being at least as effective as fentanyl- or alfentanil-containing regimens in terms of attenuation of haemodynamic, autonomic and somatic intraoperative responses, and postoperative recovery parameters. The rapid offset of action and short context-sensitive half-time of remifentanil, irrespective of the duration of the infusion, makes the drug a valuable opioid analgesic option for use during balanced general inhalational or total intravenous anaesthesia (TIVA) where rapid, titratable, intense analgesia of variable duration, and a fast and predictable recovery are required.
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Affiliation(s)
- Ju-Mei Ng
- Department of Anaesthesia & Surgical Intensive Care, Singapore General Hospital, Singapore, Singapore.
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Ouattara A, Boccara G, Lemaire S, Köckler U, Landi M, Vaissier E, Léger P, Coriat P. Target-controlled infusion of propofol and remifentanil in cardiac anaesthesia: influence of age on predicted effect-site concentrations. Br J Anaesth 2003; 90:617-22. [PMID: 12697589 DOI: 10.1093/bja/aeg124] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Propofol-anaesthesia administrated via target-controlled infusion (TCI) has been proposed for cardiac surgery. Age-related changes in pharmacology explain why propofol dose requirement is reduced in elderly patients. However, the Marsh pharmacokinetic model incorporated in the Diprifusor propofol device does not take age into account as a covariable. In the absence of depth of anaesthesia monitoring, this limitation could cause adverse cardiovascular effects resulting from propofol overdose in older patients. We assessed the influence of age on effect-site propofol concentrations predicted by the Diprifusor and titrated to the bispectral index score (BIS) during cardiac anaesthesia. METHODS Forty-five patients received propofol by Diprifusor and remifentanil by software including Minto model. Propofol and remifentanil effect-site concentrations were adapted to BIS (40-60) and haemodynamic profile, respectively. The influence of age on effect-site concentrations was assessed by dividing patients into two groups: young (<65 yr) and elderly (> or =65 yr). RESULTS For a similar depth of anaesthesia, effect-site propofol concentrations were significantly lower in elderly patients at the different stages of cardiac surgery. The mean dose of propofol required to perform tracheal intubation was significantly lower in elderly patients. However, the overall doses of propofol were comparable in both groups. Neither effect-site remifentanil concentrations nor overall doses of remifentanil were significantly different between the two groups. CONCLUSIONS In cardiac anaesthesia, target concentrations of propofol must be reduced in elderly patients. Although this probably contributes to improving intraoperative haemodynamic stability, the absence of decrease in overall dose requirement of propofol suggests that this adjustment is relatively moderate.
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Affiliation(s)
- A Ouattara
- Institute of Cardiology, Department of Anaesthesia and Intensive Care, Pitié-Salpêtrière University Hospital, Paris, France.
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Servin F. Remifentanil; from Pharmacological Properties to Clinical Practice. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2003; 523:245-60. [PMID: 15088856 DOI: 10.1007/978-1-4419-9192-8_22] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Barvais L, Sutcliffe N. Remifentanil for Cardiac Anaesthesia. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2003; 523:171-87. [PMID: 15088850 DOI: 10.1007/978-1-4419-9192-8_16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Affiliation(s)
- Luc Barvais
- Erasmus hospital, 808 Lennikstreet, Brussels, Belgium
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