1
|
Ikki Y, Sato T, Nishiwaki K. Successful Second Awake Craniotomy Reoperation With Dexmedetomidine After an Initial Abandonment Case Due to Restlessness. Cureus 2024; 16:e61506. [PMID: 38952610 PMCID: PMC11216107 DOI: 10.7759/cureus.61506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2024] [Indexed: 07/03/2024] Open
Abstract
Awake craniotomy (AC) is sometimes aborted due to poor arousal and restlessness. Dexmedetomidine (DEX), an α2-adrenoreceptor agonist, has sedative, analgesic, and anesthetic-sparing effects, with a low risk of respiratory depression, making it effective for intraoperative pain and agitation during the awake phase. We report a case in which AC was successfully performed in combination with low-dose continuous administration of DEX during reoperation in a patient who experienced poor arousal and restlessness during their first surgery, leading to the abandonment of AC. The patient is a 48-year-old male who is scheduled for AC reoperation. Two years ago, the first AC was scheduled and performed under anesthesia with propofol and remifentanil. However, AC was abandoned due to poor intraoperative arousal and restlessness. At reoperation, general anesthesia was induced with propofol and continuous administration of remifentanil (0.1 µg/kg/min); following anesthesia induction (continuous infusion of propofol, remifentanil, and a bolus infusion of fentanyl), DEX was also administered (0.2 µg/kg/hour). We performed a scalp nerve block. Before the awake phase, the propofol dose was decreased as was DEX to 0.1 µg/kg/hour, and propofol and remifentanil were discontinued. The patient gradually awoke without any agitation and restlessness 24 min after stopping propofol and remifentanil and could perform language tasks without any complications. In this case, AC was successfully performed in combination with continuous low-dose administration of DEX at the time of reoperation in a patient who experienced poor arousal and restlessness during their first operation and had to discontinue AC.
Collapse
Affiliation(s)
- Yutaro Ikki
- Anesthesiology, Handa City Hospital, Handa, JPN
| | - Takehito Sato
- Anesthesiology, Nagoya University Hospital, Nagoya, JPN
| | | |
Collapse
|
2
|
Jeon S, Kim J, Karm MH, Kim JT. Effect of converting from propofol to remimazolam with flumazenil reversal on recovery from anesthesia in outpatients with mental disabilities: a randomized controlled trial. BMC Anesthesiol 2024; 24:151. [PMID: 38649838 PMCID: PMC11034095 DOI: 10.1186/s12871-024-02526-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 04/05/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND General anesthesia is often necessary for dental treatment of outpatients with mental disabilities. Rapid recovery and effective management of postoperative nausea and vomiting (PONV) are critical for outpatients. This study aimed to investigate the effect of transitioning from propofol to remimazolam with flumazenil reversal administered toward the end of surgery during propofol-based total intravenous anesthesia (TIVA) on recovery. METHODS Adults with mental disabilities scheduled to undergo dental treatment were randomly assigned to receive either propofol-based TIVA (Group P) or propofol-remimazolam-based TIVA with flumazenil reversal (Group PR). Propofol was replaced with remimazolam 1 h before the end of surgery in Group PR; moreover, 0.5 mg of flumazenil was administered after the neuromuscular blockade reversal agent. The primary outcome was the duration of stay in the post-anesthesia care unit (PACU). The secondary outcomes included time to eye-opening, time to extubation, occurrence of PONV, and quality of recovery. RESULTS Fifty-four patients were included in this study. The duration of stay in the PACU in Group PR was significantly shorter than that in Group P (mean difference, 8.7 min; confidence interval [95% CI], 3.3-14.2; P = 0.002). Group PR exhibited a shorter time to eye opening (mean difference, 5.4 min; 95% CI, 3.3-8.1; P < 0.001) and time to extubation (mean difference, 5.5 min; 95% CI, 3.6-7.9; P < 0.001) than Group P. Neither group required the administration of rescue analgesics, and the incidence of PONV was not reported. CONCLUSIONS Transitioning from propofol to remimazolam 1 h before the end of surgery followed by flumazenil reversal reduced the duration of stay in the PACU and the time to eye opening and extubation without affecting the incidence of PONV and quality of recovery. TRIAL REGISTRATION NUMBER Clinical Research Information Service (KCT0007794), Clinical trial first registration date: 12/10/2022.
Collapse
Affiliation(s)
- Sooyoung Jeon
- National Dental Care Center for Persons with Special Needs, Seoul National University Dental Hospital, Seoul, Republic of Korea
| | - Jieun Kim
- National Dental Care Center for Persons with Special Needs, Seoul National University Dental Hospital, Seoul, Republic of Korea
| | - Myong-Hwan Karm
- Department of Dental Anesthesiology, School of Dentistry and Dental Research Institute, Seoul National University, Seoul, Republic of Korea
| | - Jin-Tae Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, Republic of Korea.
| |
Collapse
|
3
|
Redaelli S, Suleiman A, von Wedel D, Ashrafian S, Munoz-Acuna R, Chen G, Khany M, Stewart C, Ratajczak N, Hertig J, Nabel S, Schaefer MS, Ramachandran SK. Intraoperative Opioid Waste and Association of Intraoperative Opioid Dose with Postoperative Adverse Outcomes: A Hospital Registry Study. Pain Ther 2024; 13:211-225. [PMID: 38281221 DOI: 10.1007/s40122-023-00574-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 12/29/2023] [Indexed: 01/30/2024] Open
Abstract
INTRODUCTION Perioperative opioid use has been associated with adverse clinical outcomes. Additionally, opioid disposal carries significant costs, due to the waste of pharmaceutical products and the time needed by skilled labor to report the waste. In this study, we aimed to estimate costs and predict factors of opioid-associated intraoperative product waste, as well as to evaluate whether higher intraoperative opioid doses are associated with increased risk of adverse postoperative outcomes. METHODS We included 170,607 patients undergoing general anesthesia and receiving intraoperative fentanyl, hydromorphone, or morphine at Beth Israel Deaconess Medical Center, Boston, MA, USA, between January 2010 and June 2020. We estimated product waste-associated costs based on various opioid syringe sizes and determined predictors of opioid waste. Further, we evaluated whether higher opioid doses were associated with postoperative adverse events according to the severity-indexed, incident report-based medication error-reporting program classification. The primary outcome included post-extubation desaturation, postoperative nausea or vomiting, or postoperative somnolence or sedation. RESULTS The use of the smallest syringe sizes (50 mcg for fentanyl, 0.2 mg for hydromorphone, and 2 mg for morphine) resulted in the lowest product waste-associated costs. The main predictor of opioid waste was the administration of more than one intraoperative opioid (adjusted odds ratio [aOR] = 7.64, 95% CI 7.40-7.89, P < 0.001). Intraoperative doses of fentanyl > 50-100 mcg (aOR = 1.17 [1.10-1.25], P < 0.001, adjusted risk difference [ARD] 2%) and > 100 mcg (aOR = 1.24 [1.16-1.33], P < 0.001, ARD 3%), hydromorphone > 1 mg (aOR = 1.13 [1.06-1.20], P < 0.001, ARD 2%), and morphine > 2-4 mg (aOR = 1.26 [1.02-1.56], P = 0.04, ARD 3%) and > 4 mg (aOR = 1.45 [1.18-1.77], P < 0.001, ARD 5%) were associated with higher risk of the primary outcome. CONCLUSION Smaller syringe sizes of intraoperative opioids may help to reduce product waste and associated costs, as well postoperative adverse events through utilization of lower intraoperative opioid doses.
Collapse
Affiliation(s)
- Simone Redaelli
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, USA
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Aiman Suleiman
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, USA
- Department of Anesthesia and Intensive Care, Faculty of Medicine, University of Jordan, Amman, Jordan
| | - Dario von Wedel
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, USA
| | - Sarah Ashrafian
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, USA
| | - Ricardo Munoz-Acuna
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, USA
| | - Guanqing Chen
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, USA
| | - Mitra Khany
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, USA
| | - Catriona Stewart
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, USA
| | - Nikolai Ratajczak
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, USA
| | - John Hertig
- College of Pharmacy and Health Sciences, Butler University, Indianapolis, IN, USA
| | - Sarah Nabel
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, USA
| | - Maximilian S Schaefer
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, USA.
- Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany.
| | - Satya Krishna Ramachandran
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, USA
| |
Collapse
|
4
|
Mishra LD, Agarwal A, Singh AK, Sriganesh K. Paving the way to environment-friendly greener anesthesia. J Anaesthesiol Clin Pharmacol 2024; 40:9-14. [PMID: 38666164 PMCID: PMC11042111 DOI: 10.4103/joacp.joacp_283_22] [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: 08/04/2022] [Revised: 11/07/2022] [Accepted: 11/08/2022] [Indexed: 04/28/2024] Open
Abstract
Health-care settings have an important responsibility toward environmental health and safety. The operating room is a major source of environmental pollution within a hospital. Inhalational agents and nitrous oxide are the commonly used gases during general anesthesia for surgeries, especially in the developing world. These greenhouse gases contribute adversely to the environmental health both inside the operating room and in the outside atmosphere. Impact of these anesthetic agents depends on the total consumption, characteristics of individual agents, and gas flows, with higher levels increasing the environmental adverse effects. The inimical impact of nitrous oxide is higher due to its longer atmospheric half-life and potential for destruction of the ozone layer. Anesthesiologist of today has a choice in the selection of anesthetic agents. Prudent decisions will help in mitigating environmental pollution and contributing positively to a greener planet. Therefore, a shift from inhalational to intravenous-based technique will reduce the carbon footprint of anesthetic agents and their impact on global climate. Propofol forms the mainstay of intravenous anesthesia technique and is a proven drug for anesthetic induction and maintenance. Anesthesiologists should appreciate growing concerns about the role of inhalational anesthetics on the environment and join the cause of environmental responsibility. In this narrative review, we revisit the pharmacological and pharmacokinetic considerations, clinical uses, and discuss the merits of propofol-based intravenous anesthesia over inhalational anesthesia in terms of environmental effects. Increased awareness about the environmental impact and adoption of newer, versatile, and user-friendly modalities of intravenous anesthesia administration will pave the way for greener anesthesia practice.
Collapse
Affiliation(s)
- Lal Dhar Mishra
- Department of Anaesthesiology, IMS, BHU, Varanasi, Uttar Pradesh, India
| | - Ankit Agarwal
- Department of Anaesthesiology, AIIMS, Rishikesh, Uttarakhand, India
| | - Atul K. Singh
- Department of Anaesthesiology, IMS, BHU, Varanasi, Uttar Pradesh, India
| | - Kamath Sriganesh
- Department of Neuroanaesthesia and Neurocritical Care, NIMHANS, Bengaluru, Karnataka, India
| |
Collapse
|
5
|
Jarzebowski ML, Hill AD, Burry L, Bosch NA, Viglianti EM, Teja B, Wunsch H. Patterns of opioid prescribing in mechanically ventilated patients with septic shock. Br J Anaesth 2023; 131:e197-e199. [PMID: 37863771 DOI: 10.1016/j.bja.2023.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 09/20/2023] [Accepted: 09/21/2023] [Indexed: 10/22/2023] Open
Affiliation(s)
- Mary L Jarzebowski
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA; Department of Anesthesiology, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA.
| | - Andrea D Hill
- Department of Critical Care Medicine, Sunnybrook Health Sciences Center, Toronto, ON, Canada
| | - Lisa Burry
- Sinai Health System, Toronto, ON, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Nicholas A Bosch
- The Pulmonary Center, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Elizabeth M Viglianti
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA; Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Bijan Teja
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada; Department of Anesthesiology, St Michael's Hospital, Toronto, ON, Canada
| | - Hannah Wunsch
- Department of Critical Care Medicine, Sunnybrook Health Sciences Center, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
6
|
Sprung J, Deljou A, Warner DO, Schroeder DR, Weingarten TN. Postanesthesia Care Unit Recovery Time According to Volatile Anesthetic Used in Clinical Practice. Anesth Analg 2023; 137:1066-1074. [PMID: 37713329 DOI: 10.1213/ane.0000000000006647] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/17/2023]
Abstract
BACKGROUND Whether volatile anesthetic solubility affects postanesthesia recovery time in clinical practice is unclear. We investigated the association among 3 volatile agents and 2 clinically relevant outcomes-postanesthesia care unit (PACU) recovery time (time from PACU admission to fulfillment of discharge criteria) and oversedation (Richmond Agitation-Sedation Scale score ≤-3)-as a potential contributor to delaying PACU discharge. The volatile agents studied were isoflurane, desflurane, and sevoflurane. We hypothesized that increased solubility of the volatile agent (isoflurane versus desflurane or sevoflurane) would be associated with longer PACU recovery time and higher rates of oversedation. METHODS This retrospective observational study included adults (≥18 years) who underwent surgical procedures under general anesthesia with a volatile agent and were admitted to the PACU from May 5, 2018, to December 31, 2020. The primary outcome was PACU recovery time, and the secondary outcome was oversedation. PACU recovery time was log-transformed and analyzed with linear regression. Oversedation was analyzed by using logistic regression. To account for potential confounding, inverse probability of treatment weighting (IPTW) was used. Pairwise comparisons of the 3 agents were performed, with P < .017 (Bonferroni-adjusted) considered significant. RESULTS Of 47,847 patients included, 11,817 (24.7%) received isoflurane, 11,286 (23.6%) received desflurane, and 24,744 (51.7%) received sevoflurane. Sevoflurane had an estimated 4% shorter PACU recovery time (IPTW-adjusted median [interquartile range {IQR}], 61 [42-89] minutes) than isoflurane (64 [44-92] minutes) (ratio of geometric means [98.3% confidence interval {CI}], 0.96 [0.95-0.98]; P < .001). Differences in PACU recovery time between desflurane and the other agents were not significant. The IPTW-adjusted frequency of oversedation was 8.8% for desflurane, 12.2% for sevoflurane, and 16.7% for isoflurane; all pairwise comparisons were observed to be significant (odds ratio [98.3% CI], 0.70 [0.62-0.79] for desflurane versus sevoflurane, 0.48 [0.42-0.55] for desflurane vs isoflurane, and 0.69 [0.63-0.76] for sevoflurane versus isoflurane; all P < .001). Although oversedated patients had longer PACU recovery time, differences in the oversedation rate across agents did not result in meaningful differences in time to PACU recovery. CONCLUSIONS In clinical practice, only small, clinically unimportant differences in PACU recovery time were observed between the volatile anesthetics. Although oversedation was associated with increased PACU recovery time, differences in the rate of oversedation among agents were insufficient to produce meaningful differences in overall PACU recovery time across the 3 volatile agents. Practical attempts to decrease PACU recovery time should address factors other than volatile agent selection.
Collapse
Affiliation(s)
- Juraj Sprung
- From the Department of Anesthesiology and Perioperative Medicine
| | - Atousa Deljou
- From the Department of Anesthesiology and Perioperative Medicine
| | - David O Warner
- Emeritus Member, Department of Anesthesiology and Perioperative Medicine
| | - Darrell R Schroeder
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | | |
Collapse
|
7
|
Gao YQ, Ihmsen H, Hu ZY, Sun W, Fang YB, Wang Z, Schüttler J, Jeleazcov C, Liu HC. Pharmacokinetics of remimazolam after intravenous infusion in anaesthetised children. Br J Anaesth 2023; 131:914-920. [PMID: 37739904 DOI: 10.1016/j.bja.2023.08.019] [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: 05/17/2023] [Revised: 07/19/2023] [Accepted: 08/03/2023] [Indexed: 09/24/2023] Open
Abstract
BACKGROUND The pharmacokinetic properties of the new benzodiazepine remimazolam have been studied only in adults. We investigated the pharmacokinetics of remimazolam after i.v. infusion in anaesthetised paediatric patients. METHODS Twenty-four children (2-6 yr, ASA physical status 1-2, BMI 15-18 kg m-2) undergoing general anaesthesia with sevoflurane were enrolled. During surgery, remimazolam was administered as an i.v. infusion over 1 h at 5 mg kg-1 h-1 for 5 min, followed by 1.5 mg kg-1 h-1 for 55 min. Plasma concentrations of remimazolam and its metabolite CNS7054 were determined from arterial blood samples using ultra-high performance liquid chromatography-mass spectrometry. Pharmacokinetic modelling was performed by population analysis. RESULTS Pharmacokinetics were best described by a three-compartment model for remimazolam and a two-compartment model for CNS7054 linked by a transit compartment. Remimazolam showed a high clearance of 15.9 (12.9, 18.2) ml kg-1 min-1 (median, Q25, Q75), a small central volume of distribution of 0.11 (0.08, 0.14) L kg-1 and a short terminal half-life of 67 (49, 85) min. The context-sensitive half-time after an infusion of 4 h was 17 (12, 21) min. The metabolite CNS7054 showed a low clearance of 0.89 (0.33, 1.40) ml kg-1 min-1, a small central volume of distribution of 0.011 (0.005, 0.016) L kg-1, and a long terminal half-life of 321 (230, 770) min. CONCLUSIONS Remimazolam in children was characterised by a high clearance and short context-sensitive half-time. When normalised to weight, pharmacokinetic properties were similar to those reported for adults. CLINICAL TRIAL REGISTRATION ChiCTR2200057629.
Collapse
Affiliation(s)
- Yu-Qing Gao
- Department of Anesthesiology and Perioperative Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China; Key Laboratory of Pediatric Anesthesiology, Ministry of Education, Wenzhou Medical University, Wenzhou, Zhejiang, China; Key Laboratory of Anesthesiology of Zhejiang Province, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Harald Ihmsen
- Department of Anesthesiology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Zhi-Yan Hu
- Department of Anesthesiology and Perioperative Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China; Key Laboratory of Pediatric Anesthesiology, Ministry of Education, Wenzhou Medical University, Wenzhou, Zhejiang, China; Key Laboratory of Anesthesiology of Zhejiang Province, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Wei Sun
- Department of Pharmacy, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Yu-Bo Fang
- Department of Anesthesiology and Perioperative Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China; Key Laboratory of Pediatric Anesthesiology, Ministry of Education, Wenzhou Medical University, Wenzhou, Zhejiang, China; Key Laboratory of Anesthesiology of Zhejiang Province, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Zhen Wang
- Laboratory Medicine Center, Allergy Center, Department of Transfusion Medicine, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Jürgen Schüttler
- Department of Anesthesiology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Christian Jeleazcov
- Department of Anesthesiology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Hua-Cheng Liu
- Department of Anesthesiology and Perioperative Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China; Key Laboratory of Pediatric Anesthesiology, Ministry of Education, Wenzhou Medical University, Wenzhou, Zhejiang, China; Key Laboratory of Anesthesiology of Zhejiang Province, Wenzhou Medical University, Wenzhou, Zhejiang, China.
| |
Collapse
|
8
|
Nakagawa H, Hanamoto H, Kozu F, Yokoe C, Maegawa H, Kudo C, Niwa H. Initial loading of dexmedetomidine and continuous propofol sedation for prevention of delayed recovery: A randomized controlled trial. J Am Dent Assoc 2023; 154:1008-1018.e2. [PMID: 37725033 DOI: 10.1016/j.adaj.2023.08.003] [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: 05/31/2023] [Revised: 07/11/2023] [Accepted: 08/07/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Sedation with continuous dexmedetomidine and bolus midazolam administration provides a lower incidence of unacceptable patient movement during procedures but requires a longer recovery time. The authors aimed to compare recovery time and unacceptable patient movement during sedation with initial loading of dexmedetomidine followed by continuous propofol infusion with those during sedation with continuous dexmedetomidine and bolus midazolam administration. METHODS In this prospective randomized controlled trial, 54 patients undergoing dental surgery and requiring intravenous sedation were assigned to either the dexmedetomidine and propofol group (n = 27, dexmedetomidine administered at 6 μg/kg/h for 5 minutes, followed by continuous propofol infusion using a target-controlled infusion) or the dexmedetomidine and midazolam group (n = 27, dexmedetomidine administered at 0.2-0.7 μg/kg/h continuously after the same initial loading dose with bolus midazolam). A bispectral index of 70 through 80 was maintained during the procedure. Patient movement that interfered with the procedure and time from the end of sedation to achieving a negative Romberg sign were assessed. RESULTS Times from the end of sedation to achieving a negative Romberg sign in the dexmedetomidine and propofol group (median, 14 minutes [interquartile range, 12-15 minutes]) were significantly shorter (P < .001) than in the dexmedetomidine and midazolam group (median, 22 minutes [interquartile range, 17.5-30.5 minutes]). The incidence of unacceptable patient movement was comparable between groups (n = 3 in the dexmedetomidine and propofol group, n = 4 in the dexmedetomidine and midazolam group; P = .999). CONCLUSIONS Sedation with a single loading dose of dexmedetomidine followed by continuous propofol infusion can prevent delayed recovery without increasing unacceptable patient movement. PRACTICAL IMPLICATIONS The combination of dexmedetomidine and propofol may provide high-quality sedation for ambulatory dental practice. This clinical trial was registered in the University Hospital Medical Information Network Clinical Trials Registry. The registration number is UMIN000039668.
Collapse
|
9
|
Parikh H, Hoffman K, Sun H, Zafar SF, Ge W, Jing J, Liu L, Sun J, Struck A, Volfovsky A, Rudin C, Westover MB. Effects of epileptiform activity on discharge outcome in critically ill patients in the USA: a retrospective cross-sectional study. Lancet Digit Health 2023; 5:e495-e502. [PMID: 37295971 PMCID: PMC10528143 DOI: 10.1016/s2589-7500(23)00088-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 02/13/2023] [Accepted: 04/19/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Epileptiform activity is associated with worse patient outcomes, including increased risk of disability and death. However, the effect of epileptiform activity on neurological outcome is confounded by the feedback between treatment with antiseizure medications and epileptiform activity burden. We aimed to quantify the heterogeneous effects of epileptiform activity with an interpretability-centred approach. METHODS We did a retrospective, cross-sectional study of patients in the intensive care unit who were admitted to Massachusetts General Hospital (Boston, MA, USA). Participants were aged 18 years or older and had electrographic epileptiform activity identified by a clinical neurophysiologist or epileptologist. The outcome was the dichotomised modified Rankin Scale (mRS) at discharge and the exposure was epileptiform activity burden defined as mean or maximum proportion of time spent with epileptiform activity in 6 h windows in the first 24 h of electroencephalography. We estimated the change in discharge mRS if everyone in the dataset had experienced a specific epileptiform activity burden and were untreated. We combined pharmacological modelling with an interpretable matching method to account for confounding and epileptiform activity-antiseizure medication feedback. The quality of the matched groups was validated by the neurologists. FINDINGS Between Dec 1, 2011, and Oct 14, 2017, 1514 patients were admitted to Massachusetts General Hospital intensive care unit, 995 (66%) of whom were included in the analysis. Compared with patients with a maximum epileptiform activity of 0 to less than 25%, patients with a maximum epileptiform activity burden of 75% or more when untreated had a mean 22·27% (SD 0·92) increased chance of a poor outcome (severe disability or death). Moderate but long-lasting epileptiform activity (mean epileptiform activity burden 2% to <10%) increased the risk of a poor outcome by mean 13·52% (SD 1·93). The effect sizes were heterogeneous depending on preadmission profile-eg, patients with hypoxic-ischaemic encephalopathy or acquired brain injury were more adversely affected compared with patients without these conditions. INTERPRETATION Our results suggest that interventions should put a higher priority on patients with an average epileptiform activity burden 10% or greater, and treatment should be more conservative when maximum epileptiform activity burden is low. Treatment should also be tailored to individual preadmission profiles because the potential for epileptiform activity to cause harm depends on age, medical history, and reason for admission. FUNDING National Institutes of Health and National Science Foundation.
Collapse
Affiliation(s)
- Harsh Parikh
- Department of Computer Science, Duke University, Durham, NC, USA
| | - Kentaro Hoffman
- Deptartment of Statistics and Operation Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Haoqi Sun
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Sahar F Zafar
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Wendong Ge
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Jin Jing
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Lin Liu
- Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA; Institute of Natural Sciences, MOELSC, School of Mathematical Sciences and SJTU-Yale Joint Center for Biostatistics and Data Science, Shanghai Jiao Tong University, Shanghai, China
| | - Jimeng Sun
- The Grainger College of Engineering, University of Illinois Urbana-Champaign, Urbana-Champaign, IL, USA
| | - Aaron Struck
- Department of Neurology, University of Wisconsin-Madison, Madison, WI, USA
| | | | - Cynthia Rudin
- Department of Computer Science, Duke University, Durham, NC, USA
| | - M Brandon Westover
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.
| |
Collapse
|
10
|
Wang X, Wu H, Wang D, Wang W, Wang W, Jin WQ, Luo J, Jiang W, Tang YL, Ren YP, Yang CL, Ma X, Li R. Reduced suicidality after electroconvulsive therapy is linked to increased frontal brain activity in depressed patients: a resting-state fMRI study. Front Psychiatry 2023; 14:1224914. [PMID: 37502809 PMCID: PMC10368865 DOI: 10.3389/fpsyt.2023.1224914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 06/27/2023] [Indexed: 07/29/2023] Open
Abstract
Objective Suicidality is commonly observed in patients with depressive episodes, and electroconvulsive therapy (ECT) has been found to be effective in treating these patients. However, the role of ECT in suicidality remains unclear. This study used resting-state functional magnetic resonance imaging (rs-fMRI) to explore the changes in brain function before and after ECT in depressed patients with suicidality. Methods In total, 26 depressed patients with suicidality underwent rs-fMRI at baseline and after 8-12 sessions of ECT. In addition, 32 healthy controls (HCs) matched for age, gender, and educational level underwent rs-fMRI once. The amplitude of low-frequency fluctuations (ALFF), the fractional amplitude of low-frequency fluctuations (fALFF), and regional homogeneity (ReHo) were measured to evaluate whole brain function. Differences between the groups and time points (before and after ECT) were compared. Clinical symptoms were assessed using the 17-item Hamilton Depression Scale (HAMD-17) and Beck Scale for Suicide Ideation (BSSI). Results At baseline, patients exhibited decreased ALFF in the right postcentral and precentral gyrus and decreased fALFF in the right supramarginal and postcentral gyrus, left superior frontal gyrus (SFG), as well as the superior and middle temporal gyrus compared to HCs. Patients also had lower ReHo in the left amygdala, anterior cingulate, and postcentral gyrus, and in the right thalamus, insula, and postcentral gyrus. They also exhibited higher ALFF in the bilateral temporal gyrus and insula as well as higher fALFF in the cerebellum. Following ECT, fALFF in the left SFG and orbital frontal cortex (OFC) significantly increased and was inversely correlated with the reduction of BSSI scores (r = -0.416, p = 0.048), whereas no correlation was found with changes in HAMD-17scores. Conclusion Our findings suggest that the left SFG and OFC may play a key role in the mechanism of ECT for suicidality. The decrease of fALFF in the left SFG and OFC may represent a potential mechanism through which ECT effectively treats suicidality in depressed patients.
Collapse
Affiliation(s)
- Xue Wang
- Beijing Key Laboratory of Mental Disorders, National Clinical Research Center for Mental Disorders & National Center for Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Han Wu
- Beijing Key Laboratory of Mental Disorders, National Clinical Research Center for Mental Disorders & National Center for Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Dan Wang
- Beijing Key Laboratory of Mental Disorders, National Clinical Research Center for Mental Disorders & National Center for Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Wei Wang
- Beijing Key Laboratory of Mental Disorders, National Clinical Research Center for Mental Disorders & National Center for Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Wen Wang
- Beijing Key Laboratory of Mental Disorders, National Clinical Research Center for Mental Disorders & National Center for Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Wen-qing Jin
- Beijing Key Laboratory of Mental Disorders, National Clinical Research Center for Mental Disorders & National Center for Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Jiong Luo
- Beijing Key Laboratory of Mental Disorders, National Clinical Research Center for Mental Disorders & National Center for Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Wei Jiang
- Beijing Key Laboratory of Mental Disorders, National Clinical Research Center for Mental Disorders & National Center for Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Yi-lang Tang
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, United States
- Mental Health Service Line, Joseph Maxwell Cleland Atlanta VA Medical Center, Decatur, GA, United States
| | - Yan-ping Ren
- Beijing Key Laboratory of Mental Disorders, National Clinical Research Center for Mental Disorders & National Center for Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
- Beijing Institution of Mental Health Care, Beijing, China
| | - Chun-lin Yang
- Beijing Key Laboratory of Mental Disorders, National Clinical Research Center for Mental Disorders & National Center for Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Xin Ma
- Beijing Key Laboratory of Mental Disorders, National Clinical Research Center for Mental Disorders & National Center for Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Rena Li
- Beijing Key Laboratory of Mental Disorders, National Clinical Research Center for Mental Disorders & National Center for Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| |
Collapse
|
11
|
Choi EJ, Kim CH, Yoon JY, Kim EJ. Ketamine-propofol (ketofol) in procedural sedation: a narrative review. J Dent Anesth Pain Med 2023; 23:123-133. [PMID: 37313271 PMCID: PMC10260354 DOI: 10.17245/jdapm.2023.23.3.123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 05/15/2023] [Accepted: 05/18/2023] [Indexed: 06/15/2023] Open
Abstract
Sedation methods for dental treatment are increasingly explored. Recently, ketofol, which is a combination of ketamine and propofol, has been increasingly used because the advantages and disadvantages of propofol and ketamine complement each other and increase their effectiveness. In this review, we discuss the pharmacology of ketamine and propofol, use of ketofol in various clinical situations, and differences in efficacy between ketofol and other sedatives.
Collapse
Affiliation(s)
- Eun-Ji Choi
- Department of Dental Anesthesia and Pain Medicine, School of Dentistry, Dental Research Institute, Dental and Life Science Institute, Pusan National University, Yangsan, Republic of Korea
| | - Cheul-Hong Kim
- Department of Dental Anesthesia and Pain Medicine, School of Dentistry, Dental Research Institute, Dental and Life Science Institute, Pusan National University, Yangsan, Republic of Korea
| | - Ji-Young Yoon
- Department of Dental Anesthesia and Pain Medicine, School of Dentistry, Dental Research Institute, Dental and Life Science Institute, Pusan National University, Yangsan, Republic of Korea
| | - Eun-Jung Kim
- Department of Dental Anesthesia and Pain Medicine, School of Dentistry, Dental Research Institute, Dental and Life Science Institute, Pusan National University, Yangsan, Republic of Korea
| |
Collapse
|
12
|
Adams TJ, Aljohani DM, Forget P. Perioperative opioids: a narrative review contextualising new avenues to improve prescribing. Br J Anaesth 2023; 130:709-718. [PMID: 37059626 DOI: 10.1016/j.bja.2023.02.037] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 02/17/2023] [Accepted: 02/28/2023] [Indexed: 04/16/2023] Open
Abstract
Opioids have dominated the management of perioperative pain in recent decades with higher doses than ever before used in some circumstances. Through the expanding use of opioids, growing research has highlighted their associated side-effects and the intertwined phenomena of acute withdrawal syndrome, opioid tolerance, and opioid-induced hyperalgesia. With multiple clinical guidelines now endorsing multimodal analgesia, a diverse array of opioid-sparing agents emerges and has been studied to variable degrees, including techniques of opioid-free anaesthesia. It remains unclear to what extent such methods should be adopted, yet current evidence does suggest dependence on opioids as the primary perioperative analgesic might not meet the principles of 'rational prescribing' as described by Maxwell. In this narrative review we describe how, using current evidence, a patient-centred rational-prescribing approach can be applied to opioids in the perioperative period. To contextualise this approach, we discuss the historical adoption of opioids in anaesthesia, our growing understanding of associated side-effects and emerging strategies of opioid-sparing and opioid-free anaesthesia. We discuss avenues and challenges for improving opioid prescribing to limit persistent postoperative opioid use and how these may be incorporated into a rational-prescribing approach.
Collapse
Affiliation(s)
- Tobias J Adams
- Department of Anaesthesia, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK; Pain AND Opioids after Surgery (PANDOS) European Society of Anaesthesiology and Intensive Care (ESAIC) Research Group, Aberdeen, UK.
| | - Dalia Mohammed Aljohani
- Pain AND Opioids after Surgery (PANDOS) European Society of Anaesthesiology and Intensive Care (ESAIC) Research Group, Aberdeen, UK; Epidemiology Group, Institute of Applied Health Sciences, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, UK; Department of Anesthesia Technology, Prince Sultan Military College of Health Sciences, Dhahran, Saudi Arabia
| | - Patrice Forget
- Department of Anaesthesia, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK; Pain AND Opioids after Surgery (PANDOS) European Society of Anaesthesiology and Intensive Care (ESAIC) Research Group, Aberdeen, UK; Epidemiology Group, Institute of Applied Health Sciences, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, UK
| |
Collapse
|
13
|
Mechanical Ventilation in Patients with Traumatic Brain Injury: Is it so Different? Neurocrit Care 2023; 38:178-191. [PMID: 36071333 DOI: 10.1007/s12028-022-01593-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 08/16/2022] [Indexed: 10/14/2022]
Abstract
Patients with traumatic brain injury (TBI) frequently require invasive mechanical ventilation and admission to an intensive care unit. Ventilation of patients with TBI poses unique clinical challenges, and careful attention is required to ensure that the ventilatory strategy (including selection of appropriate tidal volume, plateau pressure, and positive end-expiratory pressure) does not cause significant additional injury to the brain and lungs. Selection of ventilatory targets may be guided by principles of lung protection but with careful attention to relevant intracranial effects. In patients with TBI and concomitant acute respiratory distress syndrome (ARDS), adjunctive strategies include sedation optimization, neuromuscular blockade, recruitment maneuvers, prone positioning, and extracorporeal life support. However, these approaches have been largely extrapolated from studies in patients with ARDS and without brain injury, with limited data in patients with TBI. This narrative review will summarize the existing evidence for mechanical ventilation in patients with TBI. Relevant literature in patients with ARDS will be summarized, and where available, direct data in the TBI population will be reviewed. Next, practical strategies to optimize the delivery of mechanical ventilation and determine readiness for extubation will be reviewed. Finally, future directions for research in this evolving clinical domain will be presented, with considerations for the design of studies to address relevant knowledge gaps.
Collapse
|
14
|
Chambrin C, de Souza S, Gariel C, Chassard D, Bouvet L. Association Between Anesthesia Provider Education and Carbon Footprint Related to the Use of Inhaled Halogenated Anesthetics. Anesth Analg 2023; 136:101-110. [PMID: 35986678 DOI: 10.1213/ane.0000000000006172] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Inhaled halogenated anesthetics are responsible for half of operating room total greenhouse gas emissions. Sustainable anesthesia groups were set up in 4 Lyon, France, university hospitals (Hospices Civils de Lyon) in January 2018 and have supported a specific information campaign about the carbon footprint related to the use of inhaled halogenated anesthetics in June 2019. We aimed to assess whether implementing such information campaigns was associated with a decrease in the carbon footprint related to inhaled halogenated anesthetics. METHODS This retrospective cohort study was conducted from January 1, 2015, to February 29, 2020, in 4 hospitals of the Hospices Civils de Lyon in France. Information meetings on sustainable anesthesia practices were organized by sustainable anesthesia groups that were set up in January 2018. In addition, a specific information campaign about the carbon footprint related to inhaled halogenated anesthetics was conducted in June 2019; it was followed by a questionnaire to be completed online. The monthly purchase of sevoflurane, desflurane, and propofol was recorded, and the estimated monthly carbon footprint from desflurane- and sevoflurane-related perioperative emissions was calculated. The interrupted time-series data from January 2015 to February 2020 were analyzed by segmented regression, considering both interventions (setting up of the sustainable anesthesia groups and specific information campaign) in the analysis and adjusting for 2 confounding factors (seasonality of the data and number of general anesthesia uses). RESULTS Among the 641 anesthesia providers from the study hospitals, 121 (19%) attended the information meetings about the carbon footprint of inhaled halogenated anesthetics, and 180 (28%) completed the questionnaire. The anesthetic activity from all 641 providers was considered in the analysis. After the sustainable anesthesia groups were set up, the carbon footprint of sevoflurane and desflurane started decreasing: the slope significantly changed ( P < .01) and became significantly negative, from -0.27 (95% confidence interval [CI], -1.08 to 0.54) tons.month -1 to -14.16 (95% CI, -16.67 to -11.65) tons.month -1 . After the specific information campaign, the carbon footprint kept decreasing, with a slope of -7.58 (95% CI, -13.74 to -1.41) tons.month -1 ( P = .02), which was not significantly different from the previous period ( P = .07). CONCLUSIONS The setup of the sustainable anesthesia groups was associated with a dramatic reduction in the carbon footprint related to halogenated anesthetics. These results should encourage health care institutions to undertake information campaigns toward anesthesia providers so that they also take into account the environmental impact in the choice of anesthetic drugs, in addition to the benefits for the patient and economic concerns.
Collapse
Affiliation(s)
- Coralie Chambrin
- From the Department of Anesthesia and Critical Care, Femme Mère Enfant Hospital, Hospices Civils de Lyon, Lyon, France
| | - Sander de Souza
- Department of Medical Public Health, Hospices Civils de Lyon, Lyon, France
| | - Claire Gariel
- From the Department of Anesthesia and Critical Care, Femme Mère Enfant Hospital, Hospices Civils de Lyon, Lyon, France
| | - Dominique Chassard
- From the Department of Anesthesia and Critical Care, Femme Mère Enfant Hospital, Hospices Civils de Lyon, Lyon, France
| | - Lionel Bouvet
- From the Department of Anesthesia and Critical Care, Femme Mère Enfant Hospital, Hospices Civils de Lyon, Lyon, France
| |
Collapse
|
15
|
Methamphetamine detection using nanoparticle-based biosensors: A comprehensive review. SENSING AND BIO-SENSING RESEARCH 2022. [DOI: 10.1016/j.sbsr.2022.100538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
|
16
|
Iggena D, Maier PM, Häußler SM, Menk M, Olze H, Larkum ME, Finke C, Ploner CJ. Post-encoding modulation of spatial memory consolidation by propofol. Cortex 2022; 156:1-12. [DOI: 10.1016/j.cortex.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 05/09/2022] [Accepted: 08/10/2022] [Indexed: 11/03/2022]
|
17
|
Svedmyr A, Hack H, Anderson BJ. Interactions of the protease inhibitor, ritonavir, with common anesthesia drugs. Paediatr Anaesth 2022; 32:1091-1099. [PMID: 35842922 PMCID: PMC9543968 DOI: 10.1111/pan.14529] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 07/12/2022] [Accepted: 07/13/2022] [Indexed: 11/27/2022]
Abstract
The protease inhibitor, ritonavir, is a strong inhibitor of CYP 3A. The drug is used for management of the human immunovirus and is currently part of an oral antiviral drug combination (nirmatrelvir-ritonavir) for the early treatment of SARS-2 COVID-19-positive patients aged 12 years and over who have recognized comorbidities. The CYP 3A enzyme system is responsible for clearance of numerous drugs used in anesthesia (e.g., alfentanil, fentanyl, methadone, rocuronium, bupivacaine, midazolam, ketamine). Ritonavir will have an impact on drug clearances that are dependent on ritonavir concentration, anesthesia drug intrinsic hepatic clearance, metabolic pathways, concentration-response relationship, and route of administration. Drugs with a steep concentration-response relationship (ketamine, midazolam, rocuronium) are mostly affected because small changes in concentration have major changes in effect response. An increase in midazolam concentration is observed after oral administration because CYP 3A in the gastrointestinal wall is inhibited, causing a large increase in relative bioavailability. Fentanyl infusion may be associated with a modest increase in plasma concentration and effect, but the large between subject variability of pharmacokinetic and pharmacodynamic concentration changes suggests it will have little impact on an individual patient, especially when used with adverse effect monitoring. It has been proposed that drugs that have no or only a small metabolic pathway involving the CYP 3A enzyme be used during anesthesia, for example, propofol, atracurium, remifentanil, and the volatile agents. That anesthesia approach denies children of drugs with considerable value. It is better that the inhibitory changes in clearance of these drugs are understood so that rational drug choices can be made to tailor drug use to the individual patient. Altered drug dose, anticipation of duration of effect, timing of administration, use of reversal agents and perioperative monitoring would better behoove children undergoing anesthesia.
Collapse
Affiliation(s)
- Anders Svedmyr
- Dept AnaesthesiaStarship Children's HospitalAucklandNew Zealand
| | - Henrik Hack
- Dept AnaesthesiaStarship Children's HospitalAucklandNew Zealand
| | | |
Collapse
|
18
|
Casamento A, Jones D, Warrillow S. Measuring analgesia in ICU: no pain, no gain? CRIT CARE RESUSC 2022; 24:200-201. [PMID: 38046209 PMCID: PMC10692612 DOI: 10.51893/2022.3.e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Andrew Casamento
- Department of Intensive Care, Austin Hospital, Melbourne,VIC, Australia
- Department of Intensive Care, Northern Hospital, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
| | - Daryl Jones
- Department of Intensive Care, Austin Hospital, Melbourne,VIC, Australia
- Department of Surgery, University of Melbourne, Melbourne, VIC, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Stephen Warrillow
- Department of Intensive Care, Austin Hospital, Melbourne,VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
- Department of Surgery, University of Melbourne, Melbourne, VIC, Australia
- Critical Care Institute, Epworth HealthCare, Melbourne, VIC, Australia
| |
Collapse
|
19
|
Lin YJ, Wang YC, Huang HH, Huang CH, Lin PL. Efficacy and safety of remifentanil for endoscopic ultrasound-guided tissue acquisition: a single center retrospective study. Surg Endosc 2022; 36:6516-6521. [PMID: 35041053 PMCID: PMC9402747 DOI: 10.1007/s00464-021-09006-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 12/31/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Remifentanil is a rapid onset and rapid recovery opioid. The combination of remifentanil and propofol for deep sedation decreases the incidents of movement, cough, and hiccup. We evaluated the efficacy and safety of remifentanil during endoscopic ultrasound-guided tissue acquisition. METHODS We retrospectively reviewed patients in whom endoscopic ultrasound-guided tissue acquisition was performed for solid mass lesions of the upper gastrointestinal tract and adjacent organs. All patients were premedicated with midazolam (2 mg), and target-controlled infusion of propofol, opioid, and Bispectral Index (BIS) monitoring were administered as necessary to maintain moderate-to-deep sedation. The opioids used were a bolus of alfentanil or remifentanil infusion. The discharge time, consumption of propofol and opioid, adverse events, diagnostic accuracy, and sensitivity and specificity for malignancy, were compared. RESULTS Tissue acquisition was achieved in 123 patients (alfentanil group, n = 64; remifentanil group, n = 59). The discharge time of the remifentanil group (16.5 ± 3.2 min) was significantly shorter than that of the alfentanil group (19.0 ± 4.9 min, P = 0.001). The consumption of propofol, adverse events, diagnostic accuracy, sensitivity, and specificity for malignancy in the alfentanil group were not significantly different from those in the remifentanil group. CONCLUSIONS Use of alfentanil or remifentanil for target-controlled infusion of propofol-BIS monitoring can provide good sedative and diagnostic quality for endoscopic ultrasound-guided tissue acquisition. However, remifentanil resulted in faster recovery than alfentanil.
Collapse
Affiliation(s)
- Yueh-Juh Lin
- Department of Cardiology, En Chu Kong Hospital, New Taipei City, Taiwan
| | - Yi-Chia Wang
- Department of Anesthesiology, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, 100225, Taiwan
| | - Hui-Hsun Huang
- Department of Anesthesiology, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, 100225, Taiwan
| | - Chi-Hsiang Huang
- Department of Anesthesiology, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, 100225, Taiwan
| | - Pei-Lin Lin
- Department of Anesthesiology, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, 100225, Taiwan.
| |
Collapse
|
20
|
Aratani Y, Tokinaga Y, Tanioku T, Maruyama T, Kawamata T. A Case of Decreased Amplitude in Motor Evoked Potentials Under Remimazolam Anesthesia. Cureus 2022; 14:e27593. [PMID: 36059311 PMCID: PMC9434351 DOI: 10.7759/cureus.27593] [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] [Accepted: 08/01/2022] [Indexed: 11/05/2022] Open
Abstract
Remimazolam is a newly developed benzodiazepine derivative. Although one case report on the use of remimazolam for motor evoked potential (MEP) monitoring has been reported, there has been no report of changes in the MEP response under remimazolam anesthesia, which is associated with impairment of the corticospinal motor track. This is a case of a 54-year-old woman who was diagnosed with an extradural extramedullary tumor. The patient reported being allergic to chicken eggs. We used remimazolam instead of propofol for anesthesia management. During tumor resection, the amplitudes of MEP responses at the left quadriceps femoris, left tibialis anterior, and left abductor hallucis muscle decreased. The surgery was scaled down and the tumor was removed in a reduced size. The patient had muscle weakness immediately after surgery but eventually recovered. In this case, we could detect changes in MEP response under remimazolam anesthesia, which suggested impairment of the motor tracts during surgery.
Collapse
|
21
|
A population pharmacokinetic model of remimazolam for general anesthesia and consideration of remimazolam dose in clinical practice. J Anesth 2022; 36:493-505. [PMID: 35708787 DOI: 10.1007/s00540-022-03079-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 05/24/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Remimazolam besylate is a novel short-acting benzodiazepine. An appropriate pharmacokinetic model of remimazolam is desirable in anesthesia practice. The aim of the study was to develop a pharmacokinetic model using plasma samples from patients anesthetized with remimazolam. Influence of patient characteristics, context-sensitive decrement-times, and dose regimens were also examined. METHODS Data were obtained from four trials on patients, and seven trials on healthy volunteers. The characteristics of 416 male and 246 female subjects were as follows: age, 18-93 years; body weight, 34-149 kg; and American Society of Anesthesiologists physical status (ASA-PS), I-IV. 2231 arterial and 3200 venous samples were used for the final model. The equilibration rate constant between arterial plasma and effect-site was estimated using the concept of time to peak effect. The final model was used to generate context-sensitive decrement times and dose regimens for general anesthesia. RESULTS A three-compartment model plus virtual venous compartment with allometric scaling of adjusted body weight (ABW), age, sex, and ASA-PS as covariates were selected as the final model. Elimination clearance was lower in males, and in subjects with higher ABW and ASA-PS scores. Approximately 10% or 20% higher dose rate was necessary in females than in males or ASA-PS I/II than III/IV patient. The context-sensitive half-time for effect-site concentration in a 55-year-old, 70-kg, 170-cm male or female ASA-PS I/II patient after > 6-h infusion was 16.7 or 15.9 min. CONCLUSION Remimazolam pharmacokinetic model for general anesthesia was successfully developed. ABW, ASA-PS, and sex has a considerable impact on the remimazolam concentration.
Collapse
|
22
|
Nie Z, Cui X, Zhang R, Li Z, Lu B, Li S, Cao T, Zhuang P. Effectiveness of Patient-Controlled Intravenous Analgesia (PCIA) with Sufentanil Background Infusion for Post-Cesarean Analgesia: A Randomized Controlled Trial. J Pain Res 2022; 15:1355-1364. [PMID: 35573842 PMCID: PMC9091317 DOI: 10.2147/jpr.s363743] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 04/29/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose To investigate the effectiveness of sufentanil patient-controlled intravenous analgesia pump (PCIA) and background infusion in patients of post-cesarean analgesia. Patients and Methods This trial compared two groups of women undergoing cesarean section and receiving PCIA: no background infusion group (n=30), 6-min lockout time, and background infusion group (n=30), 2 mL/h infusion, 10-min lockout time. Both groups with 2 μg/kg sufentanil was diluted to 100 mL with normal saline. VAS scores at rest at 36 h was the primary endpoint. The secondary endpoints were the VAS scores at rest at 6, 12, and 24 h, the total amount of sufentanil consumed, the Ramsay sedation score (RSS) assessed at the same time points, postpartum bleeding within 24 h, the injection/attempt (I/A) ratio, BP and HR, PONV, side effects of sufentanil. Results Compared with the no background infusion group, the background infusion group showed lower VAS pain scores at 6, 12, and 24 h (P<0.01), but no differences at 36 h (95% CI = -0.5-0.8. P>0.05). Attempts, injections, and total sufentanil consumption were significantly different between the two groups (P<0.001), but without difference in I/A. Bleeding was less in the background infusion group at 1 h (P=0.03). The minimal respiration rates were not significantly different between groups. Conclusion Background infusion increased the total consumption of sufentanil within 36 h after cesarean section. Although it did not reduce uterine contraction pain and wound pain at 36 h, it significantly reduced the pain at 6, 12, and 24 h after cesarean section. It improved patient satisfaction and reduced the amount of bleeding after 1 h. Importantly, it did not increase the incidence of hypertension, PONV and respiratory depression.
Collapse
Affiliation(s)
- Zhongbiao Nie
- Pharmaceutical Department, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, 030012, People’s Republic of China
| | - Xianmei Cui
- Obstetrics Department, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, 030012, People’s Republic of China
| | - Ran Zhang
- Nephrology Department, Affiliated Hospital of Shanxi University of Traditional Chinese Medicine, Taiyuan, 030036, People’s Republic of China
| | - Zhihong Li
- Pharmaceutical Department, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, 030012, People’s Republic of China
| | - Bin Lu
- Anesthesiology Department, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, 030012, People’s Republic of China
| | - Suxian Li
- Pharmaceutical Department, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, 030012, People’s Republic of China
| | - Tao Cao
- Obstetrics Department, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, 030012, People’s Republic of China
| | - Ping Zhuang
- Anesthesiology Department, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, 030012, People’s Republic of China
| |
Collapse
|
23
|
Rosén J, Frykholm P, Fors D. Effect of high‐flow nasal oxygen on postoperative oxygenation in obese patients: A randomized controlled trial. Health Sci Rep 2022; 5:e616. [PMID: 35509395 PMCID: PMC9059212 DOI: 10.1002/hsr2.616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 03/12/2022] [Accepted: 04/01/2022] [Indexed: 11/13/2022] Open
Abstract
Background and Aim Postoperative hypoxemia is common after general anesthesia in obese patients. We investigated if early application of high‐flow nasal oxygen (HFNO) improved postoperative oxygenation in obese patients compared with standard oxygen therapy following general anesthesia for laparoscopic bariatric surgery. Methods This was an open labeled randomized controlled trial conducted at a university hospital in Sweden between October 23, 2018 and February 11, 2020. The study was performed as a substudy within a previously published trial. After ethics committee approval and written informed consent, 40 obese patients (body mass index [BMI] ≥ 35 kg m−2) scheduled for laparoscopic bariatric surgery were randomized to receive oxygen using a standard low‐flow nasal cannula (NC group) or HFNO at 40 L min−1 (HF group) immediately upon arrival to the post‐anesthesia care unit. Flow rate (NC group) or FiO2 (HF group) was titrated to reach an initial SpO2 of 95%–98% after which settings were left unchanged. The primary outcome was PaO2 at 60 min following postoperative baseline values. Secondary outcomes included PaCO2, SpO2, hemodynamic variables, and patient self‐assessed discomfort. Results Thirty‐four patients were available for analysis. PaO2 was similar between groups at postoperative baseline. After 60 min, PaO2 had increased to 12.6 ± 2.8 kPa in the NC group (n = 15) and 14.0 ± 2.7 kPa in the HF group (n = 19); (mean difference 1.4 kPa, 95% confidence interval −0.6 to 3.3; p = 0.16). There were no differences in PaCO2, hemodynamic variables, or self‐assessed discomfort between groups after 60 min. Conclusion In obese patients, HFNO did not improve postoperative short‐term oxygenation compared with standard low‐flow oxygen following general anesthesia for laparoscopic bariatric surgery.
Collapse
Affiliation(s)
- Jacob Rosén
- Department of Surgical Sciences, Section of Anaesthesiology and Intensive Care Medicine Uppsala University Uppsala Sweden
| | - Peter Frykholm
- Department of Surgical Sciences, Section of Anaesthesiology and Intensive Care Medicine Uppsala University Uppsala Sweden
| | - Diddi Fors
- Department of Surgical Sciences, Section of Anaesthesiology and Intensive Care Medicine Uppsala University Uppsala Sweden
| |
Collapse
|
24
|
Morse JD, Cortinez LI, Meneely S, Anderson BJ. Propofol context-sensitive decrement times in children. Paediatr Anaesth 2022; 32:396-403. [PMID: 34971456 DOI: 10.1111/pan.14391] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 12/10/2021] [Accepted: 12/28/2021] [Indexed: 11/29/2022]
Abstract
Plasma drug concentration is the variable linking dose to effect. The decrement time required for plasma concentration of anesthetic agents to decrease by 50% (context-sensitive half-time) correlates with the time taken to regain consciousness. However, the decrement time to consciousness may not be 50%. An effect compartment concentration is associated more closely with return of consciousness than plasma concentration. An alternative decrement time, the time required for propofol to decrease to a predetermined effect compartment concentration associated with movement (eg, 2 µg.ml-1 ), was used to simulate time for the concentration to decrease from steady state at a typical targeted effect compartment concentration 3.5 µg.ml-1 in children. These times were short and reflected a decrement time to consciousness (CSTAWAKE ) increase that was small with longer infusion time. CSTAWAKE ranged from 7.5 min in 1-year-old infant given propofol for 15 min to 13.5 min in a 15-year-old adolescent given a 2-hour infusion. Changes in decrement time with age reflect maturation of drug clearance. Neonates had prolonged increment times, 10 min after 15 min infusion and 18 min after 120 min infusion using a target concentration of 3.5 µg.ml-1 . Decrement times to a targeted arousal concentration are context-sensitive. Use of a higher target concentration of 6 µg.ml-1 doubled decrement times. Decrement times are associated with variability: delayed recovery beyond these simulated times is likely more attributable to the use of adjuvant drugs or the child's clinical status. An understanding of propofol decrement times can be used to guide recovery after anesthesia.
Collapse
Affiliation(s)
- James D Morse
- Department of Pharmacology & Clinical Pharmacology, Auckland University, Auckland, New Zealand
| | - Luis Ignacio Cortinez
- División Anestesiología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Stephen Meneely
- Department of Anaesthesia, Starship Children's Hospital, Auckland, New Zealand
| | - Brian J Anderson
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| |
Collapse
|
25
|
Differential Effects of Gamma-Aminobutyric Acidergic Sedatives on Risk of Post-Extubation Delirium in the ICU: A Retrospective Cohort Study From a New England Health Care Network. Crit Care Med 2022; 50:e434-e444. [PMID: 34982739 DOI: 10.1097/ccm.0000000000005425] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate whether different gamma-aminobutyric acidergic (GABAergic) sedatives such as propofol and benzodiazepines carry differential risks of post-extubation delirium in the ICU. DESIGN Retrospective cohort study. SETTING Seven ICUs in an academic hospital network, Beth Israel Deaconess Medical Center (Boston, MA). PATIENTS Ten thousand five hundred and one adult patients mechanically ventilated for over 24 hours. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We tested the hypothesis that benzodiazepine versus propofol-based sedation is associated with fewer delirium-free days within 14 days after extubation. Further, we hypothesized that the measured sedation level evoked by GABAergic drugs is a better predictor of delirium than the drug dose administered. The proportion of GABAergic drug-induced deep sedation was defined as the ratio of days with a mean Richmond Agitation-Sedation Scale of less than or equal to -3 during mechanical ventilation. Multivariable regression and effect modification analyses were used. Delirium-free days were lower in patients who received a high proportion of deep sedation using benzodiazepine compared with propofol-based sedation (adjusted absolute difference, -1.17 d; 95% CI, -0.64 to -1.69; p < 0.001). This differential effect was magnified in elderly patients (age > 65) and in patients with liver or kidney failure (p-for-interaction < 0.001) but not observed in patients who received a low proportion of deep sedation (p = 0.95). GABAergic-induced deep sedation days during mechanical ventilation was a better predictor of post-extubation delirium than the GABAergic daily average effective dose (area under the curve 0.76 vs 0.69; p < 0.001). CONCLUSIONS Deep sedation during mechanical ventilation with benzodiazepines compared with propofol is associated with increased risk of post-extubation delirium. Our data do not support the view that benzodiazepine-based compared with propofol-based sedation in the ICU is an independent risk factor of delirium, as long as deep sedation can be avoided in these patients.
Collapse
|
26
|
Casamento AJ, Serpa Neto A, Young M, Lawrence M, Taplin C, Eastwood GM, Ghosh A, Bellomo R. A Phase II Cluster-Crossover Randomized Trial of Fentanyl versus Morphine for Analgosedation in Mechanically Ventilated Patients. Am J Respir Crit Care Med 2021; 204:1286-1294. [PMID: 34543581 DOI: 10.1164/rccm.202106-1515oc] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: The continuous infusion of fentanyl or morphine is often prescribed to assist with analgesia and sedation (analgosedation) during mechanical ventilation. Objectives: To compare the effect of fentanyl versus morphine on patient-centered outcomes in ventilated patients. Methods: We conducted a cluster-randomized, cluster-crossover trial between July 2019 and August 2020 in two adult ICUs. We compared two continuous infusion regimens (fentanyl versus morphine). One ICU was randomized to the fentanyl-morphine sequence and the other to the morphine-fentanyl sequence. The primary outcome was the number of ventilator-free days at Day 28. Secondary outcomes included, among others, duration of mechanical ventilation in survivors and ICU-free days at Day 28. Measurements and Main Results: Via cluster allocation, we randomized 737 patients. Of these, 56 were excluded because of the opt-out consent process, leaving 681 (344 to fentanyl and 337 to morphine) for primary analysis (median [interquartile range] age, 59 [44-69] years). Median ventilator-free days at Day 28 were 26.1 (20.7-27.3) in the fentanyl versus 25.3 (19.1-27.2) in the morphine group (median difference, 0.79 [95% confidence interval, 0.31 to 1.28], P = 0.001). ICU-free days were greater (P < 0.001) and length of stay in the ICU for survivors shorter (P < 0.001) in the fentanyl group. All other secondary outcomes were not statistically different by treatment group. Conclusions: Among adult patients requiring mechanical ventilation, compared with morphine, fentanyl infusion significantly increased the median number of ventilator-free days at Day 28. The choice of opioid infusion agent may affect clinical outcomes and requires further investigation.
Collapse
Affiliation(s)
- Andrew J Casamento
- Department of Intensive Care, Austin Hospital, Melbourne, Australia.,Department of Intensive Care, Northern Hospital, Melbourne, Australia.,Department of Critical Care and
| | - Ary Serpa Neto
- Department of Intensive Care, Austin Hospital, Melbourne, Australia.,Department of Critical Care and.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Data Analytics Research and Evaluation (DARE) Center, University of Melbourne and Austin Hospital, Melbourne, Australia; and.,Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Marcus Young
- Department of Critical Care and.,Data Analytics Research and Evaluation (DARE) Center, University of Melbourne and Austin Hospital, Melbourne, Australia; and
| | - Mervin Lawrence
- Department of Intensive Care, Northern Hospital, Melbourne, Australia
| | - Christina Taplin
- Department of Intensive Care, Northern Hospital, Melbourne, Australia
| | - Glenn M Eastwood
- Department of Intensive Care, Austin Hospital, Melbourne, Australia.,Department of Critical Care and
| | - Angajendra Ghosh
- Department of Intensive Care, Northern Hospital, Melbourne, Australia.,Department of Medical Education, University of Melbourne, Melbourne, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Australia.,Department of Critical Care and.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Data Analytics Research and Evaluation (DARE) Center, University of Melbourne and Austin Hospital, Melbourne, Australia; and
| |
Collapse
|
27
|
Morse JD, Cortinez LI, Anderson BJ. Pharmacokinetic concepts for dexmedetomidine target-controlled infusion pumps in children. Paediatr Anaesth 2021; 31:924-931. [PMID: 34085357 DOI: 10.1111/pan.14235] [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: 03/27/2021] [Revised: 05/26/2021] [Accepted: 05/31/2021] [Indexed: 12/15/2022]
Abstract
Pharmacokinetic parameter estimates are used in mathematical equations (pharmacokinetic models) to describe concentration changes with time in a population and are specific to that population. Simulation using these models and their parameter estimates can enrich understanding of drug behavior and serve as a basis for study design. Pharmacokinetic concepts are presented pertaining to future designs of dexmedetomidine target-controlled infusion pumps in children. This manuscript provides the pediatric anesthesiologist with an understanding of the nuances that should be considered when using target-controlled infusion pumps; how the central volume may differ between populations, how clearance changes with age, and the impact of adverse effects on dose. In addition, the ideal loading dose and rate of delivery to achieve target concentration without adverse cardiovascular effects are reviewed, and finally, dose considerations for obese children, based on contact-sensitive half-time, are introduced. An understanding of context-sensitive half-time changes with age enables anesthetic practitioners to better estimate duration of effect after cessation of dexmedetomidine infusion. Use of these known pharmacokinetic parameters and covariate information for the pediatric patient could readily be incorporated into commercial target-controlled infusion pumps to allow effective and safe open-loop administration of dexmedetomidine in children.
Collapse
Affiliation(s)
- James D Morse
- Department of Pharmacology & Clinical Pharmacology, Auckland University, Auckland, New Zealand
| | - Luis Ignacio Cortinez
- División Anestesiología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago de Chile, Chile
| | - Brian J Anderson
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| |
Collapse
|
28
|
Comment on: "Impact of opioid-free anaesthesia on postoperative nausea, vomiting and pain after gynaecological laparoscopy - A randomised controlled trial". J Clin Anesth 2021; 75:110492. [PMID: 34461374 DOI: 10.1016/j.jclinane.2021.110492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 08/16/2021] [Accepted: 08/22/2021] [Indexed: 11/22/2022]
|
29
|
Sakai DM, Howard SL, Reed RA, Quandt JE, Barletta M, Wallace ML, Grimes JA, Schmiedt CW. Influence of doxapram and intermittent 10% carbon dioxide inspiration on cardiovascular and laryngeal functions in anesthetized dogs. Vet Surg 2021; 50:1418-1426. [PMID: 34355421 DOI: 10.1111/vsu.13709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 05/04/2021] [Accepted: 07/24/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To compare the effects of two doses of doxapram intravenous injection and carbon dioxide inhalation on the cardiovascular and laryngeal functions of anesthetized hounds. STUDY DESIGN Experimental study. ANIMALS Six healthy adult dogs. METHODS In a Latin-square design, the mean arterial blood pressure (MABP) and heart rate (HR) were recorded continuously. The inspiratory normalized glottic gap areas (iNGGA) were measured before and after each stimulation with 0.55 mg/kg of doxapram (L-DOX), 2.2 mg/kg of doxapram (H-DOX), or 90 s of inhalation of 10% carbon dioxide in oxygen (I-CO2 ). The stimulations were tested in duplicate or triplicate. Video clips of the laryngeal movement were scored by board-certified surgeons masked to the treatment. RESULTS The MABP increased with L-DOX and H-DOX up to 81% (both p < .001 compared to I-CO2 ), and persisted during the other stimulations (both p < .001). An intermittent tachycardic effect of up to 79% increase in HR was observed with doxapram. The HR following H-DOX was higher than L-DOX and I-CO2 (both p < .016). Neither hypertension nor tachycardia was observed with I-CO2 . The iNGGA increased with all treatments (p < .001). The iNGGA was greater with H-DOX than L-DOX and I-CO2 (both p < .007). All treatments received higher scores (all p < .001) with acceptable inter- and intra-observers Krippendorff's alphas. CONCLUSION All treatments were effective respiratory stimulants in anesthetized dogs; however, doxapram caused hypertension and tachycardia. CLINICAL SIGNIFICANCE Carbon dioxide inhalation might improve arytenoid motion without cardiovascular effects in dogs during clinical airway examinations.
Collapse
Affiliation(s)
- Daniel M Sakai
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, The University of Georgia, Athens, Georgia, USA
| | - Shenise L Howard
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, The University of Georgia, Athens, Georgia, USA
| | - Rachel A Reed
- Department of Large Animal Medicine, College of Veterinary Medicine, The University of Georgia, Athens, Georgia, USA
| | - Jane E Quandt
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, The University of Georgia, Athens, Georgia, USA
| | - Michele Barletta
- Department of Large Animal Medicine, College of Veterinary Medicine, The University of Georgia, Athens, Georgia, USA
| | - Mandy L Wallace
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, The University of Georgia, Athens, Georgia, USA
| | - Janet A Grimes
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, The University of Georgia, Athens, Georgia, USA
| | - Chad W Schmiedt
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, The University of Georgia, Athens, Georgia, USA
| |
Collapse
|
30
|
Son HW, Lee JM, Park SH, Lee YJ, Oh JM, Hwang SK. Fentanyl versus Remifentanil for Cough Suppression and Recovery after Video-Assisted Thoracic Surgery. J Chest Surg 2021; 54:200-205. [PMID: 33767013 PMCID: PMC8181691 DOI: 10.5090/jcs.20.136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 12/08/2020] [Accepted: 12/21/2020] [Indexed: 11/16/2022] Open
Abstract
Background Various methods have been used to reduce postoperative pain after thoracic surgery. However, these methods may affect the patient's respiratory response and delay recovery from anesthesia. We aimed to evaluate the effects of fentanyl and remifentanil during extubation after video-assisted thoracic surgery (VATS). Methods This study included 45 randomly-selected male patients who underwent VATS for pneumothorax between July 2011 and August 2012. We divided the participants into 3 groups: the F group, which received a bolus injection of 1.0 μg/kg of fentanyl; the R1 group, which received a 0.04 μg/kg/min remifentanil infusion; and the R2 group, which received a 0.08 μg/kg/min remifentanil infusion. Hemodynamics, pain, cough, consciousness level, and nausea were assessed for each group. Results The number and severity of coughs were lower in the R1 and R2 groups than in the F group, and there were no differences between the R1 and R2 groups. Respiratory depression and loss of consciousness were not observed in any of the patients, and there were no differences in hemodynamics. Conclusion In comparison with fentanyl, remifentanil did not result in a wide fluctuation of blood pressure and heart rate upon emergence from general anesthesia. Moreover, remifentanil contributed to cough suppression and postoperative pain control. Remifentanil seems to be a safe and effective analgesic after VATS.
Collapse
Affiliation(s)
- Hee Won Son
- Department of Anesthesiology and Pain Medicine, Ulsan University Hospital, Ulsan, Korea
| | - Ji Min Lee
- Department of Thoracic and Cardiovascular Surgery, Ulsan University Hospital, Ulsan, Korea
| | - Se Hun Park
- Department of Anesthesiology and Pain Medicine, Ulsan University Hospital, Ulsan, Korea
| | - Yong Jic Lee
- Department of Thoracic and Cardiovascular Surgery, Ulsan University Hospital, Ulsan, Korea
| | - Ji Mi Oh
- Department of Anesthesiology and Pain Medicine, Ulsan University Hospital, Ulsan, Korea
| | - Su Kyung Hwang
- Department of Thoracic and Cardiovascular Surgery, Ulsan University Hospital, Ulsan, Korea
| |
Collapse
|
31
|
Association of Sedation, Coma, and In-Hospital Mortality in Mechanically Ventilated Patients With Coronavirus Disease 2019-Related Acute Respiratory Distress Syndrome: A Retrospective Cohort Study. Crit Care Med 2021; 49:1524-1534. [PMID: 33861551 DOI: 10.1097/ccm.0000000000005053] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES In patients with coronavirus disease 2019-associated acute respiratory distress syndrome, sedatives and opioids are commonly administered which may lead to increased vulnerability to neurologic dysfunction. We tested the hypothesis that patients with coronavirus disease 2019-associated acute respiratory distress syndrome are at higher risk of in-hospital mortality due to prolonged coma compared with other patients with acute respiratory distress syndrome matched for disease severity. DESIGN Propensity-matched cohort study. SETTING Seven ICUs in an academic hospital network, Beth Israel Deaconess Medical Center (Boston, MA). PATIENTS All mechanically ventilated coronavirus disease 2019 patients between March and May 2020 were identified and matched with patients with acute respiratory distress syndrome of other etiology. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Using clinical data obtained from a hospital registry, we matched 114 coronavirus disease 2019 patients to 228 noncoronavirus disease 2019-related acute respiratory distress syndrome patients based on baseline disease severity. Coma was identified using the Richmond Agitation Sedation Scale less than or equal to -3. Multivariable logistic regression and mediation analyses were used to assess the percentage of comatose days, sedative medications used, and the association between coronavirus disease 2019 and in-hospital mortality. In-hospital mortality (48.3% vs 31.6%, adjusted odds ratio, 2.15; 95% CI, 1.34-3.44; p = 0.002), the percentage of comatose days (66.0% ± 31.3% vs 36.0% ± 36.9%, adjusted difference, 29.35; 95% CI, 21.45-37.24; p < 0.001), and the hypnotic agent dose (51.3% vs 17.1% of maximum hypnotic agent dose given in the cohort; p < 0.001) were higher among patients with coronavirus disease 2019. Brain imaging did not show a higher frequency of structural brain lesions in patients with coronavirus disease 2019 (6.1% vs 7.0%; p = 0.76). Hypnotic agent dose was associated with coma (adjusted coefficient, 0.61; 95% CI, 0.45-0.78; p < 0.001) and mediated (p = 0.001) coma. Coma was associated with in-hospital mortality (adjusted odds ratio, 5.84; 95% CI, 3.58-9.58; p < 0.001) and mediated 59% of in-hospital mortality (p < 0.001). CONCLUSIONS Compared with matched patients with acute respiratory distress syndrome of other etiology, patients with coronavirus disease 2019 received higher doses of hypnotics, which was associated with prolonged coma and higher mortality.
Collapse
|
32
|
Godai K. What are mechanisms of re-sedation caused by remimazolam? J Anesth 2021; 35:466. [PMID: 33751202 DOI: 10.1007/s00540-021-02926-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 03/16/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Kohei Godai
- Department of Anesthesiology and Critical Care Medicine, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890-8520, Japan.
| |
Collapse
|
33
|
Karamchandani K, Dalal R, Patel J, Modgil P, Quintili A. Challenges in Sedation Management in Critically Ill Patients with COVID-19: a Brief Review. CURRENT ANESTHESIOLOGY REPORTS 2021; 11:107-115. [PMID: 33654458 PMCID: PMC7907309 DOI: 10.1007/s40140-021-00440-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2021] [Indexed: 01/08/2023]
Abstract
Purpose of Review To highlight the challenges associated with providing sedation and analgesia to critically ill patients with coronavirus disease 2019 (COVID-19) and also understand the pathophysiological alterations induced by the disease process as well as the logistical difficulties encountered by providers caring for these patients. We also discuss the rationale and risks associated with the use of common sedative agents specifically within the context of COVID-19 and provide evidence-based management strategies to help manage sedation and analgesia in such patients. Recent Findings A significant proportion of patients with COVID-19 require intensive care and mechanical ventilation, thus requiring sedation and analgesia. These patients tend to require higher doses of sedative medications and often for long periods of time. Most of the commonly used sedative and analgesic agents carry unique risks that should be considered within the context of the unique pathophysiology of COVID-19, the logistical issues the disease poses, and the ongoing drug shortages. Summary With little attention being paid to sedation practices specific to patients with COVID-19 in critical care literature and minimal mention in national guidelines, there is a significant gap in knowledge. We review the existing literature to discuss the unique challenges that providers face while providing sedation and analgesia to critically ill patients with COVID-19 and propose evidence-based management strategies.
Collapse
Affiliation(s)
- Kunal Karamchandani
- Department of Anesthesiology and Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA 17033 USA
| | - Rajeev Dalal
- Department of Anesthesiology and Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA 17033 USA
| | - Jina Patel
- Department of Pharmacy, Penn State Health Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA 17033 USA
| | - Puneet Modgil
- Penn State University College of Medicine, 500 University Drive, Hershey, PA 17033 USA
| | - Ashley Quintili
- Department of Pharmacy, Penn State Health Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA 17033 USA
| |
Collapse
|
34
|
Taharabaru S, Tamura T, Higashi M, Matsuda N, Satomoto M, Adachi YU, Sato AB, Okuda M. JM-1232(-) and propofol, a new combination of hypnotics with short-acting and non-cumulative preferable properties. Exp Anim 2021; 70:101-107. [PMID: 33071272 PMCID: PMC7887627 DOI: 10.1538/expanim.20-0071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 09/10/2020] [Indexed: 10/31/2022] Open
Abstract
Drug interactions are significant in anesthesiology because drug combinations can potentially possess novel properties. The pharmacological advantages of a new combination of the benzodiazepine receptor agonist JM-1232(-) and propofol were investigated in mice. Male adult mice were administered JM-1232(-) or propofol or combinations of the two drugs intravenously. Loss of the righting reflex was evaluated as achieving hypnosis, and the time until recovery of the reflex was measured as hypnosis time. After determining the ED50, doses double and triple the ED50 of propofol were injected with JM-1232(-) to compare hypnosis time. The injections were repeated four times, and the hypnosis times were compared. Flumazenil was administered separately immediately after the last dose was injected. The ED50 values ([95% confidence interval]) for hypnosis were 3.76 [3.36-4.10] for JM-1232(-) and 9.88 [8.03-11.58] mg kg-1 for propofol. Co-administration of 0.5 and 1 mg kg-1 JM-1232(-) reduced the ED50 values of propofol to 1.76 [1.21-2.51] and 1.00 [0.46-1.86] mg kg-1, respectively. The drug combination for hypnosis produced a supra-additive interaction. Hypnosis time was significantly shorter in the groups given the mixtures compared to each hypnotic administered alone. After repeated injections, hypnosis time with the mixtures showed smaller prolongation than that with the hypnotic alone. Flumazenil completely restored the recovery time after anesthesia. The combination of JM-1232(-) and propofol showed a supra-additive interaction, and the reduced hypnotic dose contributed to a faster recovery even after multiple injections.
Collapse
Affiliation(s)
- Saori Taharabaru
- Department of Anesthesia, Nishio Municipal Hospital, Nishio Municipal Hospital, 6 Kamiawahara, Kumami-cho, Nishio, Aichi 4458510, Japan
- Department of Anesthesiology, Aichi Gakuin University School of Dentistry, 2-11 Suemori-dori, Chikusa-ku, Nagoya, Aichi 4658651, Japan
| | - Takahiro Tamura
- Department of Surgical Intensive Care Medicine, Nagoya University Hospital, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi 4668550, Japan
| | - Michiko Higashi
- Department of Emergency & Critical Care Medicine, Nagoya University Graduate School of Medicine, Nagoya University Hospital, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi 4668550, Japan
| | - Naoyuki Matsuda
- Department of Emergency & Critical Care Medicine, Nagoya University Graduate School of Medicine, Nagoya University Hospital, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi 4668550, Japan
| | - Maiko Satomoto
- Department of Anesthesiology, Toho University School of Medicine, Toho University Medical Center, Ohmori Hospital, 6-11-1 Ohmori-Nishi, Ohta-ku, Tokyo 1438541, Japan
| | - Yushi U Adachi
- Department of Anesthesia and Intensive Care Medicine, International University of Health and Welfare, 537-3 Iguchi, Nasushiobara, Tochigi 3292763, Japan
| | - Aiji Boku Sato
- Department of Anesthesiology, Aichi Gakuin University School of Dentistry, 2-11 Suemori-dori, Chikusa-ku, Nagoya, Aichi 4658651, Japan
| | - Masahiro Okuda
- Department of Anesthesiology, Aichi Gakuin University School of Dentistry, 2-11 Suemori-dori, Chikusa-ku, Nagoya, Aichi 4658651, Japan
| |
Collapse
|
35
|
Ihmsen H, Schüttler J, Jeleazcov C. Pharmacokinetics of Morphine and Morphine-6-Glucuronide During Postoperative Pain Therapy in Cardiac Surgery Patients. Eur J Drug Metab Pharmacokinet 2021; 46:249-263. [PMID: 33547559 DOI: 10.1007/s13318-020-00663-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND OBJECTIVE Morphine is a standard analgesic drug for postoperative pain therapy. This study aimed to evaluate the pharmacokinetics of morphine and its active metabolite morphine-6-glucuronide (M6G) in cardiac surgery patients during postoperative analgesia. METHODS Twenty-five adult patients undergoing cardiac surgery received postoperative pain therapy by patient-controlled analgesia with intravenous bolus doses of morphine. Plasma concentrations of morphine and M6G were determined from arterial samples. Population pharmacokinetic parameters were estimated using nonlinear mixed-effects modeling. RESULTS Data from twenty-one patients (aged 44-79 years) were analyzed. Pharmacokinetics were best described by a three-compartment model for morphine and a two-compartment model for M6G, linked by a transit compartment. Mean (±SD) population estimates for morphine were: clearance (CL) = 1.35±0.40 L/min, central volume of distribution (V1) = 8.1±2.2 L, steady-state volume of distribution (Vss) = 207±83 L, terminal elimination half-life (T1/2γ) = 177±50 min. Clearance of morphine was proportional to cardiac output. Mean (±SD) population estimates for M6G were: CL = 0.098±0.037 L/min, V1 = 5.5±0.8 L, Vss = 15.8±0.8 L, T1/2β = 227±74 min. The time to peak concentration of M6G after a bolus dose of morphine was 53±20 min. Clearance of M6G was proportional to estimated glomerular filtration rate. CONCLUSIONS The pharmacokinetics of morphine and M6G in pain therapy of cardiac surgery patients could be well described by standard compartmental models. Cardiac output was identified as a significant covariate for morphine clearance, whereas renal function was identified as the most significant covariate for clearance of M6G. These effects should be particularly considered if morphine is administered as a continuous infusion. The developed pharmacokinetic model also enables patient-controlled target-controlled infusion for pain therapy with morphine. TRIAL REGISTRATION Clinical Trials NCT02483221 (June 26, 2015).
Collapse
Affiliation(s)
- Harald Ihmsen
- Department of Anesthesiology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Krankenhausstrasse 12, 91054, Erlangen, Germany.
| | - Jürgen Schüttler
- Department of Anesthesiology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Krankenhausstrasse 12, 91054, Erlangen, Germany
| | - Christian Jeleazcov
- Department of Anesthesiology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Krankenhausstrasse 12, 91054, Erlangen, Germany
| |
Collapse
|
36
|
Satomi H, Oka S, Tanaka H, Nakai K, Ozaki M, Kawato T, Oi Y. Continuous Administration of Propofol Suppresses Osteoclast Differentiation of RAW264.7 Cells. J HARD TISSUE BIOL 2021. [DOI: 10.2485/jhtb.30.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Hitomi Satomi
- Nihon University Graduate School of Dentistry
- Department of Anesthesiology, Nihon University School of Dentistry
- Division of Immunology and Pathobiology, Dental Research Center, Nihon University School of Dentistry
| | - Shunichi Oka
- Department of Anesthesiology, Nihon University School of Dentistry
- Division of Immunology and Pathobiology, Dental Research Center, Nihon University School of Dentistry
| | - Hideki Tanaka
- Department of Oral Health Sciences, Nihon University School of Dentistry
- Division of Functional Morphology, Dental Research Center, Nihon University School of Dentistry
| | - Kumiko Nakai
- Department of Oral Health Sciences, Nihon University School of Dentistry
- Division of Functional Morphology, Dental Research Center, Nihon University School of Dentistry
| | - Manami Ozaki
- Department of Oral Health Sciences, Nihon University School of Dentistry
- Division of Functional Morphology, Dental Research Center, Nihon University School of Dentistry
| | - Takayuki Kawato
- Department of Oral Health Sciences, Nihon University School of Dentistry
- Division of Functional Morphology, Dental Research Center, Nihon University School of Dentistry
| | - Yoshiyuki Oi
- Department of Anesthesiology, Nihon University School of Dentistry
- Division of Immunology and Pathobiology, Dental Research Center, Nihon University School of Dentistry
| |
Collapse
|
37
|
Bienert A, Sobczyński P, Młodawska K, Hartmann-Sobczyńska R, Grześkowiak E, Wiczling P. The influence of cardiac output on propofol and fentanyl pharmacokinetics and pharmacodynamics in patients undergoing abdominal aortic surgery. J Pharmacokinet Pharmacodyn 2020; 47:583-596. [PMID: 32840723 PMCID: PMC7652808 DOI: 10.1007/s10928-020-09712-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 08/13/2020] [Indexed: 12/27/2022]
Abstract
Cardiac output (CO) is expected to affect elimination and distribution of highly extracted and perfusion rate-limited drugs. This work was undertaken to quantify the effect of CO measured by the pulse pressure method on pharmacokinetics and pharmacodynamics of propofol and fentanyl administrated during total intravenous anesthesia (TIVA). The data were obtained from 22 ASA III patients undergoing abdominal aortic surgery. Propofol was administered via target-controlled infusion system (Diprifusor) and fentanyl was administered at a dose of 2-3 µg/kg each time analgesia appeared to be inadequate. Hemodynamic measurements as well as bispectral index were monitored and recorded throughout the surgery. Data analysis was performed by using a non-linear mixed-effect population modeling (NONMEM 7.4 software). Three compartment models that incorporated blood flows as parameters were used to describe propofol and fentanyl pharmacokinetics. The delay of the anesthetic effect, with respect to plasma concentrations, was described using a biophase (effect) compartment. The bispectral index was linked to the propofol and fentanyl effect site concentrations through a synergistic Emax model. An empirical linear model was used to describe CO changes observed during the surgery. Cardiac output was identified as an important predictor of propofol and fentanyl pharmacokinetics. Consequently, it affected the depth of anesthesia and the recovery time after propofol-fentanyl TIVA infusion cessation. The model predicted (not observed) CO values correlated best with measured responses. Patients' age was identified as a covariate affecting the rate of CO changes during the anesthesia leading to age-related difference in individual patient's responses to both drugs.
Collapse
Affiliation(s)
- Agnieszka Bienert
- Department of Clinical Pharmacy and Biopharmacy, Poznan University of Medical Sciences, Sw. Marii Magdaleny 14 Street, 61-861, Poznan, Poland.
| | - Paweł Sobczyński
- Department of Anesthesiology and Intensive Therapy, Poznan University of Medical Sciences, 1/2 Długa Str., 61-848, Poznań, Poland
| | - Katarzyna Młodawska
- Department of Clinical Pharmacy and Biopharmacy, Poznan University of Medical Sciences, Sw. Marii Magdaleny 14 Street, 61-861, Poznan, Poland
| | - Roma Hartmann-Sobczyńska
- Department of Experimental Anaesthesiology, Poznan University of Medical Sciences, Sw. Marii Magdaleny 14 Street, 61-861, Poznan, Poland
| | - Edmund Grześkowiak
- Department of Clinical Pharmacy and Biopharmacy, Poznan University of Medical Sciences, Sw. Marii Magdaleny 14 Street, 61-861, Poznan, Poland
| | - Paweł Wiczling
- Department of Biopharmacy and Pharmacodynamics, Medical University of Gdansk, Hallera 107 Street, 80-416, Gdansk, Poland
| |
Collapse
|
38
|
Proekt A, Kelz MB. Explaining anaesthetic hysteresis with effect-site equilibration. Br J Anaesth 2020; 126:265-278. [PMID: 33081972 DOI: 10.1016/j.bja.2020.09.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/16/2020] [Accepted: 09/07/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Anaesthetic induction occurs at higher plasma drug concentrations than emergence in animal studies. Some studies find evidence for such anaesthetic hysteresis in humans, whereas others do not. Traditional thinking attributes hysteresis to drug equilibration between plasma and the effect site. Indeed, a key difference between human studies showing anaesthetic hysteresis and those that do not is in how effect-site equilibration was modelled. However, the effect-site is a theoretical compartment in which drug concentration cannot be measured experimentally. Thus, it is not clear whether drug equilibration models with experimentally intractable compartments are sufficiently constrained to unequivocally establish evidence for the presence or absence of anaesthetic hysteresis. METHODS We constructed several models. One lacked hysteresis beyond effect-site equilibration. In another, neuronal dynamics contributed to hysteresis. We attempted to distinguish between these two systems using drug equilibration models. RESULTS Our modelling studies showed that one can always construct an effect-site equilibration model such that hysteresis collapses. So long as the concentration in the effect-site cannot be measured directly, the correct effect-site equilibration model and the one that erroneously collapses hysteresis are experimentally indistinguishable. We also found that hysteresis can naturally arise even in a simple network of neurones independently of drug equilibration. CONCLUSIONS Effect-site equilibration models can readily collapse hysteresis. However, this does not imply that hysteresis is solely attributable to the kinetics of drug equilibration.
Collapse
Affiliation(s)
- Alex Proekt
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Max B Kelz
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
39
|
Van Tittelboom V, Poelaert R, Malbrain MLNG, La Meir M, Staessens K, Poelaert J. Sublingual Sufentanil Tablet System Versus Continuous Morphine Infusion for Postoperative Analgesia in Cardiac Surgery Patients. J Cardiothorac Vasc Anesth 2020; 35:1125-1133. [PMID: 32951999 DOI: 10.1053/j.jvca.2020.08.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 08/11/2020] [Accepted: 08/12/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE(S) To assess the effectiveness and side effects of a patient-controlled sublingual sufentanil tablet system for postoperative analgesia after cardiac surgery and to compare it to a nurse-controlled continuous morphine infusion. DESIGN Prospective, open-label, randomized controlled trial. SETTING Single university academic center. PARTICIPANTS Adult patients undergoing cardiac surgery, which included a sternotomy. INTERVENTIONS Sublingual sufentanil tablet system versus nurse-controlled continuous morphine infusion. MEASUREMENTS AND MAIN RESULTS A total of 483 cardiac surgery patients were screened for eligibility, of whom 64 patients completed the study. No statistically significant differences were found for baseline characteristics between both groups. All mean numeric rating scale (NRS) pain scores from after extubation until intensive care unit discharge were ≤3 in both groups. The cumulative mean NRS pain score from 24 hours after extubation (primary outcome) (t = hours after extubation) was significantly different in favor of the morphine group: (t = 0-24) (0.8 [0.7] v 1.3 [0.8]; p = 0.006). Later cumulative mean pain scores were also in favor of the morphine group: (t = 24-48) (0.2 [0.3] v 0.6 [0.5]; p = 0.001) and (t = 48-63) (0.0 [0.0] v 0.1 [0.2]; p = 0.013). The cumulative opioid dose (in milligrams intravenous morphine equivalents) was significantly higher in the morphine group compared with the sublingual sufentanil group (241.94 [218.73] v 39.84 [21.96]; p = 0.0001). No differences were found for the incidences of postoperative nausea and vomiting, sedation, hypoventilation, bradycardia, or hypotension between both groups (secondary outcomes). CONCLUSIONS Despite resulting in statistically significantly higher pain scores, a patient-controlled sublingual sufentanil tablet system offers adequate analgesia after cardiac surgery and reduces opioid consumption when compared with continuous morphine infusion.
Collapse
Affiliation(s)
| | - Ruben Poelaert
- Department of Anesthesiology and Perioperative Medicine, UZ Brussels, Jette, Belgium
| | - Manu L N G Malbrain
- Department of Intensive Care, UZ Brussels, Faculty of Medicine and Pharmacy, Jette, Belgium
| | - Mark La Meir
- Department of Cardiac Surgery, UZ Brussels, Faculty of Medicine and Pharmacy, Jette, Belgium
| | | | - Jan Poelaert
- Department of Anesthesiology and Perioperative Medicine, UZ Brussels, Faculty of Medicine and Pharmacy, Jette, Belgium
| |
Collapse
|
40
|
Krause A, Lott D, Dingemanse J. Estimation of Attainment of Steady-State Conditions for Compounds With a Long Half-Life. J Clin Pharmacol 2020; 61:82-89. [PMID: 32656870 DOI: 10.1002/jcph.1701] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 06/23/2020] [Indexed: 01/01/2023]
Abstract
Half-life is a standard result reported with analysis of pharmacokinetic data. Different definitions such as noncompartmental half-life, terminal half-life, effective half-life, and context-sensitive half-life can yield substantially different estimates of the quantity "half-life." Time to attainment of steady-state conditions is generally derived from (terminal) half-life and therefore sensitive toward the definition of half-life. Thus, estimates of the time to attain steady state must be provided with a precise definition of steady state and the method used for estimation, particularly for drugs with long (terminal) half-life. For clinical purposes, terminal half-life can have limited relevance if drug concentrations in the terminal elimination phase are low. A general rule for which half-life to use is infeasible. While limited accumulation can be negligible if a plateau in pharmacokinetics/pharmacodynamics is reached or with a wide therapeutic window (ie, exposure range), small additional drug accumulation can be highly relevant for drugs with a narrow therapeutic window. Beyond the average, estimation of individual time to attainment of steady state can add highly relevant information about the variability between subjects. Simulations from population models and the use of different definitions of steady state provide an assessment of robustness of the results. The relevance of accurate estimation of time to attainment of steady state is illustrated with cenerimod, an sphingosine-1-phosphate 1 receptor modulator with long half-life currently in clinical development for which estimates of time to steady state ranged from 35 to 110 days with different calculations.
Collapse
Affiliation(s)
- Andreas Krause
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
| | - Dominik Lott
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
| | - Jasper Dingemanse
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
| |
Collapse
|
41
|
Pharmacokinetics and Pharmacodynamics of Remimazolam (CNS 7056) after Continuous Infusion in Healthy Male Volunteers: Part I. Pharmacokinetics and Clinical Pharmacodynamics. Anesthesiology 2020; 132:636-651. [PMID: 31972655 DOI: 10.1097/aln.0000000000003103] [Citation(s) in RCA: 128] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Remimazolam (CNS 7056) is a new ultra-short-acting benzodiazepine for intravenous sedation and anesthesia. Its pharmacokinetics and pharmacodynamics have been reported for bolus administration. This study aimed to investigate the pharmacokinetics and pharmacodynamics of remimazolam after continuous infusion. METHODS Twenty healthy male volunteers (20 to 38 yr, 64 to 99 kg) received remimazolam as continuous intravenous infusion of 5 mg/min for 5 min, 3 mg/min for the next 15 min, and 1 mg/min for further 15 min. Pharmacokinetics of remimazolam and its metabolite were determined from arterial plasma concentrations. Sedation was assessed using the Modified Observer's Assessment of Alertness and Sedation scale. Pharmacokinetic-pharmacodynamic modeling was performed by population analysis. Hemodynamics and the electrocardiogram were also investigated. RESULTS Pharmacokinetics was best described by a three-compartment model for remimazolam and a two-compartment model with transit compartment for the metabolite. Remimazolam showed a high clearance (1.15 ± 0.12 l/min, mean ± SD), a small steady-state volume of distribution (35.4 ± 4.2 l) and a short terminal half-life (70 ± 10 min). The simulated context-sensitive halftime after an infusion of 4 h was 6.8 ± 2.4 min. Loss of consciousness was observed 5 ± 1 min after start, and full alertness was regained 19 ± 7 min after stop of infusion. Pharmacodynamics of Modified Observer's Assessment of Alertness and Sedation score was best described by a sigmoid probability model with effect site compartment. The half-maximum effect site concentration for a Modified Observer's Assessment of Alertness and Sedation score less than or equal to 1 was 695 ± 239 ng/ml. The equilibration half-time between central and effect compartment was 2.7 ± 0.6 min. Mean arterial blood pressure decreased by 24 ± 6%, and heart rate increased by 28 ± 15%. Spontaneous breathing was maintained throughout the study. There was no significant prolongation of the QT interval of the electrocardiogram observed. CONCLUSIONS Remimazolam was characterized by a pharmacokinetic-pharmacodynamic profile with fast onset, fast recovery, and moderate hemodynamic side effects.
Collapse
|
42
|
Pharmacokinetics and Pharmacodynamics of Remimazolam (CNS 7056) after Continuous Infusion in Healthy Male Volunteers: Part II. Pharmacodynamics of Electroencephalogram Effects. Anesthesiology 2020; 132:652-666. [PMID: 31972657 DOI: 10.1097/aln.0000000000003102] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Remimazolam (CNS 7056) is a new ultra-short acting benzodiazepine for IV sedation. This study aimed to investigate the electroencephalogram (EEG) pharmacodynamics of remimazolam infusion. METHODS Twenty healthy male volunteers received remimazolam as continuous IV infusion of 5 mg/min for 5 min, 3 mg/min for the next 15 min, and 1 mg/min for further 15 min. Continuous EEG monitoring was performed by a neurophysiologic system with electrodes placed at F3, F4, C3, C4, O1, O2, Cz, and Fp1 (10/20 system) and using the Narcotrend Index. Sedation was assessed clinically by using the Modified Observer's Assessment of Alertness and Sedation scale. Pharmacodynamic models were developed for selected EEG variables and Narcotrend Index. RESULTS EEG changes during remimazolam infusion were characterized by an initial increase in beta frequency band and a late increase in delta frequency band. The EEG beta ratio showed a prediction probability of Modified Observer's Assessment of Alertness and Sedation score of 0.79, and could be modeled successfully using a standard sigmoid Emax model. Narcotrend Index showed a prediction probability of Modified Observer's Assessment of Alertness and Sedation score of 0.74. The time course of Narcotrend Index was described by an extended sigmoid Emax model with two sigmoid terms and different plasma-effect equilibration times. CONCLUSIONS Beta ratio was identified as a suitable EEG variable for monitoring remimazolam sedation. Narcotrend Index appeared less suitable than the beta ratio for monitoring the sedative effect if remimazolam is administered alone.
Collapse
|
43
|
Propofol Modulates Early Memory Consolidation in Humans. eNeuro 2020; 7:ENEURO.0537-19.2020. [PMID: 32295771 PMCID: PMC7307630 DOI: 10.1523/eneuro.0537-19.2020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 03/21/2020] [Accepted: 03/23/2020] [Indexed: 02/06/2023] Open
Abstract
Maintenance of memory across time is crucial for adaptive behavior. Current theories posit that the underlying consolidation process depends on stabilization of synapses and reorganization of interactions between hippocampus and neocortex. However, the temporal properties of hippocampal-neocortical network reconfiguration during consolidation are still a matter of debate. Translational research on this issue is challenged by the paucity of techniques to transiently interfere with memory in the healthy human brain. Here, we report a neuro-pharmacological approach with the GABAAergic anesthetic propofol and a memory task sensitive to hippocampal dysfunction. Patients undergoing minor surgery learned word lists before injection of an anesthetic dose of propofol. Results show that administration of the drug shortly after learning (∼13 min) impairs recall after awakening but spares recognition. By contrast, later administration (∼105 min) has no effect. These findings suggest significant changes in memory networks very early after learning that are decisive for later recall. Propofol general anesthesia provides an experimental tool to modulate the first steps of hippocampus-mediated memory consolidation in humans.
Collapse
|
44
|
Landry I, Nakai K, Ferry J, Aluri J, Hall N, Lalovic B, Moline ML. Pharmacokinetics, Pharmacodynamics, and Safety of the Dual Orexin Receptor Antagonist Lemborexant: Findings From Single-Dose and Multiple-Ascending-Dose Phase 1 Studies in Healthy Adults. Clin Pharmacol Drug Dev 2020; 10:153-165. [PMID: 32468649 PMCID: PMC7891412 DOI: 10.1002/cpdd.817] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 04/20/2020] [Indexed: 12/30/2022]
Abstract
Lemborexant, a dual orexin receptor antagonist, is approved for the treatment of insomnia and is under investigation for treating other sleep disorders. Here we summarize pharmacokinetic, pharmacodynamic, and safety data from 3 randomized, double‐blind, placebo‐controlled phase 1 studies: single ascending doses in healthy adults (Study 001; 1‐200 mg; N = 64), multiple ascending doses in healthy and elderly adults (Study 002; 2.5‐75 mg; N = 55), and multiple doses in healthy white and Japanese adults (Study 003; 2.5‐25 mg; N = 32). Lemborexant exposure increased with increasing dose. The time to maximum concentration ranged from approximately 1 to 3 hours for the 5‐ and 10‐mg doses. The mean effective half‐life was 17 hours for lemborexant 5 mg and 19 hours for lemborexant 10 mg. The plasma concentration at 9 hours postdose was 27% of the maximum concentration following multiple dosing with lemborexant 10 mg. There were no clinically relevant effects on next‐morning residual sleepiness (Karolinska Sleepiness Scale, Digital Symbol Substitution Test, Psychomotor Vigilance Test) for doses through 10 mg/day, indicating no effect of residual plasma concentrations on next‐day residual effects. Lemborexant was well tolerated across the doses tested. There were no clinically relevant effects of age, sex, or race on lemborexant pharmacokinetics, pharmacodynamics, or safety. These results suggest that lemborexant at doses through 25 mg provides an overall pharmacokinetic, pharmacodynamic, and safety profile suitable for obtaining the target pharmacologic effect supporting treatment of insomnia while minimizing residual effects during wake time.
Collapse
Affiliation(s)
| | | | - Jim Ferry
- Eisai Inc, Woodcliff Lake, New Jersey, USA
| | | | - Nancy Hall
- Eisai Inc, Woodcliff Lake, New Jersey, USA
| | | | | |
Collapse
|
45
|
Hyun DG, Huh JW, Hong SB, Koh Y, Lim CM. Iatrogenic Opioid Withdrawal Syndrome in Critically Ill Patients: a Retrospective Cohort Study. J Korean Med Sci 2020; 35:e106. [PMID: 32301295 PMCID: PMC7167401 DOI: 10.3346/jkms.2020.35.e106] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 02/11/2020] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Opioid withdrawal syndrome (OWS) may occur following the reduction or discontinuation of opioid analgesics. In critically ill pediatric patients, OWS is a common and clinically significant condition. However, OWS in adult patients has not been assessed in detail. Therefore, we aimed to investigate the incidence, risk factors, and clinical features of OWS in mechanically ventilated patients treated in an adult intensive care unit (ICU). METHODS This study was a retrospective evaluation of data from patients treated in the medical ICU for > 3 days and who received only one type of opioid analgesic. OWS was assessed over a 24 hours period from discontinuation or reduction (by > 50%) of continuous opioid infusion. OWS was defined as the presence of ≥ 3 central nervous system or autonomic nervous system symptoms. RESULTS In 126 patients treated with remifentanil (n = 58), fentanyl (n = 47), or morphine (n = 21), OWS was seen in 31.0%, 36.2%, and 9.5% of patients, respectively (P = 0.078). The most common symptom was a change in respiratory rate (remifentanil, 94.4%; fentanyl, 76.5%; morphine, 100%). Multivariate Cox-proportional hazards model showed that OWS was negatively associated with morphine treatment (hazard ratio [HR], 0.17; 95% confidence interval [CI], 0.037-0.743) and duration of opioid infusion (HR, 0.566; 95% CI, 0.451-0.712). CONCLUSION OWS is not uncommon in mechanically ventilated adult patients who received continuous infusion of opioids for > 3 days. The use of morphine may be associated with a decreased risk of OWS.
Collapse
Affiliation(s)
- Dong Gon Hyun
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Won Huh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Bum Hong
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Younsuck Koh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chae Man Lim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| |
Collapse
|
46
|
Remimazolam besilate, a benzodiazepine, has been approved for general anesthesia!! J Anesth 2020; 34:479-482. [DOI: 10.1007/s00540-020-02755-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Accepted: 02/22/2020] [Indexed: 12/11/2022]
|
47
|
Kurzová A, Málek J, Hess L, Jaček M, Slíva J. Non-traditional administration of remifentanil in an experimental setting. Physiol Res 2019; 68:S97-S103. [PMID: 31755295 DOI: 10.33549/physiolres.934330] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Remifentanil is ultrashort-acting opioid with a unique pharmacokinetic profile. It is used exclusively intravenously. While considering its rapid onset of action and other pharmacokinetic properties, we decided to assess its effects following administration via non-traditional routes. Rabbits (n=10 per each group) were randomized into six groups: remifentanil 1 microg/kg and 3 microg/kg IM, 5.0 and 10.0 microg/kg conjunctivally, and 10 microg/kg and 25.0 microg/kg intranasally. Sedating effects were assessed via a loss of the righting reflex. Secondary, mean arterial blood pressure, arterial oxygen saturation of hemoglobin, and pulse rate was monitored in all rabbits. Non-traditional routes of administration were shown to provide a rapid onset of action as well as fast recovery. Importantly, the administration of remifentanil did not result in any deterioration of cardiovascular functions.
Collapse
Affiliation(s)
- A Kurzová
- Department of Anesthesiology and Resuscitation, Third Faculty of Medicine, Faculty Hospital Královské Vinohrady, Prague, Czech Republic, Department of Pharmacology, Third Faculty of Medicine, Charles University, Prague, Czech Republic.
| | | | | | | | | |
Collapse
|
48
|
Oh SK, Lee IO, Lim BG, Jeong H, Kim YS, Ji SG, Park JS. Comparison of the Analgesic Effect of Sufentanil versus Fentanyl in Intravenous Patient-Controlled Analgesia after Total Laparoscopic Hysterectomy: A Randomized, Double-blind, Prospective Study. Int J Med Sci 2019; 16:1439-1446. [PMID: 31673234 PMCID: PMC6818204 DOI: 10.7150/ijms.34656] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 08/12/2019] [Indexed: 12/16/2022] Open
Abstract
Background: Fentanyl is one of the most widely used opioids for intravenous patient-controlled analgesia (IV-PCA). Sufentanil, a fentanyl analog, is suitable for postoperative pain control because it has no active metabolites and shows a higher therapeutic index and lower frequency of respiratory suppression than fentanyl. This study aimed to compare the two opioids for postoperative pain relief on the basis of analgesic efficacy, adverse effects, and patient satisfaction. Methods: Sixty-four patients undergoing total laparoscopic hysterectomy were randomly allocated into a fentanyl group (n = 31) or a sufentanil group (n = 33). The patients received 50-μg fentanyl or 10-μg sufentanil before induction of anesthesia and 5 minutes after uterine incision during surgery in the fentanyl and sufentanil group, respectively. After arriving at the post-anesthesia care unit (PACU), verbal pain score (VPS) and sedation score were assessed. IV-PCA (fentanyl 1250 μg or sufentanil 250 μg with ondansetron 8 mg; total volume, 60 ml) was connected and continued for 48 h postoperatively. Postoperative pain was evaluated by using the numeric rating scale (NRS; at rest/during cough) at 6, 12, 24, 36, and 48 hours after surgery. The cumulative PCA consumption, patient satisfaction scores, and adverse effects were measured. Results: In the PACU, VPS was significantly higher and rescue fentanyl consumption was higher in the fentanyl group than in the sufentanil group, while the sedation score and adverse effects were comparable between the groups. No significant differences were observed in the NRS scores for pain (at rest/during cough) in the ward over 48 hours postoperatively, but the cumulative PCA consumption was significantly higher in the fentanyl group (47.4 ± 9.9 ml vs. 36.2 ± 14.6 ml, P = 0.01). There were no significant intergroup differences in patient satisfaction score and the incidence of adverse effects in the ward, except for a higher incidence of dry mouth in the fentanyl group. Conclusions: In comparison with fentanyl, sufentanil showed comparable analgesic efficacy and safety with less analgesic consumption (under a potency ratio of 1:5) in IV-PCA after total laparoscopic hysterectomy. Therefore, we suggest that sufentanil can be a useful alternative to fentanyl for IV-PCA.
Collapse
Affiliation(s)
- Seok Kyeong Oh
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Il Ok Lee
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Byung Gun Lim
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Hyerim Jeong
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Young Sung Kim
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Sul Gi Ji
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Jong Sun Park
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| |
Collapse
|
49
|
Song JW, Soh S, Shim JK. Monitored Anesthesia Care for Cardiovascular Interventions. Korean Circ J 2019; 50:1-11. [PMID: 31642214 PMCID: PMC6923237 DOI: 10.4070/kcj.2019.0269] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Accepted: 08/26/2019] [Indexed: 01/28/2023] Open
Abstract
The interventional cardiology is growing and evolving. Many complex procedures are now performed outside the operating room to manage cardiovascular pathologies which had been traditionally treated with cardiac surgery. Appropriate sedation strategy is crucial for improved patient comfort and successful procedure while ensuring safety. Sedation for cardiovascular intervention is frequently challenging, especially in critically-ill, high-risk patients. This review addresses pre-procedure evaluation and preparation of patients, proper monitoring, commonly used sedatives and analgesics, and considerations for specific procedures. Appropriate depth of sedation and analgesia should be balanced with patient, procedural and institutional factors. Understanding of the pharmacology of sedatives/analgesics, vigilant monitoring, ability and proper preparation for management of potential complications may improve outcomes in patients undergoing sedation for cardiovascular procedures.
Collapse
Affiliation(s)
- Jong Wook Song
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sarah Soh
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Kwang Shim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea.
| |
Collapse
|
50
|
Menezes DC, Vidal EIO, Costa CM, Mizubuti GB, Ho AMH, Barros GAM, Fukushima FB. [Sufentanil during anesthetic induction of remifentanil-based total intravenous anesthesia: a randomized controlled trial]. Rev Bras Anestesiol 2019; 69:327-334. [PMID: 31351679 DOI: 10.1016/j.bjan.2018.12.011] [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: 09/09/2018] [Revised: 11/26/2018] [Accepted: 12/05/2018] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND Postoperative pain represents an important concern when remifentanil is used for total intravenous anesthesia because of its ultrashort half-life. Longer acting opioids, such as sufentanil, have been used during induction of remifentanil-based total intravenous anesthesia as a means to overcome this shortcoming. However, the effectiveness and safety of such strategy still lacks evidence from randomized clinical trials. Hence, we aimed to assess the postoperative analgesic efficacy and safety of a single dose of sufentanil administered during the induction of remifentanil-based total intravenous anesthesia. METHODS Forty patients, scheduled for elective open abdominal surgery, were randomized to receive remifentanil-based total intravenous anesthesia with or without a single dose of sufentanil upon induction. We assessed the postoperative morphine consumption administered through a patient-controlled analgesia pump. Self-reported pain scores and the occurrence of nausea, vomiting, pruritus, agitation, somnolence and respiratory depression were also assessed up to 2 days after surgery. RESULTS The mean difference between the sufentanil and control groups regarding morphine consumption in the post-anesthetic care unit and at 12, 24 and 48h after surgery were -7.2mg (95%CI: -12.5 to -2.1, p<0.001), -3.9mg (95%CI: -11.9 to 4.7, p=0.26), -0.6mg (95%CI: (-12.7 to 12.7, p=0.80), and -1.8mg (95%CI: (-11.6 to 15.6, p=0.94), respectively. Neither self-reported pain nor the incidence of adverse events were significantly different between groups at any time point. CONCLUSION Our findings suggest that the administration of sufentanil during induction of remifentanil-based total intravenous anesthesia is associated with decreased early postoperative opioid consumption.
Collapse
Affiliation(s)
| | - Edison I O Vidal
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Departamento de Medicina Interna, Botucatu, SP, Brasil
| | - Cesar M Costa
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Departamento de Medicina Interna, Botucatu, SP, Brasil
| | - Glenio B Mizubuti
- Queen's University, Department of Anesthesiology and Perioperative Medicine, Kingston, Canadá
| | - Anthony M H Ho
- Queen's University, Department of Anesthesiology and Perioperative Medicine, Kingston, Canadá
| | - Guilherme A M Barros
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Departamento de Anestesiologia, Botucatu, SP, Brasil
| | - Fernanda B Fukushima
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Departamento de Anestesiologia, Botucatu, SP, Brasil.
| |
Collapse
|