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Bharadwaj S, Dougherty W. Anesthesia for office-based facial plastic surgery procedures. World J Otorhinolaryngol Head Neck Surg 2023; 9:200-205. [PMID: 37780676 PMCID: PMC10541158 DOI: 10.1002/wjo2.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 07/31/2023] [Accepted: 08/02/2023] [Indexed: 10/03/2023] Open
Abstract
Objective The objective of this study is to provide a state-of-the-art review on the use of anesthetics for in-office facial plastic procedures. Methods A search was performed on PubMed, Embase, Web of Science, and Cochrane Review using the keywords "anesthesia," "office-based procedures," "local anesthesia," "facial plastics," "oral sedation," "moderate sedation," and "deep sedation." Results and Conclusions Over the past few decades, the shift toward in-office invasive procedures has increased patient convenience and decreased hospital resource utilization. Many tools exist to reduce patient anxiety and discomfort in an office-based setting. With proper patient selection and technique, facial plastic surgeons can adequately anesthetize patients to perform Mohs reconstruction, cutaneous excisions, blepharoplasty, face-lifts, and other in-office procedures.
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Affiliation(s)
- Suhas Bharadwaj
- Department of Otolaryngology‐Head and Neck SurgeryEastern Virginia Medical SchoolNorfolkVirginiaUSA
| | - William Dougherty
- Department of Otolaryngology‐Head and Neck SurgeryEastern Virginia Medical SchoolNorfolkVirginiaUSA
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2
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Nitrous oxide abuse leading to extreme homocysteine levels and thrombosis in young adults: a case series. JOURNAL OF THROMBOSIS AND HAEMOSTASIS : JTH 2023; 21:276-283. [PMID: 36700505 DOI: 10.1016/j.jtha.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 09/09/2022] [Accepted: 10/17/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND Neurologic complications from recreational use of nitrous oxide (N2O), which are attributed to vitamin B12 deficiency, have been well documented. With increasing dosages and frequency of N2O use, an additional association with thromboembolisms is becoming apparent. OBJECTIVES To assess thrombotic complications of recreational N2O use. METHODS All medical charts at the largest hospital in Amsterdam were searched for N2O use and subsequent neurologic and/or thrombotic events. For patients with thrombotic events, we extracted data on the risk factors for arterial and venous thrombosis as well as serum vitamin B12 and homocysteine concentrations. RESULTS Between January 2015 and May 2021, 326 patients who reported recreational use of N2O were identified; of these, 17 (5%) patients presented with severe thrombotic events associated with N2O (71% men; median age, 26 years [range, 18-53 years]), 5 patients presented with arterial thrombosis (3 with acute coronary syndrome, 1 with femoral artery thrombosis, and 1 with middle cerebral artery thrombus), and 12 patients presented with venous thromboembolisms (10 with pulmonary embolisms, 1 with portal vein thrombosis and 1 with cerebral vein thrombosis). Additionally, homocysteine were concentrations severely increased (median, 125 μmol/L [range, 22-253 μmol/L]; reference, <15 μmol/L). Patients reported use of 400 to 6000 g (ie, 50-750 balloons) of N2O in 1 day. Fifty percent of these patients had experienced neurologic symptoms before the thrombotic event. CONCLUSION We describe an alarming incidence of serious thrombotic events among young adults after excessive recreational use of N2O, accompanied by extremely high homocysteine concentrations. The upward trend in the recreational use of N2O warrants more awareness of its dangers among both users and medical professionals. Furthermore, these findings could reopen the discussion on possible associations between hyperhomocysteinemia and thrombosis mediated through N2O.
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3
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Schorer R, Dombret AL, Hagerman A, Bédat B, Putzu A. Impact of pharmacological interventions on intrapulmonary shunt during one-lung ventilation in adult thoracic surgery: a systematic review and component network meta-analysis. Br J Anaesth 2023; 130:e92-e105. [PMID: 36939497 DOI: 10.1016/j.bja.2022.08.039] [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: 05/24/2022] [Revised: 08/05/2022] [Accepted: 08/24/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Intrapulmonary shunt is a major determinant of oxygenation in thoracic surgery under one-lung ventilation. We reviewed the effects of available treatments on shunt, Pao2/FiO2 and haemodynamics through systematic review and network meta-analysis. METHODS Online databases were searched for RCTs comparing pharmacological interventions and intrapulmonary shunt in thoracic surgery under one-lung ventilation up to March 30, 2022. Random-effects (component) network meta-analysis compared 24 treatments and 19 treatment components. The Confidence in Network Meta-Analysis (CINeMA) framework assessed evidence certainty. The primary outcome was intrapulmonary shunt fraction during one-lung ventilation. RESULTS A total of 55 RCTs were eligible for systematic review (2788 participants). The addition of N2O (mean difference [MD]=-15%; 95% confidence interval [CI], -25 to -5; P=0.003) or almitrine (MD=-13%; 95% CI, -20 to -6; P<0.001) to propofol anaesthesia were efficient at decreasing shunt. Combined epidural anaesthesia (MD=3%; 95% CI, 1-5; P=0.005), sevoflurane (MD=5%; 95% CI, 2-8; P<0.001), isoflurane (MD=6%; 95% CI, 4-9; P<0.001), and desflurane (MD=9%; 95% CI, 4-14; P=0.001) increased shunt vs propofol. Almitrine (MD=147 mm Hg; 95% CI, 58-236; P=0.001), dopexamine (MD=88 mm Hg; 95% CI, 4-171; P=0.039), and iloprost (MD=81 mm Hg; 95% CI, 4-158; P=0.038) improved Pao2/FiO2. Certainty of evidence ranged from very low to moderate. CONCLUSIONS Adding N2O or almitrine to propofol anaesthesia reduced intrapulmonary shunt during one-lung ventilation. Halogenated anaesthetics increased shunt in comparison with propofol. The effects of N2O, iloprost, and dexmedetomidine should be investigated in future research. N2O results constitute a research hypothesis currently not backed by any direct evidence. The clinical availability of almitrine is limited. SYSTEMATIC REVIEW PROTOCOL PROSPERO CRD42022310313.
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Affiliation(s)
- Raoul Schorer
- Department of Acute Medicine, Geneva University Hospitals, Geneva, Switzerland.
| | - Anna-Luna Dombret
- Department of Acute Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Andres Hagerman
- Department of Acute Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Benoît Bédat
- Division of Thoracic and Endocrine Surgery, Geneva University Hospitals, Geneva, Switzerland
| | - Alessandro Putzu
- Department of Acute Medicine, Geneva University Hospitals, Geneva, Switzerland
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Luigi C, Stefania DS. Nitrous oxide intoxication: systematic literature review and proposal of new diagnostic possibilities. EGYPTIAN JOURNAL OF FORENSIC SCIENCES 2022. [DOI: 10.1186/s41935-022-00315-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Abstract
Background
Nitrous oxide (N2O), also called “laughing gas,” is the most commonly used inhalation anesthetic in dentistry. The N2O is no longer used, because of the long-term neurologic and cardiovascular sequelae. Due to its sedative and euphoric properties, N2O is often used for recreational use or in some erotic activities. Accidental deaths are mainly associated with the uses of N2O: death can occur from sudden cardiac arrhythmia or, most commonly, acute asphyxiation due to hypoxia. This paper aims to study the literature concerning deaths due to N2O intoxication and highlight pathological findings useful for diagnosis when the crime scene investigation does not reveal any evidence.
Materials and methods
The authors conducted the literature search by PubMed and Scopus databases, searching for articles from 1 January 1970 to 1 March 2020 using the key terms: “Nitrous oxide,” “Laughing gas,” “Hypoxic damage,” “Nitrous oxide anesthesia,” and “Nitrous oxide death.”
Results and discussion
A total of 244 articles were collected. Only 26 articles were included in the systematic review. Most of the deaths from intoxication are due to asphyxiation; the diagnosis is often difficult and immunohistochemistry could be helpful. Nitrous oxide increases the intracellular adhesion molecule expression, E- and P-Selectin (markers of the early inflammatory response), and HIF-1 α (indicative of oxidative stress during ischemia-reperfusion).
Conclusion
The macroscopic and microscopic signs of N2O intoxication are non-specific, but N2O has been proven to cause hypoxic damage to the brain. The suspicion of the presence of the gas in the environment should guide the pathologist. Tissue analyzes provide important information; immunohistochemical stains can confirm hypoxic damage through the use of markers such as HIF-1 α, E-Selectin, and P-Selectin.
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Sood R, Parent T. Peripheral polyneuropathy and acute psychosis from chronic nitrous oxide poisoning: A case report with literature review. Medicine (Baltimore) 2022; 101:e28611. [PMID: 35945749 PMCID: PMC9351869 DOI: 10.1097/md.0000000000028611] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Nitrous oxide (NO) is a commonly used drug in medical practice, restoration, and the automobile industry. Recreational abuse is an emerging public health problem owing to its accessibility and drug properties. PATIENT CONCERNS A 25-year-old male was hospitalized with acute psychosis and lower-extremity sensorimotor proprioceptive ataxia due to nitrous oxide abuse. DIAGNOSIS Laboratory studies confirmed a vitamin B12 deficiency. Magnetic resonance imaging of the spinal cord showed normal findings. Electrophysiological testing confirmed length-dependent sensorimotor polyneuropathy, with a predominant motor component and axonal degeneration. INTERVENTION AND OUTCOMES Abstinence from toxic substances was suggested, and vitamin B12 substitution was introduced. The patient was lost to follow up. LESSONS Nitrous oxide toxicity is multisystemic and is thought to result from vitamin B12 inactivation. Recent case reports postulated direct paranodal lesions resulting from nitrous oxide consumption. Neurological, neuropsychiatric, and hematological toxicities are among those explored in this case report. Correction of the functional vitamin B12 status and nitrous oxide abstinence are essential in the treatment process.
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Affiliation(s)
- Radhika Sood
- Department of Internal Medicine, Hôpitaux Universitaires de Genève, HUG, Geneva, Switzerland
- *Correspondence: Radhika Sood, Department of internal medicine, Hôpitaux universitaires de Genève, HUG, Rue Gabrielle Perret Gentil 4, 1205 Genève, Switzerland (e-mail: )
| | - Thibault Parent
- Department of Internal Medicine, Hôpitaux Universitaires de Genève, HUG, Geneva, Switzerland
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Oulkadi S, Peters B, Vliegen AS. Thromboembolic complications of recreational nitrous oxide (ab)use: a systematic review. J Thromb Thrombolysis 2022; 54:686-695. [PMID: 35759070 DOI: 10.1007/s11239-022-02673-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/31/2022] [Indexed: 10/17/2022]
Abstract
The recreatinal use of nitrous oxide has become more common in recent years, especially in adolescents and young adults. It has been mainly associated with medical conditions like megaloblastic anemia and (myelo)neuropathy. We report on the thromboembolic complications, a less known side effect, associated with recreational inhalation of nitrous oxide. An extensive literature search was performed for publications reporting on the thromboembolic complications associated with recreational nitrous oxide abuse. Data about sex, age, location of thrombosis, laboratory findings, therapy and outcome were collected. A total of 13 case reports or case series were identified comprising a total of 14 patients. The reported thromboembolic side effects included deep venous thrombosis, pulmonary embolism, mesenterial-, portal and splenic vein thrombosis, cerebral sinus thrombosis, cortical vein thrombosis, stroke, acute myocardial infarction and peripheral artery thromboembolism. These side effects are possibly mediated by the interaction of nitrous oxide with vitamin B12, a cofactor of the methionine synthase complex, which eventually results in elevation of plasma levels of homocysteine. Despite being a known risk factor for cardiovascular disease, the exact pathophysiological mechanism remains unclear. Cessation of nitrous oxide inhalation is necessary to prevent recurrent thrombosis. Nitrous oxide abuse may thus result in a wide spectrum of thromboembolic complications. One should be aware of this etiology, especially in a young person with no obvious risk factors for cardiovascular disease. Spreading awareness is important to inform people about the potentially serious side effects associated with nitrous oxide inhalation.
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Affiliation(s)
- Sanad Oulkadi
- Department of Radiology, Resident Radiology, Jessa Hospital, Hasselt, Belgium. .,Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.
| | - Benjamin Peters
- Department of Radiology, Radiologist, Cardiac Imaging, Jessa Hospital, Hasselt, Belgium
| | - Anne-Sophie Vliegen
- Department of Radiology, Radiologist, Thoracic Imaging, Jessa Hospital, Hasselt, Belgium
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7
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Kuipers RS, Paes AJ, Amoroso G, Riezebos RK. Thrombosis within the left anterior descending coronary artery and left ventricle after high-dose nitrous oxide use. BMJ Case Rep 2022; 15:e248281. [PMID: 35589263 PMCID: PMC9121436 DOI: 10.1136/bcr-2021-248281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2022] [Indexed: 11/04/2022] Open
Abstract
We present a man in his 30s with acute anterior myocardial infarction due to thrombotic occlusion of the left anterior descending artery and subsequent left ventricular thrombus formation after high-dose recreational use of nitrous oxide (N2O). Initial questioning for use of illicit substances was negative, but low vitamin B12 levels and severely elevated homocysteine levels prompted us to interrogate for the use of laughing gas. On questioning, the patient admitted to have used this substance, which he presumed to be innocent. Neither percutaneous coronary intervention with balloon dilatation nor intravenous glycoprotein IIb/IIIa receptor antagonist, nor continuous use of anticoagulation and double antiplatelet therapy resulted in thrombus resolution. Due to a severely reduced left ventricular function, despite 3 months on heart failure therapy, the patient is being counselled for intracardiac defibrillator implantation. We conclude that N2O, notably when consumed in conjunction with other proatherogenic substances, is associated with thrombosis: a relation possibly mediated by severe hyperhomocysteinaemia.
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Affiliation(s)
| | - Aron J Paes
- Cardiology, OLVG, Amsterdam, The Netherlands
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Ruetzler K, Smilowitz NR, Berger JS, Devereaux PJ, Maron BA, Newby LK, de Jesus Perez V, Sessler DI, Wijeysundera DN. Diagnosis and Management of Patients With Myocardial Injury After Noncardiac Surgery: A Scientific Statement From the American Heart Association. Circulation 2021; 144:e287-e305. [PMID: 34601955 DOI: 10.1161/cir.0000000000001024] [Citation(s) in RCA: 79] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Myocardial injury after noncardiac surgery is defined by elevated postoperative cardiac troponin concentrations that exceed the 99th percentile of the upper reference limit of the assay and are attributable to a presumed ischemic mechanism, with or without concomitant symptoms or signs. Myocardial injury after noncardiac surgery occurs in ≈20% of patients who have major inpatient surgery, and most are asymptomatic. Myocardial injury after noncardiac surgery is independently and strongly associated with both short-term and long-term mortality, even in the absence of clinical symptoms, electrocardiographic changes, or imaging evidence of myocardial ischemia consistent with myocardial infarction. Consequently, surveillance of myocardial injury after noncardiac surgery is warranted in patients at high risk for perioperative cardiovascular complications. This scientific statement provides diagnostic criteria and reviews the epidemiology, pathophysiology, and prognosis of myocardial injury after noncardiac surgery. This scientific statement also presents surveillance strategies and treatment approaches.
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Farhat W, Pariente A, Mijahed R. Extensive Cerebral Venous Thrombosis Secondary to Recreational Nitrous Oxide Abuse. Cerebrovasc Dis 2021; 51:114-117. [PMID: 34515072 DOI: 10.1159/000518524] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 07/03/2021] [Indexed: 11/19/2022] Open
Abstract
Nitrous oxide, colloquially known as "whippets," is a commonly abused inhalant by adolescents and young adults. There are limited data describing the adverse effects of this abuse. We present a 16-year-old girl with no medical history who presented to the emergency department for confusion, hallucinations, weakness, and headaches. Imaging revealed extensive cerebral thrombosis. She had no prior history of venous or arterial thrombosis. Hypercoagulability workup demonstrated an elevated homocysteine level. She was treated with effective anticoagulation and vitamin B12 folate supplementation. To our knowledge, there are a very few cases in the medical literature of cerebral venous thrombosis following the use of nitrous oxide. The pathophysiology of the disorder appears to be linked to the metabolism of vitamin B12 inducing hyperhomocysteinemia and a procoagulant state.
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Affiliation(s)
- Wassim Farhat
- Department of Neurology and Stroke Unit, Fondation Hôpital Saint Joseph, Paris, France
| | - Aaron Pariente
- Department of Emergency, Fondation Hôpital Saint Joseph, Paris, France
| | - Rami Mijahed
- Department of Emergency, Fondation Hôpital Saint Joseph, Paris, France
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10
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Chan CS, Chan MTV. Use of nitrous oxide in contemporary anesthesia-an ongoing tug of war. Can J Anaesth 2021; 68:1597-1600. [PMID: 34448128 DOI: 10.1007/s12630-021-02094-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 08/02/2021] [Accepted: 08/02/2021] [Indexed: 11/25/2022] Open
Affiliation(s)
- Chee Sam Chan
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China
| | - Matthew T V Chan
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China.
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11
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Perioperative Care of Patients at High Risk for Stroke During or After Non-cardiac, Non-neurological Surgery: 2020 Guidelines From the Society for Neuroscience in Anesthesiology and Critical Care. J Neurosurg Anesthesiol 2021; 32:210-226. [PMID: 32433102 DOI: 10.1097/ana.0000000000000686] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Perioperative stroke is associated with considerable morbidity and mortality. Stroke recognition and diagnosis are challenging perioperatively, and surgical patients receive therapeutic interventions less frequently compared with stroke patients in the outpatient setting. These updated guidelines from the Society for Neuroscience in Anesthesiology and Critical Care provide evidence-based recommendations regarding perioperative care of patients at high risk for stroke. Recommended areas for future investigation are also proposed.
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12
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Benesch C, Glance LG, Derdeyn CP, Fleisher LA, Holloway RG, Messé SR, Mijalski C, Nelson MT, Power M, Welch BG. Perioperative Neurological Evaluation and Management to Lower the Risk of Acute Stroke in Patients Undergoing Noncardiac, Nonneurological Surgery: A Scientific Statement From the American Heart Association/American Stroke Association. Circulation 2021; 143:e923-e946. [PMID: 33827230 DOI: 10.1161/cir.0000000000000968] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Perioperative stroke is a potentially devastating complication in patients undergoing noncardiac, nonneurological surgery. This scientific statement summarizes established risk factors for perioperative stroke, preoperative and intraoperative strategies to mitigate the risk of stroke, suggestions for postoperative assessments, and treatment approaches for minimizing permanent neurological dysfunction in patients who experience a perioperative stroke. The first section focuses on preoperative optimization, including the role of preoperative carotid revascularization in patients with high-grade carotid stenosis and delaying surgery in patients with recent strokes. The second section reviews intraoperative strategies to reduce the risk of stroke, focusing on blood pressure control, perioperative goal-directed therapy, blood transfusion, and anesthetic technique. Finally, this statement presents strategies for the evaluation and treatment of patients with suspected postoperative strokes and, in particular, highlights the value of rapid recognition of strokes and the early use of intravenous thrombolysis and mechanical embolectomy in appropriate patients.
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Abstract
Stroke is associated with substantial morbidity and mortality. The aim of this review is to provide an evidence-based synthesis of the literature related to perioperative stroke, including its etiology, common risk factors, and potential risk reduction strategies. In addition, the authors will discuss screening methods for the detection of postoperative cerebral ischemia and how multidisciplinary collaborations, including endovascular interventions, should be considered to improve patient outcomes. Lastly, the authors will discuss the clinical and scientific knowledge gaps that need to be addressed to reduce the incidence and improve outcomes after perioperative stroke.
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14
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Sixtus RP, Gray C, Berry MJ, Dyson RM. Nitrous oxide improves cardiovascular, respiratory, and thermal stability during prolonged isoflurane anesthesia in juvenile guinea pigs. Pharmacol Res Perspect 2021; 9:e00713. [PMID: 33543602 PMCID: PMC7862177 DOI: 10.1002/prp2.713] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 12/11/2020] [Accepted: 12/13/2020] [Indexed: 12/26/2022] Open
Abstract
Anesthesia is frequently used to facilitate physiological monitoring during interventional animal studies. However, its use may induce cardiovascular (central and peripheral), respiratory, and thermoregulatory depression, confounding results in anesthetized animals. Despite the wide utility of guinea pigs as a translational platform, anesthetic protocols remain unstandardized for extended physiological studies in this species. Therefore, optimizing an anesthetic protocol that balances stable anesthesia with intact cardiorespiratory and metabolic function is crucial. To achieve this, 12 age and sex-matched juvenile Dunkin Hartley guinea pigs underwent extended anesthesia (≤150 min) with either (a) isoflurane (ISO: 1.5%), or (b) isoflurane + N2 O (ISO+ N2 O: 0.8% +70%), in this randomized cross-over designed study. Cardiovascular (HR, SBP, peripheral microvascular blood flow), respiratory (respiratory rate, SpO2 ), and thermal (Tre and Tsk ) measures were recorded continuously throughout anesthesia. Blood gas measures pre- and post- anesthesia were performed. Incorporation of 70% N2 O allowed for significant reductions in isoflurane (to 0.8%) while maintaining an effective anesthetic depth for prolonged noninvasive physiological examination in guinea pigs. ISO+N2 O maintained heart rate, peripheral blood flow, respiratory rate, and thermoregulatory function at levels closest to those of conscious animals, especially in females; however, it did not fully rescue anesthesia-induced hypotension. These results suggest that for studies requiring prolonged physiological examination (≤150 min) in guinea pigs, 0.8% isoflurane with a 70% N2 O adjuvant provides adequate anesthesia, while minimizing associated cardiorespiratory depression. The preservation of cardiorespiratory status is most marked throughout the first hour of anesthesia.
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Affiliation(s)
- Ryan P. Sixtus
- Department of Paediatrics and Child HealthUniversity of OtagoWellingtonNew Zealand
- Centre for Translational PhysiologyUniversity of OtagoWellingtonNew Zealand
| | - Clint Gray
- Department of Paediatrics and Child HealthUniversity of OtagoWellingtonNew Zealand
- Centre for Translational PhysiologyUniversity of OtagoWellingtonNew Zealand
| | - Mary J. Berry
- Department of Paediatrics and Child HealthUniversity of OtagoWellingtonNew Zealand
- Centre for Translational PhysiologyUniversity of OtagoWellingtonNew Zealand
| | - Rebecca M. Dyson
- Department of Paediatrics and Child HealthUniversity of OtagoWellingtonNew Zealand
- Centre for Translational PhysiologyUniversity of OtagoWellingtonNew Zealand
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Birgy C, Trimaille A, Messas N, Ristorto J, Kayali A, Marchandot B, Cardi T, Hess S, Kibler M, Jesel L, Ohlmann P, Morel O. Impact of Opioid Analgesia and Inhalation Sedation Kalinox on Pain and Radial Artery Spasm during Transradial Coronary Angiography. J Clin Med 2020; 9:jcm9092747. [PMID: 32854384 PMCID: PMC7564999 DOI: 10.3390/jcm9092747] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/20/2020] [Accepted: 08/21/2020] [Indexed: 12/13/2022] Open
Abstract
With respect to the transfemoral approach, transradial procedures enable a drastic reduction of bleeding events and are associated with a reduction of mortality. Radial artery spasm (RAS) is one of the most common complications and may lead to patient discomfort and procedural failure. Currently, there is no consensus on the optimal sedation protocol to avoid RAS. The aim of this study was to investigate the respective impact of opioids analgesia and inhalation sedation with a 50% nitrous oxide/oxygen premix (Kalinox) on pain and occurrence of RAS during transradial coronary procedures. Consecutive patients undergoing transradial coronary angiography were prospectively enrolled in one, single center observational study (Nouvel Hôpital Civil, Strasbourg, France). Patients received opioids analgesia or inhalation sedation with Kalinox. The primary endpoints of the study were the incidence of a pain scale ≥5/10 and the occurrence of RAS. The secondary endpoints were the incidence of side effects. A total of 325 patients were enrolled (185 in the opioids analgesia group, 140 in the Kalinox group). RAS and pain scale ≥5 rates were not significantly different in the opioids analgesia and Kalinox groups (respectively 13.5% vs. 10.0% and 16.2% vs. 11.4%). Headache was more frequently observed in the Kalinox group (6.4% vs. 0.0%; p = 0.002). By multivariate analysis, female gender, BMI <25 kg/m2, puncture difficulty, the use of plastic needle and 6F sheath were identified as independent predictors of RAS. Procedural inhalation sedation by Kalinox is as safe as opioids analgesia during transradial coronary angiography.
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Affiliation(s)
- Caroline Birgy
- Pôle d’Activité Médico-Chirurgicale Cardiovasculaire, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, 67000 Strasbourg, France; (C.B.); (A.T.); (N.M.); (J.R.); (A.K.); (B.M.); (T.C.); (S.H.); (M.K.); (L.J.); (P.O.)
| | - Antonin Trimaille
- Pôle d’Activité Médico-Chirurgicale Cardiovasculaire, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, 67000 Strasbourg, France; (C.B.); (A.T.); (N.M.); (J.R.); (A.K.); (B.M.); (T.C.); (S.H.); (M.K.); (L.J.); (P.O.)
- INSERM UMR-1260 Regenerative Nanomedicine, Université de Strasbourg, 67000 Strasbourg, France
| | - Nathan Messas
- Pôle d’Activité Médico-Chirurgicale Cardiovasculaire, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, 67000 Strasbourg, France; (C.B.); (A.T.); (N.M.); (J.R.); (A.K.); (B.M.); (T.C.); (S.H.); (M.K.); (L.J.); (P.O.)
| | - Jessica Ristorto
- Pôle d’Activité Médico-Chirurgicale Cardiovasculaire, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, 67000 Strasbourg, France; (C.B.); (A.T.); (N.M.); (J.R.); (A.K.); (B.M.); (T.C.); (S.H.); (M.K.); (L.J.); (P.O.)
| | - Anas Kayali
- Pôle d’Activité Médico-Chirurgicale Cardiovasculaire, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, 67000 Strasbourg, France; (C.B.); (A.T.); (N.M.); (J.R.); (A.K.); (B.M.); (T.C.); (S.H.); (M.K.); (L.J.); (P.O.)
| | - Benjamin Marchandot
- Pôle d’Activité Médico-Chirurgicale Cardiovasculaire, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, 67000 Strasbourg, France; (C.B.); (A.T.); (N.M.); (J.R.); (A.K.); (B.M.); (T.C.); (S.H.); (M.K.); (L.J.); (P.O.)
| | - Thomas Cardi
- Pôle d’Activité Médico-Chirurgicale Cardiovasculaire, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, 67000 Strasbourg, France; (C.B.); (A.T.); (N.M.); (J.R.); (A.K.); (B.M.); (T.C.); (S.H.); (M.K.); (L.J.); (P.O.)
| | - Sébastien Hess
- Pôle d’Activité Médico-Chirurgicale Cardiovasculaire, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, 67000 Strasbourg, France; (C.B.); (A.T.); (N.M.); (J.R.); (A.K.); (B.M.); (T.C.); (S.H.); (M.K.); (L.J.); (P.O.)
| | - Marion Kibler
- Pôle d’Activité Médico-Chirurgicale Cardiovasculaire, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, 67000 Strasbourg, France; (C.B.); (A.T.); (N.M.); (J.R.); (A.K.); (B.M.); (T.C.); (S.H.); (M.K.); (L.J.); (P.O.)
| | - Laurence Jesel
- Pôle d’Activité Médico-Chirurgicale Cardiovasculaire, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, 67000 Strasbourg, France; (C.B.); (A.T.); (N.M.); (J.R.); (A.K.); (B.M.); (T.C.); (S.H.); (M.K.); (L.J.); (P.O.)
- INSERM UMR-1260 Regenerative Nanomedicine, Université de Strasbourg, 67000 Strasbourg, France
| | - Patrick Ohlmann
- Pôle d’Activité Médico-Chirurgicale Cardiovasculaire, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, 67000 Strasbourg, France; (C.B.); (A.T.); (N.M.); (J.R.); (A.K.); (B.M.); (T.C.); (S.H.); (M.K.); (L.J.); (P.O.)
| | - Olivier Morel
- Pôle d’Activité Médico-Chirurgicale Cardiovasculaire, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, 67000 Strasbourg, France; (C.B.); (A.T.); (N.M.); (J.R.); (A.K.); (B.M.); (T.C.); (S.H.); (M.K.); (L.J.); (P.O.)
- INSERM UMR-1260 Regenerative Nanomedicine, Université de Strasbourg, 67000 Strasbourg, France
- Correspondence: ; Tel.: +33-369-551-736
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Spence J, Ioannidis JPA, Avidan MS. Achieving balance with power: lessons from the Balanced Anaesthesia Study. Br J Anaesth 2020; 124:366-370. [PMID: 31973826 DOI: 10.1016/j.bja.2019.12.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 12/16/2019] [Accepted: 12/19/2019] [Indexed: 11/21/2022] Open
Affiliation(s)
- Jessica Spence
- Departments of Anesthesia, Critical Care and Health Research Methods, Evaluation, and Impact, McMaster University and Population Health Research Institute, Hamilton, ON, Canada.
| | - John P A Ioannidis
- Departments of Medicine, Health Research and Policy (Epidemiology), Statistics and Biomedical Data Sciences and Meta-Research Innovation Center at Stanford, Stanford University, Palo Alto, CA, USA
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
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Zhong X, Zhang M, Tian Z, Wang Q, Wang Z. The Study of Enhanced High-Intensity Focused Ultrasound Therapy by Sonodynamic N 2O Microbubbles. NANOSCALE RESEARCH LETTERS 2019; 14:381. [PMID: 31845016 PMCID: PMC6915195 DOI: 10.1186/s11671-019-3219-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 11/27/2019] [Indexed: 05/13/2023]
Abstract
High-intensity focused ultrasound (HIFU) is a representative non-invasive method of cancer therapy, but its low therapeutic efficacy and risk of damage to surrounding normal tissue hinder its further clinical development and application. Sonodynamic therapy (SDT) kills tumor cells through reactive oxygen molecules produced by sonosensitizers during ultrasound treatment. SDT can enhance HIFU efficacy like microbubbles. In this work, we developed nanoscale N2O microbubbles (N2O-mbs) by an improved mechanical oscillation method. These microbubbles showed good biocompatibility and tumor cell binding. The sonosensitivity of the N2O-mbs was detected both extracellularly and intracellularly through the detection of reactive oxygen species generation. The toxic effects of these sonodynamic microbubbles on tumor cells and the synergistic effect on HIFU treatment were evaluated. Significant apoptosis was caused by reactive oxygen species produced by N2O-mbs under ultrasound irradiation. N2O-mbs combined with HIFU increased tumor cell necrosis and apoptosis in vitro and the coagulative necrotic volume and echo intensity in the bovine liver target area ex vivo. These sonodynamic microbubbles have been also demonstrated to efficiently inhibit tumor growth in vivo. N2O-mbs have a significant impact on the treatment and ablation effect of HIFU due to the advantages of microbubble and extraordinary sonosensitivity. This finding suggests that N2O-mbs may be a novel auxiliary agent for ultrasound that can be used to promote HIFU tumor thermal ablation.
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Affiliation(s)
- Xiaowen Zhong
- The Department of Anesthesiology, The Second Affiliated Hospital of Chongqing Medical University, No. 74 Linjiang Road, Yuzhong District, Chongqing, 400010, People's Republic of China
- Chongqing Key Laboratory of Ultrasound Molecular Imaging, Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, People's Republic of China
| | - Mei Zhang
- The Department of Anesthesiology, The Second Affiliated Hospital of Chongqing Medical University, No. 74 Linjiang Road, Yuzhong District, Chongqing, 400010, People's Republic of China
| | - Zedan Tian
- The Department of Anesthesiology, The Second Affiliated Hospital of Chongqing Medical University, No. 74 Linjiang Road, Yuzhong District, Chongqing, 400010, People's Republic of China.
| | - Qi Wang
- Institute of Ultrasonic Engineering in Medical, Chongqing Medical University, Chongqing, 400010, China
| | - Zhigang Wang
- Chongqing Key Laboratory of Ultrasound Molecular Imaging, Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, People's Republic of China
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Lin MJ, Dubin DP, Khorasani H. Nitrous Oxide Reduces Pain Associated With Local Anesthetic Injections. J Cutan Med Surg 2019; 23:602-607. [PMID: 31402695 DOI: 10.1177/1203475419867606] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Local anesthetic injections can be painful and distressing. OBJECTIVE The aim of this study was to determine whether nitrous oxide, ice, vibration, or topical anesthetic improves analgesia for local anesthetic injections. METHOD A cohort study of 400 patients undergoing Mohs micrographic surgery with local anesthetic was conducted. Patients received no intervention (n = 200), ice (n = 50), topical anesthetic cream (n = 50), vibration device (n = 50), or nitrous oxide (n = 50). Pain was rated using the Visual Analogue Scale (VAS) and Wong-Baker FACES Pain Rating Scale. RESULTS Without intervention, mean VAS was 4.2 and FACES was 4.6. Nitrous oxide was the most successful in reducing pain (mean VAS 1.6 vs. 4.2, P < .01, FACES 1.2 vs. 4.6, P < .01). Topical ice reduced pain (mean VAS 3.0 vs. 4.2, P < .01, FACES 3.0 vs. 4.6, P < .01). Vibration reduced pain (mean VAS 3.5 vs. 4.2, P < .01, FACES 3.6 vs. 4.6, P < .01). Higher pain scores were associated with age <50 (P = .02), male sex (P = .05), and surgery on the nose, lip, ear, or eyelid (P = .02). CONCLUSION Nitrous oxide, ice, and vibration reduce injection pain. These interventions are especially useful for younger males undergoing surgery on the nose, lip, ear, or eyelid.
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Affiliation(s)
- Matthew J Lin
- Division of Dermatologic Surgery, Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Danielle P Dubin
- Division of Dermatologic Surgery, Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Hooman Khorasani
- Division of Dermatologic Surgery, Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Heller BJ, DeMaria S, Mendoza E, Hyman J, Iloreta AMC, Lin HM, Govindaraj S, Levine AI. Nitrous oxide anesthetic versus total intravenous anesthesia for functional endoscopic sinus surgery. Laryngoscope 2019; 130:E299-E304. [PMID: 31369152 DOI: 10.1002/lary.28201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 06/30/2019] [Accepted: 07/08/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND Functional endoscopic sinus surgery is a common procedure for sinonasal disease, frequently performed in the outpatient setting. General anesthesia maintained with total intravenous anesthesia (TIVA) with propofol has been shown to give superior surgical conditions compared to inhaled anesthetics. This study evaluated the effects of TIVA versus a predominantly nitrous oxide (N2 O)-based anesthetic with a low-dose propofol and remifentanil infusion on sinus surgery. METHODS Patients were randomized to either a N2 O-based (nitrous oxide with propofol and remifentanil) or TIVA (propofol and remifentanil without nitrous oxide) group. The surgeon was blinded to the anesthetic technique. Surgical field grading was performed in real time by the otolaryngologist every 15 minutes with the Boezaart grading system. RESULTS There were no statistically significant differences between the Boezaart scores, duration of surgery, or estimated blood loss between the two anesthetic techniques. However, the use of N2 O provided a statistically significant, 38% reduction in time from surgery end to extubation. The TIVA group had significantly decreased mean and median pain scores in the post-anesthesia care unit (PACU). There was no difference in the rate of postoperative nausea and vomiting between the two groups. CONCLUSION A N2 O-based anesthetic for functional endoscopic sinus surgery provides similar intraoperative and postoperative conditions when compared to TIVA, while being superior in terms of time to extubation. Although the TIVA group had significantly decreased pain scores, this did not lead to a decrease in pain medicine received in the PACU, and there was no difference between groups in time to discharge. LEVEL OF EVIDENCE 1b Laryngoscope, 130:E299-E304, 2020.
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Affiliation(s)
- Benjamin J Heller
- The Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - Samuel DeMaria
- The Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - Erick Mendoza
- The Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - Jaime Hyman
- The Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | | | - Hung-Mo Lin
- The Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - Satish Govindaraj
- The Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - Adam I Levine
- The Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
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Buhre W, Disma N, Hendrickx J, DeHert S, Hollmann MW, Huhn R, Jakobsson J, Nagele P, Peyton P, Vutskits L. European Society of Anaesthesiology Task Force on Nitrous Oxide: a narrative review of its role in clinical practice. Br J Anaesth 2019; 122:587-604. [PMID: 30916011 DOI: 10.1016/j.bja.2019.01.023] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 12/26/2018] [Accepted: 01/13/2019] [Indexed: 12/12/2022] Open
Abstract
Nitrous oxide (N2O) is one of the oldest drugs still in use in medicine. Despite its superior pharmacokinetic properties, controversy remains over its continued use in clinical practice, reflecting in part significant improvements in the pharmacology of other anaesthetic agents and developing awareness of its shortcomings. This narrative review describes current knowledge regarding the clinical use of N2O based on a systematic and critical analysis of the available scientific literature. The pharmacological properties of N2O are reviewed in detail along with current evidence for the indications and contraindications of this drug in specific settings, both in perioperative care and in procedural sedation. Novel potential applications for N2O for the prevention or treatment of chronic pain and depression are also discussed. In view of the available evidence, we recommend that the supply of N2O in hospitals be maintained while encouraging its economic delivery using modern low flow delivery systems. Future research into its potential novel applications in prevention or treatment of chronic conditions should be pursued to better identify its role place in the developing era of precision medicine.
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Affiliation(s)
- Wolfgang Buhre
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Center, University of Maastricht, Maastricht, the Netherlands
| | - Nicola Disma
- Department of Anesthesia, Istituto Giannina Gaslini, Genoa, Italy
| | - Jan Hendrickx
- Department of Anesthesiology, Onze-Lieve-Vrouwziekenhuis Hospital Aalst, Aalst, Belgium
| | - Stefan DeHert
- Department of Anesthesiology and Perioperative Medicine, University Hospital Ghent, Ghent, Belgium
| | - Markus W Hollmann
- Department of Anesthesiology, Amsterdam University Medical Center (AUMC), AMC, University of Amsterdam, Amsterdam, the Netherlands.
| | - Ragnar Huhn
- Department of Anesthesiology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Jan Jakobsson
- Department of Anesthesiology and Intensive Care, Institution for Clinical Science, Karolinska Institute, Danderyds University Hospital, Danderyd, Sweden
| | - Peter Nagele
- Department of Anesthesia and Critical Care, University of Chicago Medicine, Chicago, IL, USA
| | - Philip Peyton
- Department of Anaesthesia, Austin Health, and Anaesthesia Perioperative and Pain Medicine Unit, Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - Laszlo Vutskits
- Department of Anesthesiology, Pharmacology and Intensive Care, University Hospitals Geneva, Genève, Switzerland
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Intra-operative tachycardia is not associated with a composite of myocardial injury and mortality after noncardiac surgery. Eur J Anaesthesiol 2019; 36:105-113. [DOI: 10.1097/eja.0000000000000925] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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22
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The prevalence of cardiovascular autonomic neuropathy and its influence on post induction hemodynamic variables in patients with and without diabetes; A prospective cohort study. PLoS One 2018; 13:e0207384. [PMID: 30475825 PMCID: PMC6261040 DOI: 10.1371/journal.pone.0207384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 10/30/2018] [Indexed: 11/30/2022] Open
Abstract
Background Cardiovascular autonomic neuropathy (CAN) is a known complication of diabetes, but is also diagnosed in patients without diabetes. CAN may be related to perioperative hemodynamic instability. Our objective was to investigate if patients with diabetes would have a higher prevalence of CAN compared to patients without diabetes undergoing surgery. We further studied its relation to changes in post-induction hemodynamic variables. Methods We prospectively included 82 adult patients, 55 with DM, 27 without DM, scheduled for major abdominal or cardiac surgery. Patients performed four autonomic function tests on the day before surgery. Primary outcomes were the prevalence of CAN and the relation between CAN and severe post-induction hypotension, defined as mean arterial pressure (MAP) < 50 mmHg or ≥ 50% decrease from baseline. Secondary outcomes were the relation between CAN, intraoperative hypotension, MAP < 65 mmHg for more than 13 minutes, and the use of vasopressor therapy. Results The prevalence of CAN in patients with or without DM was 71% versus 63%, (p = 0.437). CAN was not associated with severe post induction hypotension (CAN+ vs. CAN–: 21% vs. 19.2%, p = 0.819) nor with intraoperative hypotension (16% vs. 15%, p = 0.937). Patients with definite CAN received more norepinephrine in the perioperative period compared to patients with mild CAN or no CAN (0.07 mcg kg-1 min-1 (0.05–0.08) vs. 0.03 (0.01–0.07) vs. 0.02 (0.01–0.06) respectively, p = 0.001). Conclusions The majority of patients studied had mild to moderate CAN, regardless of the presence of DM. Assessing CAN before surgery did not identify patients at risk for post induction and intraoperative hypotension in our cohort. Trial registration Dutch Trial Registry (www.trialregister.nl) NTR4976.
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Beattie WS, Wijeysundera DN, Chan MTV, Peyton PJ, Leslie K, Paech MJ, Sessler DI, Wallace S, Myles PS, Galagher W, Farrington C, Ditoro A, Baulch S, Sidiropoulos S, Bulach R, Bryant D, O’Loughlin E, Mitteregger V, Bolsin S, Osborne C, McRae R, Backstrom M, Cotter R, March S, Silbert B, Said S, Halliwell R, Cope J, Fahlbusch D, Crump D, Thompson G, Jefferies A, Reeves M, Buckley N, Tidy T, Schricker T, Lattermann R, Iannuzzi D, Carroll J, Jacka M, Bryden C, Badner N, Tsang MWY, Cheng BCP, Fong ACM, Chu LCY, Koo EGY, Mohd N, Ming LE, Campbell D, McAllister D, Walker S, Olliff S, Kennedy R, Eldawlatly A, Alzahrani T, Chua N, Sneyd R, McMillan H, Parkinson I, Brennan A, Balaji P, Nightingale J, Kunst G, Dickinson M, Subramaniam B, Banner-Godspeed V, Liu J, Kurz A, Hesler B, Fu AY, Egan C, Fiffick AN, Hutcherson MT, Turan A, Naylor A, Obal D, Cooke E. Implication of Major Adverse Postoperative Events and Myocardial Injury on Disability and Survival. Anesth Analg 2018. [DOI: 10.1213/ane.0000000000003310] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Koyama Y, Oshika H, Nishioka H, Kamoshida N, Tanaka S, Inagawa G, Andoh T. K-Y™ jelly inhibits increase in endotracheal tube cuff pressure during nitrous oxide exposure in vitro. BMC Anesthesiol 2018; 18:99. [PMID: 30055572 PMCID: PMC6064625 DOI: 10.1186/s12871-018-0566-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 07/24/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The increase in endotracheal tube cuff pressure due to nitrous oxide diffusion is a well-known risk during general anesthesia using nitrous oxide. We hypothesized that lubricating endotracheal tube cuffs with K-Y™ Jelly might inhibit the increase in cuff pressure that occurs during exposure to nitrous oxide. METHODS We used two types of endotracheal tube cuffs: one made from ultrathin polyurethane (PU) and another made from conventional polyvinyl chloride (PVC). Using a pediatric trachea model, which consisted of an acrylic cylinder with an internal diameter of 12 mm, we measured changes in the cuff pressure during nitrous oxide exposure in size 5.0-mm internal diameter endotracheal tubes with each type of cuff, with and without lubrication with K-Y™ Jelly. RESULTS During nitrous oxide exposure, the increase in cuff pressure was significantly lower in the lubricated cuffs than in the non-lubricated cuffs in both types of cuffs (PVC, P < 0.0001; PU, P < 0.0001). However, the cuff compliance in the trachea model was unaffected by lubrication in both types of cuffs. CONCLUSIONS Lubrication of endotracheal tube cuffs with K-Y™ Jelly may effectively delay the increase in cuff pressure that occurs during general anesthesia using nitrous oxide.
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Affiliation(s)
- Yukihide Koyama
- Department of Anesthesiology, Mizonokuchi Hospital, Teikyo University School of Medicine, 5-1-1 Futako, Takatsu-ku, Kawasaki, Kanagawa, 213-8507, Japan.
| | - Hiroyuki Oshika
- Department of Anesthesiology, Mizonokuchi Hospital, Teikyo University School of Medicine, 5-1-1 Futako, Takatsu-ku, Kawasaki, Kanagawa, 213-8507, Japan
| | - Hiroko Nishioka
- Department of Anesthesiology, Mizonokuchi Hospital, Teikyo University School of Medicine, 5-1-1 Futako, Takatsu-ku, Kawasaki, Kanagawa, 213-8507, Japan
| | - Naoko Kamoshida
- Department of Anesthesiology, Mizonokuchi Hospital, Teikyo University School of Medicine, 5-1-1 Futako, Takatsu-ku, Kawasaki, Kanagawa, 213-8507, Japan
| | - Sousuke Tanaka
- Department of Medical Engineering, Mizonokuchi Hospital, Teikyo University School of Medicine, Kawasaki, Japan
| | - Gaku Inagawa
- Department of Anesthesiology, Yokohama Municipal Citizen's Hospital, Yokohama, Japan
| | - Tomio Andoh
- Department of Anesthesiology, Mizonokuchi Hospital, Teikyo University School of Medicine, 5-1-1 Futako, Takatsu-ku, Kawasaki, Kanagawa, 213-8507, Japan
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Abstract
BACKGROUND Many dermatologic procedures are painful and can be distressing to patients. OBJECTIVE To determine whether nitrous oxide has been used in dermatology and whether literature supports its use in terms of providing analgesia and anxiety associated with dermatologic procedures. METHODS A search of PubMed and Cochrane databases was conducted through July 15, 2016, to identify studies involving nitrous oxide use in dermatology. RESULTS Eight studies were identified and reviewed. The use of nitrous oxide/oxygen mixture resulted in a significant reduction in pain when used for photodynamic therapy, botulinum toxin therapy for hyperhidrosis of both the palms and axilla, aesthetic procedures involving various laser procedures, and in the treatment of bed sores and leg ulcers. However, pain scores were higher when nitrous oxide/oxygen was used in the debridement of chronic ulcers when compared with the use of topical anesthesia. In addition, nitrous oxide has been reported effective at reducing pain in hair transplants, dermabrasion, excision and repairs, and pediatric procedures. CONCLUSION Current literature provides some evidence that nitrous oxide, used alone or as adjunct anesthesia, is effective at providing analgesia for many dermatologic procedures. Nitrous oxide has many potential applications in dermatology; however, further evidence from randomized controlled trials is needed.
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Abstract
INTRODUCTION For a drug that has been omnipresent for nearly 200 years, nitrous oxide's (N2O) future seems less certain than its illustrious past. Environmental concerns are coming to the fore and may yet outweigh important clinical benefits. SOURCES OF DATA After determining the scope of the review, the authors used PubMed with select phrases encompassing the words in the scope. Both preclinical and clinical reports were considered. AREAS OF AGREEMENT The analgesic and anaesthetic advantages of N2O remain despite a plethora of newer agents. AREAS OF CONTROVERSY N2O greenhouse gas effect and its inhibition of key enzymes involved in protein and DNA synthesis have provided further fuel for those intent on eliminating its further clinical use. GROWING POINTS The use of N2O for treatment-resistant depression has gained traction. AREAS TIMELY FOR DEVELOPING RESEARCH Comparative studies for N2O role in combatting the prescription opioid analgesic epidemic may well provide further clinical impetus.
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Affiliation(s)
- V Lew
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA,USA
| | - E McKay
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA,USA
| | - M Maze
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA,USA
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Hounsome J, Greenhalgh J, Schofield-Robinson OJ, Lewis SR, Cook TM, Smith AF. Nitrous oxide-based vs. nitrous oxide-free general anaesthesia and accidental awareness in surgical patients: an abridged Cochrane systematic review. Anaesthesia 2017; 73:365-374. [PMID: 29034449 DOI: 10.1111/anae.14065] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2017] [Indexed: 12/29/2022]
Abstract
Accidental awareness during general anaesthesia can arise from a failure to deliver sufficient anaesthetic agent, or from a patient's resistance to an expected sufficient dose of such an agent. Awareness is 'explicit' if the patient is subsequently able to recall the event. We conducted a systematic review into the effect of nitrous oxide used as part of a general anaesthetic on the risk of accidental awareness in people over the age of five years undergoing general anaesthesia for surgery. We included 15 randomised controlled trials, 14 of which, representing a total of 3439 participants, were included in our primary analysis of the frequency of accidental awareness events. The awareness incidence rate was rare within these studies, and all were considered underpowered with respect to this outcome. The risk of bias across all studies was judged to be high, and 76% of studies failed adequately to conceal participant allocation. We considered the available evidence to be of very poor quality. There were a total of three accidental awareness events reported in two studies, one of which reported that the awareness was the result of a kink in a propofol intravenous line. There were insufficient data to conduct a meta- or sub-group analysis and there was insufficient evidence to draw outcome-related conclusions. We can, however, recommend that future studies focus on potentially high-risk groups such as obstetric or cardiac surgery patients, or those receiving neuromuscular blocking drugs or total intravenous anaesthesia.
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Affiliation(s)
- J Hounsome
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - J Greenhalgh
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - O J Schofield-Robinson
- Patient Safety Research Unit, Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK
| | - S R Lewis
- Patient Safety Research Unit, Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK
| | - T M Cook
- Royal United Hospital Bath NHS Foundation Trust, Bath, UK
- School of Clinical Sciences, University of Bristol, Bristol, UK
| | - A F Smith
- Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK
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Peyton PJ, Wu C, Jacobson T, Hogg M, Zia F, Leslie K. The effect of a perioperative ketamine infusion on the incidence of chronic postsurgical pain-a pilot study. Anaesth Intensive Care 2017; 45:459-465. [PMID: 28673215 DOI: 10.1177/0310057x1704500408] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Chronic postsurgical pain (CPSP) is a common and debilitating complication of major surgery. We undertook a pilot study at three hospitals to assess the feasibility of a proposed large multicentre placebo-controlled randomised trial of intravenous perioperative ketamine to reduce the incidence of CPSP. Ketamine, 0.5 mg/kg pre-incision, 0.25 mg/kg/hour intraoperatively and 0.1 mg/kg/hour for 24 hours, or placebo, was administered to 80 patients, recruited over a 15-month period, undergoing abdominal or thoracic surgery under general anaesthesia. The primary endpoint was CPSP in the area of the surgery reported at six-month telephone follow-up using a structured questionnaire. Fourteen patients (17.5%) reported CPSP (relative risk [95% confidence interval] if received ketamine 1.18 [0.70 to 1.98], P=0.56). Four patients in the treatment group and three in the control group reported ongoing analgesic use to treat CPSP and two patients in each group reported their worst pain in the previous 24 hours at ≥3/10 at six months. There were no significant differences in adverse event rates, quality of recovery scores, or cumulative morphine equivalents consumption in the first 72 hours. Numeric Rating Scale pain scores (median [interquartile range, IQR]) for average pain in the previous 24 hours among those patients reporting CPSP were 17.5 [0 to 40] /100 with no difference between treatment groups. A large (n=4,000 to 5,000) adequately powered multicentre trial is feasible using this population and methodology.
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Affiliation(s)
- P J Peyton
- Associate Professor, Anaesthesia, Perioperative and Pain Medicine Unit, Melbourne Medical School, University of Melbourne, Associate Professor, Department of Surgery, Austin Health, University of Melbourne, Head of Research, Dept of Anaesthesia, Austin Health, Melbourne, Victoria
| | - C Wu
- Anaesthetic Registrar, Department of Anaesthesia, Austin Health, Melbourne, Victoria
| | - T Jacobson
- Medical student, University of Melbourne, Austin Health Medical Education, Melbourne, Victoria
| | - M Hogg
- Head of Pain Services, Melbourne Health, Melbourne, Victoria
| | - F Zia
- Staff Anaesthetist, Ballarat Health Services, Department of Anaesthesia, Ballarat, Victoria
| | - K Leslie
- Honorary Professorial Fellow, Anaesthesia, Perioperative and Pain Medicine Unit, Melbourne Medical School, and Department of Pharmacology and Therapeutics, University of Melbourne; Honorary Adjunct Professor, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria
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Beattie WS, Wijeysundera DN, Chan MT, Peyton PJ, Leslie K, Paech MJ, Devereaux P, Sessler DI, Wallace S, Myles PS. Survival After Isolated Post-Operative Troponin Elevation. J Am Coll Cardiol 2017; 70:907-908. [DOI: 10.1016/j.jacc.2017.06.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 04/30/2017] [Accepted: 06/13/2017] [Indexed: 10/19/2022]
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Park HY, Kim D, In J. Comparison of the endotracheal tube intracuff pressure with cylindrical and tapered cuffs during nitrous oxide exposure: a randomized single-blinded clinical study. Anesth Pain Med (Seoul) 2017. [DOI: 10.17085/apm.2017.12.3.275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Ha Yeon Park
- Department of Anesthesiology and Pain Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Daehwan Kim
- Department of Anesthesiology and Pain Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Junyong In
- Department of Anesthesiology and Pain Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
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Joshi GP, Pennant JH, Kehlet H. Evaluation of Nitrous Oxide in the Gas Mixture for Anesthesia (ENIGMA) Studies. Anesth Analg 2017; 124:2077-2079. [DOI: 10.1213/ane.0000000000001749] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Chan M, Peyton P, Myles P, Leslie K, Buckley N, Kasza J, Paech M, Beattie W, Sessler D, Forbes A, Wallace S, Chen Y, Tian Y, Wu W. Chronic postsurgical pain in the Evaluation of Nitrous Oxide in the Gas Mixture for Anaesthesia (ENIGMA)-II trial. Br J Anaesth 2016; 117:801-811. [DOI: 10.1093/bja/aew338] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2016] [Indexed: 12/18/2022] Open
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Hounsome J, Nicholson A, Greenhalgh J, Cook TM, Smith AF, Lewis SR. Nitrous oxide-based versus nitrous oxide-free general anaesthesia and accidental awareness during general anaesthesia in surgical patients. Cochrane Database Syst Rev 2016; 2016:CD011052. [PMID: 27508523 PMCID: PMC9284342 DOI: 10.1002/14651858.cd011052.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Accidental awareness during general anaesthesia (AAGA) is when a patient unintentionally becomes conscious during a procedure performed with general anaesthesia and subsequently has explicit recall of this event. Incidence estimates for AAGA vary, with the most common estimate being one to two cases per 1000 general anaesthetics. Evidence linking nitrous oxide use and an increased risk of AAGA has come from observational studies data but the literature is contradictory, with some studies finding a protective effect of nitrous oxide. OBJECTIVES To assess the effect of general anaesthesia including nitrous oxide on the risk of AAGA in patients aged five years and over. SEARCH METHODS We searched the following databases: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and trial registers ((www.clinicaltrials.gov), the WHO International Clinical Trials Registry Platform (www.who.int/ictrp/network/en/) and Current Controlled Trials (www.isrctn.com/)) for eligible studies on December 9 2015. In addition, we conducted forward and backward citation searching using key identified papers. SELECTION CRITERIA We considered all randomized controlled trials (RCTs), including quasi-randomized studies and cluster-randomized studies, of participants aged five years or older receiving general anaesthesia for any type of surgery.We included trials in which participants receiving general anaesthesia that included nitrous oxide for maintenance at a concentration of at least 30% were compared with participants receiving no nitrous oxide during general anaesthesia. The intervention group must have received nitrous oxide in conjunction with an additional anaesthetic. We excluded studies where the depth of anaesthesia differed between the study arms. For inclusion in the review, studies needed to state in their methods that they planned to assess AAGA. We defined this as when a patient becomes conscious during a procedure performed with general anaesthesia and subsequently has explicit recall of this event. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane to identify studies. We extracted data and conducted 'Risk of bias' assessment using the Covidence database. MAIN RESULTS We included 15 studies. The total number of participants included in the analyses was 3520. Most studies were small with fewer than 120 participants, although two larger studies with 2012 and 671 participants were included. There was considerable variation in many of the study characteristics, including the anaesthetics used. The concentrations of nitrous oxide varied between 50% and 70%, and half of the studies used clinical signs and haemodynamic changes to monitor depth of anaesthesia.As it was not possible to blind the anaesthetist to the anaesthetic used, we rated all studies at high risk of performance bias and we therefore downgraded the quality of evidence by one level for risk of bias using the GRADE approach. Other types of bias were generally low, or were rated unclear due to missing information.No studies were designed to measure AAGA as the primary outcome, and were therefore statistically underpowered to answer this review question. Despite the inclusion of 3520 participants, only three awareness events were reported by two studies. In one study the event was due to technical failure. Due to the rarity of the events, we did not consider it appropriate to pool the data, and we therefore downgraded the quality of evidence by a further level for imprecision using GRADE. AUTHORS' CONCLUSIONS It is not possible to draw any conclusions from this review. The included studies were mainly small (fewer than 120 participants) and there were limited estimates of effect, with only two studies reporting any events. We cannot therefore determine whether the use of nitrous oxide in general anaesthesia increases, decreases or has no effect on the risk of accidental awareness.
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Affiliation(s)
- Juliet Hounsome
- University of LiverpoolLiverpool Reviews and Implementation GroupSherrington BuildingAshton StreetLiverpoolUKL69 3GE
| | - Amanda Nicholson
- University of LiverpoolLiverpool Reviews and Implementation GroupSherrington BuildingAshton StreetLiverpoolUKL69 3GE
- Q Medical Technologies LimitedUnit 1A Summerlands Trading EstateEndmoorKendalUKLA8 0FB
| | - Janette Greenhalgh
- University of LiverpoolLiverpool Reviews and Implementation GroupSherrington BuildingAshton StreetLiverpoolUKL69 3GE
| | - Tim M Cook
- Royal United HospitalDepartment of AnaesthesiaCombe ParkBathUKBA1 3NG
| | - Andrew F Smith
- Royal Lancaster InfirmaryDepartment of AnaesthesiaAshton RoadLancasterLancashireUKLA1 4RP
| | - Sharon R Lewis
- Royal Lancaster InfirmaryPatient Safety Research DepartmentPointer Court 1, Ashton RoadLancasterUKLA1 1RP
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Garakani A, Jaffe RJ, Savla D, Welch AK, Protin CA, Bryson EO, McDowell DM. Neurologic, psychiatric, and other medical manifestations of nitrous oxide abuse: A systematic review of the case literature. Am J Addict 2016; 25:358-69. [PMID: 27037733 DOI: 10.1111/ajad.12372] [Citation(s) in RCA: 158] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 01/28/2016] [Accepted: 03/11/2016] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND/OBJECTIVES Nitrous oxide (N2 O) is known to have abuse potential, although debate regarding the toxic effects of such abuse continues. Our objective was to review the case literature and present the neurologic, psychiatric and medical consequences of N2 O abuse. METHODS A systematic literature review was completed for case reports using keywords "nitrous oxide" with "abuse/abusing" or "misuse/misusing" or "overuse/overusing" or "addiction." Non-English-language cases and cases not involving direct toxic effects of N2 O were excluded as were commentaries or personal essays. Clinical presentation, frequency of N2 O abuse, laboratory studies, imaging, ancillary tests, treatments and outcomes were collected from case reports. RESULTS Our review returned 335 Pubmed, 204 Web of Science, 73 PsycINFO, 6 CINAHL, 55 EMBASE and 0 Grey Literature results, and after exclusion and removal of duplicates, 91 individual cases across 77 publications were included. There were also 11 publications reporting 29 cases of death related to N2 O abuse. The majority of cases (N = 72) reported neurologic sequelae including myeloneuropathy and subacute combined degeneration, commonly (N = 39) with neuroimaging changes. Psychiatric (N = 11) effects included psychosis while other medical effects (N = 8) included pneumomediastinum and frostbite. Across all cases N2 O abuse was correlated with low or low-normal Vitamin B12 (cyanocobalamin) levels (N = 52) and occasionally elevated homocysteine and methylmalonic acid. CONCLUSIONS/SCIENTIFIC SIGNIFICANCE N2 O abuse represents a significant problem because of the difficulty involved with identification and the toxicity related to chronic abuse including possible death. Health professionals should be aware of the toxic effects of N2 O and be able to identify potential N2 O abuse. (Am J Addict 2016;25:358-369).
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Affiliation(s)
- Amir Garakani
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York.,Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut.,Silver Hill Hospital, New Canaan, Connecticut
| | - Robert J Jaffe
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Dipal Savla
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alison K Welch
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Caroline A Protin
- Department of Anesthesiology, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Ethan O Bryson
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York.,Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, New York
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Abstract
Medical research has evolved, from individual expert described opinions and techniques, to scientifically designed methodology-based studies. Evidence-based medicine (EBM) was established to re-evaluate medical facts and remove various myths in clinical practice. Research methodology is now protocol based with predefined steps. Studies were classified based on the method of collection and evaluation of data. Clinical study methodology now needs to comply to strict ethical, moral, truth, and transparency standards, ensuring that no conflict of interest is involved. A medical research pyramid has been designed to grade the quality of evidence and help physicians determine the value of the research. Randomised controlled trials (RCTs) have become gold standards for quality research. EBM now scales systemic reviews and meta-analyses at a level higher than RCTs to overcome deficiencies in the randomised trials due to errors in methodology and analyses.
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Affiliation(s)
- Mukul Chandra Kapoor
- Department of Anesthesiology, Max Smart Super Specialty Hospital, New Delhi, India
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