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Qin Y, Lina H, Lv W, Hong S, Huang Z. Adrenal insufficiency associated with long-term use of electronic cigarettes reportedly containing etomidate in two patients. Clin Toxicol (Phila) 2024:1-2. [PMID: 39226024 DOI: 10.1080/15563650.2024.2396462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2024] [Revised: 08/19/2024] [Accepted: 08/20/2024] [Indexed: 09/04/2024]
Affiliation(s)
- Yongzhang Qin
- Department of Endocrinology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
| | - Huimin Lina
- Department of Endocrinology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
| | - Weimin Lv
- Department of Endocrinology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
| | - Shihua Hong
- Department of Endocrinology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
| | - Ziqian Huang
- Department of Pharmacy, The First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
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Faine BA, Carroll E, Sharma A, Mohr N. Rapid Sequence Intubation, is it Time to Find an Alternative Induction Agent? A Narrative Review. J Pharm Pract 2024; 37:977-984. [PMID: 37594256 DOI: 10.1177/08971900231197501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
Abstract
Objective: To review the efficacy, safety, and place in therapy of fentanyl as an induction agent for rapid sequence intubation (RSI) in critically ill patients. Data Sources: A comprehensive search of PubMed, EMBASE, and clinical trial registries (1964-June 2021) was performed utilizing the keywords fentanyl, rapid sequence intubation, intubation, induction, anesthesia, hemodynamics, operating room (OR), and emergency. Study Selection and Data Extraction: Only primary literature evaluating fentanyl in combination with a sedative or as the sole induction agent was included in the final analysis. Primary literature included peer-reviewed publications and results posted on ClinicalTrials.gov actively recruiting participants. Data Synthesis: Fentanyl has been used for decades as an adjunct, and sole induction agent in the OR. Questions surrounding the use of fentanyl as a sole induction agent include optimal dosing and safety in critically ill patients as evaluation in non-OR settings remain limited. Relevance to Patient Care and Clinical Practice: Commonly used induction agents (eg, etomidate and ketamine) are associated with adverse events that may increase risk of morbidity and mortality. Fentanyl, a high-potency opioid could serve as an alternative induction agent for RSI due to its neutral hemodynamic response and fast onset of action. This paper compiles and describes existing data on the use of fentanyl as an induction agent for RSI. Conclusion: Fentanyl in combination with sedatives provides optimal intubating conditions with minimal impact on hemodynamic parameters. Future studies should focus on safety and impact of awareness during paralysis before fentanyl can be considered as a sole induction agent.
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Affiliation(s)
- Brett A Faine
- Department of Emergency Medicine and Pharmacy, University of Iowa, Iowa City, IA, USA
| | - Elisabeth Carroll
- Department of Pharmaceutical Care and Emergency Medicine, University of Iowa, Iowa City, IA, USA
| | - Archit Sharma
- Department of Anesthesia Critical Care, University of Iowa, Iowa City, IA, USA
| | - Nicholas Mohr
- Department of Emergency Medicine and Anesthesia Critical Care, University of Iowa, Iowa City, IA, USA
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Randhawa VK, Lee R, Alviar CL, Rali AS, Arias A, Vaidya A, Zern EK, Fagan A, Proudfoot AG, Katz JN. Extra-cardiac management of cardiogenic shock in the intensive care unit. J Heart Lung Transplant 2024; 43:1051-1058. [PMID: 38823968 DOI: 10.1016/j.healun.2024.03.017] [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: 12/30/2023] [Revised: 03/23/2024] [Accepted: 03/25/2024] [Indexed: 06/03/2024] Open
Abstract
Cardiogenic shock (CS) is a heterogeneous clinical syndrome characterized by low cardiac output leading to end-organ hypoperfusion. Organ dysoxia ranging from transient organ injury to irreversible organ failure and death occurs across all CS etiologies but differing by incidence and type. Herein, we review the recognition and management of respiratory, renal and hepatic failure complicating CS. We also discuss unmet needs in the CS care pathway and future research priorities for generating evidence-based best practices for the management of extra-cardiac sequelae. The complexity of CS admitted to the contemporary cardiac intensive care unit demands a workforce skilled to care for these extra-cardiac critical illness complications with an appreciation for how cardio-systemic interactions influence critical illness outcomes in afflicted patients.
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Affiliation(s)
- Varinder K Randhawa
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Division of Cardiology, St Michael's Hospital, and Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ran Lee
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Sections of Critical Care Cardiology and Advanced Heart Failure and Transplant Cardiology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Carlos L Alviar
- The Leon H Charney Division of Cardiovascular Medicine, NYU Langone Medical Center, New York, New York
| | - Aniket S Rali
- Department of Internal Medicine, Division of Cardiovascular Diseases, and Department of Anesthesiology, Division of Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alexandra Arias
- Instituto Nacional de Cardiologia Ignacio Chavez, Mexico City, Mexico
| | - Anjali Vaidya
- Pulmonary Hypertension, Right Heart Failure, and CTEPH Program, Division of Cardiology, Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania
| | - Emily K Zern
- Department of Cardiology, Keck School of Medicine of University of Southern California, Los Angeles General Medicine Center, Los Angeles General Medical Center, Keck School of Medicine of University of Southern California, Los Angeles, California
| | - Andrew Fagan
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alastair G Proudfoot
- Department of Perioperative Medicine, Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom
| | - Jason N Katz
- Division of Cardiology, NYU Grossman School of Medicine and Bellevue Hospital Center, New York, New York.
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Thomas A, Banna S, Shahu A, Ali T, Schenck C, Patel B, Notarianni A, Phommalinh M, Kochar A, Heck C, van Diepen S, Miller PE. Propofol vs etomidate for induction prior to invasive mechanical ventilation in patients with acute myocardial infarction. Am Heart J 2024; 272:116-125. [PMID: 38554762 DOI: 10.1016/j.ahj.2024.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/19/2024] [Accepted: 03/21/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND Patients with acute myocardial infarction (AMI) requiring invasive mechanical ventilation (IMV) have a high mortality. However, little is known regarding the impact of induction agents, used prior to IMV, on clinical outcomes in this population. We assessed for the association between induction agent and mortality in patients with AMI requiring IMV. METHODS We compared clinical outcomes between those receiving propofol compared to etomidate for induction among adults with AMI between October 2015 and December 2019 using the Vizient® Clinical Data Base, a multicenter, US national database. We used inverse probability treatment weighting (IPTW) to assess for the association between induction agent and in-hospital mortality. RESULTS We identified 5,147 patients, 1,386 (26.9%) of received propofol and 3,761 (73.1%) received etomidate for IMV induction. The mean (SD) age was 66.1 (12.4) years, 33.0% were women, and 51.6% and 39.8% presented with STEMI and cardiogenic shock, respectively. Patients in the propofol group were more likely to require preintubation vasoactive medication and mechanical circulatory support (both, P < .05). Utilization of propofol was associated with lower mortality compared to etomidate (32.3% vs 36.1%, P = .01). After propensity weighting, propofol use remained associated with lower mortality (weighted mean difference -4.7%; 95% confidence interval: -7.6% to -1.8%, P = .002). Total cost, ventilator days, and length of stay were higher in the propofol group (all, P < .001). CONCLUSIONS Induction with propofol, compared with etomidate, was associated with lower mortality for patients with AMI requiring IMV. Randomized trials are needed to determine the optimal induction agent for this critically ill patient population.
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Affiliation(s)
- Alexander Thomas
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT
| | - Soumya Banna
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Andi Shahu
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT
| | - Tariq Ali
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT
| | | | - Bhoumesh Patel
- Department of Anesthesiology, Cardiothoracic Division, Yale University School of Medicine, New Haven, CT
| | - Andrew Notarianni
- Department of Anesthesiology, Cardiothoracic Division, Yale University School of Medicine, New Haven, CT
| | | | - Ajar Kochar
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA
| | - Cory Heck
- Heart and Vascular Center, Yale New Haven Hospital, New Haven, CT
| | - Sean van Diepen
- Department of Critical Care and Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - P Elliott Miller
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT.
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Dhoon TQ, Tiwari A, Villaluz E, Morrison DE. Understanding the Physiological Connection: Cardiac Arrest Following Prone Positioning. Cureus 2024; 16:e63050. [PMID: 39050332 PMCID: PMC11268726 DOI: 10.7759/cureus.63050] [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: 06/24/2024] [Indexed: 07/27/2024] Open
Abstract
Prone positioning of patients is a routine occurrence in procedural suites and operating rooms (ORs). However, the physiological changes that occur with prone positioning are frequently underappreciated by proceduralists, surgeons, and anesthesiologists. This may be related to a sense of the routine or a lack of familiarity with physiological changes that accompany the prone position. The prone position, while aiding visualization and cannulation of the ampulla of Vater during endoscopic retrograde cholangiopancreatography (ERCP), can induce physiological changes such as reduced preload, inferior vena cava filling, and cardiac output; it can also increase intrathoracic pressure and mediastinal compression. Anesthetic agents can further impact cardiopulmonary physiology, decreasing systemic vascular resistance and reducing cardiac contractility. In addition, the transition from negative to positive pressure ventilation following endotracheal intubation can increase pulmonary artery pressures and right ventricular (RV) strain. Therefore, caution is needed with patients who have RV dysfunction, pulmonary hypertension, or preload dependency, as they may not tolerate prone positioning. We describe a case in which a 73-year-old male patient scheduled for an ERCP suffered cardiac arrest after being transitioned to the prone position. The patient was repositioned in the supine position and resuscitated. The case was completed in the supine position.
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Affiliation(s)
- Taizoon Q Dhoon
- Anesthesiology, University of California, Irvine (UCI) Health, Orange, USA
| | - Anil Tiwari
- Anesthesiology and Perioperative Medicine, University of California, Irvine (UCI) Health, Orange, USA
| | - Evan Villaluz
- Anesthesiology and Perioperative Medicine, University of California, Irvine (UCI) Health, Orange, USA
| | - Debra E Morrison
- Anesthesiology and Perioperative Medicine, University of California, Irvine (UCI) Health, Orange, USA
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6
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Moran JL, Linden A. Problematic meta-analyses: Bayesian and frequentist perspectives on combining randomized controlled trials and non-randomized studies. BMC Med Res Methodol 2024; 24:99. [PMID: 38678213 PMCID: PMC11056075 DOI: 10.1186/s12874-024-02215-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 04/10/2024] [Indexed: 04/29/2024] Open
Abstract
PURPOSE In the literature, the propriety of the meta-analytic treatment-effect produced by combining randomized controlled trials (RCT) and non-randomized studies (NRS) is questioned, given the inherent confounding in NRS that may bias the meta-analysis. The current study compared an implicitly principled pooled Bayesian meta-analytic treatment-effect with that of frequentist pooling of RCT and NRS to determine how well each approach handled the NRS bias. MATERIALS & METHODS Binary outcome Critical-Care meta-analyses, reflecting the importance of such outcomes in Critical-Care practice, combining RCT and NRS were identified electronically. Bayesian pooled treatment-effect and 95% credible-intervals (BCrI), posterior model probabilities indicating model plausibility and Bayes-factors (BF) were estimated using an informative heavy-tailed heterogeneity prior (half-Cauchy). Preference for pooling of RCT and NRS was indicated for Bayes-factors > 3 or < 0.333 for the converse. All pooled frequentist treatment-effects and 95% confidence intervals (FCI) were re-estimated using the popular DerSimonian-Laird (DSL) random effects model. RESULTS Fifty meta-analyses were identified (2009-2021), reporting pooled estimates in 44; 29 were pharmaceutical-therapeutic and 21 were non-pharmaceutical therapeutic. Re-computed pooled DSL FCI excluded the null (OR or RR = 1) in 86% (43/50). In 18 meta-analyses there was an agreement between FCI and BCrI in excluding the null. In 23 meta-analyses where FCI excluded the null, BCrI embraced the null. BF supported a pooled model in 27 meta-analyses and separate models in 4. The highest density of the posterior model probabilities for 0.333 < Bayes factor < 1 was 0.8. CONCLUSIONS In the current meta-analytic cohort, an integrated and multifaceted Bayesian approach gave support to including NRS in a pooled-estimate model. Conversely, caution should attend the reporting of naïve frequentist pooled, RCT and NRS, meta-analytic treatment effects.
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Affiliation(s)
- John L Moran
- The Queen Elizabeth Hospital, Woodville, SA, 5011, Australia.
| | - Ariel Linden
- Department of Medicine, School of Medicine, University of California, San Francisco, USA
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Lu B, Wei L, Shi G, Du J. Nanotherapeutics for Alleviating Anesthesia-Associated Complications. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2024; 11:e2308241. [PMID: 38342603 PMCID: PMC11022745 DOI: 10.1002/advs.202308241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/22/2023] [Indexed: 02/13/2024]
Abstract
Current management of anesthesia-associated complications falls short in terms of both efficacy and safety. Nanomaterials with versatile properties and unique nano-bio interactions hold substantial promise as therapeutics for addressing these complications. This review conducts a thorough examination of the existing nanotherapeutics and highlights the strategies for developing prospective nanomedicines to mitigate anesthetics-related toxicity. Initially, general, regional, and local anesthesia along with the commonly used anesthetics and related prevalent side effects are introduced. Furthermore, employing nanotechnology to prevent and alleviate the complications of anesthetics is systematically demonstrated from three aspects, that is, developing 1) safe nano-formulization for anesthetics; 2) nano-antidotes to sequester overdosed anesthetics and alter their pharmacokinetics; 3) nanomedicines with pharmacodynamic activities to treat anesthetics toxicity. Finally, the prospects and challenges facing the clinical translation of nanotherapeutics for anesthesia-related complications are discussed. This work provides a comprehensive roadmap for developing effective nanotherapeutics to prevent and mitigate anesthesia-associated toxicity, which can potentially revolutionize the management of anesthesia complications.
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Affiliation(s)
- Bin Lu
- Department of AnesthesiologyThird Hospital of Shanxi Medical UniversityShanxi Bethune HospitalShanxi Academy of Medical SciencesTongji Shanxi HospitalTaiyuan030032China
- Key Laboratory of Cellular Physiology at Shanxi Medical UniversityMinistry of EducationTaiyuanShanxi Province030001China
| | - Ling Wei
- Shanxi Bethune Hospital Center Surgery DepartmentShanxi Academy of Medical SciencesTongji Shanxi HospitalThird Hospital of Shanxi Medical UniversityTaiyuan030032China
| | - Gaoxiang Shi
- Department of AnesthesiologyThird Hospital of Shanxi Medical UniversityShanxi Bethune HospitalShanxi Academy of Medical SciencesTongji Shanxi HospitalTaiyuan030032China
| | - Jiangfeng Du
- Key Laboratory of Cellular Physiology at Shanxi Medical UniversityMinistry of EducationTaiyuanShanxi Province030001China
- Department of Medical ImagingShanxi Key Laboratory of Intelligent Imaging and NanomedicineFirst Hospital of Shanxi Medical UniversityTaiyuanShanxi Province030001China
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Park YJ, Seo KH, Joo JD, Jung HS, Kim YS, Lee JY, Park H. The effects of etomidate on expression of high mobility group box 1 via the nuclear factor kappa B pathway in rat model of sepsis. Libyan J Med 2023; 18:2182683. [PMID: 36855243 PMCID: PMC9980160 DOI: 10.1080/19932820.2023.2182683] [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] [Indexed: 03/02/2023] Open
Abstract
Etomidate is an anesthetic agent used in hemodynamically unstable patients, but its use has been controversial in septic patients. The response of high-mobility group box 1 (HMGB1), a late-phase lethal cytokine in sepsis, to etomidate has not been reported. This study investigated the effects of etomidate on the expression and release of HMGB1 and the underlying mechanism using a cecal ligation and puncture (CLP) model. Thirty-six male Sprague-Dawley rats were divided into sham, CLP, and Etomi groups. Sepsis was induced in the CLP and Etomi groups, and intravenous etomidate (4 mg/kg) was infused for 40 min immediately after operation in the Etomi group. Serum creatinine, alanine aminotransferase (ALT), tumor necrosis factor (TNF)-α, interleukin (IL)-6, and HMGB1 levels were measured 6 and 24 hours after surgery. Activation of nuclear factor (NF)-ĸB and HMGB1 mRNA expression in the liver, lung, kidney, and ileum tissues were measured, and immunohistochemical staining of HMGB1 was implemented. Increases of the TNF-α level 6 h after CLP and ALT and IL-6 levels 24 h after CLP were significantly inhibited by etomidate treatment. Etomidate treatment also significantly attenuated the increase in serum HMGB1 level at 6 and 24 h after CLP and suppressed the NF-ĸB and HMGB1 mRNA in multiple organs 24 h after CLP. Immunohistochemical staining also revealed that etomidate treatment inhibited HMGB1 expression. Etomidate inhibited the systemic release of HMGB1 and its expression in various organs. The mechanism may be associated with the inhibitory effects of etomidate on pro-inflammatory cytokine release and NF-ĸB activity.
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Affiliation(s)
- Yoo Jung Park
- Department of Anesthesiology and Pain Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Suwon, Republic of Korea
| | - Kwon Hui Seo
- Department of anesthesiology and Pain medicine, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea,Seoul, Republic of Korea,CONTACT Kwon Hui Seo Department of Anesthesiology and Pain Medicine, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 10 63-ro, Yeoungdeungpo-gu, Seoul07345, Republic of Korea
| | - Jin Deok Joo
- Department of Anesthesiology and Pain Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Suwon, Republic of Korea
| | - Hong Soo Jung
- Department of Anesthesiology and Pain Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Suwon, Republic of Korea
| | - Yong Shin Kim
- Department of Anesthesiology and Pain Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Suwon, Republic of Korea
| | - Ji Yung Lee
- Department of anesthesiology and Pain medicine, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea,Seoul, Republic of Korea
| | - Hunwoo Park
- Department of anesthesiology and Pain medicine, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea,Seoul, Republic of Korea
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Tangkulpanich P, Angkoontassaneeyarat C, Trainarongsakul T, Jenpanitpong C. Factors Associated with Postintubation Hypotension Among Patients with Suspected Sepsis in Emergency Department. Open Access Emerg Med 2023; 15:427-436. [PMID: 38022743 PMCID: PMC10656833 DOI: 10.2147/oaem.s426822] [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: 06/20/2023] [Accepted: 11/01/2023] [Indexed: 12/01/2023] Open
Abstract
Purpose Postintubation hypotension (PIH) is a recognized complication that increases both in-hospital mortality and hospital length of stay. Sepsis is reportedly a factor associated with PIH. However, no study to date has examined which factors, including the intubation method, may be clinical predictors of PIH in patients with sepsis. This study aims to investigate factors associated with the occurrence of PIH in patients with suspected sepsis in emergency department. Patients and Methods This retrospective cross-sectional study was performed over a 5-year period (January 2013-December 2017) and involved patients with suspected sepsis who underwent endotracheal intubation in the emergency department of Ramathibodi Hospital. The patients were divided into those with and without PIH, and factors associated with the occurrence of PIH were analyzed. PIH was defined as any recorded systolic blood pressure of <90 mmHg within 60 minutes of intubation. Results In total, 394 patients with suspected sepsis were included. PIH occurred in 106 patients (26.9%) and was associated with increased in-hospital mortality (43.00% in the PIH group vs 31.25% in the non-PIH group, P = 0.034). Multivariable logistic regression showed that the factors associated with PIH were an age of ≥61 years (adjusted odds ratio [aOR] 2.25; 95% confidence interval [CI] 1.14-4.43; P = 0.019) and initial serum lactate concentration of >4.4 mmol/L (aOR 2.00; 95% CI 1.16-3.46; P = 0.013). Rapid sequence intubation and difference types of induction agents was unrelated to PIH. Conclusion Monitoring the development of PIH in patients with sepsis is essential because of its correlation with higher in-hospital mortality. This is particularly critical for older individuals and those with severe infections and high initial lactate concentrations.
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Affiliation(s)
- Panvilai Tangkulpanich
- Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Thavinee Trainarongsakul
- Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chetsadakon Jenpanitpong
- Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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10
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Knack SKS, Prekker ME, Moore JC, Klein LR, Atkins AH, Miner JR, Driver BE. The Effect of Ketamine Versus Etomidate for Rapid Sequence Intubation on Maximum Sequential Organ Failure Assessment Score: A Randomized Clinical Trial. J Emerg Med 2023; 65:e371-e382. [PMID: 37741737 DOI: 10.1016/j.jemermed.2023.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 05/22/2023] [Accepted: 06/13/2023] [Indexed: 09/25/2023]
Abstract
BACKGROUND The use of induction agents for rapid sequence intubation (RSI) has been associated with hypotension in critically ill patients. Choice of induction agent may be important and the most commonly used agents are etomidate and ketamine. OBJECTIVE This study aimed to compare the effects of a single dose of ketamine vs. etomidate for RSI on maximum Sequential Organ Failure Assessment (SOFA) score and incidence of hypotension. METHODS This single-center, randomized, parallel-group trial compared the use of ketamine and etomidate for RSI in critically ill adult patients in the emergency department. The study was performed under Exception from Informed Consent. The primary outcome was the maximum SOFA score within 3 days of hospitalization. RESULTS A total of 143 patients were enrolled in the trial, 70 in the ketamine group and 73 in the etomidate group. Maximum median SOFA score for the ketamine group was 6.5 (interquartile range [IQR] 5-9) vs. 7 (IQR 5-9) for etomidate with no significant difference (-0.2; 95% CI -1.4 to 1.1; p = 0.79). The incidence of post-intubation hypotension was 28% in the ketamine group vs. 26% in the etomidate group (difference 2%; 95% CI -13% to 17%). There were no significant differences in intensive care unit outcomes. Thirty-day mortality rate for the ketamine group was 11% (8 deaths) and for the etomidate group was 21% (15 deaths), which was not statistically different. CONCLUSIONS There were no significant differences in maximum SOFA score or post-intubation hypotension between critically ill adults receiving ketamine vs. etomidate for RSI.
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Affiliation(s)
- Sarah K S Knack
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Matthew E Prekker
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota; Department of Medicine, Division of Pulmonary and Critical Care, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Johanna C Moore
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Lauren R Klein
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Alexandra H Atkins
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - James R Miner
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
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11
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Schurr JW, Sigal I, Usman A, Patel P, Lefebvre B, Kurcik K, Atluri P, Acker M, Bermudez C, Rame JE, Hanff T, Cevasco M, Wald J. Effect of Anesthesia Induction on Cardiac Hemodynamics in Patients Undergoing Durable Left Ventricular Assist Device Implantation: The EACH-LVAD Study. ASAIO J 2023; 69:907-914. [PMID: 37578995 DOI: 10.1097/mat.0000000000002010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2023] Open
Abstract
Right ventricular (RV) dysfunction is common after left ventricular assist device (LVAD) implantation leading to clinical right heart failure (RHF) associated with worsened survival and quality of life. It is likely that intraoperative events such as anesthesia induction play a role in the development or unmasking of RV dysfunction in addition to known effects from hemodynamic changes that occur after LVAD implantation. The EACH-LVAD Study is a prospective, single-center, single-arm, observational cohort study of adult patients with advanced heart failure undergoing durable LVAD implantation with standard anesthesia induction. Intraoperative RV hemodynamics via central venous pressure, mean pulmonary artery pressure, pulmonary artery pulsatility index, and vasoactive-inotropic score (a simple weighted summation of standardized drug doses) and echocardiographic parameters (RV fractional area change, RV area in diastole, RV basal diameter, septum position, RV function, tricuspid regurgitation) were measured and compared at prespecified timepoints, including postinduction. Postoperative clinical RHF was determined based on published definitions. Forty-two patients receiving a first-time LVAD were included between September 2017 and March 2019. Propofol-based induction was used in 31 patients and etomidate-based induction in eight patients. A significant increase in central venous pressure (CVP; p < 0.001), mean pulmonary artery pressure (mPAP; p < 0.001), and vasoactive inotropic score (VIS; p < 0.001) with associated decrease in pulmonary artery pulsatility index (PAPi; p < 0.001) was observed. Right ventricular function worsened throughout. Right heart failure occurred in 70% of patients. Propofol-based induction was not associated with a higher risk of RHF (relative risk [RR], 1.01 [95% confidence interval {CI}, 0.64-1.61]). The EACH-LVAD study demonstrates an effect of anesthesia induction on worsened RV hemodynamics and echocardiographic changes which may have an effect on the development of RHF.
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Affiliation(s)
- James W Schurr
- From the Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ian Sigal
- From the Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Asad Usman
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Prakash Patel
- Department of Anesthesiology, Yale University, New Haven, Connecticut
| | - Benedicte Lefebvre
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kristy Kurcik
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pavan Atluri
- Division of Cardiothoracic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael Acker
- Division of Cardiothoracic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christian Bermudez
- Division of Cardiothoracic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - J Eduardo Rame
- Division of Cardiovascular Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Thomas Hanff
- Division of Cardiovascular Medicine, University of Utah Hospital, Salt Lake City, Utah
| | - Marisa Cevasco
- Division of Cardiothoracic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joyce Wald
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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12
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Budde AM, Tung A. Airway management during resuscitation. Int Anesthesiol Clin 2023; 61:9-14. [PMID: 37678199 DOI: 10.1097/aia.0000000000000410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Affiliation(s)
- Anna M Budde
- Department of Anesthesiology, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Avery Tung
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois
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Srivilaithon W, Bumrungphanithaworn A, Daorattanachai K, Limjindaporn C, Amnuaypattanapon K, Imsuwan I, Diskumpon N, Dasanadeba I, Siripakarn Y, Ueamsaranworakul T, Pornpanit C, Pornpachara V. Clinical outcomes after a single induction dose of etomidate versus ketamine for emergency department sepsis intubation: a randomized controlled trial. Sci Rep 2023; 13:6362. [PMID: 37076524 PMCID: PMC10115773 DOI: 10.1038/s41598-023-33679-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 04/17/2023] [Indexed: 04/21/2023] Open
Abstract
Patients with sepsis often require emergency intubation. In emergency departments (EDs), rapid-sequence intubation with a single-dose induction agent is standard practice, but the best choice of induction agent in sepsis remains controversial. We conducted a randomized, controlled, single-blind trial in the ED. We included septic patients who were aged at least 18 years and required sedation for emergency intubation. Patients were randomly assigned by a blocked randomization to receive 0.2-0.3 mg/kg of etomidate or 1-2 mg/kg of ketamine for intubation. The objectives were to compare the survival outcomes and adverse events after intubation between etomidate and ketamine. Two hundred and sixty septic patients were enrolled; 130 patients/drug arm whose baseline characteristics were well balanced at baseline. In the etomidate group, 105 patients (80.8%) were alive at 28 days, compared with 95 patients (73.1%) in the ketamine group (risk difference [RD], 7.7%; 95% confidence interval [CI], - 2.5 to 17.9%; P = 0.092). There was no significant difference in the proportion of patients who survived at 24 h (91.5% vs. 96.2%; P = 0.097) and survived at 7 days (87.7% vs. 87.7%; P = 0.574). A significantly higher proportion of the etomidate group needed a vasopressor within 24 h after intubation: 43.9% vs. 17.7%, RD, 26.2% (95% CI, 15.4 to 36.9%; P < 0.001). In conclusion, there were no differences in early and late survival rates between etomidate and ketamine. However, etomidate was associated with higher risks of early vasopressor use after intubation. Trial registration: The trial protocol was registered in the Thai Clinical Trials Registry (identification number: TCTR20210213001). Registered 13 February 2021-Retrospectively registered, https://www.thaiclinicaltrials.org/export/pdf/TCTR20210213001 .
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Affiliation(s)
- Winchana Srivilaithon
- Department of Emergency Medicine, Faculty of Medicine, Thammasat University, 99/209 Phahon Yothin Road, Klong Luang District, Pathum Thani, 12120, Thailand.
| | - Atidtaya Bumrungphanithaworn
- Department of Emergency Medicine, Faculty of Medicine, Thammasat University, 99/209 Phahon Yothin Road, Klong Luang District, Pathum Thani, 12120, Thailand
| | - Kiattichai Daorattanachai
- Department of Emergency Medicine, Faculty of Medicine, Thammasat University, 99/209 Phahon Yothin Road, Klong Luang District, Pathum Thani, 12120, Thailand
| | - Chitlada Limjindaporn
- Department of Emergency Medicine, Faculty of Medicine, Thammasat University, 99/209 Phahon Yothin Road, Klong Luang District, Pathum Thani, 12120, Thailand
| | - Kumpol Amnuaypattanapon
- Department of Emergency Medicine, Faculty of Medicine, Thammasat University, 99/209 Phahon Yothin Road, Klong Luang District, Pathum Thani, 12120, Thailand
| | - Intanon Imsuwan
- Department of Emergency Medicine, Faculty of Medicine, Thammasat University, 99/209 Phahon Yothin Road, Klong Luang District, Pathum Thani, 12120, Thailand
| | - Nipon Diskumpon
- Department of Emergency Medicine, Faculty of Medicine, Thammasat University, 99/209 Phahon Yothin Road, Klong Luang District, Pathum Thani, 12120, Thailand
| | - Ittabud Dasanadeba
- Department of Emergency Medicine, Faculty of Medicine, Thammasat University, 99/209 Phahon Yothin Road, Klong Luang District, Pathum Thani, 12120, Thailand
| | - Yaowapha Siripakarn
- Department of Emergency Medicine, Faculty of Medicine, Thammasat University, 99/209 Phahon Yothin Road, Klong Luang District, Pathum Thani, 12120, Thailand
| | - Thosapol Ueamsaranworakul
- Department of Emergency Medicine, Faculty of Medicine, Thammasat University, 99/209 Phahon Yothin Road, Klong Luang District, Pathum Thani, 12120, Thailand
| | - Chatchanan Pornpanit
- Department of Emergency Medicine, Faculty of Medicine, Thammasat University, 99/209 Phahon Yothin Road, Klong Luang District, Pathum Thani, 12120, Thailand
| | - Vanussarin Pornpachara
- Division of Endocrinology, Department of Medicine, Rajavithi Hospital, Bangkok, Thailand
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14
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Brakke BD, Smischney NJ. Pro: The Best Induction for the Physiologically Difficult Airway is Ketamine-Propofol Admixture ("Ketofol"). J Cardiothorac Vasc Anesth 2023:S1053-0770(22)00931-4. [PMID: 36707380 DOI: 10.1053/j.jvca.2022.12.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 12/27/2022] [Accepted: 12/29/2022] [Indexed: 01/09/2023]
Affiliation(s)
- Benjamin D Brakke
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Nathan J Smischney
- Department of Anesthesiology & Perioperative Medicine, Division of Critical Care Medicine, Mayo Clinic, Rochester, MN.
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15
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Horn P, Radtke S, Metzing UB, Steidl R, Sponholz C, Sommerfeld O, Roth J, Claus RA, Birkenfeld AL, Settmacher U, Rauchfuß F, von Loeffelholz C. Associations of Betatrophin/ANGPTL8 with Septic Dyslipidemia in Human Peritonitis: An Explorative Analysis. Biomedicines 2022; 10:biomedicines10123151. [PMID: 36551906 PMCID: PMC9775570 DOI: 10.3390/biomedicines10123151] [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] [Received: 10/23/2022] [Revised: 11/17/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022] Open
Abstract
Sepsis is defined by life-threatening organ dysfunction mediated by the host’s response to infection. This can result in septic dyslipidemia, which is involved in the neutralization of pathogen-related lipids. Knowledge of the regulatory mechanisms of septic dyslipidemia is incomplete. The cytokine betatrophin/Angiopoietin-like protein 8 (ANGPTL8) plays a role in the regulation of triacylglyceride metabolism, though its function in septic dyslipidemia remains unknown. Sixty-six patients were enrolled in a cross-sectional study. Circulating concentrations and adipose tissue (AT) mRNA expression of betatrophin/ANGPTL8 were studied in patients suffering from peritoneal sepsis. Insulin-resistant individuals and subjects without metabolic derangement/systemic inflammation were enrolled as controls. All underwent open abdominal surgery. Circulating betatrophin/ANGPTL8 was analyzed by an enzyme-linked immunosorbent assay and AT mRNA expression levels were assessed by real-time PCR. Standard laboratory analyses including lipid electrophoresis were evaluated. Sepsis patients showed pronounced septic dyslipidemia (p < 0.05 for all major lipid classes). Despite comparable betatrophin/ANGPTL8 mRNA expression in AT (p = 0.24), we found significantly increased circulating betatrophin/ANGPTL8 with septic dyslipidemia (p = 0.009). Expression levels of betatrophin/ANGPTL8 in AT correlated with circulating concentrations in both control groups (r = 0.61; p = 0.008 and r = 0.43; p = 0.034), while this association was undetectable in sepsis. After stratification, betatrophin/ANGPTL8 remained associated with hypertriacylglyceridemia (p < 0.05).
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Affiliation(s)
- Paul Horn
- Department of Internal Medicine IV, Gastroenterology, Hepatology and Infectious Diseases, Jena University Hospital, 07747 Jena, Germany
| | - Sascha Radtke
- Department of Anaesthesiology and Intensive Care, Jena University Hospital, Friedrich Schiller University, Am Klinikum 1, 07747 Jena, Germany
| | - Uta Barbara Metzing
- Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University, Am Klinikum 1, 07747 Jena, Germany
| | - Ricardo Steidl
- Department of Anaesthesiology and Intensive Care, Jena University Hospital, Friedrich Schiller University, Am Klinikum 1, 07747 Jena, Germany
| | - Christoph Sponholz
- Department of Anaesthesiology and Intensive Care, Jena University Hospital, Friedrich Schiller University, Am Klinikum 1, 07747 Jena, Germany
| | - Oliver Sommerfeld
- Department of Anaesthesiology and Intensive Care, Jena University Hospital, Friedrich Schiller University, Am Klinikum 1, 07747 Jena, Germany
| | - Johannes Roth
- Department of Anaesthesiology and Intensive Care, Jena University Hospital, Friedrich Schiller University, Am Klinikum 1, 07747 Jena, Germany
| | - Ralf A. Claus
- Department of Anaesthesiology and Intensive Care, Jena University Hospital, Friedrich Schiller University, Am Klinikum 1, 07747 Jena, Germany
| | - Andreas L. Birkenfeld
- Department of Diabetology Endocrinology and Nephrology, University Hospital Tübingen, Eberhard Karls University Tübingen, 72076 Tübingen, Germany
- Department of Therapy of Diabetes, Institute of Diabetes Research and Metabolic Diseases in the Helmholtz Center Munich, Eberhard Karls University Tübingen, 72076 Tübingen, Germany
- Division of Diabetes and Nutritional Sciences, Rayne Institute, King’s College London, London SE5 9RJ, UK
| | - Utz Settmacher
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany
| | - Falk Rauchfuß
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany
| | - Christian von Loeffelholz
- Department of Anaesthesiology and Intensive Care, Jena University Hospital, Friedrich Schiller University, Am Klinikum 1, 07747 Jena, Germany
- Correspondence: ; Tel.: +49-3641-9323-277; Fax: +49-3641-9323-102
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Arteaga Velásquez J, Rodríguez JJ, Higuita-Gutiérrez LF, Montoya Vergara ME. A systematic review and meta-analysis of the hemodynamic effects of etomidate versus other sedatives in patients undergoing rapid sequence intubation. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2022; 69:663-673. [PMID: 36241514 DOI: 10.1016/j.redare.2021.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 05/29/2021] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Rapid sequence intubation is an airway rescue and protection technique in which different sedatives are used to perform orotracheal intubation. Etomidate, due to its pharmacokinetic and pharmacodynamic qualities, particularly hemodynamic stability, is the most widely used sedative in this scenario. However, its superiority over other sedatives is controversial. MATERIALS AND METHODS We performed a meta-analysis using a pre-designed protocol and PRISMA guidelines to evaluate the mean difference between systolic blood pressure before and after administration of the sedative. We also analyzed the relative risks of hypotension. RESULTS Ten studies were included. The incidence of hypotension in patients receiving etomidate ranged from 6.4% to 75.2%, and between 24.0% and 65.9% in patients receiving other sedatives. No significant differences were found in the mean difference in systolic blood pressure during pre-intubation 0.01 mm Hg (95% CI: -0.90; 0.92) or in post-intubation 0.98 mmHg (95% CI: -0.24; 2.20). The relative risk analysis showed that the risk of hypotension is equal to an RR of 1.19 (95% CI: 0.92-1.54) between those who received etomidate and those who received the other sedatives. CONCLUSIONS The risk of hypotension after rapid intubation sequence with etomidate does not differ significantly compared to other sedatives. However, the studies included in this review were heterogeneous.
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Affiliation(s)
- J Arteaga Velásquez
- Grupo de Investigación Infettare, Facultad de Medicina Universidad Cooperativa de Colombia, Medellín, Colombia.
| | - J J Rodríguez
- Grupo de Investigación Infettare, Facultad de Medicina Universidad Cooperativa de Colombia, Medellín, Colombia; Servicio de Anestesiología de la Institución Prestadora de Servicios IPS Universitaria, Universidad de Antioquia, Servicio de Anestesiología, Clínica Antioquia, Medellín, Colombia
| | - L F Higuita-Gutiérrez
- Grupo de Investigación Infettare, Facultad de Medicina Universidad Cooperativa de Colombia, Medellín, Colombia; Escuela de Microbiología, Universidad de Antioquia, Medellín, Colombia
| | - M E Montoya Vergara
- Grupo de Investigación Infettare, Facultad de Medicina Universidad Cooperativa de Colombia, Medellín, Colombia
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Zhang K, Hu Y, Li R, Li T. Single-cell atlas of murine adrenal glands reveals immune-adrenal crosstalk during systemic <i>Candida albicans</i> infection. Front Immunol 2022; 13:966814. [PMID: 36389688 PMCID: PMC9664004 DOI: 10.3389/fimmu.2022.966814] [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: 06/11/2022] [Accepted: 10/10/2022] [Indexed: 11/25/2022] Open
Abstract
Fungal sepsis remains a major health threat with high mortality, where the adrenal gland stress response has been rarely reported. <i>Candida albicans</i> (<i>C.albicans</i>) is the most common opportunistic fungal pathogen of life-threatening disseminated candidiasis and fungal sepsis. In the present study, we performed single-cell RNA sequencing (scRNA-Seq) using the 10x Genomics platform to analyze the changes in murine adrenal transcriptome following systemic <i>C.albicans</i> infection. A total of 16 021 cells were categorized into 18 transcriptionally distinct clusters, representing adrenocortical cells, endothelial cells, various immune cells, mesenchymal cells, smooth muscle cells, adrenal capsule, chromaffin cells, neurons and glials. As the main cell component in the adrenal gland responsible for steroidogenesis, the adrenocortical cells dramatically diminished and were further grouped into 10 subclusters, which differently distributed in the infected and uninfected samples. Pseudo-time analysis revealed transitions of the adrenocortical cells from the initial normal states to active or dysfunctional states following systemic <i>C.albicans</i> infection <i>via</i> two trajectory paths. Endothelial cells in the highly vascularized organ of adrenal gland further proliferated following infection, with the upregulation of genes positively regulating angiogenesis and downregulation of protective genes of endothelial cells. Immune cells were also excessively infiltrated in adrenal glands of <i>C.albicans</i>-infected mice. Macrophages dominated the immune microenvironments in murine adrenal glands both before and after <i>C.albicans</i> infection, mediating the crosstalk among the steroid-producing cells, endothelial cells and immune cells within the adrenal gland. NLR family, pyrin domain containing 3 (NLRP3, encoded by <i>Nlrp3</i>) and complement receptor 3 (CR3, encoded by <i>Itgam</i>) were found to be significantly upregulated on the adrenal macrophages upon systemic <i>C.albicans</i> infection and might play critical roles in mediating the myeloid response. Meanwhile, the number and strength of the interactions between the infiltrating immune cells and adrenal resident cells were unveiled by cell-cell communication analysis to be dramatically increased after systemic <i>C.albicans</i> infection, indicating that the immune-adrenal crosstalk might contribute to the compromised functions of adrenal cells. Overall, our comprehensive picture of the murine adrenal gland microenvironment in systemic <i>C.albicans</i> infection provides deeper insights into the immune-adrenal cell communications during fungal sepsis.
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Affiliation(s)
- Kai Zhang
- Department of Dermatology and Venerology, Peking University First Hospital, Beijing, China,National Clinical Research Center for Skin and Immune Diseases, Beijing, China,Research Center for Medical Mycology, Peking University, Beijing, China,Beijing Key Laboratory of Molecular Diagnosis on Dermatoses, Beijing, China
| | - Yuzhe Hu
- Department of Immunology, School of Basic Medical Sciences, Peking University Health Science Center, Beijing, China,Key Laboratory of Medical Immunology, National Health Commission of the People's Republic of China, Beijing, China,Peking University Center for Human Disease Genomics, Beijing, China
| | - Ruoyu Li
- Department of Dermatology and Venerology, Peking University First Hospital, Beijing, China,National Clinical Research Center for Skin and Immune Diseases, Beijing, China,Research Center for Medical Mycology, Peking University, Beijing, China,Beijing Key Laboratory of Molecular Diagnosis on Dermatoses, Beijing, China,*Correspondence: Ting Li, ; Ruoyu Li,
| | - Ting Li
- Department of Immunology, School of Basic Medical Sciences, Peking University Health Science Center, Beijing, China,Key Laboratory of Medical Immunology, National Health Commission of the People's Republic of China, Beijing, China,Peking University Center for Human Disease Genomics, Beijing, China,*Correspondence: Ting Li, ; Ruoyu Li,
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18
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Foster M, Self M, Gelber A, Kennis B, Lasoff DR, Hayden SR, Wardi G. Ketamine is not associated with more post-intubation hypotension than etomidate in patients undergoing endotracheal intubation. Am J Emerg Med 2022; 61:131-136. [PMID: 36096015 PMCID: PMC10106101 DOI: 10.1016/j.ajem.2022.08.054] [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: 04/05/2022] [Revised: 08/13/2022] [Accepted: 08/27/2022] [Indexed: 10/31/2022] Open
Abstract
INTRODUCTION Emergency department (ED) patients undergoing emergent tracheal intubation often have multiple physiologic derangements putting them at risk for post-intubation hypotension. Prior work has shown that post-intubation hypotension is independently associated with increased morbidity and mortality. The choice of induction agent may be associated with post-intubation hypotension. Etomidate and ketamine are two of the most commonly used agents in the ED, however, there is controversy regarding whether either agent is superior in the setting of hemodynamic instability. The goal of this study is to determine whether there is a difference in the rate of post-intubation hypotension who received either ketamine or etomidate for induction. Additionally, we provide a subgroup analysis of patients at pre-existing risk of cardiovascular collapse (identified by pre-intubation shock index (SI) > 0.9) to determine if differences in rates of post-intubation hypotension exist as a function of sedative choice administered during tracheal intubation in these high-risk patients. We hypothesize that there is no difference in the incidence of post-intubation hypotension in patients who receive ketamine versus etomidate. METHODS A retrospective cohort study was conducted on a database of 469 patients having undergone emergent intubation with either etomidate or ketamine induction at a large academic health system. Patients were identified by automatic query of the electronic health records from 1/1/2016-6/30/2019. Exclusion criteria were patients <18-years-old, tracheal intubation performed outside of the ED, incomplete peri-intubation vital signs, or cardiac arrest prior to intubation. Patients at high risk for hemodynamic collapse in the post-intubation period were identified by a pre-intubation SI > 0.9. The primary outcome was the incidence of post-intubation hypotension (systolic blood pressure < 90 mmHg or mean arterial pressure < 65 mmHg). Secondary outcomes included post-intubation vasopressor use and mortality. These analyses were performed on the full cohort and an exploratory analysis in patients with SI > 0.9. We also report adjusted odds ratios (aOR) from a multivariable logistic regression model of the entire cohort controlling for plausible confounding variables to determine independent factors associated with post-intubation hypotension. RESULTS A total of 358 patients were included (etomidate: 272; ketamine: 86). The mean pre-intubation SI was higher in the group that received ketamine than etomidate, (0.97 vs. 0.83, difference: -0.14 (95%, CI -0.2 to -0.1). The incidence of post-intubation hypotension was greater in the ketamine group prior to SI stratification (difference: -10%, 95% CI -20.9% to -0.1%). Emergency physicians were more likely to use ketamine in patients with SI > 0.9. In our multivariate logistic regression analysis, choice of induction agent was not associated with post-intubation hypotension (aOR 1.45, 95% CI 0.79 to 2.65). We found that pre-intubation shock index was the strongest predictor of post-intubation hypotension. CONCLUSION In our cohort of patients undergoing emergent tracheal intubation, ketamine was used more often for patients with an elevated shock index. We did not identify an association between the incidence of post-intubation hypotension and induction agent between ketamine and etomidate. Patients with an elevated shock index were at higher risk of cardiovascular collapse regardless of the choice of ketamine or etomidate.
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Affiliation(s)
- Mitchell Foster
- University of California San Diego School of Medicine, California, United States; Department of Emergency Medicine, NYU Langone Health and NYC Health + Hospitals/Bellevue, New York, United States.
| | - Michael Self
- Department of Emergency Medicine, UC San Diego Health, California, United States; Department of Anesthesiology, Division of Anesthesia Critical Care Medicine, UC San Diego Health, California, United States.
| | - Alon Gelber
- University of California San Diego School of Medicine, California, United States; Department of Bioengineering, University of California at San Diego, California, United States.
| | - Brent Kennis
- University of California San Diego School of Medicine, California, United States.
| | - Daniel R Lasoff
- Department of Emergency Medicine, UC San Diego Health, California, United States; Division of Medical Toxicology, UC San Diego Health, California, United States.
| | - Stephen R Hayden
- Department of Emergency Medicine, UC San Diego Health, California, United States.
| | - Gabriel Wardi
- Department of Emergency Medicine, UC San Diego Health, California, United States; Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, UC San Diego Health, California, United States.
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19
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Chang P, Su Y, Gong D, Kang Y, Liu J, Zhang Y, Zhang WS. The preclinical pharmacological study of a novel intravenous anesthetic, ET-26 hydrochloride, in aged rats. PeerJ 2022; 10:e13995. [PMID: 36196398 PMCID: PMC9527020 DOI: 10.7717/peerj.13995] [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: 05/24/2022] [Accepted: 08/12/2022] [Indexed: 01/19/2023] Open
Abstract
Background ET-26 hydrochloride (ET-26HCl) is a novel analogue of etomidate approved for clinical trials. However, all results from recent studies were accomplished in young adult animals. The objective of this study was to evaluate the efficacy and safety of ET-26HCl in aged rats. Methods Aged Sprague-Dawley rats were randomly divided into three groups (three males and three females in each group) were given dose of two-fold of median effective dose (ED50) of ET-26HCl, etomidate and propofol: the measurements of loss of the righting reflex (LORR) and cardiovascular and respiratory function after injection at the two-fold dose of the median effective dose were used for evaluation of effectiveness and safety, and the modified adrenocorticotropic hormone-stimulation experiment was used to evaluate the inhibition effect of the drugs on the synthesis of adrenal cortical hormones. Results There was no significant difference in the onset time among propofol, etomidate and ET-26HCl. The duration of propofol (850.5 ± 77.4 s) was significantly longer than that caused by etomidate (489.8 ± 77.0 s, p = 0.007) and ET-26HCl (347.3 ± 49.0 s, p = 0.0004). No significant difference was observed in the time to stand and normal activity among drugs. A total of 66.7% of rats in the ET-26HCl group were evaluated to have mild hematuria. Then, etomidate and ET-26HCl had a milder blood pressure inhibition effect than propofol. Apnea was observed in all rats administered propofol and the duration for this side effect was 45.0 ± 9.0 s. For etomidate and ET-26HCl, no apnea was observed. No other clinical signs of side-effect were observed, and no rats died. No significant difference was observed in corticosterone concentrations between ET-26HCl and solvent group. However, rats administered etomidate had lower corticosterone concentrations than those administered ET-26HCl at 15, 30, and 60 min. Conclusions Our results indicate ET-26HCl in aged rats is an effective sedative-hypnotic with stable myocardial and respiratory performance and also have mild adrenocortical suppression. Thus, these findings increase the potential for the clinical use of ET-26HCl in the elderly population.
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Affiliation(s)
- Pan Chang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - YongWei Su
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - DeYing Gong
- Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, China,National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Yi Kang
- Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, China,National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Jin Liu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China,Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, China,National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - YuJun Zhang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China,Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, China,National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Wen-sheng Zhang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China,Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, China,National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
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20
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Chin YX, Loganathan N, Kirthinanda DS. Non-diabetic euglycaemic ketoacidosis and rapid weight loss in a post-traumatic surgical patient: is the outré preventable? BMJ Case Rep 2022; 15:e250796. [PMID: 35793842 PMCID: PMC9260800 DOI: 10.1136/bcr-2022-250796] [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] [Accepted: 06/16/2022] [Indexed: 11/03/2022] Open
Abstract
To highlight the implications of the metabolic stress response and the role of anaesthesia in attenuating its deleterious effects, we present this extremely rare case of non-diabetic euglycaemic ketoacidosis with rapid weight loss in a post-traumatic surgical patient. Ketoacidosis is the accumulation of ketone bodies in blood and is generally associated with relative or absolute insulin deficiency secondary to diabetes mellitus, sodium-glucose cotransporter 2 inhibitors and extensive fasting. The stress of systemic disease, trauma or surgery in such predisposed patients could precipitate ketoacidosis. Our patient developed high anion gap metabolic acidosis intraoperatively due to ketosis, a potentially life-threatening complication, without any predisposing factors as a result of metabolic stress of major trauma and surgery. Aiding the interpretation, he lost 15 kg weight perioperatively, suggesting his body was in a hypercatabolic state. This report emphasises the value of anaesthetic techniques to prevent such rare complications.
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Affiliation(s)
- Yun Xin Chin
- Department of Anaesthesia, Intensive Care and Pain Medicine, Singapore General Hospital, Singapore
| | - Nivan Loganathan
- Department of Anaesthesiology, Jurong Health Campus, National University Health System, Singapore
| | - Dinoo Suran Kirthinanda
- Department of Anaesthesiology, Jurong Health Campus, National University Health System, Singapore
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21
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Pansiritanachot W, Ruangsomboon O, Limsuwat C, Chakorn T. Independent risk factors of mortality in patients with sepsis receiving single-dose etomidate as an induction agent during rapid sequence intubation in a large tertiary emergency department in Thailand. BMC Emerg Med 2022; 22:94. [PMID: 35659186 PMCID: PMC9164430 DOI: 10.1186/s12873-022-00658-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 05/27/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND There is limited evidence regarding factors associated with mortality in septic patients receiving etomidate. This study aimed to determine independent pre-intubation factors predicting 28-day mortality in septic patients receiving single-dose etomidate as an induction agent during rapid sequence intubation (RSI). METHODS This single-center retrospective cohort study included intubated septic patients receiving etomidate as an induction agent during RSI in the emergency department of Siriraj hospital, Bangkok, Thailand, between January 1st, 2016 and June 30th, 2020. Pre-intubation characteristics were compared between survivors and non-survivors. Independent risk factors associated with 28-day mortality were identified using the Cox proportional hazards regression model. Association between etomidate dosage and mortality was also determined. RESULTS A total of 344 patients, 238 (69%) survivors and 106 (31%) non-survivors, were included in the analyses. The initial Cox hazards model identified a pre-intubation lactate level ≥ 4 mmol/L as an independent factor associated with mortality (adjusted Hazards ratio [aHR] 2.66, 95% confidence interval [CI] 1.55-4.56). After removing lactate level from the model due to limited lactate values in the data, cancer was also predictive of 28-day mortality (aHR 1.83, 95%CI 1.10-3.04), while patients with respiratory infections and underlying chronic lung disease were associated with lower mortality (aHR 0.54, 95%CI 0.37-0.80 and aHR 0.57, 0.33-0.96, respectively). Etomidate dosage was not associated with mortality in our study. CONCLUSION In septic patients who received a single dose of etomidate, a pre-intubation lactate level ≥ 4 mmol/L and cancer were associated with increased 28-day mortality, while respiratory infection and underlying chronic lung disease were associated with lower mortality. Physicians may take these factors into consideration when selecting induction agents for septic patients.
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Affiliation(s)
- Wasin Pansiritanachot
- Department of Emergency Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok, 10700 Thailand
| | - Onlak Ruangsomboon
- Department of Emergency Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok, 10700 Thailand
| | - Chok Limsuwat
- Department of Emergency Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok, 10700 Thailand
| | - Tipa Chakorn
- Department of Emergency Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok, 10700 Thailand
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22
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Wang B, Gong D, Kang Y, Liu J, Yang J, Zhang WS. E161111 is an ultra-short-acting etomidate analogue with stable haemodynamics that elicits only slight adrenocortical suppression in rats. PeerJ 2022; 10:e13492. [PMID: 35646481 PMCID: PMC9138173 DOI: 10.7717/peerj.13492] [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: 12/21/2021] [Accepted: 05/03/2022] [Indexed: 02/05/2023] Open
Abstract
Purpose We report on a novel ultra-short-acting etomidate analogue, E161111, which has the same primary metabolite as etomidate. Methods The metabolic rate of E161111 was determined in rat plasma and liver homogenate. Rats were infused for 30 or 60 min to maintain light sedation at Richmond Agitation-Sedation Scale (RASS) for -2 to 0 score. Mean arterial pressure (MAP) was monitored during 30 min infusion. The serum corticosterone was determined during and 3 h after infusion as a measure of adrenocortical function. Results E161111 was not detected in rat plasma at 1 min (t1/2 = 6.69 ± 0.07 s) and in rat liver homogenates at 5 min (t1/2 = 10.20 ± 3.76 s); its main metabolic product was etomidate acid. The recovery time from loss of righting reflex (LORR) was 4.3 ± 1.5 min after 1-h infusion of E161111. During 30 min infusion, E161111 did not cause MAP changes. The stimulated serum corticosterone levels after 1-h infusion of E161111 were significantly higher than that after 1-h infusion of etomidate at all time points tested for the 3 h study. Conclusions E161111 was metabolised rapidly, the metabolites were same as etomidate, and the recovery time after 1-h infusion was short. It elicited haemodynamic stability and milder suppression of corticosterone than that elicited by etomidate.
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Affiliation(s)
- Bin Wang
- Department of Anesthesiology, People’s Hospital of Guizhou Province, Guiyang, Guizhou, China,Laboratory of Anaesthesia and Critical Care Medicine, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Deying Gong
- Laboratory of Anaesthesia and Critical Care Medicine, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China,National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yi Kang
- Laboratory of Anaesthesia and Critical Care Medicine, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China,National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jin Liu
- Laboratory of Anaesthesia and Critical Care Medicine, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China,National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jun Yang
- Laboratory of Anaesthesia and Critical Care Medicine, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China,National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Wen-sheng Zhang
- Laboratory of Anaesthesia and Critical Care Medicine, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China,National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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23
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Tarwade P, Smischney NJ. Endotracheal intubation sedation in the intensive care unit. World J Crit Care Med 2022; 11:33-39. [PMID: 35433310 PMCID: PMC8788207 DOI: 10.5492/wjccm.v11.i1.33] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 06/21/2021] [Accepted: 11/04/2021] [Indexed: 02/06/2023] Open
Abstract
Endotracheal intubation is one of the most common, yet most dangerous procedure performed in the intensive care unit (ICU). Complications of ICU intubations include severe hypotension, hypoxemia, and cardiac arrest. Multiple observational studies have evaluated risk factors associated with these complications. Among the risk factors identified, the choice of sedative agents administered, a modifiable risk factor, has been reported to affect these complications (hypotension). Propofol, etomidate, and ketamine or in combination with benzodiazepines and opioids are commonly used sedative agents administered for endotracheal intubation. Propofol demonstrates rapid onset and offset, however, has drawbacks of profound vasodilation and associated cardiac depression. Etomidate is commonly used in the critically ill population. However, it is known to cause reversible inhibition of 11 β-hydroxylase which suppresses the adrenal production of cortisol for at least 24 h. This added organ impairment with the use of etomidate has been a potential contributing factor for the associated increased morbidity and mortality observed with its use. Ketamine is known to provide analgesia with sedation and has minimal respiratory and cardiovascular effects. However, its use can lead to tachycardia and hypertension which may be deleterious in a patient with heart disease or cause unpleasant hallucinations. Moreover, unlike propofol or etomidate, ketamine requires organ dependent elimination by the liver and kidney which may be problematic in the critically ill. Lately, a combination of ketamine and propofol, “Ketofol”, has been increasingly used as it provides a balancing effect on hemodynamics without any of the side effects known to be associated with the parent drugs. Furthermore, the doses of both drugs are reduced. In situations where a difficult airway is anticipated, awake intubation with the help of a fiberoptic scope or video laryngoscope is considered. Dexmedetomidine is a commonly used sedative agent for these procedures.
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Affiliation(s)
- Pritee Tarwade
- Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN 55905, United States
| | - Nathan J Smischney
- Anesthesiology and Perioperative Medicine, Division of Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, United States
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24
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Matchett G, Gasanova I, Riccio CA, Nasir D, Sunna MC, Bravenec BJ, Azizad O, Farrell B, Minhajuddin A, Stewart JW, Liang LW, Moon TS, Fox PE, Ebeling CG, Smith MN, Trousdale D, Ogunnaike BO. Etomidate versus ketamine for emergency endotracheal intubation: a randomized clinical trial. Intensive Care Med 2022; 48:78-91. [PMID: 34904190 DOI: 10.1007/s00134-021-06577-x] [Citation(s) in RCA: 46] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 11/02/2021] [Indexed: 01/15/2023]
Abstract
PURPOSE Etomidate and ketamine are hemodynamically stable induction agents often used to sedate critically ill patients during emergency endotracheal intubation. In 2015, quality improvement data from our hospital suggested a survival benefit at Day 7 from avoidance of etomidate in critically ill patients during emergency intubation. In this clinical trial, we hypothesized that randomization to ketamine instead of etomidate would be associated with Day 7 survival after emergency endotracheal intubation. METHODS A prospective, randomized, open-label, parallel assignment, single-center clinical trial performed by an anesthesiology-based Airway Team under emergent circumstances at one high-volume medical center in the United States. 801 critically ill patients requiring emergency intubation were randomly assigned 1:1 by computer-generated, pre-randomized sealed envelopes to receive etomidate (0.2-0.3 mg/kg, n = 400) or ketamine (1-2 mg/kg, n = 401) for sedation prior to intubation. The pre-specified primary endpoint of the trial was Day 7 survival. Secondary endpoints included Day 28 survival. RESULTS Of the 801 enrolled patients, 396 were analyzed in the etomidate arm, and 395 in the ketamine arm. Day 7 survival was significantly lower in the etomidate arm than in the ketamine arm (77.3% versus 85.1%, difference - 7.8, 95% confidence interval - 13, - 2.4, p = 0.005). Day 28 survival rates for the two groups were not significantly different (etomidate 64.1%, ketamine 66.8%, difference - 2.7, 95% confidence interval - 9.3, 3.9, p = 0.294). CONCLUSION While the primary outcome of Day 7 survival was greater in patients randomized to ketamine, there was no significant difference in survival by Day 28.
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Affiliation(s)
- Gerald Matchett
- Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA.
| | - Irina Gasanova
- Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
| | - Christina A Riccio
- Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
| | - Dawood Nasir
- Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
| | - Mary C Sunna
- Department of Anesthesiology, Parkland Health and Hospital System, Dallas, TX, USA
| | - Brian J Bravenec
- Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
| | - Omaira Azizad
- Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
| | - Brian Farrell
- Department of Anesthesiology, Parkland Health and Hospital System, Dallas, TX, USA
| | - Abu Minhajuddin
- Department of Population and Data Sciences, UT-Southwestern Medical Center, Dallas, TX, USA
- Department of Psychiatry, UT-Southwestern Medical Center, Dallas, TX, USA
| | - Jesse W Stewart
- Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
| | - Lawrence W Liang
- Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
| | - Tiffany Sun Moon
- Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
| | - Pamela E Fox
- Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
| | - Callie G Ebeling
- Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
| | - Miakka N Smith
- Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
| | - Devin Trousdale
- Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
| | - Babatunde O Ogunnaike
- Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
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25
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Xu X, Wei Y, Dong Y, Qiu Y, Mei Z, Wang K, Xiu J, Wang T, Zeng L, Dong X, Shen Y, Jiang W, Li Q. A Novel Etomidate Analogue EL-0052 Retains Potent Hypnotic Effect and Stable Hemodynamics without Suppressing Adrenocortical Function. J Pharmacol Exp Ther 2021; 379:324-330. [PMID: 34521699 DOI: 10.1124/jpet.121.000691] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 08/04/2021] [Indexed: 11/22/2022] Open
Abstract
Etomidate is a potent and rapidly acting anesthetic with high therapeutic index (TI) and superior hemodynamic stability. However, side-effect of suppressing adrenocortical function limits its clinical use. To overcome this side-effect, we designed a novel etomidate analogue EL-0052, aiming to retain beneficial properties of etomidate and avoid its disadvantage of suppressing adrenocortical steroid synthesis. Results exhibited that EL-0052 enhanced GABAA receptors currents with a concentration for 50% of maximal effect (EC50) of 0.98 {plus minus} 0.02 μM, which was about three times more potent than etomidate (3.07 {plus minus} 1.67 μM). Similar to hypnotic potency of etomidate, EL-0052 exhibited loss of righting reflex (LORR) with ED50s of 1.02 (0.93-1.20) mg/kg in rats, and 0.5 (0.45-0.56) mg/kg in dogs. The TI of EL-0052 in rats was 28, higher than 22 of etomidate. There was no significant difference in hypnotic onset time, recovery time and walking time between EL-0052 and etomidate in rats. Both of them had minor effects on mean arterial pressure (MAP) in dogs. EL-0052 had no significant effect on adrenocortical function in dogs even at a high dose (4.3×ED50), whereas etomidate significantly inhibited corticosteroid secretion. The inhibition of cortisol synthesis assay showed that EL-0052 had a weak inhibition on cortisol biosynthesis in human H259 cells with a half inhibitory concentration (IC50) of 1050 {plus minus} 100 nM, which was 2.09 {plus minus} 0.27 nM for etomidate. EL-0052 retains the favorable properties of etomidate, including potent hypnotic effect, rapid onset and recovery, stable hemodynamics and high therapeutic index without suppression of adrenocortical function. Significance Statement The novel etomidate analogue EL-0052 retains the favorable properties of etomidate without suppressing adrenocortical function and provides a new strategy to optimize the structure of etomidate.
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Affiliation(s)
| | - Yaqin Wei
- School of Pharmacy, Xuzhou Medical University, China
| | | | - Yinli Qiu
- Jiangsu Nhwa Pharmaceutical Co., Ltd., China
| | | | - Kai Wang
- Jiangsu Nhwa-Luokang Pharma R&D Ltd., China
| | - Jingya Xiu
- Jiangsu Nhwa-Luokang Pharma R&D Ltd., China
| | - Tao Wang
- Jiangsu Nhwa-Luokang Pharma R&D Ltd., China
| | | | | | - Yi Shen
- Jiangsu Nhwa-Luokang Pharma R&D Ltd., China
| | - Wengao Jiang
- The Key laboratory of molecular and biochemistry, School of Pharmacy, Chongqing Medical University, China
| | - Qingeng Li
- Jiangsu Nhwa-Luokang Pharma R&D Ltd.; Division of Medicinal Chemistry, School of Pharmacy, Chongqing Medical University, China
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26
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Weiss B, Schiefenhövel F, Grunow JJ, Krüger M, Spies CD, Menk M, Kruppa J, Grubitzsch H, Sander M, Treskatsch S, Balzer F. Infectious Complications after Etomidate vs. Propofol for Induction of General Anesthesia in Cardiac Surgery-Results of a Retrospective, before-after Study. J Clin Med 2021; 10:jcm10132908. [PMID: 34209919 PMCID: PMC8269440 DOI: 10.3390/jcm10132908] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 06/24/2021] [Accepted: 06/26/2021] [Indexed: 12/17/2022] Open
Abstract
Background: Etomidate is typically used as an induction agent in cardiac surgery because it has little impact on hemodynamics. It is a known suppressor of adrenocortical function and may increase the risk for post-operative infections, sepsis, and mortality. The aim of this study was to evaluate whether etomidate increases the risk of postoperative sepsis (primary outcome) and infections (secondary outcome) compared to propofol. Methods: This was a retrospective before–after trial (IRB EA1/143/20) performed at a tertiary medical center in Berlin, Germany, between 10/2012 and 01/2015. Patients undergoing cardiac surgery were investigated within two observation intervals, during which etomidate and propofol were the sole induction agents. Results: One-thousand, four-hundred, and sixty-two patients, and 622 matched pairs, after caliper propensity-score matching, were included in the final analysis. Sepsis rates did not differ in the matched cohort (etomidate: 11.5% vs. propofol: 8.2%, p = 0.052). Patients in the etomidate interval were more likely to develop hospital-acquired pneumonia (etomidate: 18.6% vs. propofol: 14.0%, p = 0.031). Conclusion: Our study showed that a single-dose of etomidate is not statistically associated with higher postoperative sepsis rates after cardiac surgery, but is associated with a higher incidence of hospital-acquired pneumonia. However, there is a notable trend towards a higher sepsis rate.
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Affiliation(s)
- Björn Weiss
- Department of Anesthesiology and Intensive Care Medicine (Campus Charité Mitte, Campus Virchow-Klinikum), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, 13353 Berlin, Germany; (B.W.); (F.S.); (J.J.G.); (M.K.); (C.D.S.); (M.M.)
| | - Fridtjof Schiefenhövel
- Department of Anesthesiology and Intensive Care Medicine (Campus Charité Mitte, Campus Virchow-Klinikum), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, 13353 Berlin, Germany; (B.W.); (F.S.); (J.J.G.); (M.K.); (C.D.S.); (M.M.)
- Institute of Health, Institute of Medical Informatics, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, 10117 Berlin, Germany;
| | - Julius J. Grunow
- Department of Anesthesiology and Intensive Care Medicine (Campus Charité Mitte, Campus Virchow-Klinikum), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, 13353 Berlin, Germany; (B.W.); (F.S.); (J.J.G.); (M.K.); (C.D.S.); (M.M.)
| | - Michael Krüger
- Department of Anesthesiology and Intensive Care Medicine (Campus Charité Mitte, Campus Virchow-Klinikum), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, 13353 Berlin, Germany; (B.W.); (F.S.); (J.J.G.); (M.K.); (C.D.S.); (M.M.)
| | - Claudia D. Spies
- Department of Anesthesiology and Intensive Care Medicine (Campus Charité Mitte, Campus Virchow-Klinikum), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, 13353 Berlin, Germany; (B.W.); (F.S.); (J.J.G.); (M.K.); (C.D.S.); (M.M.)
| | - Mario Menk
- Department of Anesthesiology and Intensive Care Medicine (Campus Charité Mitte, Campus Virchow-Klinikum), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, 13353 Berlin, Germany; (B.W.); (F.S.); (J.J.G.); (M.K.); (C.D.S.); (M.M.)
| | - Jochen Kruppa
- Institute of Health, Institute of Medical Informatics, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, 10117 Berlin, Germany;
| | - Herko Grubitzsch
- Department of Cardiovascular Surgery, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany;
| | - Michael Sander
- Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Gieβen, Justus-Liebig University Gieβen, 35390 Gieβen, Germany;
| | - Sascha Treskatsch
- Department of Anesthesiology and Operative Intensive Care Medicine (Campus Benjamin Franklin), Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, 12203 Berlin, Germany;
| | - Felix Balzer
- Department of Anesthesiology and Intensive Care Medicine (Campus Charité Mitte, Campus Virchow-Klinikum), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, 13353 Berlin, Germany; (B.W.); (F.S.); (J.J.G.); (M.K.); (C.D.S.); (M.M.)
- Institute of Health, Institute of Medical Informatics, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, 10117 Berlin, Germany;
- Correspondence: ; Tel.: +49-30-450-651-166
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27
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Zimmerman DE, Sarangarm P, Brown CS, Faine B, Flack T, Gilbert BW, Howington GT, Kelly G, Laub J, Porter BA, Slocum GW, Rech MA. Staying InformED: Top emergency Medicine pharmacotherapy articles of 2020. Am J Emerg Med 2021; 49:200-205. [PMID: 34139435 PMCID: PMC8204853 DOI: 10.1016/j.ajem.2021.05.061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 05/14/2021] [Accepted: 05/24/2021] [Indexed: 01/13/2023] Open
Abstract
The year 2020 was not easy for Emergency Medicine (EM) clinicians with the burden of tackling a pandemic. A large focus, rightfully so, was placed on the evolving diagnosis and management of patients with COVID-19 and, as such, the ability of clinicians to remain up to date on key EM pharmacotherapy literature may have been compromised. This article reviews the most important EM pharmacotherapy publications indexed in 2020. A modified Delphi approach was utilized for selected journals to identify the most impactful EM pharmacotherapy studies. A total of fifteen articles, eleven trials and four meta-analyses, were identified. This review provides a summary of each study, along with a commentary on the impact to the EM literature and EM clinician.
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Affiliation(s)
- David E Zimmerman
- Duquesne University School of Pharmacy, University of Pittsburgh Medical Center-Mercy Hospital, Room 311 Bayer Learning Center, 600 Forbes Avenue, Pittsburgh, PA 15282, United States of America.
| | - Preeyaporn Sarangarm
- Department of Pharmacy, University of New Mexico Hospital, Albuquerque, NM 87106, United States of America
| | - Caitlin S Brown
- Department of Pharmacy, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Brett Faine
- Department of Emergency Medicine and Pharmacy Practice, University of Iowa, Iowa City, IA 52242, United States of America
| | - Tara Flack
- Department of Pharmacy, IU Health Methodist Hospital, Indianapolis, IN 46202, United States of America
| | - Brian W Gilbert
- Department of Pharmacy, Wesley Medical Center, Wichita, KS 67205, United States of America
| | - Gavin T Howington
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY 40506, United States of America; Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY 40536, United States of America
| | - Gregory Kelly
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, United States of America
| | - Jessica Laub
- Department of Pharmacy, New York-Presbyterian-Brooklyn Methodist Hospital, Brooklyn, NY 11215, United States of America
| | - Blake A Porter
- Department of Pharmacy, University of Vermont Medical Center, Burlington, VT 05401, United States of America
| | - Giles W Slocum
- Department of Emergency Medicine and Department of Pharmacy, Rush University Medical Center, Chicago, IL 60612, United States of America
| | - Megan A Rech
- Loyola University Chicago, Loyola University Medical Center, Stritch School of Medicine, Department of Emergency Medicine, S 1st Ave, Maywood 60153, IL, United States of America; Loyola University Medical Center, Department of Pharmacy, S 1st Ave, Maywood, IL 60153, United States of America
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28
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Zhang Y, Jiang Y, Chang P, Kang Y, Gong D, Liu J, Zhang W. Safety Pharmacology Study of ET-26 Hydrochloride, a Potential Drug for Intravenous General Anesthesia, in Rats and Beagle Dogs. Front Pharmacol 2021; 12:679381. [PMID: 34135759 PMCID: PMC8201096 DOI: 10.3389/fphar.2021.679381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 05/04/2021] [Indexed: 02/05/2023] Open
Abstract
Background: ET-26 hydrochloride (ET-26HCl), a class 1 new drug, was developed to reserve the advantages of etomidate with a mild adrenocortical inhibition. Purpose: this study was to evaluate the potential adverse effects on the cardiovascular system of beagle dogs and the respiratory and central nervous systems of rats. Methods: three established methods, the whole-body plethysmography for respiratory function, the prototype telemetry transmitter for cardiovascular function, and the standardized functional observational battery for central nervous system function, were accomplished with Good Laboratory Practice standards. Results: no significant difference in the tidal volume, but the respiratory rate and minute ventilation were reduced. The degree of inhibition was the most serious in the first 15 min after dosing and function fully recovered after 1 h. For male rats, the respiratory rate of male rats was reduced significantly at 15 min after injection with ET-26HCl (4 mg/kg, 28.6%, p ≤ 0.01; 8 mg/kg, 24.5%, p ≤ 0.01; 16 mg/kg, 44.5%, p ≤ 0.001), and the minute ventilation at 15 min was decreased by 20.1% (4 mg/kg, p = 0.034), 22.2% (8 mg/kg, p = 0.019), and 44.6% (16 mg/kg, p ≤ 0.001) as compared to control group. As with male rats, the respiratory rate of the female rats was reduced significantly at 15 min (4 mg/kg, 23.3%, p ≤ 0.01; 8 mg/kg, 29.2%, p ≤ 0.001; 16 mg/kg, 44.1%, p ≤ 0.001), and the minute ventilation was decreased by 25.2% (4 mg/kg, p ≤ 0.001), 23.0% (8 mg/kg, p ≤ 0.01), and 47.6% (16 mg/kg, p ≤ 0.001). Then, all the variations in cardiovascular functions were within the expected range for normal biological variation, we concluded that ET-26HCl, even at 10-fold ED50, still does not exert toxicological effects on the cardiovascular system. For male beagle dogs, the systolic blood pressure after 24 h following administration of vehicle control or 8, 12, or 16 mg/kg ET-26HCl was 137.80 ± 5.55, 131.76 ± 10.03, 139.88 ± 8.35, and 141.28 ± 8.75 mmHg, respectively. The diastolic blood pressure was 71.16 ± 4.84, 66.52 ± 8.50, 73.64 ± 8.51, and 74.24 ± 8.68 mmHg, respectively. For female beagle dogs, the systolic blood pressure after 24 h following administration of vehicle control or 8, 12, or 16 mg/kg ET-26HCl was 128.28 ± 5.22, 124.76 ± 7.29, 134.88 ± 5.56, and 135.36 ± 8.72 mmHg, respectively. The diastolic blood pressure was 67.00 ± 4.10, 62.12 ± 7.87, 69.44 ± 6.40, and 70.20 ± 8.42 mmHg, respectively. In central nervous system function experiment, all the changes observed in the functional observational battery tests, including motor activity, behavior, coordination, and sensory and motor reflex responses, and reduced body temperature, were resulted in general anesthesia effect of ET-26HCl. Conclusion: ET-26HCl exerts mild, reversible effects on respiratory, cardiovascular, and central nervous system function as verified by standard in vivo animal models.
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Affiliation(s)
- YuJun Zhang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China.,Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, China.,National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - YingYing Jiang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China.,Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, China.,National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Pan Chang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China.,Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, China.,National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Yi Kang
- Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, China.,National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - DeYing Gong
- Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, China.,National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Jin Liu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China.,Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, China.,National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - WenSheng Zhang
- Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, China.,National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
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Propofol, Ketamine, and Etomidate as Induction Agents for Intubation and Outcomes in Critically Ill Patients: A Retrospective Cohort Study. Crit Care Explor 2021; 3:e0435. [PMID: 34046636 PMCID: PMC8148417 DOI: 10.1097/cce.0000000000000435] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Propofol, ketamine, and etomidate are common anesthetic agents for induction of anesthesia in the ICU. The choice between these agents is complex and may not depend solely upon severity of illness. OBJECTIVES To evaluate the association between the administration of propofol, ketamine, and etomidate and ICU, hospital mortality, and length of stay. DESIGN SETTING AND PARTICIPANTS Retrospective single-center cohort study. ICUs in a tertiary medical center, between January 01, 2012, and December 31, 2017. Critically ill adult patients given a single IV anesthetic for intubation. MAIN OUTCOME AND MEASURES Primary outcomes were ICU and hospital mortality. Secondary outcomes were ICU- and hospital-free days through 28 days. An inverse probability of treatment weighed approach was used. The propensity score was estimated using a generalized logit model as a function of patient characteristics, admission source, ICU type, readmission status, length of ICU stays prior to intubation, and acute physiology score. Mortality outcomes were assessed with weighted logistic regression and -free days assessed by weighted linear regression with Bonferroni correction for pairwise comparisons. RESULTS Of 2,673 patients, 36% received propofol, 30% ketamine and 34% etomidate. Overall ICU and hospital mortality were 19% and 29%, respectively. Patients given ketamine had higher odds of ICU mortality (1.45; [95% CI, 1.07-1.94]; p = 0.015) and patients given etomidate had higher odds of ICU mortality (1.87; 1.40-2.49; p < 0.001), hospital mortality (1.43; 1.09-1.86; p = 0.009), and less ICU-free days (-2.10; -3.21 to -1.00; p < 0.001) than those given propofol. Patients given ketamine and etomidate had similar odds of hospital mortality (1.06; 0.80-1.42; p = 0.761) and similar hospital-free days (0.30; -0.81 to 1.40; p = 0.600). CONCLUSIONS AND RELEVANCE Compared with ketamine and etomidate, propofol was associated with better outcome in critically ill patients undergoing anesthesia for intubation. Even after adjusting for severity of illness prior to intubation, residual confounders cannot be excluded.
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Ramineni A, Roberts EA, Vora M, Mahboobi SK, Nozari A. Anesthesia Considerations in Neurological Emergencies. Neurol Clin 2021; 39:319-332. [PMID: 33896521 DOI: 10.1016/j.ncl.2021.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Airway obstruction and respiratory failure are common complications of neurological emergencies. Anesthesia is often employed for airway management, surgical and endovascular interventions or in the intensive care units in patients with altered mental status or those requiring burst suppression. This article provides a summary of the unique airway management and anesthesia considerations and controversies for neurologic emergencies in general, as well as for specific commonly encountered conditions: elevated intracranial pressure, neuromuscular respiratory failure, acute ischemic stroke, and acute cervical spinal cord injury.
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Affiliation(s)
- Anil Ramineni
- Department of Neurology, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA 01805, USA
| | - Erik A Roberts
- Boston University School of Medicine, 72 East Concord Street, Boston, MA 02118, USA
| | - Molly Vora
- Boston University School of Medicine, 72 East Concord Street, Boston, MA 02118, USA
| | - Sohail K Mahboobi
- Department of Anesthesiology, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA 01805, USA; Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA 02111, USA
| | - Ala Nozari
- Boston University School of Medicine, 72 East Concord Street, Boston, MA 02118, USA; Department of Anesthesiology, Boston Medical Center, 750 Albany Street, Power Plant 2R, Boston, MA 02118, USA.
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31
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Cagliani JA, Ruhemann A, Molmenti E, Smith C, Coppa G, Barrera R. Association between Etomidate Use for Rapid Sequence Intubation and Adrenal Insufficiency in Sepsis. Cureus 2021; 13:e13445. [PMID: 33767929 PMCID: PMC7982295 DOI: 10.7759/cureus.13445] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background The risk of adrenal insufficiency (AI) in using single-dose etomidate for intubation among patients with sepsis remains controversial. Our aim was to assess the prevalence of AI and characterize the risk factors in patients who received etomidate for rapid sequence intubation (RSI). Methods This is a retrospective study of prospectively-acquired data evaluating surgical intensive care unit (SICU) patients who developed respiratory failure undergoing RSI. Results Of the 44 adult SICU patients who developed respiratory failure, 34 patients received etomidate. The average age for the total cohort, for the patients that received etomidate and for those who did not, was 70.91 ± 14.92, 72.82 ± 13.61 years and 64.40 ± 15.93, respectively. Twenty-four patients of the total cohort (54.55%) developed AI; 26 had septic shock (59.09%), and 16 patients had AI and septic shock (36.36%). There was no statistical significance between the incidence of AI in patients who received etomidate (47%) and those who did not (80%). However, in the subset of patients who received etomidate for RSI, there was a non-significant trend toward increased incidence of AI in those who were septic compared to those who were not (p = 0.06). Conclusion A single dose of etomidate used for RSI in SICU patients is not associated with the development of AI or mortality. However, a trend was shown, although not statistically significant, towards the development of AI in septic patients. High-quality and adequately powered randomized control trials (RCTs) are warranted.
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Affiliation(s)
- Joaquin A Cagliani
- Anesthesiology, State University of New York (SUNY) Downstate Medical Center, New York, USA
| | - Andres Ruhemann
- Internal Medicine, Instituto Alfredo Lanari, Buenos Aires, ARG
| | | | - Candace Smith
- Internal Medicine, College of Pharmacy and Health Sciences - St. John's University, New York, USA
| | - Gene Coppa
- General Surgery, Northwell Health, New York, USA
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Kornas RL, Owyang CG, Sakles JC, Foley LJ, Mosier JM. Evaluation and Management of the Physiologically Difficult Airway: Consensus Recommendations From Society for Airway Management. Anesth Analg 2021; 132:395-405. [PMID: 33060492 DOI: 10.1213/ane.0000000000005233] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Multiple international airway societies have created guidelines for the management of the difficult airway. In critically ill patients, there are physiologic derangements beyond inadequate airway protection or hypoxemia. These risk factors contribute to the "physiologically difficult airway" and are associated with complications including cardiac arrest and death. Importantly, they are largely absent from international guidelines. Thus, we created management recommendations for the physiologically difficult airway to provide practical guidance for intubation in the critically ill. Through multiple rounds of in-person and telephone conferences, a multidisciplinary working group of 12 airway specialists (Society for Airway Management's Special Projects Committee) over a time period of 3 years (2016-2019) reviewed airway physiology topics in a modified Delphi fashion. Consensus agreement with the following recommendations among working group members was generally high with 80% of statements showing agreement within a 10% range on a sliding scale from 0% to 100%. We limited the scope of this analysis to reflect the resources and systems of care available to out-of-operating room adult airway providers. These recommendations reflect the practical application of physiologic principles to airway management available during the analysis time period.
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Affiliation(s)
- Rebecca L Kornas
- From the Department of Emergency Medicine, Denver Health, Denver, Colorado
| | - Clark G Owyang
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York
| | - John C Sakles
- Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, Arizona
| | - Lorraine J Foley
- Department of Anesthesiology, Winchester Hospital, Tufts University School of Medicine, Boston, Massachusetts
| | - Jarrod M Mosier
- Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, Arizona.,Division of Pulmonary, Allergy, Critical Care and Sleep, Department of Medicine, University of Arizona College of Medicine, Tucson, Arizona
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33
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Dalia AA, Raines DE. Etomidate and Adrenocortical Suppression: Should We Take the Concerns to Heart? J Cardiothorac Vasc Anesth 2021; 35:1086-1088. [PMID: 33579572 DOI: 10.1053/j.jvca.2021.01.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 01/15/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Adam A Dalia
- Division of Cardiac Anesthesiology, Department of Critical Care, Anesthesia, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Critical Care, Anesthesia, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Douglas E Raines
- Department of Critical Care, Anesthesia, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
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34
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Chalkias A, Barreto EF, Laou E, Kolonia K, Scheetz MH, Gourgoulianis K, Pantazopoulos I, Xanthos T. A Critical Appraisal of the Effects of Anesthetics on Immune-system Modulation in Critically Ill Patients With COVID-19. Clin Ther 2021; 43:e57-e70. [PMID: 33549310 PMCID: PMC7833032 DOI: 10.1016/j.clinthera.2021.01.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 12/26/2020] [Accepted: 01/02/2021] [Indexed: 02/07/2023]
Abstract
Purpose The aim of the present article was to briefly summarize current knowledge about the immunomodulatory effects of general anesthetics and the possible clinical effects of this immunomodulation in patients with COVID-19. Methods The PubMed, Scopus, and Google Scholar databases were comprehensively searched for relevant studies. Findings The novel coronavirus causes a wide spectrum of clinical manifestations, with a large absolute number of patients experiencing severe pneumonia and rapid progression to acute respiratory distress syndrome and multiple organ failure. In these patients, the equilibrium of the inflammatory response is a major determinant of survival. The impact of anesthetics on immune-system modulation may vary and includes both pro-inflammatory and anti-inflammatory effects. Implications Inhibition of the development of severe inflammation and/or the enhancement of inflammation resolution by anesthetics may limit organ damage and improve outcomes in patients with COVID-19.
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Affiliation(s)
- Athanasios Chalkias
- Faculty of Medicine, Department of Anesthesiology, School of Health Sciences, University of Thessaly, Larisa, Greece.
| | - Erin F Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Eleni Laou
- Faculty of Medicine, Department of Anesthesiology, School of Health Sciences, University of Thessaly, Larisa, Greece
| | - Konstantina Kolonia
- Faculty of Medicine, Department of Anesthesiology, School of Health Sciences, University of Thessaly, Larisa, Greece
| | - Marc H Scheetz
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA; Pharmacometrics Center of Excellence, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA; Department of Pharmacology, College of Graduate Studies, Midwestern University, Downers Grove, IL, USA
| | - Konstantinos Gourgoulianis
- Faculty of Medicine, Department of Respiratory Medicine, School of Health Sciences, University of Thessaly, Larisa, Greece
| | - Ioannis Pantazopoulos
- Faculty of Medicine, Department of Emergency Medicine, School of Health Sciences, University of Thessaly, Larisa, Greece
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Discovery of the EL-0052 as a potential anesthetic drug. Comput Struct Biotechnol J 2021; 19:710-718. [PMID: 33510871 PMCID: PMC7817531 DOI: 10.1016/j.csbj.2021.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 01/03/2021] [Accepted: 01/05/2021] [Indexed: 01/13/2023] Open
Abstract
As a γ-aminobutyric acid A receptor (GABAAR) inhibitor, etomidate fulfills several characteristics of an ideal anesthetic agent, such as rapid onset with rapid clearance and high potency, along with cardiovascular stability. Unfortunately, etomidate has been reported to inhibit CYP11B1 at hypnotic doses, which is associated with a marked increase in patient deaths due to this unexpected off-target effect. In this study, molecular docking was used to simulate the binding mode of etomidate with GABAAR and CYP11B1. Based on the in-depth analysis of the binding mode, strong electron-withdrawing group on the C4 position of the imidazole ring was introduced to reduce the charge density of the nitrogen, which is beneficial in reducing the coordination bond between the imidazole nitrogen and heme iron in CYP11B1, as well as in reducing the adrenocortical suppression. Based on the results of ADMET property prediction, MEP analysis, and molecular docking simulation, 4-fluoroetomidate (EL-0052) was designed and synthesized. In vivo studies in rats and mice confirmed that EL-0052 had the efficacy similar to etomidate, but without adrenocortical suppression. These findings suggested that EL-0052 was superior to etomidate and support the continued development of EL-0052 as a preclinical candidate as an anesthetic.
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Yao YT, He LX, Fang NX, Ma J. Anesthetic Induction With Etomidate in Cardiac Surgical Patients: A PRISMA-Compliant Systematic Review and Meta-Analysis. J Cardiothorac Vasc Anesth 2020; 35:1073-1085. [PMID: 33384231 DOI: 10.1053/j.jvca.2020.11.068] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/28/2020] [Accepted: 11/30/2020] [Indexed: 01/10/2023]
Abstract
OBJECTIVE This meta-analysis aimed to systematically review the effects of etomidate (ETM) during anesthetic induction on patients undergoing cardiac surgery. DESIGN Systematic review and meta-analysis. SETTING Operating room. PARTICIPANTS Patients undergoing cardiac surgery. INTERVENTIONS ETM or control drugs. MEASUREMENTS AND MAIN RESULTS PubMed, Cochrane Library, OVID, and EMBASE were searched through August 31, 2020. Primary outcomes included hemodynamic profiles and stress responses. Secondary outcomes included morbidity, mortality, and postoperative recovery. For continuous/dichotomous variables, treatment effects were calculated as weighted mean difference (WMD)/odds ratio (OR) and 95% confidence interval (CI). A database search yielded 18 randomized controlled trials including 1,241 patients. The present meta-analysis demonstrated that ETM-anesthetized patients had lower heart rates (WMD, -3.31; 95% CI -5.43 to -1.19; p = 0.002), higher blood pressures (systolic blood pressure: WMD, 12.02; 95% CI 6.24 to 17.80; p < 0.0001; diastolic blood pressure: WMD, 5.23; 95% CI 2.39 to 8.08; p = 0.0003; mean arterial pressure (MAP): WMD, 8.64; 95% CI 5.85 to 11.43; p < 0.00001), less requirement for vasopressor (OR, 0.26; 95% CI 0.15 to 0.44; p < 0.00001), and more nitroglycerin usage (OR, 14.89; 95% CI 4.92 to 45.08; p < 0.00001) during anesthetic induction. Current meta-analysis also demonstrated that single-dose ETM lowered cortisol levels transiently and did not have a significant effect on endogenous norepinephrine and epinephrine levels and was not associated with increased postoperative inotrope and/or vasopressor requirement. Additionally, the meta-analysis suggested that ETM anesthesia was associated with neither increased mortality nor morbidity, except a higher incidence of transient adrenal insufficiency in ETM recipients. CONCLUSION The present meta-analysis suggested that single-dose ETM during anesthetic induction could be associated with more stable hemodynamics, transient and reversible lower cortisol levels, and a higher adrenal insufficiency incidence, but not worse outcomes in cardiac surgical patients.
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Affiliation(s)
- Yun-Tai Yao
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.
| | - Li-Xian He
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Neng-Xin Fang
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Jie Ma
- Department of Pharmacy, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
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Park HY, Lee Y, Lim CY, Kim M, Park J, Lee T. Effects of etomidate use in ICU patients on ventilator therapy: a study of 12,526 patients in an open database from a single center. Korean J Anesthesiol 2020; 74:300-307. [PMID: 33233029 PMCID: PMC8342844 DOI: 10.4097/kja.20509] [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: 09/11/2020] [Accepted: 11/23/2020] [Indexed: 11/10/2022] Open
Abstract
Background There is a debate regarding the safety of etomidate. We evaluated the effects of etomidate on mortality in a large cohort of critical care patients. Methods This retrospective matched-cohort study was performed using the Medical Information Mart for Intensive Care version 3 (MIMIC-III) database. Among 12,526 adult patients who were prescribed etomidate or propofol on the first day of mechanical ventilation, 625 patients administered etomidate were statistically matched with 6,250 patients administered propofol. The primary outcome measures were all-cause in-hospital mortality, 48-hour survival, cardiovascular morbidity, and infectious morbidity. Logistic regression analysis with stepwise selection of variables was performed to examine the dose–mortality relationship of etomidate. Results All-cause in-hospital mortality was 1.84 times higher in the etomidate cohort (OR: 1.84, 98.75% CI: 1.42, 2.37). Compared to the propofol cohort, the etomidate cohort showed 57% lower odds of 48-hour survival (0.43 [0.27, 0.73]), no difference in odds of cardiovascular morbidity (0.86 [0.66, 1.12]), and 1.77 times higher odds of infectious morbidity (1.77 [1.35, 2.31]). Additionally, the odds of mortality increased by 1.36 times per 0.1 mg/kg of etomidate (1.36 [95% CI: 1.23, 1.49]). Conclusions Etomidate is a poor choice as a hypnotic drug on the first day of mechanical ventilation, as it is associated with a dose-dependent increase in all-cause mortality, and does not improve survival for the first 48 h.
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Affiliation(s)
- Ha Yeon Park
- Department of Anesthesiology and Pain Medicine, Korea University Anam Hospital, Seoul, Korea
| | - Younsuk Lee
- Department of Anesthesiology and Pain Medicine, Dongguk University Ilsan Hospital, Goyang, Korea.,D/M Statistics Institute, Dongguk University, Goyang, Korea
| | - Chi-Yeon Lim
- D/M Statistics Institute, Dongguk University, Goyang, Korea.,Department of Biostatistics, Dongguk University College of Medicine, Goyang, Korea
| | - Mina Kim
- Department of Anesthesiology and Pain Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Jieun Park
- Department of Anesthesiology and Pain Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Teakseon Lee
- Department of Anesthesiology and Pain Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
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Mohr NM, Pape SG, Runde D, Kaji AH, Walls RM, Brown CA. Etomidate Use Is Associated With Less Hypotension Than Ketamine for Emergency Department Sepsis Intubations: A NEAR Cohort Study. Acad Emerg Med 2020; 27:1140-1149. [PMID: 32602974 DOI: 10.1111/acem.14070] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The objectives of this study were 1) to describe the current use of etomidate and other induction agents in patients with sepsis and 2) to compare adverse events between etomidate and ketamine in sepsis. METHODS This was an observational cohort study of the prospective National Emergency Airway Registry (NEAR) data set. Descriptive statistics were used to report the distribution of induction agents used in patients with sepsis. Adverse events were compared using bivariate analysis, and a sensitivity analysis was conducted using a propensity score-adjusted analysis of etomidate versus ketamine. RESULTS A total of 531 patients were intubated for sepsis, and the majority (71%) were intubated with etomidate as the initial induction agent. Etomidate was less frequently used in sepsis patients than nonsepsis patients (71% vs. 85%, odds ratio [OR] = 0.4, 95% confidence interval [CI] = 0.4 to 0.5). Sepsis patients had a greater risk of adverse events, and vasopressor therapy was required for 25% of patients after intubation. Postprocedure hypotension was higher between those intubated for sepsis with ketamine versus etomidate (74% vs. 50%, OR = 2.9, 95% CI = 1.9 to 4.5). After confounding by indication in the propensity score-adjusted analysis was accounted for, ketamine was associated with more postprocedure hypotension (OR = 2.7, 95% CI = 1.1 to 6.7). No difference in emergency department deaths was observed. CONCLUSIONS Etomidate is used less frequently in sepsis patients than nonsepsis patients, with ketamine being the most frequently used alternative. Ketamine was associated with more postprocedural hypotension than etomidate. Future clinical trials are needed to determine the optimal induction agent in patients with sepsis.
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Affiliation(s)
- Nicholas M. Mohr
- From the Department of Emergency Medicine University of Iowa Carver College of Medicine Iowa City IA USA
- the Division of Critical Care Department of Anesthesia University of Iowa Carver College of Medicine Iowa City IA USA
- the Department of Epidemiology University of Iowa College of Public Health Iowa City IA USA
| | - Stephen G. Pape
- From the Department of Emergency Medicine University of Iowa Carver College of Medicine Iowa City IA USA
| | - Dan Runde
- From the Department of Emergency Medicine University of Iowa Carver College of Medicine Iowa City IA USA
| | - Amy H. Kaji
- the Department of Emergency Medicine University of California–Los Angeles Los Angeles CA USA
| | - Ron M. Walls
- and the Department of Emergency Medicine Brigham and Women's Hospital Boston MA USA
| | - Calvin A. Brown
- and the Department of Emergency Medicine Brigham and Women's Hospital Boston MA USA
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Farrell NM, Killius K, Kue R, Langlois BK, Nelson KP, Golenia P. A Comparison of Etomidate, Ketamine, and Methohexital in Emergency Department Rapid Sequence Intubation. J Emerg Med 2020; 59:508-514. [PMID: 32739131 DOI: 10.1016/j.jemermed.2020.06.054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 05/30/2020] [Accepted: 06/06/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Rapid sequence intubation (RSI) is routinely used for emergent airway management in the emergency department (ED). It involves the use of induction, and paralytic agents help facilitate endotracheal tube placement. OBJECTIVE In response to a previous national drug shortage resulting in the use of alternative induction agents for RSI, we describe the effectiveness and safety of ED RSI with ketamine or methohexital compared with etomidate. METHODS We conducted a retrospective, single-center observational study from March 1-August 31, 2012 describing RSI with etomidate, ketamine, and methohexital. All adult patients undergoing RSI in the ED who received etomidate prior to its shortage and methohexital or ketamine during the shortage were included. RESULTS The study included 47, 9, and 26 patients in the etomidate, ketamine, and methohexital groups, respectively. Successful intubation on the first attempt occurred in 74.5%, 55.6%, and 73.1% of the etomidate, ketamine, and methohexital groups, respectively. The mean number of intubation attempts and time to intubation seemed to be similar in all groups. At least three intubation attempts were required in 22.2% and 7.7% of the ketamine and methohexital groups, respectively, compared with none in the etomidate group. Two aspirations were observed in the etomidate group. CONCLUSION Methohexital and etomidate had similar rates of successful intubation on the first attempt and seem to be more effective than ketamine. Etomidate may reduce the need for three or more intubation attempts. Larger, prospective studies are needed to determine if ketamine or methohexital are more effective than etomidate for RSI.
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Affiliation(s)
- Natalija M Farrell
- Department of Pharmacy, Boston Medical Center, Boston, Massachusetts; Department of Emergency Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Kelly Killius
- Department of Pharmacy, Boston Medical Center, Boston, Massachusetts
| | - Ricky Kue
- Department of Emergency Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Breanne K Langlois
- Department of Emergency Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Kerrie P Nelson
- Department of Biostatistics, Boston University, Boston, Massachusetts
| | - Peter Golenia
- Department of Pharmacy, Boston Medical Center, Boston, Massachusetts
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Albert SG, Sitaula S. Etomidate, Adrenal Insufficiency and Mortality Associated With Severity of Illness: A Meta-Analysis. J Intensive Care Med 2020; 36:1124-1129. [PMID: 32912050 DOI: 10.1177/0885066620957596] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE Etomidate causes adrenal insufficiency. Yet in critically ill patients, it is controversial whether it increases mortality rates above that of comparator anesthetic induction agents. We postulated that etomidate would increase relative mortality rates correspondingly to the severity of illness as defined by SAPS or APACHE scores. MATERIALS AND METHODS A literature search was performed on Pub Med, SCOPUS, and Cochrane Reviews for human studies, regardless of language, between 1983 and February 2020. The search strategy used keywords, "etomidate," "adrenal insufficiency," "glucocorticoid," and "intensive care." Both authors reviewed electronic data search titles, abstracts and extracted data, which were checked by the other reviewer. Primary outcome was 28-day survival. Secondary outcome was adrenal insufficiency. RESULTS There were 29 trials of etomidate versus comparators in 8584 patients. Etomidate was associated with adrenal insufficiency (risk ratio (rr) = 1·54, 95% CI; 1·42, 1·67, p < 0.001) and increased overall relative mortality rates (rr = 1.09, CI;1.04,1.16, p = 0.001). Meta-regression showed that with etomidate there was a continuous progressive relative risk of mortality associated with increasing severity of illness (predefined in each article by standard critical illness scores). In those patients who had a predicted mortality rate > the median for this analysis (predicted mortality 44%) the relative mortality rate (rr) = 1.20, Ci;1.12,1.29, p < 0.001, the absolute risk difference (rd) = 0.08, CI;0.05,0.11, p < 0.0001 and the number needed to harm (1/rd) was 12.5. In those with a calculated predicted mortality <44% there was no increase in relative mortality rate. CONCLUSIONS Whereas etomidate causes adrenal insufficiency, it was not shown to increase mortality in many analyzed here in ICU settings. However, etomidate associated relative mortality rates increased progressively and correlated with the severity of critical illness scores. Intensivists should anticipate the need for glucocorticoid supplementation after etomidate in those with severe critical illness and in those with acute deterioration of vital signs.
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Affiliation(s)
- Stewart G Albert
- Division of Endocrinology, Department of Internal Medicine, Saint Louis University School of Medicine, St Louis, MO, USA
| | - Sujata Sitaula
- Division of Endocrinology, Department of Internal Medicine, Saint Louis University School of Medicine, St Louis, MO, USA
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Chai CM, Seier K, Tan KS, Chu I, Isbell JM, Fischer GW, Afonso AM. Pericardial Effusions in Patients With Cancer: Anesthetic Management and Survival Outcomes. J Cardiothorac Vasc Anesth 2020; 35:571-577. [PMID: 32967792 DOI: 10.1053/j.jvca.2020.08.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 08/20/2020] [Accepted: 08/21/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The objective of this study was to describe practice patterns of anesthetic management during pericardial window creation. DESIGN Retrospective observational cohort study. SETTING Single tertiary cancer center. PARTICIPANTS A total of 150 patients treated for cancer between 2011 and 2015 were included in the study. MEASUREMENTS AND MAIN RESULTS The primary objective was to evaluate anesthetic management in pericardial window creation. Secondary outcomes were 30-day mortality and overall survival after pericardial window creation. Thirty-day mortality was 19.3%, and median survival was 5.84 months. Higher American Society of Anesthesiologists (ASA) physical status of patients was associated with preinduction arterial line placement (51% ASA 3 v 79% ASA 4; p = 0.002) and use of etomidate for anesthetic induction (34% ASA 3 v 60% ASA 4; p = 0.003). However, there was no association between anesthetic management and presence of tamponade in these patients. Cardiac aspirate volume (per 10 mL: odds ratio [OR], 1.02 [95% CI, 1.0-1.04]; p = 0.026) and intraoperative arrhythmia (atrial fibrillation: OR, 6.76 [95% CI, 1.2-37.49]; p = 0.029; sinus tachycardia: OR, 4.59 [95% CI, 1.25-16.90]; p = 0.022) were associated independently with increased 30-day mortality. High initial heart rate (per 10 beats per minute: hazard ratio [HR], 1.18 [95% CI, 1.05-1.33]; p = 0.005) in the operating room and intraoperative sinus tachycardia (HR, 1.86 [95% CI, 1.15-3.03]; p = 0.012) were associated independently with worse overall survival. CONCLUSION Risk of death after pericardial window creation remains high in patients with cancer. Variations in anesthetic management did not affect survival in oncologic patients with pericardial effusions.
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Affiliation(s)
- Casey M Chai
- Department of Anesthesiology, New York Presbyterian Hospital-Weill Cornell Medicine, New York, NY
| | - Kenneth Seier
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kay See Tan
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Iris Chu
- Department of Anesthesiology, New York Presbyterian Hospital-Weill Cornell Medicine, New York, NY
| | - James M Isbell
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Gregory W Fischer
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Anoushka M Afonso
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY.
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Chung M, Santer P, Raub D, Zhao Y, Zhao T, Strom J, Houle T, Shen C, Eikermann M, Yeh RW. Use of etomidate in patients with heart failure undergoing noncardiac surgery. Br J Anaesth 2020; 125:943-952. [PMID: 32807381 DOI: 10.1016/j.bja.2020.06.059] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 06/05/2020] [Accepted: 06/22/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Patients with symptomatic and asymptomatic heart failure undergoing noncardiac surgery may benefit from the haemodynamic profile of etomidate. However, the safety of etomidate in this population is unknown. We examined anaesthesiologist variation in etomidate use and assessed its safety using an instrumental variable approach to account for differences in treatment selection. METHODS A retrospective cohort study of 19 714 patients with heart failure undergoing noncardiac surgery at two tertiary care institutions from January 2006 to December 2017 was performed. The proportion of etomidate use among 294 anaesthesiologists was examined and adjusted risk differences (aRD) for in-hospital and 30-day mortality were calculated using physician preference for etomidate as an instrumental variable. RESULTS Etomidate was used in 14.3% (2821/19 714) of patients. Preference for etomidate varied substantially among individual anaesthesiologists with the lowest and highest quartile users using etomidate in 0-4.7% and 20.4-66.7% of their own heart failure patients, respectively. The adjusted instrumental variable analysis showed no significant differences in the risk of in-hospital (aRD -0.2%; 95% confidence interval, -2.4%-1.9%; P=0.83) or 30 day mortality (aRD 0.2%; 95% confidence interval, -2.5%-2.9%; P=0.90). Anaesthesiologists with higher preferences for etomidate were more experienced (greater heart failure and total case volume) than anaesthesiologists with lower preferences for etomidate. CONCLUSIONS We found substantial variability in anaesthesiologists' preference for etomidate for use in patients with heart failure undergoing noncardiac surgery. There was no association between etomidate use and in-hospital or 30-day mortality. Etomidate is not inferior to other currently used options for induction of general anaesthesia in patients with heart failure.
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Affiliation(s)
- Mabel Chung
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | - Peter Santer
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Dana Raub
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Yuansong Zhao
- Department of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; University of Texas Health Science Center at Houston, School of Public Health, Houston, TX, USA
| | - Tianyi Zhao
- Department of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jordan Strom
- Department of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Timothy Houle
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Changyu Shen
- Department of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Matthias Eikermann
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Robert W Yeh
- Department of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Zhang YJ, Deng C, Yang J, Gong D, Kang Y, Liu J, Zhang W. Preclinical Pharmacokinetics Study of a Novel Intravenous Anesthetic ET-26 Hydrochloride. Curr Drug Metab 2020; 20:1073-1081. [PMID: 31870260 DOI: 10.2174/1389200221666191223105504] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 11/27/2019] [Accepted: 12/01/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND ET-26 hydrochloride is a novel intravenous anesthetic, approved for clinical trials, that produces a desirable sedative-hypnotic effect with stable myocardial performance and mild adrenocortical suppression in rats and beagle dogs. The objective of this study was to assess the absorption, distribution, metabolism, and excretion of ET-26 hydrochloride. METHODS Hepatocytes from human, monkey, dog, rat, and mouse were used to determine the metabolites of ET-26 hydrochloride. Distribution and excretion were assessed in rats and pharmacokinetic studies were performed in beagle dogs. RESULTS The metabolic pathway and proposed structure of metabolites were fully assessed resulting from the biotransformation reactions of hydrolysis, dehydrogenation, demethylation and glucuronic acid conjugation. The main distribution of the drug was in fat (15067 ± 801 ng/ml) and liver (13647 ± 1126 ng/ml), and the kidney was the primary excretion route (4.47%-11.94%). The Cmax after injection with 1.045 mg/kg, 2.09 mg/kg, and 4.18 mg/kg was 1476.5 ± 138.9 ng/ml, 2846.1 ± 223.3 ng/ml, and 6233.3 ± 238.9 ng/ml, respectively. The t1/2 of the drug was similar across dose groups at 74.8 ± 10.8 min to 81.4 ± 4.2 min. The AUC0-t values were 30208.1 ± 2026.5 min*ng/ml, 62712.8 ± 1808.3 min*ng/ml, and 130465.2 ± 7457.4 min*ng/ml, respectively. CONCLUSION The metabolic pathway and the proposed structure of metabolites for ET-26 hydrochloride were fully assessed. The majority of distribution for ET-26 hydrochloride occurs in the fat and liver, while the primary route of excretion for ET-26 hydrochloride is through the kidney. In dogs, pharmacokinetic features of ET-26 hydrochloride had a linear relationship with dosage.
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Affiliation(s)
- Yu Jun Zhang
- Department of Anesthesiology, Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China.,National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - ChaoYi Deng
- Department of Anesthesiology, Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China.,National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Jun Yang
- Department of Anesthesiology, Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China.,National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - DeYing Gong
- Department of Anesthesiology, Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China.,National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Yi Kang
- Department of Anesthesiology, Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China.,National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Jin Liu
- Department of Anesthesiology, Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China.,National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - WenSheng Zhang
- Department of Anesthesiology, Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China.,National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
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Soft drugs in anesthesia: remifentanil as prototype to modern anesthetic drug development. Curr Opin Anaesthesiol 2020; 33:499-505. [PMID: 32530892 DOI: 10.1097/aco.0000000000000879] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE OF REVIEW The unique demands of modern anesthesia practice require that medications be effective, well tolerated, and efficient. These attributes are increasingly achieved with the soft drug approach, wherein novel active compounds are specifically designed to be susceptible to rapid biotransformation to inactive metabolites. The present review summarizes the historical background and recent trends in soft drug development in anesthesiology. RECENT FINDINGS Soft drug development programs for propranadid, etomidate, and benzodiazepine analogues have been undertaken in recent years. Although all three drugs advanced into human trials, neuro-excitatory adverse effects hampered the propranadid and etomidate analogue projects. Remimazolam, the soft benzodiazepine analogue, is at an advanced stage of development, having already received regulatory approval or review in several countries. SUMMARY With succinylcholine as the historical forerunner and remifentanil as the modern prototype, the soft drug paradigm continues to hold promise for the future of anesthesia drug development.
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Au Yong PSA, Kwa CWX, Chan XHD. Anaesthetic Considerations for Rationalizing Drug Use in the Operating Theatre: Strategies in a Singapore Hospital During COVID-19. ACTA ACUST UNITED AC 2020; 2:871-873. [PMID: 32838142 PMCID: PMC7289710 DOI: 10.1007/s42399-020-00345-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2020] [Indexed: 11/18/2022]
Abstract
COVID-19 patients in the critical care unit tend to have prolonged hospital stay requiring high doses of sedation and paralysis to treat acute respiratory distress syndrome, resulting in a shortage of these drugs. In our hospital, we have instituted strategies to rationalise drug and oxygen usage. This includes prioritising time-sensitive elective cases, reducing overall elective case load, favouring opioid-reduction strategies and usage of alternative anaesthetic agents not commonly used in ICU. Both intensive care physicians and anaesthesiologists have to cooperate on drug conservation as similar drugs are used in elective operating lists as in the ICU. Patient safety is of utmost importance and we should keep in mind some pitfalls and ethical concerns of these alternative strategies.
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Affiliation(s)
- Phui Sze Angie Au Yong
- Division of Anesthesiology and Perioperative Medicine, Singapore General Hospital, 1 Hospital Drive, Singapore, 169608 Singapore
| | - Charlene Wen Xian Kwa
- Division of Anesthesiology and Perioperative Medicine, Singapore General Hospital, 1 Hospital Drive, Singapore, 169608 Singapore
| | - Xin Hui Diana Chan
- Division of Anesthesiology and Perioperative Medicine, Singapore General Hospital, 1 Hospital Drive, Singapore, 169608 Singapore
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Yu L, Chen X, Zhang WS, Zheng L, Xu WW, Xu MY, Jiang XH, Wang L. Metabolite identification, tissue distribution, excretion and preclinical pharmacokinetic studies of ET-26-HCl, a new analogue of etomidate. ROYAL SOCIETY OPEN SCIENCE 2020; 7:191666. [PMID: 32257329 PMCID: PMC7062083 DOI: 10.1098/rsos.191666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 12/17/2019] [Indexed: 02/05/2023]
Abstract
ET-26-HCl, a novel anaesthetic agent with promising pharmacological properties, lacks extensive studies on pharmacokinetics and disposition in vitro and in vivo. In this study, we investigated the metabolic stability, metabolite production and plasma protein binding (PPB) of ET-26-HCl along with its tissue distribution, excretion and pharmacokinetics in animals after intravenous administration. Ultra-high performance liquid chromatography–tandem quadrupole time-of-flight mass spectrometry identified a total of eight new metabolites after ET-26-HCl biotransformation in liver microsomes from different species. A hypothetical cytochrome P450-metabolic pathway including dehydrogenation, hydroxylation and demethylation was proposed. The PPB rate was highest in mouse and lowest in human. After intravenous administration, ET-26-HCl distributed rapidly to all tissues in rats and beagle dogs, with the highest concentrations in fat and liver. High concentrations of ET-26-acid, a major hydroxylation metabolite of ET-26-HCl, were found in liver, plasma and kidney. Almost complete clearance of ET-26-HCl from plasma occurred within 4 h after administration. Only a small fraction of the parent compound and its acid form were excreted via the urine and faeces. Taken together, the results added to a better understanding of the metabolic and pharmacokinetic properties of ET-26-HCl, which may contribute to the further development of this drug.
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Affiliation(s)
- Lu Yu
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy Sichuan University, Chengdu 610064, People's Republic of China
| | - Xu Chen
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy Sichuan University, Chengdu 610064, People's Republic of China.,Chengdu Women and Children Central Hospital, Chengdu, Sichuan 610041, People's Republic of China
| | - Wen Sheng Zhang
- Anesthesia and Critical Aid Laboratory, Conversion Neuroscience Center, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, People's Republic of China
| | - Liang Zheng
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy Sichuan University, Chengdu 610064, People's Republic of China
| | - Wen Wen Xu
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy Sichuan University, Chengdu 610064, People's Republic of China
| | - Ming Yu Xu
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy Sichuan University, Chengdu 610064, People's Republic of China
| | - Xue Hua Jiang
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy Sichuan University, Chengdu 610064, People's Republic of China
| | - Ling Wang
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy Sichuan University, Chengdu 610064, People's Republic of China
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Use of glucocorticoids in the critical care setting: Science and clinical evidence. Pharmacol Ther 2020; 206:107428. [DOI: 10.1016/j.pharmthera.2019.107428] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 10/02/2019] [Indexed: 02/07/2023]
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Bughrara N, Cha S, Safa R, Pustavoitau A. Perioperative Management of Patients with Sepsis and Septic Shock, Part I: Systematic Approach. Anesthesiol Clin 2020; 38:107-122. [PMID: 32008646 DOI: 10.1016/j.anclin.2019.10.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Sepsis and septic shock are medical emergencies, with high associated mortality. The Surviving Sepsis Campaign has developed definitions and management guidelines, emphasizing the use of hour-1 care bundle. Anesthesiologists frequently encounter sepsis when source control is required. The authors summarize expected manifestations of organ dysfunction and state-of-the-art management of patients with sepsis and septic shock. They highlight an increasingly vital role point-of-care ultrasound examination in the recognition and management of hemodynamic derangements in this patient population. Supporting the role of anesthesiologists as perioperative physicians, the authors provide a framework for transitions of care between operating room and intensive care units.
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Affiliation(s)
- Nibras Bughrara
- Department of Anesthesiology, Albany Medical College, 47 New Scotland Avenue, MC 131, Albany, NY 12208, USA; Department of Surgery, Albany Medical College, 47 New Scotland Avenue, MC 131, Albany, NY 12208, USA.
| | - Stephanie Cha
- Division of Cardiothoracic Anesthesiology, Johns Hopkins University School of Medicine, 1800 Orleans Street, Suite 6216, Baltimore, MD 21287, USA; Division of Critical Care, Johns Hopkins University School of Medicine, 1800 Orleans Street, Suite 6216, Baltimore, MD 21287, USA
| | - Radwan Safa
- Department of Anesthesiology, Albany Medical College, 47 New Scotland Avenue, MC 131, Albany, NY 12208, USA; Department of Surgery, Albany Medical College, 47 New Scotland Avenue, MC 131, Albany, NY 12208, USA
| | - Aliaksei Pustavoitau
- Division of Adult Critical Care Medicine, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 297, Baltimore, MD 21287, USA
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Zhang Y, Deng C, Gong D, Kang Y, Liu J, Zhang W. Preclinical safety evaluation of ET-26 hydrochloride, a novel intravenous anesthetic agent, in beagle dogs. J Appl Toxicol 2019; 40:679-690. [PMID: 31867768 DOI: 10.1002/jat.3936] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
ET-26 hydrochloride (ET-26HCl) is a novel etomidate analogue, approved for clinical trials, which has an effective sedative-hypnotic effect, a stable myocardial performance, and milder adrenocortical suppression than etomidate in rats and beagle dogs. Additionally, ET-26HCl showed similar hemodynamic stability as etomidate in the rat uncontrolled hemorrhagic shock model. Furthermore, ET-26HCl, in the rat lipopolysaccharide-induced sepsis model, was found to have a higher survival rate, a lower inflammatory reaction, and less organ injury. In the present study, we measured the potential adverse effects of ET-26HCl in beagle dogs in accordance with the Guidance on single- and repeated-dose toxicity published by the China Food and Drug Administration. In toxicity studies, single and repeated (14 days) intravenous doses of up to 16 mg/kg were well tolerated, with only pharmacologically related clinical signs seen in both studies. Thus, the no-observed-adverse-effect level (NOAEL) of ET-26HCl was found at 16 mg/kg/day. Toxicokinetic examination demonstrated that ET-26HCl showed a dose-dependent increase to exposure, no gender difference, and no evidence of accumulation. These results provide useful information for guiding a phase I clinical trial of ET-26HCl in healthy volunteers.
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Affiliation(s)
- YuJun Zhang
- Department of Anesthesiology, Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China.,National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - ChaoYi Deng
- Department of Anesthesiology, Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China.,National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - DeYing Gong
- Department of Anesthesiology, Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China.,National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Yi Kang
- Department of Anesthesiology, Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China.,National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Jin Liu
- Department of Anesthesiology, Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China.,National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - WenSheng Zhang
- Department of Anesthesiology, Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China.,National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
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