1
|
Barik AK, Mohanty CR, Magoon R, Radhakrishnan RV, Suresh V. Alfentanil versus fentanyl for emergency department rapid sequence induction with ketamine: Some concerns. Am J Emerg Med 2024:S0735-6757(24)00402-9. [PMID: 39168796 DOI: 10.1016/j.ajem.2024.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2024] [Accepted: 08/14/2024] [Indexed: 08/23/2024] Open
Affiliation(s)
- Amiya Kumar Barik
- Department of Anesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Chitta Ranjan Mohanty
- Department of Trauma and Emergency, All India Institute of Medical Sciences, Bhubaneswar, India.
| | - Rohan Magoon
- Department of Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | | | - Varun Suresh
- Department of Anesthesia and Intensive Care, Jaber Al Ahmad Al Sabah Hospital, Arabian Gulf, Kuwait
| |
Collapse
|
2
|
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.
Collapse
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
| |
Collapse
|
3
|
Zhang Y, Miller M, Buttfield A, Burns B, Lawrie K, Gaston J, Ferguson I. Alfentanil versus fentanyl for emergency department rapid sequence induction with ketamine: A-FAKT, a pilot randomized trial. Am J Emerg Med 2024; 84:25-32. [PMID: 39059038 DOI: 10.1016/j.ajem.2024.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 06/12/2024] [Accepted: 07/14/2024] [Indexed: 07/28/2024] Open
Abstract
BACKGROUND Fentanyl is often administered during rapid sequence induction of anesthesia (RSI) in the emergency department (ED) to ameliorate the hypertensive response that may occur. Due to its more rapid onset, the use of alfentanil may be more consistent with both the onset time of the sedative and the commencement of laryngoscopy. As such, we compared the effect of alfentanil and fentanyl on post-induction hemodynamic changes when administered as part of a standardized induction regimen including ketamine and rocuronium in ED RSI. METHODS This was a double-blind pilot randomized controlled trial of adult patients requiring RSI in the ED of three urban Australian hospitals. Patients were randomized to receive either alfentanil or fentanyl in addition to ketamine and rocuronium for RSI. Non-invasive blood pressure and heart rate were measured immediately before and at two, four, and six minutes after induction. The primary outcome was the occurrence of at least one post-induction systolic blood pressure outside the pre-specified range of 100-160mmHg (with adjustment for patients with baseline hypertension). Secondary outcomes included hypertension, hypotension, hypoxia, first-pass intubation success, 30-day mortality, and the pattern of hemodynamic changes. RESULTS A total of 61 patients were included in the final analysis (31 in the alfentanil group and 30 in the fentanyl group). The primary outcome was met in 58% of the alfentanil group and 50% of the fentanyl group (difference 8%, 95% confidence interval: -17% to 33%). The 30-day mortality rate, first-pass success rate, and incidences of hypertension, hypotension, and hypoxia were similar between the groups. There were no significant differences in systolic blood pressure or heart rate between the groups at any of the measured time-points. CONCLUSION Alfentanil and fentanyl produced comparable post-induction hemodynamic changes when used as adjuncts to ketamine in ED RSI. Future studies could consider comparing different dosages of these opioids.
Collapse
Affiliation(s)
- Yichen Zhang
- South Western Sydney Clinical School, University of New South Wales, Warwick Farm, New South Wales, Australia.
| | - Matthew Miller
- Aeromedical Operations, New South Wales Ambulance, Bankstown Aerodrome, New South Wales, Australia; Department of Anaesthesia, St George Hospital, Kogarah, New South Wales, Australia; St George and Sutherland Clinical Schools, University of New South Wales, Kogarah, New South Wales, Australia
| | - Alexander Buttfield
- Emergency Department, Campbelltown Hospital, Campbelltown, New South Wales, Australia; School of Medicine, Western Sydney University, Campbelltown, New South Wales, Australia
| | - Brian Burns
- Aeromedical Operations, New South Wales Ambulance, Bankstown Aerodrome, New South Wales, Australia; Emergency Department, Northern Beaches Hospital, Frenchs Forest, New South Wales, Australia; Faculty of Medicine & Health, University of Sydney, Camperdown, New South Wales, Australia; Macquarie Medical School, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Kimberley Lawrie
- Aeromedical Operations, New South Wales Ambulance, Bankstown Aerodrome, New South Wales, Australia; Emergency Department, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - James Gaston
- Emergency Department, Campbelltown Hospital, Campbelltown, New South Wales, Australia; School of Medicine, Western Sydney University, Campbelltown, New South Wales, Australia
| | - Ian Ferguson
- South Western Sydney Clinical School, University of New South Wales, Warwick Farm, New South Wales, Australia; Aeromedical Operations, New South Wales Ambulance, Bankstown Aerodrome, New South Wales, Australia; Emergency Department, Liverpool Hospital, Liverpool, New South Wales, Australia
| |
Collapse
|
4
|
Tamsett Z, Douglas N, King C, Johnston T, Bentley C, Hao B, Prinsloo D, Bourke EM. Does the choice of induction agent in rapid sequence intubation in the emergency department influence the incidence of post-induction hypotension? Emerg Med Australas 2024; 36:340-347. [PMID: 38018391 DOI: 10.1111/1742-6723.14355] [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: 07/22/2023] [Revised: 10/26/2023] [Accepted: 11/14/2023] [Indexed: 11/30/2023]
Abstract
OBJECTIVE To describe the effects of different induction agents on the incidence of post-induction hypotension (PIH) and its associated interventions during rapid sequence intubation (RSI) in the ED. METHODS A single centre retrospective study of patients intubated between 2018 and 2021 was conducted in a regional Australian ED. The impact of induction agent choice, in addition to demographic and clinical factors on the incidence of PIH were determined using descriptive statistics and a multivariate analysis presented as adjusted odds ratios (aORs) and their 95% confidence intervals (CIs). RESULTS Ketamine and propofol, used either individually or in conjunction with fentanyl, were significantly associated with PIH (ketamine aOR 4.5, 95% CI 1.35-14.96; propofol aOR 4.88, 95% CI 1.46-16.29). Age >60 years was associated with a greater requirement for vasopressors (aOR 4.46, 95% CI 2.49-7.97) and a higher risk of mortality after RSI (aOR 4.2, 95% CI 1.87-9.40). Patients with a shock index >1.0 were significantly more likely to require vasopressors (aOR 5.13, 95% CI 2.35-11.2) and have a cardiac arrest within 15 min of RSI (aOR 3.56, 95% CI 1.07-11.8). CONCLUSIONS Exposure to both propofol and ketamine is significantly associated with PIH after RSI, alongside age and shock index. PIH is likely multifactorial in nature, and this data supports the sympatholytic effect of induction agents as the underlying cause of PIH rather than the choice of agent itself. Further prospective work including a randomised controlled trial between induction agents is justified to further clarify this important clinical question.
Collapse
Affiliation(s)
- Zacchary Tamsett
- Department of Emergency Medicine, Grampians Health, Ballarat, Victoria, Australia
| | - Ned Douglas
- Department of Anaesthesia, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Cathy King
- Department of Emergency Medicine, Grampians Health, Ballarat, Victoria, Australia
- School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Tanya Johnston
- Department of Emergency Medicine, Grampians Health, Ballarat, Victoria, Australia
| | - Connor Bentley
- Department of Emergency Medicine, Grampians Health, Ballarat, Victoria, Australia
| | - Brian Hao
- Department of Emergency Medicine, Grampians Health, Ballarat, Victoria, Australia
| | - Duron Prinsloo
- Department of Emergency Medicine, Grampians Health, Ballarat, Victoria, Australia
| | - Elyssia M Bourke
- Department of Emergency Medicine, Grampians Health, Ballarat, Victoria, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Emergency Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| |
Collapse
|
5
|
Jansen G, Latka E, Deicke M, Fischer D, Gretenkort P, Hoyer A, Keller Y, Kobiella A, Ristau P, Seewald S, Strickmann B, Thies KC, Johanning K, Tiesmeier J. [Prehospital postcardiac-arrest-sedation and -care in the Federal Republic of Germany-a web-based survey of emergency physicians]. Med Klin Intensivmed Notfmed 2024; 119:398-407. [PMID: 37682284 DOI: 10.1007/s00063-023-01056-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 07/12/2023] [Accepted: 07/24/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND This study evaluates the implementation of postcardiac-arrest-sedation (PCAS) and -care (PRC) by prehospital emergency physicians in Germany. MATERIALS AND METHODS Analysis of a web-based survey from October to November 2022. Questions were asked about implementation, medications used, complications, motivation for implementing or not implementing PCAS, and measures and target parameters of PRC. RESULTS A total of 500 emergency physicians participated in the survey. In all, 73.4% stated that they regularly performed PCAS (hypnotics: 84.7%; analgesics: 71.1%; relaxants: 29.7%). Indications were pressing against the respirator (88.3%), analgesia (74.1%), synchronization to respirator (59.5%), and change of airway device (52.6%). Reasons for not performing PCAS (26.6%) included unconscious patients (73.7%); concern about hypotension (31.6%), re-arrest (26.3%), and worsening neurological assessment (22.5%). Complications of PCAS were observed by 19.3% of participants (acute hypotension [74.6%]); (re-arrest [32.4%]). In addition to baseline monitoring, PRC included 12-lead-electrocardiogram (96.6%); capnography (91.6%); catecholamine therapy (77.6%); focused echocardiography (20.6%), lung ultrasound (12.0%) and abdominal ultrasound (5.6%); induction of hypothermia (13.6%) and blood gas analysis (7.4%). An etCO2 of 35-45 mm Hg was targeted by 40.6%, while 9.0% of participants targeted an SpO2 of 94-98% and 19.2% of participants targeted a systolic blood pressure of ≥ 100 mm Hg. CONCLUSIONS Prehospital PRC in Germany is heterogeneous and deviations from its target parameters are frequent. PCAS is frequent and associated with relevant complications. The development of preclinical care algorithms for PCAS and PRC within preclinical care seems urgently needed.
Collapse
Affiliation(s)
- G Jansen
- Universitätsklinikum für Anästhesiologie, Intensiv- und Notfallmedizin der Ruhr-Universität Bochum, Johannes Wesling Klinikum Minden, Minden, Deutschland.
- Universität Bielefeld, Medizinische Fakultät OWL, Universitätsstr. 25, 33615, Bielefeld, Deutschland.
- Fachbereich Medizin und Rettungswesen, Studieninstitut Westfalen-Lippe, Bielefeld, Deutschland.
| | - E Latka
- Fachbereich Medizin und Rettungswesen, Studieninstitut Westfalen-Lippe, Bielefeld, Deutschland
| | - M Deicke
- Ärztliche Leitung Rettungsdienst Landkreis Osnabrück, Osnabrück, Deutschland
| | - D Fischer
- Ärztliche Leitung Rettungsdienst Kreis Lippe, Detmold, Deutschland
| | - P Gretenkort
- Simulations- und Notfallakademie am Helios Klinikum Krefeld, Helios Klinikum Krefeld, Krefeld, Deutschland
| | - A Hoyer
- Biostatistik und Medizinische Biometrie, Medizinische Fakultät OWL, Universität Bielefeld, Bielefeld, Deutschland
| | - Y Keller
- Integrierte Regionalleitstelle Dresden, Geschäftsbereich Ordnung und Sicherheit, Brand- und Katastrophenschutzamt, Landeshauptstadt Dresden, Dresden, Deutschland
| | - A Kobiella
- Ärztliche Leitung Rettungsdienst Kreis Gütersloh, Gütersloh, Deutschland
| | - P Ristau
- Institut für Rettungs- und Notfallmedizin (IRuN), Universitätsklinikum Schleswig-Holstein, Kiel, Deutschland
| | - S Seewald
- Institut für Rettungs- und Notfallmedizin (IRuN), Universitätsklinikum Schleswig-Holstein, Kiel, Deutschland
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Schleswig-Holstein - Campus Kiel, Kiel, Deutschland
| | - B Strickmann
- Ärztliche Leitung Rettungsdienst Kreis Gütersloh, Gütersloh, Deutschland
| | - K C Thies
- Universitätsklinik für Anästhesiologie, Intensiv‑, Notfallmedizin, Transfusionsmedizin und Schmerztherapie, Universitätsklinikum OWL der Universität Bielefeld, Evangelisches Klinikum Bielefeld, Bielefeld, Deutschland
| | - K Johanning
- Klinik für Anästhesiologie, operative Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum OWL der Universität Bielefeld - Campus Klinikum Bielefeld, Bielefeld, Deutschland
| | - J Tiesmeier
- Institut für Anästhesiologie, Intensiv- und Notfallmedizin, MKK - Krankenhaus Lübbecke, Campus OWL der Ruhr-Universität Bochum, Lübbecke, Deutschland
| |
Collapse
|
6
|
Jansen G, Latka E, Bernhard M, Deicke M, Fischer D, Hoyer A, Keller Y, Kobiella A, Strickmann B, Strototte LM, Thies KC, Johanning K. Prehospital anesthesia in postcardiac arrest patients: a multicenter retrospective cohort study. Eur J Med Res 2024; 29:263. [PMID: 38698492 PMCID: PMC11067130 DOI: 10.1186/s40001-024-01864-x] [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: 02/15/2024] [Accepted: 04/24/2024] [Indexed: 05/05/2024] Open
Abstract
BACKGROUND Currently, the data regarding the impact of prehospital postcardiac arrest anesthesia on target hemodynamic and ventilatory parameters of early postresuscitation care and recommendations on its implementation are rare. The present study examines the incidence and impact of prehospital postcardiac arrest anesthesia on hemodynamic and ventilatory target parameters of postresuscitation care. METHODS In this multicentre observational study between 2019 and 2021 unconscious adult patients after out-of-hospital-cardiac arrest with the presence of a return-of-spontaneous circulation until hospital admission were included. Primary endpoint was the application of postarrest anesthesia. Secondary endpoints included the medication group used, predisposing factors to its implementation, and its influence on achieving target parameters of postresuscitation care (systolic blood pressure: ≥ 100 mmHg, etCO2:35-45 mmHg, SpO2: 94-98%) at hospital handover. RESULTS During the study period 2,335 out-of-hospital resuscitations out of 391,305 prehospital emergency operations (incidence: 0.58%; 95% CI 0.54-0.63) were observed with a return of spontaneous circulation to hospital admission in 706 patients (30.7%; 95% CI 28.8-32.6; female: 34.3%; age:68.3 ± 14.2 years). Postcardiac arrest anesthesia was performed in 482 patients (68.3%; 95% CI 64.7-71.7) with application of hypnotics in 93.4% (n = 451), analgesics in 53.7% (n = 259) and relaxants in 45.6% (n = 220). Factors influencing postcardiac arrest sedation were emergency care by an anesthetist (odds ratio: 2.10; 95% CI 1.34-3.30; P < 0.001) and treatment-free interval ≤ 5 min (odds ratio: 1.59; 95% CI 1.01-2.49; P = 0.04). Although there was no evidence of the impact of performing postcardiac arrest anesthesia on achieving a systolic blood pressure ≥ 100 mmHg at the end of operation (odds ratio: 1.14; 95% CI 0.78-1.68; P = 0.48), patients with postcardiac arrest anesthesia were significantly more likely to achieve the recommended ventilation (odds ratio: 1.59; 95% CI 1.06-2.40; P = 0.02) and oxygenation (odds ratio:1.56; 95% CI 1.04-2.35; P = 0.03) targets. Comparing the substance groups, the use of hypnotics significantly more often enabled the target values for etCO2 to be reached alone (odds ratio:2.79; 95% CI 1.04-7.50; P = 0.04) as well as in combination with a systolic blood pressure ≥ 100 mmHg (odds ratio:4.42; 95% CI 1.03-19.01; P = 0.04). CONCLUSIONS Postcardiac arrest anesthesia in out-of-hospital cardiac arrest is associated with early achievement of respiratory target parameters in prehospital postresuscitation care without evidence of more frequent hemodynamic complications.
Collapse
Affiliation(s)
- Gerrit Jansen
- University Department of Anesthesiology, Intensive Care Medicine and Emergency Medicine, Johannes Wesling Klinikum Minden, Ruhr University Bochum, Hans-Nolte-Straße 1, 32429, Minden, Germany.
- Medical School OWL, Bielefeld University, Universitätsstraße 25, 33615, Bielefeld, Germany.
- Department of Medical and Emergency Services, Study Institute Westfalen-Lippe, Remterweg 44, 33617, Bielefeld, Germany.
| | - Eugen Latka
- Department of Medical and Emergency Services, Study Institute Westfalen-Lippe, Remterweg 44, 33617, Bielefeld, Germany
| | - Michael Bernhard
- Central Emergency Department, University Hospital of Düsseldorf, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Martin Deicke
- Emergency Medical Service, Countryside of Osnabrueck, Am Schölerberg 1, 49082, Osnabrueck, Germany
- Department of Anesthesiology and Operative Intensive Care Medicine, Hospital of Osnabrueck, Am Finkenhügel 1, 49076, Osnabrueck, Germany
| | - Daniel Fischer
- Emergency Medical Service, City and District of Lippe-Detmold, Röntgenstraße 18, 32756, Detmold, Germany
| | - Annika Hoyer
- Biostatistics and Medical Biometry, Medical School OWL, Bielefeld University, Universitätsstraße 25, 33615, Bielefeld, Germany
| | - Yacin Keller
- Department of Public Order and Security, Fire and Disaster Control Office, Integrated Regional Control Centre, Scharfenberger Straße 47, 01139, Dresden, Germany
- Departement for Anesthesiology and Intensive Care Medicine, Emergency Medicine and Pain Therapy, Municipal Hospital Dresden - Friedrichstadt, Friedrichstraße 41, 01067, Dresden, Germany
| | - André Kobiella
- Emergency Medical Service, City and District of Guetersloh, Herzebrocker Strasse 140, 33324, Guetersloh, Germany
| | - Bernd Strickmann
- Emergency Medical Service, City and District of Guetersloh, Herzebrocker Strasse 140, 33324, Guetersloh, Germany
| | - Lisa Marie Strototte
- Department of Anesthesiology, Intensive Care, Emergency Medicine, Transfusion Medicine, and Pain Therapy, Protestant Hospital of the Bethel Foundation, Medical School OWL, Bielefeld University, Burgsteig 13, 33617, Bielefeld, Germany
| | - Karl-Christian Thies
- Department of Anesthesiology, Intensive Care, Emergency Medicine, Transfusion Medicine, and Pain Therapy, Protestant Hospital of the Bethel Foundation, Medical School OWL, Bielefeld University, Burgsteig 13, 33617, Bielefeld, Germany
| | - Kai Johanning
- Department of Anesthesiology, Operative Intensive Care Medicine, Emergency Medicine and Pain Therapy, Bielefeld Municipal Hospital, Medical School OWL, Bielefeld University, Campus Klinikum Bielefeld, Teutoburger Straße 50, 33604, Bielefeld, Germany
| |
Collapse
|
7
|
Sagi L, Price J, Lachowycz K, Starr Z, Major R, Keeliher C, Finbow B, McLachlan S, Moncur L, Steel A, Sherren PB, Barnard EBG. Critical hypertension in trauma patients following prehospital emergency anaesthesia: a multi-centre retrospective observational study. Scand J Trauma Resusc Emerg Med 2023; 31:104. [PMID: 38124103 PMCID: PMC10731700 DOI: 10.1186/s13049-023-01167-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 12/06/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Critical hypertension in major trauma patients is associated with increased mortality. Prehospital emergency anaesthesia (PHEA) is performed for 10% of the most seriously injured patients. Optimising oxygenation, ventilation, and cerebral perfusion, whilst avoiding extreme haemodynamic fluctuations are the cornerstones of reducing secondary brain injury. The aim of this study was to report the differential determinants of post-PHEA critical hypertension in a large regional dataset of trauma patients across three Helicopter Emergency Medical Service (HEMS) organisations. METHODS A multi-centre retrospective observational study of consecutive adult trauma patients undergoing PHEA across three HEMS in the United Kingdom; 2015-2022. Critical hypertension was defined as a new systolic blood pressure (SBP) > 180mmHg within 10 min of induction of anaesthesia, or > 10% increase if the baseline SBP was > 180mmHg prior to induction. Purposeful logistical regression was used to explore variables associated with post-PHEA critical hypertension in a multivariable model. Data are reported as number (percentage), and odds ratio (OR) with 95% confidence interval (95%CI). RESULTS 30,744 patients were attended by HEMS during the study period; 2161 received PHEA and 1355 patients were included in the final analysis. 161 (11.9%) patients had one or more new episode(s) of critical hypertension ≤ 10 min post-PHEA. Increasing age (compared with 16-34 years): 35-54 years (OR 1.76, 95%CI 1.03-3.06); 55-74 years (OR 2.00, 95%CI 1.19-3.44); ≥75 years (OR 2.38, 95%CI 1.31-4.35), pre-PHEA Glasgow Coma Scale (GCS) motor score four (OR 2.17, 95%CI 1.19-4.01) and five (OR 2.82, 95%CI 1.60-7.09), patients with a pre-PHEA SBP > 140mmHg (OR 6.72, 95%CI 4.38-10.54), and more than one intubation attempt (OR 1.75, 95%CI 1.01-2.96) were associated with post-PHEA critical hypertension. CONCLUSION Delivery of PHEA to seriously injured trauma patients risks haemodynamic fluctuation. In adult trauma patients undergoing PHEA, 11.9% of patients experienced post-PHEA critical hypertension. Increasing age, pre-PHEA GCS motor score four and five, patients with a pre-PHEA SBP > 140mmHg, and more than intubation attempt were independently associated with post-PHEA critical hypertension.
Collapse
Affiliation(s)
- Liam Sagi
- Department of Research, Audit, Innovation, and Development, East Anglian Air Ambulance, Norwich, UK.
| | - James Price
- Department of Research, Audit, Innovation, and Development, East Anglian Air Ambulance, Norwich, UK
- Emergency Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Kate Lachowycz
- Department of Research, Audit, Innovation, and Development, East Anglian Air Ambulance, Norwich, UK
| | - Zachary Starr
- Department of Research, Audit, Innovation, and Development, East Anglian Air Ambulance, Norwich, UK
| | - Rob Major
- Department of Research, Audit, Innovation, and Development, East Anglian Air Ambulance, Norwich, UK
| | | | | | - Sarah McLachlan
- Essex and Herts Air Ambulance, Earls Colne, UK
- Anglia Ruskin University, Chelmsford, UK
| | - Lyle Moncur
- Essex and Herts Air Ambulance, Earls Colne, UK
| | | | - Peter B Sherren
- Essex and Herts Air Ambulance, Earls Colne, UK
- Department of Critical Care Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Ed B G Barnard
- Department of Research, Audit, Innovation, and Development, East Anglian Air Ambulance, Norwich, UK
- Emergency Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Clinical Innovation), Birmingham, UK
| |
Collapse
|
8
|
Sanchez-Reyes OB, Zilberg G, McCorvy JD, Wacker D. Molecular insights into GPCR mechanisms for drugs of abuse. J Biol Chem 2023; 299:105176. [PMID: 37599003 PMCID: PMC10514560 DOI: 10.1016/j.jbc.2023.105176] [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: 03/03/2023] [Revised: 08/10/2023] [Accepted: 08/12/2023] [Indexed: 08/22/2023] Open
Abstract
Substance abuse is on the rise, and while many people may use illicit drugs mainly due to their rewarding effects, their societal impact can range from severe, as is the case for opioids, to promising, as is the case for psychedelics. Common with all these drugs' mechanisms of action are G protein-coupled receptors (GPCRs), which lie at the center of how these drugs mediate inebriation, lethality, and therapeutic effects. Opioids like fentanyl, cannabinoids like tetrahydrocannabinol, and psychedelics like lysergic acid diethylamide all directly bind to GPCRs to initiate signaling which elicits their physiological actions. We herein review recent structural studies and provide insights into the molecular mechanisms of opioids, cannabinoids, and psychedelics at their respective GPCR subtypes. We further discuss how such mechanistic insights facilitate drug discovery, either toward the development of novel therapies to combat drug abuse or toward harnessing therapeutic potential.
Collapse
Affiliation(s)
- Omar B Sanchez-Reyes
- Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Gregory Zilberg
- Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - John D McCorvy
- Department of Cell Biology, Neurobiology, and Anatomy, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.
| | - Daniel Wacker
- Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| |
Collapse
|
9
|
Price J, Moncur L, Lachowycz K, Major R, Sagi L, McLachlan S, Keeliher C, Steel A, Sherren PB, Barnard EBG. Predictors of post-intubation hypotension in trauma patients following prehospital emergency anaesthesia: a multi-centre observational study. Scand J Trauma Resusc Emerg Med 2023; 31:26. [PMID: 37268976 PMCID: PMC10236576 DOI: 10.1186/s13049-023-01091-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 05/24/2023] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND Post-intubation hypotension (PIH) after prehospital emergency anaesthesia (PHEA) is prevalent and associated with increased mortality in trauma patients. The objective of this study was to compare the differential determinants of PIH in adult trauma patients undergoing PHEA. METHODS This multi-centre retrospective observational study was performed across three Helicopter Emergency Medical Services (HEMS) in the UK. Consecutive sampling of trauma patients who underwent PHEA using a fentanyl, ketamine, rocuronium drug regime were included, 2015-2020. Hypotension was defined as a new systolic blood pressure (SBP) < 90 mmHg within 10 min of induction, or > 10% reduction if SBP was < 90 mmHg before induction. A purposeful selection logistic regression model was used to determine pre-PHEA variables associated with PIH. RESULTS During the study period 21,848 patients were attended, and 1,583 trauma patients underwent PHEA. The final analysis included 998 patients. 218 (21.8%) patients had one or more episode(s) of hypotension ≤ 10 min of induction. Patients > 55 years old; pre-PHEA tachycardia; multi-system injuries; and intravenous crystalloid administration before arrival of the HEMS team were the variables significantly associated with PIH. Induction drug regimes in which fentanyl was omitted (0:1:1 and 0:0:1 (rocuronium-only)) were the determinants with the largest effect sizes associated with hypotension. CONCLUSION The variables significantly associated with PIH only account for a small proportion of the observed outcome. Clinician gestalt and provider intuition is likely to be the strongest predictor of PIH, suggested by the choice of a reduced dose induction and/or the omission of fentanyl during the anaesthetic for patients perceived to be at highest risk.
Collapse
Affiliation(s)
- James Price
- Department of Research, Audit, Innovation, and Development, East Anglian Air Ambulance, Norwich, UK
- Emergency Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Lyle Moncur
- Essex and Herts Air Ambulance, Earls Colne, UK
| | - Kate Lachowycz
- Department of Research, Audit, Innovation, and Development, East Anglian Air Ambulance, Norwich, UK
| | - Rob Major
- Department of Research, Audit, Innovation, and Development, East Anglian Air Ambulance, Norwich, UK
| | - Liam Sagi
- Department of Research, Audit, Innovation, and Development, East Anglian Air Ambulance, Norwich, UK
| | - Sarah McLachlan
- Essex and Herts Air Ambulance, Earls Colne, UK
- Anglia Ruskin University, Chelmsford, UK
| | | | | | - Peter B. Sherren
- Essex and Herts Air Ambulance, Earls Colne, UK
- Department of Critical Care Medicine, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Ed B. G. Barnard
- Department of Research, Audit, Innovation, and Development, East Anglian Air Ambulance, Norwich, UK
- Emergency Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Clinical Innovation), Birmingham, UK
| |
Collapse
|
10
|
Leeies M, Rosychuk RJ, Ismath M, Xu K, Archambault P, Fok PT, Audet T, Jelic T, Hayward J, Daoust R, Chandra K, Davis P, Yan JW, Hau JP, Welsford M, Brooks SC, Hohl CM. Intubation practices and outcomes for patients with suspected or confirmed COVID-19: a national observational study by the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN). CAN J EMERG MED 2023; 25:335-343. [PMID: 37017802 PMCID: PMC10075161 DOI: 10.1007/s43678-023-00487-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 03/09/2023] [Indexed: 04/06/2023]
Abstract
OBJECTIVE Intubation practices changed during the COVID-19 pandemic to protect healthcare workers from transmission of disease. Our objectives were to describe intubation characteristics and outcomes for patients tested for SARS CoV-2 infection. We compared outcomes between patients testing SARS COV-2 positive with those testing negative. METHODS We conducted a health records review using the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN) registry. We included consecutive eligible patients who presented to one of 47 EDs across Canada between March 1, 2020 and June 20, 2021, were tested for SARS-CoV-2 and intubated in the ED. The primary outcome was the proportion of patients experiencing a post-intubation adverse event during the ED stay. Secondary outcomes included first-pass success, intubation practices, and hospital mortality. We used descriptive statistics to summarize variables with subgroup differences examined using t tests, z tests, or chi-squared tests where appropriate with 95% CIs. RESULTS Of 1720 patients with suspected COVID-19 who were intubated in the ED during the study period, 337 (19.6%) tested SARS-CoV-2 positive and 1383 (80.4%) SARS-CoV-2 negative. SARS-CoV-2 positive patients presented to hospital with lower oxygen levels than SARS-CoV-2 negative patients (mean pulse oximeter SaO2 86 vs 94%, p < 0.001). In total, 8.5% of patients experienced an adverse event post-intubation. More patients in the SARS-CoV-2 positive subgroup experienced post-intubation hypoxemia (4.5 vs 2.2%, p = 0.019). In-hospital mortality was greater for patients who experienced intubation-related adverse events (43.2 vs 33.2%, p = 0.018). There was no significant difference in adverse event-associated mortality by SARS-CoV-2 status. First-pass success was achieved in 92.4% of all intubations, with no difference by SARS-CoV-2 status. CONCLUSIONS During the COVID-19 pandemic, we observed a low risk of adverse events associated with intubation, even though hypoxemia was common in patients with confirmed SARS-CoV-2. We observed high rates of first-pass success and low rates of inability to intubate. The limited number of adverse events precluded multivariate adjustments. Study findings should reassure emergency medicine practitioners that system modifications made to intubation processes in response to the COVID-19 pandemic do not appear to be associated with worse outcomes compared to pre-COVID-19 practices.
Collapse
Affiliation(s)
- Murdoch Leeies
- Department of Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada.
- Rady Faculty of Health Sciences, Section of Critical Care Medicine, University of Manitoba, Winnipeg, MB, Canada.
| | - Rhonda J Rosychuk
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Muzeen Ismath
- Department of Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Ke Xu
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Patrick Archambault
- Department of Family Medicine and Emergency Medicine and Department of Anesthesiology and Intensive Care, Université Laval, Québec, QC, Canada
| | - Patrick T Fok
- Department of Emergency Medicine, Dalhousie University, Halifax, NS, Canada
| | - Thomas Audet
- Department of Internal Medicine, Université Laval, Québec, QC, Canada
| | - Tomislav Jelic
- Department of Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Jake Hayward
- Department of Emergency Medicine, University of Alberta, Edmonton, AB, Canada
| | - Raoul Daoust
- Department of Family and Emergency Medicine, University of Montreal, Montreal, QC, Canada
| | - Kavish Chandra
- Department of Emergency Medicine, Dalhousie University, Saint John, NB, Canada
| | - Phil Davis
- Department of Emergency Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Justin W Yan
- Division of Emergency Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, Western University and Lawson Health Research Institute, London Health Sciences Centre, London, ON, Canada
| | - Jeffrey P Hau
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, Canada
| | - Michelle Welsford
- Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada
| | - Steven C Brooks
- Department of Emergency Medicine, Queen's University, Kingston, ON, Canada
| | - Corinne M Hohl
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| |
Collapse
|
11
|
Ferguson IMC, Miller MR, Partyka C, Bliss J, Aneman A, Harris IA. The effect of ketamine and fentanyl on haemodynamics during intubation in pre-hospital and retrieval medicine. Acta Anaesthesiol Scand 2023; 67:364-371. [PMID: 36495319 DOI: 10.1111/aas.14177] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/14/2022] [Accepted: 11/26/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Ketamine use for rapid sequence intubation (RSI) is frequent in pre-hospital and retrieval medicine (PHARM) and is associated with potentially deleterious haemodynamic changes, which may be ameliorated by concurrent use of fentanyl. OBJECTIVES To describe the frequency with which fentanyl is used in conjunction with ketamine in a system where its use is discretionary, and to explore any observed changes in haemodynamics with its use. METHODS A retrospective observational study of over 800 patients undergoing RSI with ketamine ± fentanyl in the PHARM setting between 2015 and 2019. The primary outcome was the proportion of patients in each group who had a systolic blood pressure (SBP) outside a pre-specified target range, with adjustment for baseline abnormality, within 10 min of anaesthetic induction. RESULTS Eight hundred and seventy-six patients were anaesthetised with ketamine, of whom 804 were included in the analysis. 669 (83%, 95% CI 80%-86%) received ketamine alone, and 135 (17%, 95% CI 14%-20%) received both fentanyl and ketamine. Median fentanyl dose was 1.1 mcg/kg (IQR 0.75-1.5 mcg/kg). Systolic blood pressure (SBP) at induction was consistently associated with SBP after intubation in multivariable logistic regression, but fentanyl use was not associated with a change in odds of meeting the primary outcome (OR 1.08; 95% CI 0.72-1.60), becoming hypertensive (OR 1.35; 95% CI 0.88-2.07) or hypotensive (OR 0.76; 95% CI 0.47-1.21). CONCLUSIONS The addition of fentanyl to ketamine for RSI was not associated with an alteration of the odds of post-induction haemodynamic stability, although the doses used were low. These findings justify further study into the optimal dosing of fentanyl during RSI in pre-hospital and retrieval medicine.
Collapse
Affiliation(s)
- Ian M C Ferguson
- Aeromedical Retrieval Service, New South Wales Ambulance, Rozelle, New South Wales, Australia.,South West Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,Emergency Department, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Matthew R Miller
- Aeromedical Retrieval Service, New South Wales Ambulance, Rozelle, New South Wales, Australia.,St George Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,Department of Anesthesiology, St George Hospital, Sydney, New South Wales, Australia
| | - Christopher Partyka
- Aeromedical Retrieval Service, New South Wales Ambulance, Rozelle, New South Wales, Australia.,South West Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,Emergency Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - James Bliss
- Aeromedical Retrieval Service, New South Wales Ambulance, Rozelle, New South Wales, Australia.,South West Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,Emergency Department, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Anders Aneman
- South West Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,Intensive Care Unit, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Ian A Harris
- South West Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,Whitlam Orthopaedic Research Centre, Liverpool, New South Wales, Australia
| |
Collapse
|
12
|
Škulec R. Year 2022 in review - Emergency medicine. ANESTEZIOLOGIE A INTENZIVNÍ MEDICÍNA 2022. [DOI: 10.36290/aim.2022.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
|
13
|
Tejado S, Naharro A, Alcántara S. Analgesia as part of the orotracheal intubation induction sequence. Intensive Care Med 2022; 48:1833-1834. [PMID: 36194259 DOI: 10.1007/s00134-022-06886-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2022] [Indexed: 11/24/2022]
Affiliation(s)
- Sandra Tejado
- Puerta de Hierro University Hospital of Majadahonda: Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain.
| | | | - Sara Alcántara
- Puerta de Hierro University Hospital of Majadahonda: Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| |
Collapse
|
14
|
Leech C, Virgo I, George A, Anderson M, Spindler H, Bolan H, Waters J. Journal update monthly top five. J Accid Emerg Med 2022; 39:721-722. [PMID: 35998932 DOI: 10.1136/emermed-2022-212725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 08/11/2022] [Indexed: 11/03/2022]
Affiliation(s)
- Caroline Leech
- Emergency Department, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, CV2 2DX, UK
| | - Imogen Virgo
- Emergency Department, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, CV2 2DX, UK
| | - Arun George
- Emergency Department, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, CV2 2DX, UK
| | - Miriam Anderson
- Emergency Department, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, CV2 2DX, UK
| | - Helen Spindler
- Emergency Department, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, CV2 2DX, UK
| | - Hannah Bolan
- Emergency Department, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, CV2 2DX, UK
| | - Jennifer Waters
- Emergency Department, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, CV2 2DX, UK
| |
Collapse
|