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Mocanu C, Woodall KL, Solbeck P. Prevalence and blood concentrations of benzodiazepines and opioids in opioid-positive death investigations in Ontario, Canada, from 2017 to 2021. J Forensic Sci 2024; 69:607-617. [PMID: 38282130 DOI: 10.1111/1556-4029.15463] [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: 11/06/2023] [Revised: 01/04/2024] [Accepted: 01/11/2024] [Indexed: 01/30/2024]
Abstract
The aim of this study was to investigate the incidence of benzodiazepines in opioid-positive death investigations, including trends in frequency and combination of drugs, as well as demographic data and blood concentrations, where available. Additionally, naloxone concentrations in polysubstance compared to opioid-only cases were analyzed. This was a retrospective study that consisted of all post-mortem toxicology cases in Ontario, Canada, from January 01, 2017, to December 31, 2021, with an opioid finding in any analyzed autopsy specimen. There were 11,033 death investigations identified. The overall rate of benzodiazepine co-involvement was 54.5%. Males accounted for the majority of cases (71%), and the most affected age group was 30- to 39-year-olds. The most frequently detected opioid was fentanyl and the most frequently detected benzodiazepine was etizolam, which was also the most frequently observed opioid/benzodiazepine combination. Findings related to differences in concentrations of opioids when naloxone was also present were mostly non-significant, except for methadone. The rate of benzodiazepine detection with opioids grew faster than opioid detections overall, potentially due to the increasingly toxic drug supply. Detection of novel psychoactive drugs fluctuated more unpredictably than opioids and benzodiazepines associated with clinical use. These findings can help inform policy decisions by public health agencies in exploring harm reduction efforts, for example, education and drug-checking services.
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Affiliation(s)
- Cora Mocanu
- University of Toronto, Toronto, Ontario, Canada
| | - Karen L Woodall
- University of Toronto Mississauga, Mississauga, Ontario, Canada
| | - Patricia Solbeck
- Quality Assurance Unit, Centre of Forensic Sciences, Toronto, Ontario, Canada
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Lee J, Kim DH, Ju JW, Nam K, Cho YJ, Jeon Y, Lee S. Comparison of recovery profiles between total intravenous anaesthesia with propofol or remimazolam reversed with flumazenil in patients undergoing breast surgery: A randomised controlled trial. Eur J Anaesthesiol 2024; 41:199-207. [PMID: 38205822 DOI: 10.1097/eja.0000000000001951] [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: 01/12/2024]
Abstract
BACKGROUND Remimazolam, a short acting benzodiazepine, is being used for general anaesthesia. The results of studies comparing recovery after propofol with that of remimazolam are inconsistent. Given that flumazenil reverses the sedative effects of remimazolam, we hypothesised that it would speed up recovery from remimazolam general anaesthesia. OBJECTIVES The aim of this trial was to compare the speed of recovery from general anaesthesia between propofol and remimazolam reversed with flumazenil in patients undergoing minimally invasive breast surgery. DESIGN Randomised, single-centre, double-blind controlled trial. SETTING A tertiary teaching hospital in South Korea from August 2022 to December 2022. PATIENTS Adult patients (≥19 years of age) about to undergo general anaesthesia for scheduled breast cancer surgery. INTERVENTIONS Patients were randomly allocated to either the propofol or the remimazolam/flumazenil group. The emergence process was monitored by only one anaesthesiologist. MAIN OUTCOME MEASURES The primary outcome was the time to eye opening to command during recovery from the general anaesthesia. Time to removal of the supraglottic airway (SGA) time to discharge, and the Riker sedation agitation scale (SAS) score (1 to 4) during emergence were compared as secondary outcomes. RESULTS The remimazolam group had a significantly shorter mean time to eye opening than the propofol group [127 ± 51 vs. 314 ± 140 s; mean difference 187 s (95% confidence interval (CI), 133 to 241 s; P < 0.001]. The remimazolam group also had shorter times to SGA removal [169 ± 51 vs. 366 ± 149 s; mean difference 198 s (95% CI, 140 to 255 s); P < 0.001] and time to discharge from the operating room [243 ± 55 vs. 449 ± 159 s; mean difference 206 s (95% CI, 145 to 267 s); P < 0.001]. The SAS scores during emergence also differed significantly, with 1 patient in the propofol group and 25 in the remimazolam group attaining scores of 4 ( P < 0.001). CONCLUSION Administration of remimazolam with flumazenil may be a promising option for patients undergoing breast cancer surgery, providing faster recovery and better SAS scores than propofol during emergence from general anaesthesia. TRIAL REGISTRATION ClinicalTrials.gov (NCT05435911).
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Affiliation(s)
- Jaemoon Lee
- From the Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea (JL, DHK, JWJ, KN, YJC, YJ, SL) and Department of Anaesthesiology and Pain Medicine, Konkuk University Hospital, Konkuk University College of Medicine, Seoul, Republic of Korea (JL)
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Miskulin A, Wallace B, Gill C, Hore D. A strategy for the detection of benzodiazepine drugs using low-resolution paper-spray mass spectrometry for harm reduction drug checking. Drug Test Anal 2023. [PMID: 38145889 DOI: 10.1002/dta.3630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 11/02/2023] [Accepted: 12/07/2023] [Indexed: 12/27/2023]
Abstract
The ability to detect newly emerging substances is of great importance in reducing harms for people who use drugs. New psychoactive substances including novel benzodiazepines in the illicit drug supply have been linked to high rates of overdose deaths while complicating drug checking as an overdose prevention strategy. Paper-spray mass spectrometry (PS-MS) has emerged as a novel strategy to rapidly detect trace components in street drug samples. While targeted, low-resolution PS-MS methods have proven effective, newly emerging substances are often missed. To address this, a method was applied to low-resolution full-scan PS-MS data to aid in the early detection and identification of novel benzodiazepines in the unregulated drug supply. Using the developed method, true positives rates of 0.89 and 0.75 were achieved for bromazolam and etizolam in street samples obtained in a community drug checking service. The applicability of the method was further demonstrated for a novel benzodiazepine, desalkylgidazepam, that has recently emerged in the illicit drug supply.
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Affiliation(s)
- Allie Miskulin
- Department of Chemistry, University of Victoria, Victoria, British Columbia, Canada
| | - Bruce Wallace
- School of Social Work, University of Victoria, Victoria, British Columbia, Canada
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, British Columbia, Canada
| | - Chris Gill
- Department of Chemistry, University of Victoria, Victoria, British Columbia, Canada
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, British Columbia, Canada
- Department of Chemistry, Applied Environmental Research Laboratories (AERL), Vancouver Island University, Nanaimo, British Columbia, Canada
- Department of Chemistry, Simon Fraser University, Burnaby, British Columbia, Canada
- Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, Washington, USA
| | - Dennis Hore
- Department of Chemistry, University of Victoria, Victoria, British Columbia, Canada
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, British Columbia, Canada
- Department of Computer Science, University of Victoria, Victoria, British Columbia, Canada
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Bird SM. Opioid-related deaths and their counterpart by occurrence era, age group and coimplicated drugs: Scotland vs. England and Wales. Br J Clin Pharmacol 2023. [PMID: 38009544 DOI: 10.1111/bcp.15976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 11/07/2023] [Accepted: 11/10/2023] [Indexed: 11/29/2023] Open
Abstract
AIMS Compare by occurrence era and age group how opioid-related deaths (ORDs) and their counterpart evolved in Scotland vs. England and Wales during 2006-2020. For Scotland, compare coimplication rates between ORDs and non-ORDs for any benzodiazepine, cocaine or gabapentin/pregabalin, and consider whether coimplication in ORDs depended on opioid-specificity. METHODS Cross-tabulations of drug misuse deaths (DMDs) obtained by 3 yearly occurrence era (2006-2008 to 2018-2020) and age group (under 25, 25-34, 35-44, 45-54, 55+ years) for England and Wales and subdivided by whether at least 1 opiate was mentioned on death certificate (DMD-Os or not); and of Scotland's opioid-related deaths (ORDs vs. non-ORDs) together with (i) coimplication by any benzodiazepine, cocaine or gabapentin/pregabalin; and (ii) opioid-specificity of ORDs. ORD is defined by heroin/morphine, methadone or buprenorphine being implicated in DMD. RESULTS Per era between 2012-2014 and 2018-2020, Scotland's ORDs increased by 54% and non-ORDs by 34%. Increase in DMD-Os in England and Wales was more modest. Cocaine was implicated in 83% of Scotland's 2690 non-ORDs during 2006-2020; and any benzodiazepine in 53% of 8409 ORDs. However, in 2018-2020, coimplication rates in 2926 ORDs (880 non-ORDs) were 81% (33%) for any benzodiazepine, 30% (74%) for cocaine and 38% (22%) for gabapentin/pregabalin. Coimplication rate in 2018-2020 for any benzodiazepine was lowest at 70% (616/877) for heroin/morphine ORDs; and, by age group, at 66% (160/241) for ORDs aged 55+ years. CONCLUSIONS Drug testing to inform users, shared intelligence between police and public health for earlier detection of changes in supply and monitoring of prescribed daily-dose of methadone are urgent.
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Zagorski CM, Hosey RA, Moraff C, Ferguson A, Figgatt M, Aronowitz S, Stahl NE, Hill LG, McElligott Z, Dasgupta N. Reducing the harms of xylazine: clinical approaches, research deficits, and public health context. Harm Reduct J 2023; 20:141. [PMID: 37777769 PMCID: PMC10544173 DOI: 10.1186/s12954-023-00879-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 09/27/2023] [Indexed: 10/02/2023] Open
Abstract
OBJECTIVES Xylazine has emerged as a consistent part of the unregulated drug supply in recent months. We discuss major domains of xylazine's harm, current knowledge deficits, clinical and harm reduction strategies for minimizing harm, and xylazine's public health and policy context. As an interdisciplinary team from across the USA, we have pooled our knowledge to provide an overview of xylazine's current and emerging contexts. METHODS To inform this essay, the pertinent literature was reviewed, clinical knowledge and protocols were shared by multiple clinicians with direct expertise, and policy and public health context were added by expert authors. RESULTS We describe xylazine's major harm domains-acute poisoning, extended sedation, and wounds, along with anemia and hyperglycemia, which have been reported anecdotally but lack as clear of a connection to xylazine. Current successful practices for xylazine wound care are detailed. Understanding xylazine's epidemiology will also require greater investment in drug checking and surveillance. Finally, approaches to community-based wound care are discussed, along with an orientation to the larger policy and public health context. CONCLUSIONS Addressing the harms of xylazine requires interdisciplinary participation, investment in community-based harm reduction strategies, and improved drug supply surveillance. The relatively unique context of xylazine demands buy-in from public health professionals, harm reduction professionals, clinicians, basic science researchers, policymakers and more.
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Affiliation(s)
- Claire M Zagorski
- College of Pharmacy, The University of Texas at Austin, 2409 University Avenue, A1910, PHR 3.208J, Austin, TX, 78712, USA.
| | - Rebecca A Hosey
- HIV Prevention Research Division, Department of Psychiatry, School of Medicine, University of Pennsylvania, 3535 Market Street, Suite 4000, Philadelphia, PA, 19104, USA
| | | | - Aaron Ferguson
- National Survivors Union, 1116 Grove St, Greensboro, NC, 27403, USA
| | - Mary Figgatt
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, 135 Dauer Drive, Chapel Hill, NC, 27599, USA
| | - Shoshana Aronowitz
- University of Pennsylvania School of Nursing, Fagin Hall, 418 Curie Blvd, Philadelphia, PA, 19104, USA
| | - Natalie E Stahl
- Greater Lawrence Family Health Center, 34 Haverhill Street, Lawrence, MA, 01841, USA
| | - Lucas G Hill
- College of Pharmacy, The University of Texas at Austin, 2409 University Avenue, A1910, PHR 3.208J, Austin, TX, 78712, USA
| | - Zoe McElligott
- Department of Pharmacology, Bowles Center for Alcohol Studies, University of North Carolina, CB#7178, 104 Manning Road, Chapel Hill, NC, 2759, USA
| | - Nabarun Dasgupta
- University of North Carolina, 725 MLK Jr. Blvd., CB 7505, Chapel Hill, NC, 27599, USA
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Kobylarz D, Noga M, Frydrych A, Milan J, Morawiec A, Glaca A, Kucab E, Jastrzębska J, Jabłońska K, Łuc K, Zdeb G, Pasierb J, Toporowska-Kaźmierak J, Półchłopek S, Słoma P, Adamik M, Banasik M, Bartoszek M, Adamczyk A, Rędziniak P, Frączkiewicz P, Orczyk M, Orzechowska M, Tajchman P, Dziuba K, Pelczar R, Zima S, Nyankovska Y, Sowińska M, Pempuś W, Kubacka M, Popielska J, Brzezicki P, Jurowski K. Antidotes in Clinical Toxicology-Critical Review. TOXICS 2023; 11:723. [PMID: 37755734 PMCID: PMC10534475 DOI: 10.3390/toxics11090723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 08/11/2023] [Accepted: 08/20/2023] [Indexed: 09/28/2023]
Abstract
Poisoning and overdose are very important aspects in medicine and toxicology. Chemical weapons pose a threat to civilians, and emergency medicine principles must be followed when dealing with patients who have been poisoned or overdosed. Antidotes have been used for centuries and modern research has led to the development of new antidotes that can accelerate the elimination of toxins from the body. Although some antidotes have become less relevant due to modern intensive care techniques, they can still save lives or reduce the severity of toxicity. The availability of antidotes is crucial, especially in developing countries where intensive care facilities may be limited. This article aims to provide information on specific antidotes, their recommended uses, and potential risks and new uses. In the case of poisoning, supportive therapies are most often used; however, in many cases, the administration of an appropriate antidote saves the patient's life. In this review, we reviewed the literature on selected antidotes used in the treatment of poisonings. We also characterised the antidotes (bio)chemically. We described the cases in which they are used together with the dosage recommendations. We also analysed the mechanisms of action. In addition, we described alternative methods of using a given substance as a drug, an example of which is N-acetylcysteine, which can be used in the treatment of COVID-19. This article was written as part of the implementation of the project of the Polish Ministry of Education and Science, "Toxicovigilance, poisoning prevention, and first aid in poisoning with xenobiotics of current clinical importance in Poland", grant number SKN/SP/570184/2023.
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Affiliation(s)
- Damian Kobylarz
- Department of Regulatory and Forensic Toxicology, Institute of Medical Expertises, Łódź, ul. Aleksandrowska 67/93, 91-205 Łódź, Poland
| | - Maciej Noga
- Department of Regulatory and Forensic Toxicology, Institute of Medical Expertises, Łódź, ul. Aleksandrowska 67/93, 91-205 Łódź, Poland
| | - Adrian Frydrych
- Laboratory of Innovative Toxicological Research and Analyzes, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland
| | - Justyna Milan
- Laboratory of Innovative Toxicological Research and Analyzes, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland
| | - Adrian Morawiec
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Agata Glaca
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Emilia Kucab
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Julia Jastrzębska
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Karolina Jabłońska
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Klaudia Łuc
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Gabriela Zdeb
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Jakub Pasierb
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Joanna Toporowska-Kaźmierak
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Szczepan Półchłopek
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Paweł Słoma
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Magdalena Adamik
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Mateusz Banasik
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Mateusz Bartoszek
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Aleksandra Adamczyk
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Patrycja Rędziniak
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Paulina Frączkiewicz
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Michał Orczyk
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Martyna Orzechowska
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Paulina Tajchman
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Klaudia Dziuba
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Rafał Pelczar
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Sabina Zima
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Yana Nyankovska
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Marta Sowińska
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Wiktoria Pempuś
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Maria Kubacka
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Julia Popielska
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Patryk Brzezicki
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Kamil Jurowski
- Department of Regulatory and Forensic Toxicology, Institute of Medical Expertises, Łódź, ul. Aleksandrowska 67/93, 91-205 Łódź, Poland
- Laboratory of Innovative Toxicological Research and Analyzes, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland
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Zarei MJ, Ramezani M, Sahraie Z, Shadnia S, Erfan Talab Evini P, Mostafazadeh B, Rahimi M. Comparing Two Naloxone Tapering Methods in Management of Methadone Intoxication; a Quasi-experimental Study. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2023; 11:e46. [PMID: 37609540 PMCID: PMC10440751 DOI: 10.22037/aaem.v11i1.2047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
Introduction Even though naloxone is the main treatment for methadone poisoning treatment there are controversies about the proper method of its tapering. This study aimed to compare two methods in this regard. Method This study was a prospective, single-blind pilot quasi-experimental study on non-addicted adult patients poisoned with methadone. Patients were randomly divided into 2 groups. In one group, after stabilization of respiratory conditions and consciousness, naloxone was tapered using the half-life of methadone and in the other group, naloxone was tapered using the half-life of naloxone. Recurrence of symptoms and changes in venous blood gas parameters were compared between groups as outcome. Results 52 patients were included (51.92% female). 31 cases entered Group A (tapering based on methadone's half-life) and 21 cases entered Group B (tapering based on naloxone's half-life). The two groups were similar regarding mean age (p = 0.575), gender distribution (p = 0.535), the cause of methadone use (p = 0.599), previous medical history (p = 0.529), previous methadone use (p = 0.654), drug use history (p = 0.444), and vital signs on arrival to emergency department (p = 0.054). The cases of re-decreasing consciousness during tapering (52.38% vs. 25.81%; p = 0.049) and after discontinuation of naloxone (72.73% vs. 37.50%; p = 0.050) were higher in the tapering based on naloxone half-life group. The relative risk reduction (RRR) for naloxone half-life group was -1.03 and for methadone half-life group was 0.51. The absolute risk reduction (ARR) was 0.27 (95% confidence interval (CI) = 0.01-0.53) and the number needed to treat (NNT) was 3.7 (95% CI= 1.87- 150.53). There was not any statistically significant difference between groups regarding pH, HCO3, and PCO2 changes during tapering and after naloxone discontinuation (p > 0.05). However, repeated measures analysis of variance (ANOVA), showed that in the tapering based on methadone's half-life group, the number of changes and stability in the normal range were better (p < 0.001). Conclusion It seems that, by tapering naloxone based on methadone's half-life, not only blood acid-base disorders are treated, but they also remain stable after discontinuation and the possibility of symptom recurrence is reduced.
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Affiliation(s)
- Mohammad Javad Zarei
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Maral Ramezani
- Department of Pharmacology, School of Medicine, Arak University of Medical Sciences, Arak, Iran
- Traditional and Complementary Medicine Research Center, Arak University of Medical Sciences, Arak, Iran
| | - Zahra Sahraie
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Shahin Shadnia
- Toxicological Research Center, Excellence Center & Department of Clinical Toxicology
| | | | - Babak Mostafazadeh
- Toxicological Research Center, Excellence Center & Department of Clinical Toxicology
| | - Mitra Rahimi
- Toxicological Research Center, Excellence Center & Department of Clinical Toxicology
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Gonzalez-Rivera ML, Barragan-Galvez JC, Gasca-Martínez D, Hidalgo-Figueroa S, Isiordia-Espinoza M, Alonso-Castro AJ. In Vivo Neuropharmacological Effects of Neophytadiene. Molecules 2023; 28:molecules28083457. [PMID: 37110691 PMCID: PMC10142729 DOI: 10.3390/molecules28083457] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 04/03/2023] [Accepted: 04/11/2023] [Indexed: 04/29/2023] Open
Abstract
Neophytadiene (NPT) is a diterpene found in the methanolic extracts of Crataeva nurvala and Blumea lacera, plants reported with anxiolytic-like activity, sedative properties, and antidepressant-like actions; however, the contribution of neophytadiene to these effects is unknown. This study determined the neuropharmacological (anxiolytic-like, antidepressant-like, anticonvulsant, and sedative) effects of neophytadiene (0.1-10 mg/kg p.o.) and determined the mechanisms of action involved in the neuropharmacological actions using inhibitors such as flumazenil and analyzing the possible interaction of neophytadiene with GABA receptors using a molecular docking study. The behavioral tests were evaluated using the light-dark box, elevated plus-maze, open field, hole-board, convulsion, tail suspension, pentobarbital-induced sleeping, and rotarod. The results showed that neophytadiene exhibited anxiolytic-like activity only to the high dose (10 mg/kg) in the elevated plus-maze and hole-board tests, and anticonvulsant actions in the 4-aminopyridine and pentylenetetrazole-induced seizures test. The anxiolytic-like and anticonvulsant effects of neophytadiene were abolished with the pre-treatment with 2 mg/kg flumazenil. In addition, neophytadiene showed low antidepressant effects (about 3-fold lower) compared to fluoxetine. On other hand, neophytadiene had no sedative or locomotor effects. In conclusion, neophytadiene exerts anxiolytic-like and anticonvulsant activities with the probable participation of the GABAergic system.
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Affiliation(s)
- Maria L Gonzalez-Rivera
- Departamento de Farmacia, División de Ciencias Naturales y Exactas, Universidad de Guanajuato, Guanajuato 36200, Mexico
| | - Juan Carlos Barragan-Galvez
- Departamento de Farmacia, División de Ciencias Naturales y Exactas, Universidad de Guanajuato, Guanajuato 36200, Mexico
| | - Deisy Gasca-Martínez
- Unidad de Análisis Conductual, Instituto de Neurobiología, Campus UNAM-Juriquilla, Juriquilla 76230, Mexico
| | - Sergio Hidalgo-Figueroa
- CONACyT-División de Biología Molecular, Instituto Potosino de Investigación Científica y Tecnológica A.C., San Luis Potosí 78216, Mexico
| | - Mario Isiordia-Espinoza
- Instituto de Investigación en Ciencias Médicas, Departamento de Clínicas, División de Ciencias Biomédicas, Centro Universitario de los Altos, Universidad de Guadalajara, Tepatitlán de Morelos 47620, Mexico
| | - Angel Josabad Alonso-Castro
- Departamento de Farmacia, División de Ciencias Naturales y Exactas, Universidad de Guanajuato, Guanajuato 36200, Mexico
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9
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Raman R. High-potency benzodiazepine misuse in opioid-dependent patients: use naloxone with care. Emerg Med J 2023; 40:224-227. [PMID: 35977818 DOI: 10.1136/emermed-2021-212254] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 08/03/2022] [Indexed: 11/04/2022]
Abstract
The misuse of highly potent benzodiazepines is increasing in the UK, particularly among the opioid-using population in Scotland. Differentiating opioid from benzodiazepine toxicity is not always straightforward in patients with reduced level of consciousness following drug overdose. Patients on long-term opioid substitution who present with acute benzodiazepine intoxication and are given naloxone may develop severe opioid withdrawal while still obtunded from benzodiazepines. This situation can be difficult to manage, and these patients may be at increased risk of vomiting while still unable to protect their airway. Fortunately, the short half-life of naloxone means that the situation is generally short-lived. Naloxone should never be withheld from patients with life-threatening respiratory depression where opioids may be contributing, particularly in community and prehospital settings; however, where appropriate clinical experience exists, naloxone should ideally be administered in small incremental intravenous doses with close monitoring of respiratory function. Increased awareness of the potential risks of naloxone in opioid-dependent patients acutely intoxicated with benzodiazepines may reduce the risk of iatrogenic harm in an already very vulnerable population.
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Affiliation(s)
- Rajendra Raman
- Emergency Department, Victoria Hospital, NHS Fife, Kirkcaldy, UK
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10
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Mekeirele M, Verheyen S, Van Lancker R, Wuyts S, Balthazar T. Hemadsorption: A New Therapeutic Option for Selected Cases of Bromazepam Intoxication. Case Rep Nephrol Dial 2022; 12:163-166. [PMID: 36518360 PMCID: PMC9743138 DOI: 10.1159/000526323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 07/29/2022] [Indexed: 11/19/2022] Open
Abstract
Benzodiazepine ingestion is frequent in patients admitted to ICU for intoxications. Generally, a supportive approach by securing the airway, breathing, and circulation is sufficient. Flumazenil is a well-known antidote for benzodiazepines but does not influence its elimination. Following preclinical data, we applied for the first time in humans a hemadsorption filter in a patient with a bromazepam intoxication. This technique proved to be effective in eliminating bromazepam in a patient with CHILD-C cirrhosis. We conclude that hemadsorption is a viable option to reduce length of ICU stay or intubation in slow metabolizers without contraindications.
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Affiliation(s)
- Michaël Mekeirele
- aDepartment of Intensive Care Medicine, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussel, Belgium,*Michaël Mekeirele,
| | - Silke Verheyen
- bPharmacy Department, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussel, Belgium
| | - Ruth Van Lancker
- aDepartment of Intensive Care Medicine, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussel, Belgium
| | - Stephanie Wuyts
- bPharmacy Department, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussel, Belgium,cCentre for Pharmaceutical Research, Research Group Clinical Pharmacology and Clinical Pharmacy, Faculty of Medicine and Pharmacy, Vrije universiteit Brussel (VUB), Brussel, Belgium
| | - Tim Balthazar
- aDepartment of Intensive Care Medicine, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussel, Belgium,dDepartment of Cardiology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussel, Belgium
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11
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Recall of extubation after remimazolam anesthesia with flumazenil antagonism during emergence: a retrospective clinical study. J Anesth 2022; 36:688-692. [PMID: 36076100 DOI: 10.1007/s00540-022-03093-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 07/30/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE This study was performed to examine and compare the incidence of extubation recall in surgical patients who underwent remimazolam anesthesia with flumazenil antagonism during emergence and in those who underwent propofol anesthesia. METHODS One hundred sixty-three patients who underwent surgery using general endotracheal or supraglottic airway anesthesia with propofol (n = 97) or remimazolam (n = 66) were retrospectively analyzed. Remimazolam was antagonized by flumazenil after discontinuation of remimazolam at the end of surgery. The endotracheal tube or supraglottic airway was removed after surgery was complete, and consciousness and adequate spontaneous breathing were confirmed. The incidence of extubation recall was compared between the remimazolam and propofol anesthesia groups using propensity score matching. RESULTS Extubation recall was observed in 28 patients (17%). After propensity score matching, the incidence of extubation recall did not significantly differ between the remimazolam and propofol anesthesia groups (15.6% vs. 18.8%; p = 1.000). CONCLUSION The incidence of extubation recall after remimazolam anesthesia with flumazenil antagonism during emergence did not significantly differ from that after propofol anesthesia.
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12
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Gautam S, Chamlagain M, Yadav GK, Acharya S. Once was not enough: A case report of the concomitant intoxication of amlodipine (calcium channel blocker) and clonazepam (benzodiazepine). Clin Case Rep 2022; 10:e6042. [PMID: 35846941 PMCID: PMC9272439 DOI: 10.1002/ccr3.6042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 06/09/2022] [Accepted: 06/26/2022] [Indexed: 11/23/2022] Open
Abstract
We report a case of concurrent ingestion of Clonazepam and Amlodipine in a 25‐year‐old man, in a second attempt to take his life, which resulted in unconsciousness, hypotension, and hypokalemia. The clinical and/or biochemical presentation varied from the individual pattern when ingested. In the scarcity of consensus recommendations, supportive treatment helped. Supportive treatment is the rule of management of concomitant ingestion of Amlodipine and Clonazepam. The clinical and/or biochemical presentation of benzodiazepine and calcium channel blocker may vary from the individual pattern.
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Affiliation(s)
- Swotantra Gautam
- Department of Critical Care Medicine Nidan Hospital Lalitpur Nepal
| | | | - Gopal Kumar Yadav
- Department of Emergency Medicine Kakani Primary Health Care Centre Nuwakot Nepal
| | - Santosh Acharya
- Department of Anesthesiology and Critical Care Nidan Hospital Lalitpur Nepal
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13
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Muto NA, Hamoy M, da Silva Ferreira CB, Hamoy AO, Lucas DCR, de Mello VJ, Rogez H. Extract of Euterpe oleracea Martius Stone Presents Anticonvulsive Activity via the GABAA Receptor. Front Cell Neurosci 2022; 16:872743. [PMID: 35634465 PMCID: PMC9130464 DOI: 10.3389/fncel.2022.872743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 04/12/2022] [Indexed: 11/13/2022] Open
Abstract
Epilepsy is one of the most common neurological diseases globally, resulting from a disorder in brain activity. This condition can be triggered by birth trauma, traumatic brain injury (TBI), infections of the brain and stroke. More than 70 million people suffer seizures caused by neurological abnormalities. Approximately 80% of all epileptic patients reside in low-income conditions or in developing countries, and over 75% of patients do not receive proper treatment. Our previous study found an anticonvulsant property of an extract of Euterpe oleracea stone (EEOS) that caused myorelaxation, sedation, and cardiac and respiratory depression after intraperitoneal administration. The present study investigated through electroencephalographic (EEG) profiling the anticonvulsant protective properties of EEOS in induced convulsing rats. Male Wistar rats were treated with EEOS (300 mg/kg), diazepam (DZP) (5 mg/kg), pentylenetetrazol (PTZ) (60 mg/kg) and flumazenil (FMZ) (0.1 mg/kg) by intraperitoneal (i.p.). Electrodes implanted on the dura mater provided EEG data in which EEOS suppressed seizure deflagration caused by PTZ. In addition, EEOS presented no significant difference in comparison to DZP, which has the same mechanism of action. After FMZ injection, a GABAA receptor antagonist blocked the anticonvulsive effect in both the DZP and EEOS groups, suggesting that EEOS exerts it action on the GABAA receptor at the benzodiazepine (BDZ) subunit.
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Affiliation(s)
- Nilton Akio Muto
- Centre for Valorization of Amazonian Bioactive Compounds (CVACBA), Federal University of Pará (UFPA), Belém, Brazil
| | - Moisés Hamoy
- Laboratory of Pharmacology and Toxicology of Natural Products, Institute of Biological Sciences of Federal University of Pará (ICB-UFPA), Belém, Brazil
| | - Chryslen Brenda da Silva Ferreira
- Laboratory of Pharmacology and Toxicology of Natural Products, Institute of Biological Sciences of Federal University of Pará (ICB-UFPA), Belém, Brazil
| | - Akira Otake Hamoy
- Laboratory of Pharmacology and Toxicology of Natural Products, Institute of Biological Sciences of Federal University of Pará (ICB-UFPA), Belém, Brazil
| | | | - Vanessa Jóia de Mello
- Laboratory of Pharmacology and Toxicology of Natural Products, Institute of Biological Sciences of Federal University of Pará (ICB-UFPA), Belém, Brazil
| | - Hervé Rogez
- Centre for Valorization of Amazonian Bioactive Compounds (CVACBA), Federal University of Pará (UFPA), Belém, Brazil
- *Correspondence: Hervé Rogez,
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14
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Parris MA, Calello DP. Found Down: Approach to the Patient with an Unknown Poisoning. Emerg Med Clin North Am 2022; 40:193-222. [DOI: 10.1016/j.emc.2022.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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15
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Kim KM. Remimazolam: pharmacological characteristics and clinical applications in anesthesiology. Anesth Pain Med (Seoul) 2022; 17:1-11. [PMID: 35139608 PMCID: PMC8841266 DOI: 10.17085/apm.21115] [Citation(s) in RCA: 76] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 12/29/2021] [Indexed: 11/25/2022] Open
Abstract
A novel ultra-short-acting benzodiazepine (BDZ), remimazolam (CNS 7056), has been designed by ‘soft drug’ development to achieve a better sedative profile than that of the current drugs. Notably, the esterase linkage in remimazolam permits rapid hydrolysis to inactivate metabolites by non-specific tissue esterase and induces a unique and favorable pharmacological profile, including rapid onset and offset of sedation and a predictable duration of action. Similar to other BDZs, its sedative effects can be reversed using flumazenil, a BDZ antagonist. The pharmacokinetics and pharmacodynamics of remimazolam are characterized by relatively high clearance, small steady-state volume of distribution, short elimination half-life, short context-sensitive half-life, and fast onset and recovery, indicating rapid elimination, minimal tissue accumulation, and good control. In addition, remimazolam possesses a superior safety profile, including low liability for cardiorespiratory depression and injection pain, making it a preferred hypnotic agent in various clinical settings. Early clinical investigations suggest that remimazolam is well tolerated and effective for procedural sedation and for induction and maintenance of general anesthesia. To date, however, the clinical use of remimazolam has been confined to a few volunteer studies and a limited number of clinical investigations. Therefore, further studies regarding its recovery issues or postoperative complications, characteristics of electroencephalogram changes, and cost-benefit analyses are required to facilitate its widespread use.
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Affiliation(s)
- Kyung Mi Kim
- Corresponding author Kyung Mi Kim, M.D., Ph.D. Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea Tel: 82-2-3010-5631, Fax: 82-2-3010-6790, E-mail:
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16
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El Shehaby DM, Mohammed MK, Ebrahem NE, Abd El-Azim MM, Sayed IG, Eweda SA. The emerging therapeutic role of some pharmacological antidotes in management of COVID-19. THE EGYPTIAN JOURNAL OF BRONCHOLOGY 2022. [PMCID: PMC8771180 DOI: 10.1186/s43168-021-00105-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background A novel RNA coronavirus was identified in January 2020 as the cause of a pneumonia epidemic affecting the city of Wuhan; it rapidly spread across China. Aim of the review The aim is to discuss the potential efficacy of some pharmacologically known pharmacological antidotes (N-acetylcysteine; hyperbaric oxygen; deferoxamine; low-dose naloxone) for the management of COVID-19-associated symptoms and complications. Method An extensive search was accomplished in Medline, Embase, Scopus, Web of Science, and Central databases until the end of April, 2021. Four independent researchers completed the screening, and finally, the associated studies were involved. Conclusion The current proof hinders the experts for suggesting the proper pharmacological lines of treatment of COVID-19. Organizations, for example, WHO, should pursue more practical actions and design well-planned clinical trials so that their results may be used in the treatment of future outbreaks.
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18
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Giorgetti A, Sommer MJ, Wilde M, Perdekamp MG, Auwärter V. A case of fatal multidrug intoxication involving flualprazolam: distribution in body fluids and solid tissues. Forensic Toxicol 2021; 40:180-188. [DOI: 10.1007/s11419-021-00591-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 07/19/2021] [Indexed: 10/20/2022]
Abstract
Abstract
Purpose
Designer benzodiazepines (DBZDs) increasingly emerged on the novel psychoactive substance (NPS) market in the last few years. They are usually sold as readily available alternatives to prescription benzodiazepines (BZDs) or added to counterfeit medicines. BZDs are generally considered relatively safe drugs due to the low risk of serious acute adverse effects in mono-intoxication, though e.g., alprazolam seems to display an elevated risk of respiratory depression. Here we report on a fatal intoxication involving the novel DBZD flualprazolam.
Methods
A complete postmortem examination was performed. General unknown screenings and analysis of drugs of abuse were performed on postmortem samples by immunoassay, gas chromatography–mass spectrometry and liquid chromatography–mass spectrometry. The standard addition method was employed to quantify flualprazolam in postmortem blood and tissues. Finally, a toxicological significance score (TSS) was assigned.
Results
Flualprazolam was detected in heart serum (25.4 ng/mL) and peripheral blood (21.9 ng/mL) as well as in urine, stomach contents, brain, liver and kidney (65.2–323 ng/g). The cause of death was deemed as central nervous system (CNS) and respiratory depression with agonal aspiration of stomach contents, in the setting of a multiple drug intake. Given the concentration levels of the co-consumed CNS depressants, the contribution of flualprazolam to the death was considered likely (TSS of 3).
Conclusions
Our results support that highly potent DBZDs like flualprazolam carry an elevated risk for unintended toxicity, especially in association with other CNS depressants. A multidisciplinary evaluation of fatalities remains mandatory, especially when pharmacological/toxicological data on intoxicating compounds are lacking. To our knowledge this is the first report of flualprazolam concentrations in solid tissues in human.
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19
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Gutman DA, Hassid M, Jeanes Z, Redding AT, Romeo D. Prophylactic Physostigmine for Extreme and Refractory Adult Emergence Delirium, Aimed at Increasing Patient Safety and Reducing Health Care Workplace Violence: A Case Report. A A Pract 2021; 14:e01205. [PMID: 32784327 DOI: 10.1213/xaa.0000000000001205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Emergence delirium is a well-known phenomenon that may be encountered after general anesthesia. A common approach to this issue is to risk stratify patients preoperatively and treat them postoperatively if emergence delirium occurs. We present the case of a patient with Barrett esophagus and a history of severe and refractory emergence delirium, who was successfully treated prophylactically with physostigmine, resulting in decreased risk of harm to the patient, trauma to the perioperative staff, and a safer and more positive recovery.
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Affiliation(s)
- David A Gutman
- From the Department of Anesthesia, Medical University of South Carolina, Charleston, South Carolina
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20
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Lott C, Truhlář A, Alfonzo A, Barelli A, González-Salvado V, Hinkelbein J, Nolan JP, Paal P, Perkins GD, Thies KC, Yeung J, Zideman DA, Soar J. [Cardiac arrest under special circumstances]. Notf Rett Med 2021; 24:447-523. [PMID: 34127910 PMCID: PMC8190767 DOI: 10.1007/s10049-021-00891-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 01/10/2023]
Abstract
These guidelines of the European Resuscitation Council (ERC) Cardiac Arrest under Special Circumstances are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required for basic and advanced life support for the prevention and treatment of cardiac arrest under special circumstances; in particular, specific causes (hypoxia, trauma, anaphylaxis, sepsis, hypo-/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), specific settings (operating room, cardiac surgery, cardiac catheterization laboratory, dialysis unit, dental clinics, transportation [in-flight, cruise ships], sport, drowning, mass casualty incidents), and specific patient groups (asthma and chronic obstructive pulmonary disease, neurological disease, morbid obesity, pregnancy).
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Affiliation(s)
- Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Mainz, Deutschland
| | - Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Tschechien
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Králové, Charles University in Prague, Hradec Králové, Tschechien
| | - Anette Alfonzo
- Departments of Renal and Internal Medicine, Victoria Hospital, Kirkcaldy, Fife Großbritannien
| | - Alessandro Barelli
- Anaesthesiology and Intensive Care, Teaching and research Unit, Emergency Territorial Agency ARES 118, Catholic University School of Medicine, Rom, Italien
| | - Violeta González-Salvado
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Institute of Health Research of Santiago de Compostela (IDIS), Biomedical Research Networking Centres on Cardiovascular Disease (CIBER-CV), A Coruña, Spanien
| | - Jochen Hinkelbein
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Köln, Deutschland
| | - Jerry P. Nolan
- Resuscitation Medicine, Warwick Medical School, University of Warwick, CV4 7AL Coventry, Großbritannien
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, BA1 3NG Bath, Großbritannien
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Österreich
| | - Gavin D. Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, Großbritannien
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, Großbritannien
| | - Karl-Christian Thies
- Dep. of Anesthesiology and Critical Care, Bethel Evangelical Hospital, University Medical Center OLW, Bielefeld University, Bielefeld, Deutschland
| | - Joyce Yeung
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, Großbritannien
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, Großbritannien
| | | | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, Großbritannien
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21
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Masciullo M, Pichiorri F, Scivoletto G, Foti C, Molinari M. Flumazenil therapy for a gabapentin-induced coma: a case report. J Med Case Rep 2021; 15:242. [PMID: 33964989 PMCID: PMC8106827 DOI: 10.1186/s13256-021-02816-3] [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: 09/10/2020] [Accepted: 03/23/2021] [Indexed: 11/30/2022] Open
Abstract
Background Spasticity and neuropathic pain are common in patients after spinal cord injury and negatively affect patients’ quality of life. Gabapentin and baclofen are frequently used to treat these conditions. We present a flumazenil-reversed gabapentin-induced coma case, which, to our knowledge, is the second one described in scientific literature. Case presentation A 70-year-old Caucasian man was admitted to our neurorehabilitation ward following a fall with cervical trauma that resulted in immediate tetraplegia. During his stay, he suffered from lower limb pain, both neuropathic and due to severe spasticity. Gradual baclofen and gabapentin administration was prescribed, with reduction in both pain and spasticity. One morning, the patient was found unresponsive, with a Glasgow Coma Score of 3. Head computerized tomography, electrocardiogram, electroencephalogram, vital signs, blood tests, breathing, and blood oxygenation were normal. Renal and liver failure were ruled out. Intravenous 0.25 mg of flumazenil (Anexate) was administered, resulting in complete neurocognitive recovery with a Glasgow Coma Score of 15. Discussion and conclusions This case report highlights the importance of the individual response to certain pharmacological agents and suggests that further studies need to be conducted both on flumazenil and gabapentin pharmacodynamics to better understand their molecular–receptor activity, and on possible multiple flumazenil mechanisms of action, beyond its classical strict benzodiazepine antagonist action.
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Affiliation(s)
- M Masciullo
- Spinal Cord Unit, IRCCS S. Lucia Foundation, Rome, Italy.,SPInal REhabilitation Lab (SPIRE), IRCCS Fondazione Santa Lucia, Rome, Italy
| | - F Pichiorri
- Spinal Cord Unit, IRCCS S. Lucia Foundation, Rome, Italy
| | - G Scivoletto
- Spinal Cord Unit, IRCCS S. Lucia Foundation, Rome, Italy. .,SPInal REhabilitation Lab (SPIRE), IRCCS Fondazione Santa Lucia, Rome, Italy.
| | - C Foti
- Physical and Rehabilitation Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - M Molinari
- Spinal Cord Unit, IRCCS S. Lucia Foundation, Rome, Italy
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22
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Lott C, Truhlář A, Alfonzo A, Barelli A, González-Salvado V, Hinkelbein J, Nolan JP, Paal P, Perkins GD, Thies KC, Yeung J, Zideman DA, Soar J. European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances. Resuscitation 2021; 161:152-219. [PMID: 33773826 DOI: 10.1016/j.resuscitation.2021.02.011] [Citation(s) in RCA: 288] [Impact Index Per Article: 96.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
These European Resuscitation Council (ERC) Cardiac Arrest in Special Circumstances guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required to basic and advanced life support for the prevention and treatment of cardiac arrest in special circumstances; specifically special causes (hypoxia, trauma, anaphylaxis, sepsis, hypo/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), special settings (operating room, cardiac surgery, catheter laboratory, dialysis unit, dental clinics, transportation (in-flight, cruise ships), sport, drowning, mass casualty incidents), and special patient groups (asthma and COPD, neurological disease, obesity, pregnancy).
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Affiliation(s)
- Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Germany.
| | - Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Czech Republic; Department of Anaesthesiology and Intensive Care Medicine, Charles University in Prague, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Annette Alfonzo
- Departments of Renal and Internal Medicine, Victoria Hospital, Kirkcaldy, Fife, UK
| | - Alessandro Barelli
- Anaesthesiology and Intensive Care, Catholic University School of Medicine, Teaching and Research Unit, Emergency Territorial Agency ARES 118, Rome, Italy
| | - Violeta González-Salvado
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Institute of Health Research of Santiago de Compostela (IDIS), Biomedical Research Networking Centres on Cardiovascular Disease (CIBER-CV), A Coruña, Spain
| | - Jochen Hinkelbein
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Jerry P Nolan
- Resuscitation Medicine, University of Warwick, Warwick Medical School, Coventry, CV4 7AL, UK; Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, BA1 3NG, UK
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Gavin D Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Karl-Christian Thies
- Department of Anesthesiology, Critical Care and Emergency Medicine, Bethel Medical Centre, OWL University Hospitals, Bielefeld University, Germany
| | - Joyce Yeung
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, UK
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Laing MK, Ti L, Marmel A, Tobias S, Shapiro AM, Laing R, Lysyshyn M, Socías ME. An outbreak of novel psychoactive substance benzodiazepines in the unregulated drug supply: Preliminary results from a community drug checking program using point-of-care and confirmatory methods. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 93:103169. [PMID: 33627302 DOI: 10.1016/j.drugpo.2021.103169] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 02/07/2021] [Accepted: 02/08/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND From mid-2018, an increase in novel psychoactive substance (NPS) benzodiazepines was noted on surveillance of the unregulated drug market around Vancouver, British Columbia, Canada. The rise was concordant with an outbreak of atypical overdoses suspicious for benzodiazepine adulteration of unregulated opioids. This study sought to describe the number and type of NPS benzodiazepines in a sample drawn from a community drug checking program during this period, and to explore accuracy of point-of-care drug checking technologies when compared to confirmatory methods in this sample. METHODS Point-of-care drug checking data using fentanyl and benzodiazepine test strips as well as Fourier transform infrared spectroscopy were gathered at harm reduction sites in the Vancouver area from October 2018 to January 2020. A convenience subsample underwent confirmatory testing with gas chromatography-mass spectrometry, liquid chromatography-mass spectrometry, or quantitative nuclear magnetic resonance spectroscopy. RESULTS Of 159 samples with both point-of-care and confirmatory results, 24 (15.1%) contained at least one NPS benzodiazepine, including etizolam (n = 18), flubromazolam (n = 3), flualprazolam (4), and flubromazepam (n = 1). Of 114 confirmatory samples expected by participants on self-report to contain opioids, 18 (15.8%) contained some NPS benzodiazepine, with 16 (14.0%) containing both an NPS benzodiazepine and an opioid, always fentanyl. False positive and negative rates were 15.5% and 37.5% for test strips, and 3.9% and 91.7% for FTIR, respectively. Combined together, false positive and negative rates of point-of-care methods were 17.8% and 29.2%. CONCLUSIONS NPS benzodiazepine adulteration in an unregulated drug supply sample reveals new risks compounding ongoing harms associated with the synthetic opioid epidemic. Given substantial false positive and false negative rates noted in our sample for point-of-care detection methods, cautious use of combined point-of-care methods, routinely paired with confirmatory drug checking may aid in early detection and monitoring of unregulated drug markets and inform targeted harm reduction strategies and health policy approaches.
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Affiliation(s)
- Matthew K Laing
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada; British Columbia Centre on Substance Use, 1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada
| | - Lianping Ti
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada; British Columbia Centre on Substance Use, 1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada
| | - Allison Marmel
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Samuel Tobias
- British Columbia Centre on Substance Use, 1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada
| | - Aaron M Shapiro
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada; Provincial Toxicology Centre, 655W 12th Ave, Vancouver, BC, Canada
| | - Richard Laing
- Strategic Research and Science Development: Drug Analysis Service
- Stratégique et Développement Scientifique: Service d'analyse des drogues, Health Canada, 3155 Willingdon Green, Burnaby, BC, V5G 4P2, Canada
| | - Mark Lysyshyn
- School of Population and Public Health, University of British Columbia, 2206 E. Mall, Vancouver, BC, V6T 1Z3, Canada; Vancouver Coastal Health Authority, 801-601 West Broadway, Vancouver, BC, V5Z 4C2, Canada
| | - M Eugenia Socías
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada; British Columbia Centre on Substance Use, 1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada.
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24
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Abstract
There is a myriad of changes that can be produced in the eye by toxic drugs ranging from mild/no symptoms to severe loss of vision from endophthalmitis. The routes of administration include oral ingestion, smoking, nasal inhalation, intravenous injection, topical application or application to other mucosal surfaces. It is important to recognize certain clinical signs and symptoms in the eye produced by these toxins. This article describes in brief some of the ocular effects of commonly abused drugs. For identification of a particular poisoning, in addition to the clinical presentation, pulse, blood pressure, respiration and body temperature, pupillary size, pupillary reaction to light, ocular convergence and nystagmus can be useful indicators of the type of drug the patient is exposed to. Unmasking these features help the clinician in an early and accurate diagnosis of the offending drug as well as timely management.
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Affiliation(s)
- Deepika Dhingra
- Department of Ophthalmology, Advanced Eye Centre, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Savleen Kaur
- Department of Ophthalmology, Advanced Eye Centre, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Jagat Ram
- Postgraduate Institute of Medical Education & Research, Chandigarh, India
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25
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Purssell R, Godwin J, Moe J, Buxton J, Crabtree A, Kestler A, DeWitt C, Scheuermeyer F, Erdelyi S, Balshaw R, Rowe A, Cochrane CK, Ng B, Jiang A, Risi A, Ho V, Brubacher JR. Comparison of rates of opioid withdrawal symptoms and reversal of opioid toxicity in patients treated with two naloxone dosing regimens: a retrospective cohort study. Clin Toxicol (Phila) 2020; 59:38-46. [PMID: 32401548 DOI: 10.1080/15563650.2020.1758325] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION When managing opioid overdose (OD) patients, the optimal naloxone regimen should rapidly reverse respiratory depression while avoiding opioid withdrawal. Published naloxone administration guidelines have not been empirically validated and most were developed before fentanyl OD was common. In this study, rates of opioid withdrawal symptoms (OW) and reversal of opioid toxicity in patients treated with two naloxone dosing regimens were evaluated. METHODS In this retrospective matched cohort study, health records of patients who experienced an opioid OD treated in two urban emergency departments (ED) during an ongoing fentanyl OD epidemic were reviewed. Definitions for OW and opioid reversal were developed a priori. Low dose naloxone (LDN; ≤0.15 mg) and high dose naloxone (HDN; >0.15 mg) patients were matched in a 1:4 ratio based upon initial respiratory rate (RR). The proportion of patients who developed OW and who met reversal criteria were compared between those treated initially with LDN or HDN. Odds ratios (OR) for OW and opioid reversal were obtained via logistic regression stratified by matched sets and adjusted for age, sex, pre-naloxone GCS, and presence of non-opioid drugs or alcohol. RESULTS Eighty LDN patients were matched with 299 HDN patients. After adjustment, HDN patients were more likely than LDN patients to have OW after initial dose (OR = 8.43; 95%CI: 1.96, 36.3; p = 0.004) and after any dose (OR = 2.56; 95%CI: 1.17, 5.60; p = 0.019). HDN patients were more likely to meet reversal criteria after initial dose (OR = 2.73; 95%CI: 1.19, 6.26; p = 0.018) and after any dose (OR = 6.07; 95%CI: 1.81, 20.3; p = 0.003). CONCLUSIONS HDN patients were more likely to have OW but also more likely to meet reversal criteria versus LDN patients.
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Affiliation(s)
- Roy Purssell
- Department of Emergency Medicine, University of British Columbia, Vancouver, Canada.,British Columbia Drug and Poison Information Centre, British Columbia Centre for Disease Control, Vancouver, Canada
| | - Jesse Godwin
- Department of Emergency Medicine, University of British Columbia, Vancouver, Canada.,British Columbia Drug and Poison Information Centre, British Columbia Centre for Disease Control, Vancouver, Canada
| | - Jessica Moe
- Department of Emergency Medicine, University of British Columbia, Vancouver, Canada
| | - Jane Buxton
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Alexis Crabtree
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Andrew Kestler
- Department of Emergency Medicine, University of British Columbia, Vancouver, Canada
| | - Chris DeWitt
- Department of Emergency Medicine, University of British Columbia, Vancouver, Canada.,British Columbia Drug and Poison Information Centre, British Columbia Centre for Disease Control, Vancouver, Canada
| | - Frank Scheuermeyer
- Department of Emergency Medicine, University of British Columbia, Vancouver, Canada
| | - Shannon Erdelyi
- Department of Emergency Medicine, University of British Columbia, Vancouver, Canada
| | - Robert Balshaw
- Department of Community Health Sciences, Faculty of Health Sciences, College of Medicine, University of Manitoba, Winnipeg, Canada
| | - Adrianna Rowe
- Department of Emergency Medicine, University of British Columbia, Vancouver, Canada
| | | | - Benjamin Ng
- Department of Emergency Medicine, University of British Columbia, Vancouver, Canada
| | - Andy Jiang
- Department of Emergency Medicine, University of British Columbia, Vancouver, Canada
| | - Alessia Risi
- Faculty of Pharmacy, University of British Columbia, Vancouver, Canada
| | - Vi Ho
- Department of Emergency Medicine, University of British Columbia, Vancouver, Canada
| | - Jeffrey R Brubacher
- Department of Emergency Medicine, University of British Columbia, Vancouver, Canada
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26
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Zamani N, Buckley NA, Hassanian-Moghaddam H. Buprenorphine to reverse respiratory depression from methadone overdose in opioid-dependent patients: a prospective randomized trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:44. [PMID: 32033582 PMCID: PMC7006192 DOI: 10.1186/s13054-020-2740-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 01/14/2020] [Indexed: 12/12/2022]
Abstract
Background Naloxone is the usual drug used in opioid-induced respiratory depression but it has a short half-life, precipitates withdrawal in dependent patients, and thus for persistent reversal of long-acting opioids has to be given by titrated doses and infusions. The partial agonist buprenorphine has a much longer duration of action and causes less severe withdrawal, but still should largely reverse respiratory depression induced by full agonist opioids. We aimed to compare the efficacy/safety of buprenorphine and naloxone in reversing respiratory depression in methadone-poisoned opioid-dependent patients. Methods Patients with methadone-induced respiratory depression were randomized to receive naloxone (titrated doses), or lower or higher doses of buprenorphine (10 μg/kg or 15 μg/kg). The primary outcome was immediate reversal of respiratory depression. We also recorded acute opioid withdrawal, need for intubation/recurrent apnea, repeated doses of opioid antagonists, length of hospital stay, other morbidity, and mortality. The study was registered with the Iranian Registry of Clinical Trials (Trial ID: 18265; Approval code: IRCT2015011020624N1). Results Eighty-five patients were randomized; 55/56 patients who received buprenorphine had rapid reversal of respiratory depression, which persisted for at least 12 h. Naloxone was effective in 28/29 patients, but often required very high titrated doses (thus delaying time to respond) and prolonged infusions. Intubation (8/29 vs 5/56) and opioid withdrawal (15/29 vs 7/56) were less common with buprenorphine. There were no serious complications or deaths in those receiving buprenorphine. The 15-μg/kg buprenorphine dose appeared to provide a longer duration of action, but precipitated withdrawal more frequently than the 10-μg/kg dose. Conclusion Buprenorphine appears to be a safe and effective substitute for naloxone in overdosed opioid-dependent patients. Further studies are warranted to explore the optimal dosing strategy for buprenorphine to consistently maintain reversal of respiratory depression but not precipitate withdrawal. Trial registration number IRCT2015011020624N1. Registered 30 September 2015. Electronic supplementary material The online version of this article (10.1186/s13054-020-2740-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nasim Zamani
- Social Determinant of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Department of Clinical Toxicology, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, South Karegar Street, Tehran, Iran.,Toxicological Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Nicholas A Buckley
- Pharmacology, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Hossein Hassanian-Moghaddam
- Social Determinant of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran. .,Department of Clinical Toxicology, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, South Karegar Street, Tehran, Iran.
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27
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Martínez-Sánchez L, Ferrés-Padró V, Martínez-Millán D, Fernández-Calabria C, Amigó-Tadín M, Jiménez-Fàbrega FX, Nogué-Xarau S. Prehospital emergency care of patients exposed to poisoning: Assessment of epidemiological, clinical characteristics and quality of care. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.anpede.2019.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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28
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Shaw LV, Moe J, Purssell R, Buxton JA, Godwin J, Doyle-Waters MM, Brasher PMA, Hau JP, Curran J, Hohl CM. Naloxone interventions in opioid overdoses: a systematic review protocol. Syst Rev 2019; 8:138. [PMID: 31186071 PMCID: PMC6560883 DOI: 10.1186/s13643-019-1048-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 05/20/2019] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND North America is in the midst of an unabated opioid overdose epidemic due to the increasing non-medical use of fentanyl and ultra-potent opioids. Naloxone is an effective antidote to opioid toxicity, yet its optimal dosing in the context of fentanyl and ultra-potent opioid overdoses remains unknown. This review aims to determine the relationship between the first empiric dose of naloxone and reversal of toxicity, adverse events, and the total cumulative dose required among patients with undifferentiated opioid overdoses and those with suspected toxicity from ultra-potent opioids. Secondary objectives include evaluating the relationship between the cumulative naloxone dose and toxicity reversal and adverse events, among patients with undifferentiated opioid overdoses and those with suspected toxicity from ultra-potent opioids. METHODS To identify studies, we will search MEDLINE, Embase, CENTRAL, DARE, CDAG, CINAHL, Science Citation Index, multiple trial registries, and the gray literature. Included studies will evaluate patients with suspected or confirmed opioid toxicity from undifferentiated opioids and ultra-potent opioids, who received an empiric and possibly additional doses of naloxone. The main outcomes of interest are the relationship between naloxone dose and toxicity reversal and adverse events. We will include controlled and non-controlled interventional studies, observational studies, case reports/series, and reports from poison control centers. We will extract data and assess study quality in duplicate with discrepancies resolved by consensus or a third party. We will use the Downs and Black and Cochrane risk of bias tools for observational and randomized controlled studies. If we find sufficient variation in dose, we will fit a random effects one-stage model to estimate a dose-response relationship. We will conduct multiple subgroup analyses, including by type of opioid used and by suspected high and low prevalence of ultra-potent opioid use based on geographic location and time of the original studies. DISCUSSION Our review will include the most up-to-date available data including ultra-potent opioids to inform the current response to the opioid epidemic, addressing the limitations of recent reviews. We anticipate limitations relating to study heterogeneity. We will disseminate study results widely to update overdose treatment guidelines and naloxone dosing in Take Home Naloxone programs.
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Affiliation(s)
- Lindsay Victoria Shaw
- School of Social Dimensions of Health, University of Victoria, 3800 Finnerty Road, Victoria, BC V8P 5C2 Canada
- Canadian Institute for Substance Use Research, 2300 McKenzie Ave, Victoria, BC V8P 5C2 Canada
| | - Jessica Moe
- Department of Emergency Medicine, University of British Columbia, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
- Vancouver General Hospital, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
| | - Roy Purssell
- Department of Emergency Medicine, University of British Columbia, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
- Vancouver General Hospital, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
- BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC V5Z 4R4 Canada
| | - Jane A. Buxton
- Department of Emergency Medicine, University of British Columbia, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
- BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC V5Z 4R4 Canada
- School of Population and Public Health, 2329 West Mall, Vancouver, BC V6T 1Z4 Canada
| | - Jesse Godwin
- Department of Emergency Medicine, University of British Columbia, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
- Vancouver General Hospital, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
| | - Mary M. Doyle-Waters
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, 828 West 10th Avenue, Vancouver, BC V5Z 1M9 Canada
| | - Penelope M. A. Brasher
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, 828 West 10th Avenue, Vancouver, BC V5Z 1M9 Canada
| | - Jeffrey P. Hau
- Department of Emergency Medicine, University of British Columbia, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
| | - Jason Curran
- BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC V5Z 4R4 Canada
- School of Population and Public Health, 2329 West Mall, Vancouver, BC V6T 1Z4 Canada
| | - Corinne M. Hohl
- Department of Emergency Medicine, University of British Columbia, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
- Vancouver General Hospital, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, 828 West 10th Avenue, Vancouver, BC V5Z 1M9 Canada
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[Prehospital emergency care of patients exposed to poisoning: Assessment of epidemiological, clinical characteristics and quality of care]. An Pediatr (Barc) 2019; 92:37-45. [PMID: 31129026 DOI: 10.1016/j.anpedi.2019.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 03/09/2019] [Accepted: 03/20/2019] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To describe the characteristics of paediatric patients with suspected poisoning treated by advanced life support (ALS) units, and to evaluate quality indicators (QI) for the prehospital emergency care of these patients. METHOD A one-year observational study of patients under 18 years of age exposed to poisoning and treated by an ALS unit of the Medical Emergency System in Catalonia. Severe clinical criteria were defined, with 8 QI being evaluated for prehospital emergency care of poisoned paediatric patients. RESULTS The study included a total of 254 patients, with a median age of 14 years-old (p25-75 = 7-16), with intentional poisoning in 50.8% of cases. The most frequently involved toxic agent was carbon monoxide (CO) (33.8%). Poisoning was found in 48.8% of those patients, being serious in 16.5%. Intentionally (OR 5.1; 95% CI: 1.9-13.8) and knowledge of the time of exposure (OD 3.1; 95% CI: 1.3-7.3) were independent risk factors associated with the appearance of severe clinical symptoms. Five QI did not reach the quality standard and included, availability of specific clinical guidelines, activated charcoal administration in selected patients, oxygen therapy administration at maximum possible concentration in carbon monoxide poisoning, electrocardiographic assessment in patients exposed to cardiotoxic substances, and recording of the minimum data set. CONCLUSIONS Paediatric patients attended by ALS units showed specific characteristics, highlighting the involvement of CO and adolescents with voluntary poisoning. The QI assessment was useful to detect weak points in the quality of care of these patients and to develop strategies for improvement.
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30
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Retrospective study of addictive drug-induced acute toxicity of cases admitted to the Poison Control Centre of Ain Shams University Hospital (2015–2016). EGYPTIAN JOURNAL OF FORENSIC SCIENCES 2019. [DOI: 10.1186/s41935-019-0118-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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31
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32
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Ganetsky M. Commentary. Clin Chem 2018; 64:1146-1147. [DOI: 10.1373/clinchem.2017.284919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 12/05/2017] [Indexed: 11/06/2022]
Affiliation(s)
- Michael Ganetsky
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA
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33
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Abstract
Adolescent substance abuse remains common, with almost a third of adolescents admitting to ethanol use, and a quarter admitting to illicit drug use. It is essential for pediatricians to regularly screen adolescent patients for substance use, because early initiation of drug use has been associated with physical, behavioral, and social health risks. Adolescents abuse what is common and readily available; this includes ethanol, over-the-counter products, marijuana, and inhalants. The most common and effective clinical treatments for significant toxicity from substances of abuse is symptomatic and supportive care including hemodynamic support, respiratory support, and sedation to control psychomotor agitation.
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Affiliation(s)
- George Sam Wang
- Section of Emergency Medicine and Medical Toxicology, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO.,Rocky Mountain Poison and Drug Center, Denver Health Hospital, Denver, CO
| | - Christopher Hoyte
- Rocky Mountain Poison and Drug Center, Denver Health Hospital, Denver, CO.,Department of Emergency Medicine and Medical Toxicology, University of Colorado Anschutz Medical Campus, University Hospital, Aurora, CO
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34
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Retrograde amnesia after intravenous sedation and general anaesthesia in a dental hospital. Br J Oral Maxillofac Surg 2018; 56:632-635. [PMID: 30029983 DOI: 10.1016/j.bjoms.2018.06.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 06/25/2018] [Indexed: 12/17/2022]
Abstract
Midazolam, a benzodiazepine, is commonly used for intravenous sedation for dental procedures and, together with other benzodiazepines, can cause anterograde amnesia. Retrograde amnesia, however, is rare. It is defined as a loss of access to memory of events that occurred, or information that was learned, before the injury or event that caused the amnesia. We know of no reports of this occurring after the intravenous use of midazolam alone and few after general anaesthesia. We present two cases of retrograde amnesia: one after intravenous sedation and one after general anaesthesia.
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35
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Benesch MGK, Iqbal SJ. Novel psychoactive substances: overdose of 3-fluorophenmetrazine (3-FPM) and etizolam in a 33-year-old man. BMJ Case Rep 2018; 2018:bcr-2018-224995. [PMID: 29884719 DOI: 10.1136/bcr-2018-224995] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Though illegal in the UK, in many countries novel psychoactive substances are quasi-legal synthetic compounds that are widely available online under the guise of research chemicals. These substances are relatively cheap and are often undetectable in standard drug screens. Nearly 200 such compounds are introduced yearly, and little is usually known about their metabolism or physiological effects. Consequently, managing patients in overdose situations on largely unknown substances usually involves supportive care, however anticipating and managing atypical side effects are challenging in the absence of knowledge of these compounds. In this report, we discuss our encounter with a 33-year-old unconscious man presenting with coingestion of a novel stimulant 3-fluorophenmetrazine with a rarely used benzodiazepine etizolam. This patient developed seizure-like activity and delayed widespread T-wave inversions, both of which ultimately resolved without sequelae.
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Affiliation(s)
- Matthew G K Benesch
- Department of Surgery, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Sahar J Iqbal
- Department of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
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36
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Lee YJ, Kim M, Lee JY, Jung SH, Jeon HY, Lee SA, Kang S, Han ET, Park WS, Hong SH, Kim YM, Ha KS. The benzodiazepine anesthetic midazolam prevents hyperglycemia-induced microvascular leakage in the retinas of diabetic mice. FASEB J 2018; 32:fj201800014RR. [PMID: 29782207 DOI: 10.1096/fj.201800014rr] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
We investigated the beneficial effects of midazolam against vascular endothelial growth factor (VEGF)-induced vascular leakage and its molecular mechanism of action in human retinal endothelial cells (HRECs) and the retinas of diabetic mice. Midazolam inhibited VEGF-induced elevation of intracellular Ca2+, generation of reactive oxygen species (ROS), and transglutaminase activation in HRECs; these effects were reversed by the GABA, type A (GABAA) receptor antagonist flumazenil but not by the translocator protein antagonist PK11195. Midazolam also prevented VEGF-induced disassembly of adherens junctions and in vitro permeability. Intravitreal injection of midazolam prevented hyperglycemia-induced ROS generation, transglutaminase activation, and subsequent vascular leakage in the retinas of diabetic mice, and those effects were reversed by flumazenil. The roles of flumazenil were further supported by identifying GABAA receptors in mouse retinas. Thus, midazolam prevents hyperglycemia-induced vascular leakage by inhibiting VEGF-induced intracellular events in the retinas of diabetic mice.-Lee, Y.-J., Kim, M., Lee, J.-Y., Jung, S.-H., Jeon, H.-Y., Lee, S.-A., Kang, S., Han, E.-T., Park, W. S., Hong, S.-H., Kim, Y.-M., Ha, K.-S. The benzodiazepine anesthetic midazolam prevents hyperglycemia-induced microvascular leakage in the retinas of diabetic mice.
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Affiliation(s)
- Yeon-Ju Lee
- Department of Molecular and Cellular Biochemistry, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Minsoo Kim
- Department of Molecular and Cellular Biochemistry, Kangwon National University School of Medicine, Chuncheon, Korea
- Department of Anesthesiology, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Jee-Yeon Lee
- Department of Molecular and Cellular Biochemistry, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Se-Hui Jung
- Department of Molecular and Cellular Biochemistry, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Hye-Yoon Jeon
- Department of Molecular and Cellular Biochemistry, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Seung Ah Lee
- Department of Anesthesiology, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Seongsik Kang
- Department of Anesthesiology, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Eun-Taek Han
- Department of Medical Environmental Biology and Tropical Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Won Sun Park
- Department of Physiology, Kangwon National University School of Medicine, Chuncheon, Korea; and
| | - Seok-Ho Hong
- Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Young-Myeong Kim
- Department of Molecular and Cellular Biochemistry, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Kwon-Soo Ha
- Department of Molecular and Cellular Biochemistry, Kangwon National University School of Medicine, Chuncheon, Korea
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González de Molina Ortiz FJ, Gordo Vidal F, Estella García A, Morrondo Valdeolmillos P, Fernández Ortega JF, Caballero López J, Pérez Villares PV, Ballesteros Sanz MA, de Haro López C, Sanchez-Izquierdo Riera JA, Serrano Lázaro A, Fuset Cabanes MP, Terceros Almanza LJ, Nuvials Casals X, Baldirà Martínez de Irujo J. "Do not do" recommendations of the working groups of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) for the management of critically ill patients. Med Intensiva 2018; 42:425-443. [PMID: 29789183 DOI: 10.1016/j.medin.2018.04.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 03/24/2018] [Accepted: 04/02/2018] [Indexed: 02/06/2023]
Abstract
The project "Commitment to Quality of Scientific Societies", promoted since 2013 by the Spanish Ministry of Health, seeks to reduce unnecessary health interventions that have not proven effective, have little or doubtful effectiveness, or are not cost-effective. The objective is to establish the "do not do" recommendations for the management of critically ill patients. A panel of experts from the 13 working groups (WGs) of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) was selected and nominated by virtue of clinical expertise and/or scientific experience to carry out the recommendations. Available scientific literature in the management of adult critically ill patients from 2000 to 2017 was extracted. The clinical evidence was discussed and summarized by the experts in the course of consensus finding of each WG, and was finally approved by the WGs after an extensive internal review process carried out during the first semester of 2017. A total of 65 recommendations were developed, of which 5 corresponded to each of the 13 WGs. These recommendations are based on the opinion of experts and scientific knowledge, and aim to reduce those treatments or procedures that do not add value to the care process; avoid the exposure of critical patients to potential risks; and improve the adequacy of health resources.
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Affiliation(s)
- F J González de Molina Ortiz
- Servicio de Medicina Intensiva, Hospital Universitario Mutua Terrassa, Barcelona, España; Servicio de Medicina Intensiva, Hospital Universitario Quirón Dexeus, Barcelona, España.
| | - F Gordo Vidal
- Servicio de Medicina Intensiva, Hospital Universitario del Henares, Coslada, Madrid, España
| | - A Estella García
- Servicio de Medicina Intensiva, Hospital del SAS de Jerez, Jerez, Cádiz, España
| | - P Morrondo Valdeolmillos
- Servicio de Medicina Intensiva, Hospital Universitario Donostia, San Sebastián, Guipúzcoa, España
| | - J F Fernández Ortega
- Servicio de Medicina Intensiva, Complejo Hospitalario Carlos Haya, Málaga, España
| | - J Caballero López
- Servicio de Medicina Intensiva, Hospital Universitario Arnau de Vilanova, Lleida, España
| | - P V Pérez Villares
- Servicio de Medicina Intensiva, Hospital Universitario Virgen de las Nieves, Granada, España
| | - M A Ballesteros Sanz
- Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - C de Haro López
- Servicio de Medicina Intensiva, Corporació Sanitària Parc Taulí, Sabadell, Barcelona, España
| | | | - A Serrano Lázaro
- Servicio de Medicina Intensiva, Hospital Clínico Universitario, Valencia, España
| | - M P Fuset Cabanes
- Servicio de Medicina Intensiva, Hospital Universitari i Politècnic la Fe, Valencia, España
| | - L J Terceros Almanza
- Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, España
| | - X Nuvials Casals
- Servicio de Medicina Intensiva, Hospital Universitari Vall d'Hebron, Barcelona, España
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Sanello A, Gausche-Hill M, Mulkerin W, Sporer KA, Brown JF, Koenig KL, Rudnick EM, Salvucci AA, Gilbert GH. Altered Mental Status: Current Evidence-based Recommendations for Prehospital Care. West J Emerg Med 2018; 19:527-541. [PMID: 29760852 PMCID: PMC5942021 DOI: 10.5811/westjem.2018.1.36559] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 11/15/2017] [Accepted: 01/04/2018] [Indexed: 12/11/2022] Open
Abstract
Introduction In the United States emergency medical services (EMS) protocols vary widely across jurisdictions. We sought to develop evidence-based recommendations for the prehospital evaluation and treatment of a patient with an acute change in mental status and to compare these recommendations against the current protocols used by the 33 EMS agencies in the State of California. Methods We performed a literature review of the current evidence in the prehospital treatment of a patient with altered mental status (AMS) and augmented this review with guidelines from various national and international societies to create our evidence-based recommendations. We then compared the AMS protocols of each of the 33 EMS agencies for consistency with these recommendations. The specific protocol components that we analyzed were patient assessment, point-of-care tests, supplemental oxygen, use of standardized scoring, evaluating for causes of AMS, blood glucose evaluation, toxicological treatment, and pediatric evaluation and management. Results Protocols across 33 EMS agencies in California varied widely. All protocols call for a blood glucose check, 21 (64%) suggest treating adults at <60mg/dL, and half allow for the use of dextrose 10%. All the protocols recommend naloxone for signs of opioid overdose, but only 13 (39%) give specific parameters. Half the agencies (52%) recommend considering other toxicological causes of AMS, often by using the mnemonic AEIOU TIPS. Eight (24%) recommend a 12-lead electrocardiogram; others simply suggest cardiac monitoring. Fourteen (42%) advise supplemental oxygen as needed; only seven (21%) give specific parameters. In terms of considering various etiologies of AMS, 25 (76%) give instructions to consider trauma, 20 (61%) to consider stroke, and 18 (55%) to consider seizure. Twenty-three (70%) of the agencies have separate pediatric AMS protocols; others include pediatric considerations within the adult protocol. Conclusion Protocols for patients with AMS vary widely across the State of California. The evidence-based recommendations that we present for the prehospital diagnosis and treatment of this condition may be useful for EMS medical directors tasked with creating and revising these protocols.
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Affiliation(s)
- Ashley Sanello
- Los Angeles County Emergency Medical Services (EMS) Agency, Santa Fe Springs, California.,David Geffen School of Medicine, Department of Emergency Medicine, Los Angeles, California
| | - Marianne Gausche-Hill
- Los Angeles County Emergency Medical Services (EMS) Agency, Santa Fe Springs, California.,Harbor UCLA, Department of Emergency Medicine, Torrance, California.,David Geffen School of Medicine, Department of Emergency Medicine, Los Angeles, California.,EMS Medical Directors Association of California
| | - William Mulkerin
- Stanford University, Department of Emergency Medicine, Stanford, California
| | - Karl A Sporer
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California.,EMS Medical Directors Association of California
| | - John F Brown
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California.,EMS Medical Directors Association of California
| | - Kristi L Koenig
- EMS Medical Directors Association of California.,County of San Diego, Health & Human Services Agency, Emergency Medical Services, San Diego, California.,University of California, Irvine, Department of Emergency Medicine, Orange, California
| | - Eric M Rudnick
- EMS Medical Directors Association of California.,NorCal EMS Agency, Redding, California
| | - Angelo A Salvucci
- EMS Medical Directors Association of California.,Ventura County EMS Agency, Oxnard, California
| | - Gregory H Gilbert
- EMS Medical Directors Association of California.,Stanford University, Department of Emergency Medicine, Stanford, California
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Competitive Antagonism of Anesthetic Action at the γ-Aminobutyric Acid Type A Receptor by a Novel Etomidate Analog with Low Intrinsic Efficacy. Anesthesiology 2017; 127:824-837. [PMID: 28857763 DOI: 10.1097/aln.0000000000001840] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The authors characterized the γ-aminobutyric acid type A receptor pharmacology of the novel etomidate analog naphthalene-etomidate, a potential lead compound for the development of anesthetic-selective competitive antagonists. METHODS The positive modulatory potencies and efficacies of etomidate and naphthalene-etomidate were defined in oocyte-expressed α1β3γ2L γ-aminobutyric acid type A receptors using voltage clamp electrophysiology. Using the same technique, the ability of naphthalene-etomidate to reduce currents evoked by γ-aminobutyric acid alone or γ-aminobutyric acid potentiated by etomidate, propofol, pentobarbital, and diazepam was quantified. The binding affinity of naphthalene-etomidate to the transmembrane anesthetic binding sites of the γ-aminobutyric acid type A receptor was determined from its ability to inhibit receptor photoaffinity labeling by the site-selective photolabels [H]azi-etomidate and R-[H]5-allyl-1-methyl-5-(m-trifluoromethyl-diazirynylphenyl) barbituric acid. RESULTS In contrast to etomidate, naphthalene-etomidate only weakly potentiated γ-aminobutyric acid-evoked currents and induced little direct activation even at a near-saturating aqueous concentration. It inhibited labeling of γ-aminobutyric acid type A receptors by [H]azi-etomidate and R-[H]5-allyl-1-methyl-5-(m-trifluoromethyl-diazirynylphenyl) barbituric acid with similar half-maximal inhibitory concentrations of 48 μM (95% CI, 28 to 81 μM) and 33 μM (95% CI, 20 to 54 μM). It also reduced the positive modulatory actions of anesthetics (propofol > etomidate ~ pentobarbital) but not those of γ-aminobutyric acid or diazepam. At 300 μM, naphthalene-etomidate increased the half-maximal potentiating propofol concentration from 6.0 μM (95% CI, 4.4 to 8.0 μM) to 36 μM (95% CI, 17 to 78 μM) without affecting the maximal response obtained at high propofol concentrations. CONCLUSIONS Naphthalene-etomidate is a very low-efficacy etomidate analog that exhibits the pharmacology of an anesthetic competitive antagonist at the γ-aminobutyric acid type A receptor.
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40
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Donroe JH, Tetrault JM. Substance Use, Intoxication, and Withdrawal in the Critical Care Setting. Crit Care Clin 2017; 33:543-558. [PMID: 28601134 DOI: 10.1016/j.ccc.2017.03.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Substance use is common among individuals admitted to the critical care setting and may complicate treatment of underlying disorders. Management issues include the effects of intoxication as well as the risk posed by substance-withdrawal syndromes in patients being treated for critical illness. This article reviews the epidemiology of substance use in this population and the identification and treatment of common intoxication and withdrawal syndromes. The authors stress the importance of long-term planning as part of the overall treatment protocol beyond the acute presentation.
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Affiliation(s)
- Joseph H Donroe
- Department of Internal Medicine, Yale University School of Medicine, St. Raphael Campus, Office M330, 1450 Chapel Street, New Haven, CT 06511, USA.
| | - Jeanette M Tetrault
- Department of Internal Medicine, Yale University School of Medicine, 367 Cedar Street, Suite 305, New Haven, CT 06510, USA
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41
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Isbister GK, Buckley NA. Therapeutics in clinical toxicology: in the absence of strong evidence how do we choose between antidotes, supportive care and masterful inactivity. Br J Clin Pharmacol 2016; 81:408-11. [PMID: 26914603 DOI: 10.1111/bcp.12819] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 11/03/2015] [Indexed: 12/13/2022] Open
Affiliation(s)
- Geoffrey K Isbister
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, New South Wales.,NSW Poisons Information Centre, The Childrens Hospital Westmead, Sydney, New South Wales
| | - Nicholas A Buckley
- NSW Poisons Information Centre, The Childrens Hospital Westmead, Sydney, New South Wales.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
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42
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Affiliation(s)
- Howard An
- Divisions of Emergency Medicine (Godwin) and Clinical Pharmacology and Toxicology (An, Godwin), Department of Medicine, University of Toronto; Ontario Poison Centre (An, Godwin), Division of Clinical Pharmacology and Toxicology, Hospital for Sick Children, Toronto, Ont.
| | - Jesse Godwin
- Divisions of Emergency Medicine (Godwin) and Clinical Pharmacology and Toxicology (An, Godwin), Department of Medicine, University of Toronto; Ontario Poison Centre (An, Godwin), Division of Clinical Pharmacology and Toxicology, Hospital for Sick Children, Toronto, Ont
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43
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Sivilotti MLA. Flumazenil, naloxone and the 'coma cocktail'. Br J Clin Pharmacol 2016; 81:428-36. [PMID: 26469689 PMCID: PMC4767210 DOI: 10.1111/bcp.12731] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Revised: 07/29/2015] [Accepted: 07/31/2015] [Indexed: 01/14/2023] Open
Abstract
Flumazenil and naloxone are considered to be pharmacologically ideal antidotes. By competitive binding at the molecular target receptors, they are highly specific antagonists of two important drug classes, the benzodiazepines and opioids, respectively. Both antidotes enjoy rapid onset and short duration after parenteral administration, are easily titrated and are essentially devoid of agonist effects. Yet only naloxone is widely used as a component of the 'coma cocktail', a sequence of empirical treatments to correct altered mental status, while experts discourage the use of flumazenil for such patients. This review contrasts the history, indications, published evidence and novel applications for each antidote in order to explain this disparity in the clinical use of these 'ideal' antidotes.
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Affiliation(s)
- Marco L A Sivilotti
- Emergency Medicine and Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario
- Ontario Poison Centre, Hospital for Sick Children, Toronto, Ontario, Canada
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44
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Buckley NA, Dawson AH, Juurlink DN, Isbister GK. Who gets antidotes? choosing the chosen few. Br J Clin Pharmacol 2016; 81:402-7. [PMID: 26816206 DOI: 10.1111/bcp.12894] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 01/25/2016] [Accepted: 01/26/2016] [Indexed: 12/25/2022] Open
Abstract
An understanding of mechanisms, potential benefits and risks of antidotes is essential for clinicians who manage poisoned patients. Of the dozens of antidotes currently available, only a few are regularly used. These include activated charcoal, acetylcysteine, naloxone, sodium bicarbonate, atropine, flumazenil, therapeutic antibodies and various vitamins. Even then, most are used in a minority of poisonings. There is little randomized trial evidence to support the use of most antidotes. Consequently, decisions about when to use them are often based on a mechanistic understanding of the poisoning and the expected influence of the antidote on the patient's clinical course. For some antidotes, such as atropine and insulin, the doses employed can be orders of magnitude higher than standard dosing. Importantly, most poisoned patients who reach hospital can recover with supportive care alone. In low risk patients, the routine use of even low risk antidotes such as activated charcoal is unwarranted. In more serious poisonings, decisions regarding antidote use are generally guided by a risk/benefit assessment based on low quality evidence.
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Affiliation(s)
- Nicholas A Buckley
- NSW Poisons Information Centre, The Childrens Hospital Westmead, Sydney, New South Wales.,Sydney Medical School, University of Sydney, Sydney, New South Wales.,Department of Clinical Toxicology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Andrew H Dawson
- NSW Poisons Information Centre, The Childrens Hospital Westmead, Sydney, New South Wales.,Sydney Medical School, University of Sydney, Sydney, New South Wales.,Department of Clinical Toxicology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - David N Juurlink
- Departments of Medicine, Paediatrics and Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Geoffrey K Isbister
- NSW Poisons Information Centre, The Childrens Hospital Westmead, Sydney, New South Wales.,Clinical Toxicology Research Group, University of Newcastle, Newcastle, New South Wales, Australia
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