Acute pancreatitis induced by short-term propofol administration

A prospective, randomized, single-blinded study comparing the efficacy and safety of dexmedetomidine and propofol for sedation during endoscopic retrograde cholangiopancreatography

BACKGROUND

Balanced propofol sedation is extensively used in endoscopic retrograde cholangiopancreatography (ERCP), but sedation-related adverse events (SRAEs) are common. In various clinical settings, the combination of dexmedetomidine with opioids and benzodiazepines has provided effective sedation with increased safety. The aim of this investigation was to compare the efficacy and safety of dexmedetomidine and propofol for sedation during ERCP.

METHODS

Forty-one patients were randomly divided into two groups: the dexmedetomidine (DEX) group and the propofol (PRO) group. Patients in the DEX group received an additional bolus of 0.6 μg kg-1 dexmedetomidine followed by a dexmedetomidine infusion at 1.2 μg kg-1 h-1, whereas the PRO group received 1-2 mg kg-1 of propofol bolus followed by a propofol infusion at 2-3 mg kg-1 h-1. During ERCP, the primary outcome was the incidence of hypoxemia (SpO2 < 90% for > 10 s). Other intraoperative adverse events were also recorded as secondary outcomes, including respiratory depression (respiratory rate of < 10 bpm min-1), hypotension (MAP < 65 mmHg), and bradycardia (HR < 45 beats min-1).

RESULTS

The incidence of hypoxemia was significantly reduced in the DEX group compared to the PRO group (0% versus 28.6%, respectively; P = 0.032). Patients in the PRO group exhibited respiratory depression more frequently than patients in the DEX group (35% versus 81%, respectively; P = 0.003). There were no significant differences in terms of hypotension and bradycardia episodes between groups. During the procedures, the satisfaction scores of endoscopists and patients, as well as the pain and procedure memory scores of patients were comparable between groups.

CONCLUSION

In comparison with propofol, dexmedetomidine provided adequate sedation safety with no adverse effects on sedation efficacy during ERCP.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR2200061468, 25/06/2022.

Triglyceride Concentrations and Their Relationship to Sedation Choice and Outcomes in Mechanically Ventilated Patients Receiving Propofol

Rationale: Propofol is a first-line sedative agent in the intensive care unit (ICU) but may be associated with hypertriglyceridemia and pancreatitis. To date, the relationship between propofol-induced hypertriglyceridemia and pancreatitis, as well as clinician responses to propofol-induced hypertriglyceridemia, have not been comprehensively studied. Objectives: To assess the incidence of hypertriglyceridemia and pancreatitis in patients receiving continuous propofol infusions in the ICU and to describe the association between hypertriglyceridemia and the use of nonpropofol continuous sedative infusions. Methods: This was a retrospective observational cohort study conducted at three urban academic hospitals within a single health system. Findings were additionally validated using the Medical Information Mart for Intensive Care-IV (MIMIC-IV) database containing data from a separate tertiary care hospital. Mechanically ventilated adult patients who received a continuous propofol infusion between 2016 and 2021 were included. The primary exposure was serum triglyceride concentration, and hypertriglyceridemia was defined as a triglyceride concentration greater than 400 mg/dl. Outcomes included new-onset pancreatitis as well as receipt of midazolam, dexmedetomidine, or ketamine after the triglyceride measurement. The incidence of pancreatitis was compared between groups using a Fisher's Exact test. Multivariable logistic regression was used to assess the association between dichotomized triglyceride concentration and alternative sedative use. Results: In the primary cohort of 7,037 patients, 1,724 (24.5%) had one or more triglyceride concentration measured. Of these, 1,365 (79.2%) had a maximum concentration of less than 400 mg/dl, and 359 (20.8%) had a maximum concentration of greater than 400 mg/dl. Compared with patients with low triglyceride concentrations, patients with high triglyceride concentrations were more likely to receive a continuous infusion of midazolam (37.0% vs. 16.4%; adjusted odds ratio [aOR], 3.1; 95% confidence interval [CI], 2.2-4.4; P < 0.01), ketamine (22.8% vs. 6.9%; aOR, 3.5; 95% CI, 2.3-5.3; P < 0.01), and dexmedetomidine (57.7% vs. 46.6%; aOR, 1.5; 95% CI, 1.1-2.0; P < 0.01). Rates of midazolam infusion increased as triglyceride concentrations exceeded 500 mg/dl. Forty-four (0.6%) patients developed pancreatitis after propofol initiation, of which 4 (9.1%) were considered related to propofol-associated hypertriglyceridemia. Findings were similar in the MIMIC-IV cohort. Conclusions: Propofol-associated hypertriglyceridemia is relatively common in mechanically ventilated ICU patients who have triglycerides measured. Pancreatitis related to propofol-associated hypertriglyceridemia is rare. Patients who develop hypertriglyceridemia while receiving propofol are more likely to receive continuous infusions of other sedatives.

Severe necrotizing pancreatitis immediately after non-abdominal surgery under general anesthesia with propofol

Postoperative pancreatitis is a relatively rare disease and is poorly recognized. Herein, we present a case of necrotizing pancreatitis that developed immediately after non-abdominal surgery under general anesthesia. In this report, 4 h after thyroidectomy under general anesthesia using propofol, the patient developed upper abdominal pain and was diagnosed with severe acute pancreatitis with extensive pancreatic necrosis. Immediately after the diagnosis, the patient received appropriate treatment, and acute pancreatitis was improved. Subsequently, the patient has the formation of non-infectious giant walled-off necrosis and remained in good condition without additional treatment for 1.5 years after pancreatitis onset. In this case report, our detailed causative search suggested that propofol administration could be the cause of this pancreatitis. Propofol-induced pancreatitis is extremely rare but develops often severely, resulting in fatality. In this case, the patient developed severe acute pancreatitis within a very short time after surgery but was able to survive by immediate intervention of treatment. We suggest that clinicians should consider acute pancreatitis as a life-threatening adverse event under general anesthesia with propofol and perform thorough postoperative management.

Propofol-Induced Severe Necrotizing Pancreatitis

Propofol is a widely used sedative for gastrointestinal endoscopic procedures. Drug-induced pancreatitis is a relatively rare disease possibly because of poor recognition. Propofol-induced pancreatitis is an extremely rare phenomenon. We present a 22-year-old healthy man who underwent esophagogastroduodenoscopy with propofol as a sedative. Soon after, he developed acute upper gastrointestinal symptoms and was diagnosed with pancreatitis. His prolonged hospital course was complicated with necrotizing pancreatitis, acute respiratory distress syndrome, septic shock, and other end-organ damages. We hope to increase awareness of a life-threatening adverse event of a commonly used anesthetic such as propofol.

Hyperamylasemia Post Living Donor Nephrectomy Does Not Relate to Pain

Introduction The aetiology of pain after laparoscopic donor nephrectomy remains unclear. Given the proximity of the left kidney to the tail of the pancreas, we aimed to assess whether mobilisation and retrieval of the left kidney might inflame the pancreas, leading to pain and hyperamylasaemia in the post-operative period. Patient and methods In the present study, 16 consecutive live kidney donors were analysed in the same three months period. Amylase levels were measured on days 1 and 2. For each 24-hour period post-operatively analgesia consumption was recorded, as well as pain scores at rest on a visual analogue scale (VAS). Results Three out of 16 donors presented hyperamylasemia. A multiple regression analysis found levobupivacaine dose, propofol dose, transversus abdominis plane block and day 1 amylase did not significantly predict pain scores. Interestingly, body mass index significantly correlated with increased pain scores (p = 0.041). Also, increasing CO2 insufflation pressure and use of local anaesthetic infusion catheters predicted a decreased deep pain score (p = 0.036 and p = 0.037). Conclusion There was no correlation of amylase levels and pain scores. Pancreatitis is a rare complication of nephrectomy and no overt cases were seen in the case of donor nephrectomy.

Drug induced pancreatitis: A systematic review of case reports to determine potential drug associations

OBJECTIVE

A current assessment of case reports of possible drug-induced pancreatitis is needed. We systematically reviewed the case report literature to identify drugs with potential associations with acute pancreatitis and the burden of evidence supporting these associations.

METHODS

A protocol was developed a priori (PROSPERO CRD42017060473). We searched MEDLINE, Embase, the Cochrane Library, and additional sources to identify cases of drug-induced pancreatitis that met accepted diagnostic criteria of acute pancreatitis. Cases caused by multiple drugs or combination therapy were excluded. Established systematic review methods were used for screening and data extraction. A classification system for associated drugs was developed a priori based upon the number of cases, re-challenge, exclusion of non-drug causes of acute pancreatitis, and consistency of latency.

RESULTS

Seven-hundred and thirteen cases of potential drug-induced pancreatitis were identified, implicating 213 unique drugs. The evidence base was poor: exclusion of non-drug causes of acute pancreatitis was incomplete or poorly reported in all cases, 47% had at least one underlying condition predisposing to acute pancreatitis, and causality assessment was not conducted in 81%. Forty-five drugs (21%) were classified as having the highest level of evidence regarding their association with acute pancreatitis; causality was deemed to be probable or definite for 19 of these drugs (42%). Fifty-seven drugs (27%) had the lowest level of evidence regarding an association with acute pancreatitis, being implicated in single case reports, without exclusion of other causes of acute pancreatitis.

DISCUSSION

Much of the case report evidence upon which drug-induced pancreatitis associations are based is tenuous. A greater emphasis on exclusion of all non-drug causes of acute pancreatitis and on quality reporting would improve the evidence base. It should be recognized that reviews of case reports, are valuable scoping tools but have limited strength to establish drug-induced pancreatitis associations.

REGISTRATION

CRD42017060473.

Volatiles or TIVA: Which is the standard of care for pediatric airway procedures? A pro-con discussion

Anesthesia for pediatric airway procedures constitutes a true art form that requires training and experience. Communication between anesthetist and surgeon to establish procedure goals is essential in determining the most appropriate anesthetic management. But does the mode of anesthesia have an impact? Traditionally, inhalational anesthesia was the most common anesthesia technique used during airway surgery. Introduction of agents used for total intravenous anesthesia (TIVA) such as propofol, short-acting opioids, midazolam, and dexmedetomidine has driven change in practice. Ongoing debates abound as to the advantages and disadvantages of volatile-based anesthesia versus TIVA. This pro-con discussion examines both volatiles and TIVA, from the perspective of effectiveness, safety, cost, and environmental impact, in an endeavor to justify which technique is the best specifically for pediatric airway procedures.

Effect of Best Practice Advisories on Sedation Protocol Compliance and Drug-Related Hazardous Condition Mitigation Among Critical Care Patients

OBJECTIVES

To determine whether best practice advisories improved sedation protocol compliance and could mitigate potential propofol-related hazardous conditions.

DESIGN

Retrospective observational cohort study.

SETTING

Two adult ICUs at two academic medical centers that share the same sedation protocol.

PATIENTS

Adults 18 years old or older admitted to the ICU between January 1, 2016, and January 31, 2018, who received a continuous infusion of propofol.

INTERVENTIONS

Two concurrent best practice advisories built in the electronic health record as a clinical decision support tool to enforce protocol compliance with triglyceride and lipase level monitoring and mitigate propofol-related hazardous conditions.

MEASUREMENTS AND MAIN RESULTS

The primary outcomes were baseline and day 3 compliance with triglyceride and lipase laboratory monitoring per protocol and time to discontinuation of propofol in the setting of triglyceride and/or lipase levels exceeding protocol cutoffs. A total of 1,394 patients were included in the study cohort (n = 700 in the pre-best practice advisory group; n = 694 in the post-best practice advisory group). In inverse probability weighted regression analyses, implementing the best practice advisory was associated with a 56.6% (95% CI, 52.6-60.9) absolute increase and a 173% relative increase (risk ratio, 2.73; 95% CI, 2.45-3.04) in baseline laboratory monitoring. The best practice advisory was associated with a 34.0% (95% CI, 20.9-47.1) absolute increase and a 74% (95% CI, 1.39-2.19) relative increase in day 3 laboratory monitoring after inverse probability weighted analyses. Among patients with laboratory values exceeding protocol cutoffs, implementation of the best practice advisory resulted in providers discontinuing propofol an average of 16.6 hours (95% CI, 4.8-28.3) sooner than pre-best practice advisory. Findings from alternate analyses using interrupted time series were consistent with the inverse probability weighted analyses.

CONCLUSIONS

Best practice advisories can be effectively used in ICUs to improve sedation protocol compliance and may mitigate potential propofol-related hazardous conditions. Best practice advisories should undergo continuous quality assurance and optimizations to maximize clinical utility and minimize alert fatigue.

Acute pancreatitis associated with intravenous administration of propofol: evaluation of causality in a systematic review of the literature

Acute pancreatitis (AP) associated with intravenous administration of propofol has been described with unknown causal relation. We therefore assessed this causality in a systematic review. Multiple databases were searched on 16 August 2017; studies were appraised and selected by two reviewers based on a priori criteria. Propofol causality was evaluated with the Naranjo scale and Badalov classification. We identified 18 studies from 11 countries with a total of 21 patients, and the majority had adequate methodological quality. The median age was 35 years (range, 4-77) and 10 (48%) were males. Overall, propofol was administrated in 8 patients as sedative along with induction/maintenance of anesthesia in 13 patients; median dose was 200 mg, with intermediate latency (1-30 days) in 14 (67%). Serum triglycerides were >1000 mg/dL in four patients. Severe AP was observed in four patients (19%). AP recurrence occurred in one out of two patients who underwent rechallenge. Mortality related to AP was 3/21(14%). Propofol was the probable cause of AP according to the Naranjo scale in 19 patients (89%). Propofol-induced AP has a probable causal relation and evidence supports Badalov class Ib. Hypertriglyceridemia is not the only mechanism by which propofol illicit AP. Propofol-induced AP was severe in 19% of patients with a mortality rate related to AP of 14%. Future research is needed to delineate whether this risk is higher if combined with other procedures that portend inherent risk of pancreatitis such as endoscopic retrograde cholangiopancreatography.

Variation of Vegetation Ecological Water Consumption and Its Response to Vegetation Coverage Changes in the Rocky Desertification Areas in South China

Over the past several decades, rocky desertification has led to severe ecological problems in karst areas in South China. After a rocky desertification treatment project was completed, the vegetation coverage changed greatly and, consequently, increased the ecology water consumption (approximately equal to the actual evapotranspiration) of the regional vegetation. Thus, it intensified the regional water stresses. This study explored the changes in the actual evapotranspiration (ETa) response to the vegetation coverage changes in the rocky desertification areas in South China based on the precipitation (P), potential evapotranspiration (ETp) and NDVI (the normalized difference vegetation index) datasets. The revised Bagrov model was used to simulate the actual evapotranspiration changes with the supposed increasing NDVI. The results indicated that the average NDVI value was lower when the rocky desertification was more severe. The ETa, evapotranspiration efficiency (ETa/ETp) and potential humidity (P/ETp) generally increased with the increasing NDVI. The sensitivity of the ETa response to vegetation coverage changes varied due to different precipitation conditions and different rocky desertification severities. The ETa was more sensitive under drought conditions. When a drought occurred, the ETa exhibited an average increase of 40~60 mm with the NDVI increasing of 0.1 in the rocky desertification areas. Among the 5 different severity categories of rocky desertification, the ETa values' responses to NDVI changes were less sensitive in the severe rocky desertification areas but more sensitive in the extremely and potential rocky desertification areas. For example, with the NDVI increasing of 0.025, 0.05, 0.075, and 0.1, the corresponding ETa changes increased by an average of 2.64 mm, 10.62 mm, 19.19 mm, and 27.58 mm, respectively, in severe rocky desertification areas but by 4.94 mm, 14.99 mm, 26.80, and 37.13 mm, respectively, in extremely severe rocky desertification areas. Understanding the vegetation ecological water consumption response to the vegetation coverage changes is essential for the vegetation restoration and water stresses mitigation in rocky desertification areas.

Acute pancreatitis as a complication of childhood cancer treatment

Acute pancreatitis (AP) is now well recognized as a possible complication of childhood cancer treatment, interrupting the chemotherapy regimen, and requiring prolonged hospitalization, possibly with intensive care and surgical intervention, thereby compromising the effect of chemotherapy and the remission of the underlying malignant disease. This review summarizes the current literature and presents the various etiological factors for AP during chemotherapy as well as modern trends in the diagnosis and therapy of AP in children.

Comparison of dexmedetomidine versus propofol for sedation in mechanically ventilated patients after cardiovascular surgery

Many cardiovascular surgeries are fast-tracked to extubation and require short-term sedation. Dexmedetomidine and propofol have very different mechanisms of action and pharmacokinetic profiles that make them attractive sedative agents in this patient population. Recently, there has been increased use of dexmedetomidine in the intensive care unit (ICU), but few studies exist or have been published directly comparing both agents in this setting. We conducted a retrospective cohort study with patients admitted to the ICU after cardiovascular surgery from January through June 2011. Adult patients who underwent coronary artery bypass and/or cardiac valve surgery received either dexmedetomidine or propofol continuous infusion for short-term sedation after cardiovascular surgery. The primary end point was time (hours) on mechanical ventilation after surgery. Secondary end points included ICU length of stay (LOS), hospital LOS, incidence of delirium, and requirement of a second sedative agent. A total of 352 patients met study inclusion criteria, with 33 enrolled in the dexmedetomidine group and 319 in the propofol group. Time on mechanical ventilation was shorter in the dexmedetomidine group (7.4 hours vs. 12.9 hours, P = .042). No difference was seen in ICU or hospital LOS. The need for a second sedative agent to achieve optimal sedation (24% vs. 27%, P = .737) and incidence of delirium (9% vs. 7.5%, P = .747) were similar between both groups. Sedation with dexmedetomidine resulted in a significant reduction in time on mechanical ventilation. However, no difference was seen in ICU or hospital LOS, incidence of delirium, or mortality.

Propofol administration in patients with methylmalonic acidemia and intracellular cobalamin metabolism disorders: a review of theoretical concerns and clinical experiences in 28 patients

BACKGROUND

Methylmalonic acidemia and intracellular cobalamin metabolism disorders represent a heterogeneous group of inborn errors of metabolism. Most patients will require diagnostic and/or therapeutic procedures frequently requiring sedation or anesthetic management due to neurological and neurocognitive impairments. It has been stated that propofol is contraindicated in this population. We report our experience with propofol administration in a large series of patients.

METHODS

Twenty eight patients (14 mut, seven cblC, three cblA, three cblB, one cblG) aged 2-35.6 years enrolled in a natural history study (ClinicalTrials.gov identifier: NCT00078078) and required anesthetics for 39 diagnostic or therapeutic procedures. Data were collected on the anesthetic technique, perianesthetic course, and adverse events related to propofol.

RESULTS

Propofol was used as the sole induction agent in most cases (36/39) and as the primary maintenance agent in all cases. Infusion rates were 100-400 mcg kg(-1) min(-1) (mean = 214). Infusion duration was 60-325 min (mean = 158) and total doses ranged between 270-3610 mg (mean = 1217). Adverse events were recorded in two cases; neither appeared to be related to propofol administration.

CONCLUSIONS

Propofol is an effective, safe induction and maintenance agent for elective short procedures requiring anesthesia in patients with MMA and cobalamin metabolism disorders. Despite multiple comorbidities and propensity toward instability, those affected can receive anesthesia with an acceptable safety profile, if metabolically and hemodynamically stabilized prior to the event.

SYNOPSIS

A review of the perianesthetic records of 28 patients with isolated MMA and intracellular cobalamin metabolism disorders suggests that propofol anesthesia can be administered safely to these patients, in the setting of metabolic stability.

Possible Sulfamethoxazole/Trimethoprim-Induced Pancreatitis in a Complicated Adolescent Patient Posttraumatic Injury

Introduction:

Multiple medications have been associated with pancreatitis, however, data in the pediatric population are scarce secondary to the nonspecific presentation and infrequent diagnosis. The aim of this report is to characterize drug-induced pancreatitis in an adolescent patient.

Case Presentation:

A 16-year-old African-American female presented with a surgical site infection 8 weeks after a motor vehicle accident with multiple traumas. Two weeks prior to the admission, the patient was hospitalized for a urinary tract infection (UTI) and was initiated on sulfamethoxazole/trimethoprim (TMP/SMX) daily for UTI prophylaxis. On day 13, the patient was diagnosed with acute pancreatitis with an amylase level of 187 units/L (normal = 30-110) and a lipase level of 987 units/L (normal = 23-208). TMP/SMX was discontinued, and pancreatic enzyme levels decreased but did not reach normal. The patient was asymptomatic at discharge.

Discussion:

TMP/SMX was identified as the likely etiology of pancreatitis by the medical team. Evaluation with the Naranjo algorithm indicated a “possible” adverse drug reaction.

Conclusion:

Acute pancreatitis can have significant morbidity and mortality in the pediatric population but can go undiagnosed due to its lower incidence. Pediatric patients presenting with idiopathic abdominal pain should be evaluated for pancreatitis and drug therapy should be reviewed for potential causative agents.

Total intravenous anesthesia will supercede inhalational anesthesia in pediatric anesthetic practice

Inhalational anesthesia has dominated the practice of pediatric anesthesia. However, as the introduction of agents such as propofol, short-acting opioids, midazolam, and dexmedetomidine a monumental change has occurred. With increasing use, the overwhelming advantages of total intravenous anesthesia (TIVA) have emerged and driven change in practice. These advantages, outlined in this review, will justify why TIVA will supercede inhalational anesthesia in future pediatric anesthetic practice.

Novel and effective balanced intravenous-inhalant anaesthetic protocol in swine by using unrestricted drugs

Nowadays, because of increasing employment of swine for experimental studies and medical training, it is hopeful to investigate novel and effective anaesthetic protocols for preserving the animal welfare in medical investigation and concurrently improving the quality of research. Therefore, the aim of this study was to investigate a novel and effective anaesthetic protocol in swine undergoing major surgery, by translating know-how of combined anaesthesia from human protocols. Seven landrace swine were anaesthetized for three hours by a combined trial anaesthetic protocol (sedation: medetomidine, acepromazine, atropine and tramadol; induction: propofol, medetomidine and acepromazine; anaesthesia: isofluorane, propofol, medetomidine and acepromazine) and both clinical and haemodynamic parameters were compared with those of five swine anaesthetized with a control protocol (sedation: diazepam, ketamine and atropina; induction: diazepam and ketamine; anaesthesia: isofluorane). Both cardiac frequency (CF) and mean blood pressure (MBP) were significantly (P<0.05) more stable in trial protocol (CF: 78.3 ± 4.6-81.1 ± 5, MBP: 63.9 ± 10.7-96.4 ± 13.0) compared to control protocol (CF: 93.7 ± 5.5-102.5 ± 8.5, MBP: 71.0 ± 6.6-108.7 ± 7.2). The body temperature remained stable in trial protocol (°C: 36.9 ± 0.7-37.2 ± 0.3) compared to control anaesthesia (°C: 36.4 ± 0.3-37.3 ± 0.2, P<0.05). Haematosis improved undergoing combined anaesthesia (+2%, P<0.05) whereas did not change in control animals. There were no differences in respiratory rate between trial and control protocols. This study demonstrates that the proposed balanced intravenous-inhalant protocol permits to carry out a very effective, stable and safe anaesthesia in swine undergoing deep anaesthesia.

Acute pancreatitis as rare complication of the right radical transperitoneal open nephrectomy

Radical open nephrectomy is considered the standard treatment for kidney tumors or masses greater than 10 cm. We present a rare case of acute pancreatitis that occurred after right radical transperitoneal nephrectomy, which was treated by nonsurgical conservative interventions. The incidence of acute pancreatitis after renal surgery is not known in the literature. A 56-year-old man developed acute pancreatitis postoperatively after radical transperitoneal nephrectomy. An initial CT scan showed an enlarged pancreas with hypodense, heterogeneous consistency and with peripancreatic, perihepatic, mesenteric, and pelvic fluid collections. This complication was managed conservatively.

Patient-controlled analgesia and sedation with alfentanyl versus fentanyl for colonoscopy: a randomized double blind study

STUDY OBJECTIVE

The aim of this study was to evaluate whether sedo-analgesia with alfentanyl/fentanyl, using a patient-controlled analgesia (PCA) pump, may have positive outcomes in terms of safety, postprocedural workload, and expectations of the colonoscopist, nurse, and patients in elective colonoscopy.

PATIENTS

One hundred American Society of Anesthesiology physical status I and II adult patients.

INTERVENTIONS

Patients were randomized in a double-blind trial to receive either alfentanyl (n=50) or fentanyl (n=50) by PCA, and incremental doses of midazolam.

MEASUREMENTS

Patient expectations were assessed using hemodynamic variables, willingness to have a repeat colonoscopy in the same way, adverse events, discomfort scores, and patient/operator/nurse satisfaction associated with sedo-analgesia.

RESULT

All patients in both groups had adequate sedo-analgesia with high satisfaction and willingness scores. There were no serious adverse effects and except for a few events, no required medication. The total sedation times were shorter in the alfentanyl group compared with the fentanyl group.

CONCLUSIONS

PCA and sedation with alfentanyl and fentanyl for colonoscopy are safe, feasible, and acceptable to most patients. However, shorter sedation times make alfentanyl more attractive for postprocedural workload.

Drug-induced acute pancreatitis related to medications commonly used in gastroenterology

BACKGROUND

With the growing number of pharmacological agents available nowadays, the gastrointestinal drug-induced side effects become more common than ever. However, drug-induced pancreatitis belongs to rather seldom reported adverse drug reactions, probably because of the difficulty in proving the relationship between an inflammation of the pancreas and the pharmacotherapy with a certain drug.

AIM

The aim of this review is to draw attention to an infrequent but real problem of drug-induced acute pancreatitis associated with medications commonly used in the treatment of gastrointestinal disorders.

METHODOLOGY

For the purpose of that the PubMed database was searched using the keywords "drug-induced pancreatitis", "drug-associated pancreatitis", "acute pancreatitis", "pancreatitis" in various combinations and relevant literature was reviewed.

RESULTS

A substantial number of drugs commonly prescribed for gastrointestinal disorders are known to cause acute pancreatitis. Case reports and review articles published so far draw attention to medications already known to cause drug-induced pancreatic damage as well as implicate new drugs. Generally, the etiopathological mechanisms involved in drug-induced pancreatitis remain unclear. It is difficult to establish or rule out definitely such unwanted event, especially in patients taking numerous medications prescribed for multiple comorbidities.

CONCLUSION

Pharmacological agents are among etiologic factors that should be considered in all patients presenting with signs and symptoms consistent with acute pancreatitis. The diagnosis of drug-induced AP is often difficult to established. Therefore a high index of suspicion and thorough drug history are crucial for making the final diagnosis.

Sedation, analgesia, and delirium in the critically ill patient

Most critically ill patients receive a myriad of psychoactive medications during their hospital stay. An understanding of the pharmacology of the more commonly used sedative and analgesic therapies enables the clinician to aptly utilize these medications and limit toxicity. A key to the appropriate provision of sedative and analgesic pharmacotherapy is a thorough patient assessment, use of validated monitoring tools, and defined therapeutic goals. Limiting these therapies while optimizing patient comfort has been shown to reduce the duration of mechanical ventilation and reduce intensive care unit (ICU) and hospital length of stay and should be the aim of the multidisciplinary medical team. This review is intended to provide the reader with a fundamental understanding of how to facilitate comfort of the mechanically ventilated critically ill adult patients and how to minimize medication-related toxicities.

State of the art review: Intravenous fat emulsions: Current applications, safety profile, and clinical implications

OBJECTIVE

To review the current state of the science regarding intravenous fat emulsions (IVFEs), with an emphasis on their safety profile.

DATA SOURCES

Articles were identified via a search of the MEDLINE database, including publications from 1979 to December 2009, using a search string that included the terms parenteral nutrition, lipid emulsion, fat emulsion, IVFE, safety, adverse effect, neonate intralipid, and terms describing a range of specific adverse events (AEs) such as pancreatitis.

STUDY SELECTION AND DATA EXTRACTION

We selected articles that allowed us to compare the results of clinical trials involving delivery of medications via IVFEs with the historical use and effects of IVFEs in parenteral nutrition, with an emphasis on AEs. We focused on 2 drugs in current use that are administered intravenously in lipid emulsions: propofol and clevidipine.

DATA SYNTHESIS

Clearance of the fat particles in IVFEs is mediated by the enzyme lipoprotein lipase. AEs are more likely if the rate or duration of IVFE administration exceeds the enzyme's clearance capacity. AEs are also more likely after administration of a 10% IVFE formulation than a 20% formulation, because the higher concentration of free phospholipid in the 10% formulation interferes with lipoprotein lipase activity. AEs can be reduced by administering IVFEs at a dosage < or = 2.5 g/kg/day and at a rate < or = 0.11 g/kg/h. The anesthetic agent propofol, which is formulated in a 10% IVFE, has been used clinically for 25 years. Typical AEs associated with propofol use include infection, high plasma triglyceride concentrations, and pancreatitis. Recent clinical trials involving clevidipine, which is formulated in a 20% IVFE, have demonstrated a low rate of lipid-related AEs.

CONCLUSIONS

The results of this review demonstrate that IVFEs are well tolerated when administered in accordance with guideline recommendations.

Effects of medications on post-endoscopic retrograde cholangiopancreatography pancreatitis

BACKGROUND AND AIMS

Drug-induced pancreatitis accounts for about 2% of acute pancreatitis. The aim of this study is to determine whether propofol and other medications are associated with increased risk for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis.

METHODS

A retrospective study was conducted at a single tertiary care hospital. All patients who underwent ERCP from 2001 to 2004 were included. Diagnosis of acute post-ERCP pancreatitis was based on a consensus definition.

RESULTS

A total of 506 patients underwent ERCP. The total incidence of post-ERCP pancreatitis was 7.1%. There was no significant difference in post-ERCP pancreatitis between patients who received propofol compared to patients who received midazolam and fentanyl (9.0 vs. 5.9%, p = 0.18). Patients receiving an angiotensin receptor blocker were approximately 4 times more likely to develop post-ERCP pancreatitis (OR = 4.1, 95% CI 1.6-10.9). Patients younger than 65 years and smokers also had higher risk of developing acute post-ERCP pancreatitis than those who were older than 65 years (OR = 3.9, 95% CI 1.7-9.1) and non-smokers (OR = 2.8, 95% CI 1.3-6.2).

CONCLUSIONS

Propofol is a safe sedative drug for ERCP without additional risk of developing acute post-ERCP pancreatitis. Use of angiotensin receptor blockers, smoking and younger age are independent risk factors for post-ERCP pancreatitis.

Drug-induced acute pancreatitis in children receiving chemotherapy for acute leukemia: does propofol increase the risk?

BACKGROUND

The use of propofol is controversial in patients with a history of acute pancreatitis or those taking drugs, including certain chemotherapeutic drugs, that are associated with pancreatitis.

METHODS

To investigate this issue, we reviewed the medical records of all children who were diagnosed with pancreatitis while receiving chemotherapy for acute leukemia during a 5-year period.

RESULTS

A temporal relationship between propofol use and development of acute pancreatitis could not be established.

CONCLUSION

Propofol can be considered for general anesthesia in children who are receiving chemotherapeutic drugs that are themselves associated with acute pancreatitis or those who have a history of chemotherapy-induced pancreatitis.

Propofol-induced hyperamylasaemia in a general intensive care unit

This study examined the incidence of hyperamylasaemia, in the absence of other plausible causes of pancreatic dysfunction, in intensive care unit (ICU) patients who received propofol. One-hundred-and-seventy-two consecutive patients of a general ICU who stayed for more than 24 hours were studied. Patients with a diagnosis consistent with elevated serum amylase levels at admission were excluded from the study, as were patients who had received medications known to raise serum amylase levels. Forty-four patients 53 +/- 20 years of age and median duration of ICU stay of five days (range two to 55) were eligible. Thirty of those, aged 54 +/- 21 years and median duration of ICU stay of five days (range two to 27) received continuous infusion of propofol for sedation (maximum dose 45 microg/kg/min). Of the 30 patients who received propofol, 16 (53%) developed hyperamylasaemia (125 to 466 IU/l) after two to nine days of continuous infusion. Liver and kidney function remained normal throughout the observation period. Of the 14 patients who did not receive propofol (aged 51 +/- 18 years), only two (14%) developed hyperamylasaemia, a significantly lower incidence (P = 0.021). Propofol infusion is associated with biochemical evidence of pancreatic injury. Amylase levels monitoring of propofol-sedated patients is warranted.

Pharmacological and clinical evidences on the potential for abuse and dependence of propofol: a review of the literature

Propofol (2,6-diisopropylphenol) is an intravenous short-acting anaesthetic widely used for inducing and maintaining anaesthesia. Propofol is also being increasingly used for sedation. Beside medical use, propofol is abused for recreational purpose, mostly in medical professionals who are not informed of the risk of dependence to this compound. The aim of this review was to provide an overview of molecular, animal and clinical pharmacological data of the literature evidencing the potential for abuse and dependence of propofol.

Drug-induced acute pancreatitis: an evidence-based review

The diagnosis of drug-induced acute pancreatitis often is difficult to establish. Although some medications have been shown to cause acute pancreatitis with a large body of evidence, including rechallenge, some medications have been attributed as a cause of acute pancreatitis merely by a single published case report in which the investigators found no other cause. In addition, some medications reported to have caused acute pancreatitis have obvious patterns of presentation, including the time from initiation to the development of disease (latency). There also appear to be patterns in the severity of disease. After reviewing the literature, we have classified drugs that have been reported to cause acute pancreatitis based on the published weight of evidence for each agent and the pattern of clinical presentation. Based on our analysis of the level of evidence, 4 classes of drugs could be identified. Class I drugs include medications in which at least 1 case report described a recurrence of acute pancreatitis with a rechallenge with the drug. Class II drugs include drugs in which there is a consistent latency in 75% or more of the reported cases. Class III drugs include drugs that had 2 or more case reports published, but neither a rechallenge nor a consistent latency period. Class IV drugs were similar to class III drugs, but only 1 case report had been published. Our analysis allows an evidence-based approach when suspecting a drug as causing acute pancreatitis.

Value of fetal cerebral MRI in sonographically proven cardiac rhabdomyoma

BACKGROUND

Tuberous sclerosis complex (TSC) is an autosomal dominant phakomatosis associated with intracardiac rhabdomyomas.

OBJECTIVE

The aim of our study was to examine the value of cerebral MRI in diagnosing TSC in fetuses with intracardiac rhabdomyomas, applying the TSC Consensus Conference (TSCCC) criteria.

MATERIALS AND METHODS

In a prospective manner six consecutive fetuses with cardiac rhabdomyomas (21-34 weeks' gestation) underwent cerebral MRI. The MRI results were correlated with clinical follow-up at 10-34 months after birth, histology, and genetic data.

RESULTS

In five of the six fetuses the diagnosis of TSC was established. In two of five fetuses MRI demonstrated cerebral manifestations of TSC that correlated well with severe epilepsy manifesting during the follow-up period. In another two of five fetuses MRI as well as clinical follow-up were normal. One of five pregnancies was terminated and histology demonstrated microscopically small subependymal nodules not demonstrated by MRI.

CONCLUSION

The results of our study agree with the available literature that fetal MRI is sufficient for the detection of cerebral lesions in TSC and should be better promoted. The TSCCC criteria can also be applied to fetal MRI.

Intraindividual propofol dosage variability in children undergoing repetitive procedural sedations

The authors prospectively assessed intraindividual variability in propofol dosage for induction of sedation in repetitive procedures in children with malignancies. A total of 80 procedures were performed in 24 children. Primary outcome measure was the intraindividual propofol dose required to achieve adequate sedation. Intraindividual variability in propofol dosage required to achieve adequate sedation was 0.0-2.2 mg.kg-1. Twenty-five percent of the patients had a dose range of 0.0-0.5 mg x kg-1; 37.5%, >0.5-1.0 mg x kg-1; and 37.5% >1.0-2.2 mg x kg-1. Due to remarkable intraindividual differences, propofol dosage should be titrated toward the desired level of sedation.