1
|
Rittenberger JC, Clemency BM, Monaco B, Schwob J, Murphey JT, Hostler D. Comparing Hypothermic and Thermal Neutral Conditions to Induce Metabolic Suppression. Ther Hypothermia Temp Manag 2024. [PMID: 38442224 DOI: 10.1089/ther.2023.0085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024] Open
Abstract
Suppressing metabolism in astronauts could decrease CO2 production. It is unknown whether active cooling is required to suppress metabolism in sedated patients. We hypothesized that hypothermia would have an additive effect with dexmedetomidine on suppressing metabolism. This is a randomized crossover trial of healthy subjects receiving sedation with dexmedetomidine and exposure to a cold (20°C) or thermal neutral (31°C) environment for 3 hours. We measured heart rate, blood pressure, core temperature, resting oxygen consumption (VO2), resting carbon dioxide production (VCO2), and resting energy expenditure (REE) at baseline and each hour of exposure to either environment. We also evaluated components of the Defense Automated Neurobehavioral Assessment (DANA) Brief to evaluate the effect of metabolic suppression on cognition. Six subjects completed the study. Heart rate and core temperature were lower during the cold (56 bpm) condition than the thermal neutral condition (67 bpm). VO2, VCO2, and REE decreased between baseline and the 3-hour measurement in the cold condition (Δ = 0.9 mL/min, 56.94 mL/min, 487.9 Kcal/D, respectively). DANA simple response time increased between baseline and start of recovery in both conditions (20°C 136.9 cognitive efficiency [CE] and 31°C 87.83 CE). DANA procedural reaction time increased between baseline and start of recovery in the cold condition (220.6 CE) but not in the thermal neutral condition. DANA Go/No-Go time increased between baseline and start of recovery in both conditions (20°C 222.1 CE and 31°C 122.3 CE). Sedation and cold environments are required for metabolic suppression. Subjects experienced decrements in cognitive performance in both conditions. A significant recovery period may be required after metabolic suppression before completing mission critical tasks.
Collapse
Affiliation(s)
- Jon C Rittenberger
- Guthrie Robert Packer Hospital Emergency Medicine Residency, Scranton, Pennsylvania, USA
- Department of Emergency Medicine, University of Buffalo, Buffalo, New York, USA
| | - Brian M Clemency
- Department of Emergency Medicine, University of Buffalo, Buffalo, New York, USA
- Center for Research and Education in Special Environments, University of Buffalo, Buffalo, New York, USA
| | - Brian Monaco
- Department of Emergency Medicine, University of Buffalo, Buffalo, New York, USA
- Center for Research and Education in Special Environments, University of Buffalo, Buffalo, New York, USA
| | - Jacqueline Schwob
- Center for Research and Education in Special Environments, University of Buffalo, Buffalo, New York, USA
| | - Joshua T Murphey
- Center for Research and Education in Special Environments, University of Buffalo, Buffalo, New York, USA
| | - David Hostler
- Department of Emergency Medicine, University of Buffalo, Buffalo, New York, USA
- Center for Research and Education in Special Environments, University of Buffalo, Buffalo, New York, USA
| |
Collapse
|
2
|
Wintermark P, Lapointe A, Steinhorn R, Rampakakis E, Burhenne J, Meid AD, Bajraktari-Sylejmani G, Khairy M, Altit G, Adamo MT, Poccia A, Gilbert G, Saint-Martin C, Toffoli D, Vachon J, Hailu E, Colin P, Haefeli WE. Feasibility and Safety of Sildenafil to Repair Brain Injury Secondary to Birth Asphyxia (SANE-01): A Randomized, Double-blind, Placebo-controlled Phase Ib Clinical Trial. J Pediatr 2024; 266:113879. [PMID: 38142044 DOI: 10.1016/j.jpeds.2023.113879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 11/21/2023] [Accepted: 12/17/2023] [Indexed: 12/25/2023]
Abstract
OBJECTIVE To test feasibility and safety of administering sildenafil in neonates with neonatal encephalopathy (NE), developing brain injury despite therapeutic hypothermia (TH). STUDY DESIGN We performed a randomized, double-blind, placebo-controlled phase Ib clinical trial between 2016 and 2019 in neonates with moderate or severe NE, displaying brain injury on day-2 magnetic resonance imaging (MRI) despite TH. Neonates were randomized (2:1) to 7-day sildenafil or placebo (2 mg/kg/dose enterally every 12 hours, 14 doses). Outcomes included feasibility and safety (primary outcomes), pharmacokinetics (secondary), and day-30 neuroimaging and 18-month neurodevelopment assessments (exploratory). RESULTS Of the 24 enrolled neonates, 8 were randomized to sildenafil and 3 to placebo. A mild decrease in blood pressure was reported in 2 of the 8 neonates after initial dose, but not with subsequent doses. Sildenafil plasma steady-state concentration was rapidly reached, but decreased after TH discontinuation. Twelve percent of neonates (1/8) neonates died in the sildenafil group and 0% (0/3) in the placebo group. Among surviving neonates, partial recovery of injury, fewer cystic lesions, and less brain volume loss on day-30 magnetic resonance imaging were noted in 71% (5/7) of the sildenafil group and in 0% (0/3) of the placebo group. The rate of death or survival to 18 months with severe neurodevelopmental impairment was 57% (4/7) in the sildenafil group and 100% (3/3) in the placebo group. CONCLUSIONS Sildenafil was safe and well-absorbed in neonates with NE treated with TH. Optimal dosing needs to be established. Evaluation of a larger number of neonates through subsequent phases II and III trials is required to establish efficacy. CLINICAL TRIAL REGISTRATION ClinicalTrials.govNCT02812433.
Collapse
Affiliation(s)
- Pia Wintermark
- Division of Newborn Medicine, Department of Pediatrics, McGill University, Montreal, Quebec, Canada; Research Institute of the McGill University Health Center, McGill University, Montreal, Quebec, Canada.
| | - Anie Lapointe
- Department of Neonatology, Sainte-Justine Hospital, University of Montreal, Montreal, Quebec, Canada
| | - Robin Steinhorn
- Department of Pediatrics, University of California San Diego, and Rady Children's Hospital, San Diego, CA
| | | | - Jürgen Burhenne
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Andreas D Meid
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Gzona Bajraktari-Sylejmani
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
| | - May Khairy
- Department of Pediatrics, McGill University, Montreal, Québec, Canada
| | - Gabriel Altit
- Division of Newborn Medicine, Department of Pediatrics, McGill University, Montreal, Quebec, Canada; Research Institute of the McGill University Health Center, McGill University, Montreal, Quebec, Canada
| | - Marie-Therese Adamo
- Pharmacy Department, McGill University Health Center, Montreal, Québec, Canada
| | - Alishia Poccia
- Research Institute of the McGill University Health Center, McGill University, Montreal, Quebec, Canada
| | - Guillaume Gilbert
- MR Clinical Science, Philips Healthcare, Mississauga, Ontario, Canada
| | | | - Daniela Toffoli
- Department of Ophthalmology, McGill University, Montreal, Québec, Canada
| | - Julie Vachon
- Member of the Ordre des Psychologues du Quebec, Montreal, Québec, Canada
| | - Elizabeth Hailu
- Division of Newborn Medicine, Department of Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Patrick Colin
- Patrick Colin Consultant Inc, Montreal, Québec, Canada
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
| |
Collapse
|
3
|
Elmer J, Callaway CW. Temperature control after cardiac arrest. Resuscitation 2023; 189:109882. [PMID: 37355091 PMCID: PMC10530429 DOI: 10.1016/j.resuscitation.2023.109882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 06/13/2023] [Accepted: 06/14/2023] [Indexed: 06/26/2023]
Abstract
Managing temperature is an important part of post-cardiac arrest care. Fever or hyperthermia during the first few days after cardiac arrest is associated with worse outcomes in many studies. Clinical data have not determined any target temperature or duration of temperature management that clearly improves patient outcomes. Current guidelines and recent reviews recommend controlling temperature to prevent hyperthermia. Higher temperatures can lead to secondary brain injury by increasing seizures, brain edema and metabolic demand. Some data suggest that targeting temperature below normal could benefit select patients where this pathology is common. Clinical temperature management should address the physiology of heat balance. Core temperature reflects the heat content of the head and torso, and changes in core temperature result from changes in the balance of heat production and heat loss. Clinical management of patients after cardiac arrest should include measurement of core temperature at accurate sites and monitoring signs of heat production including shivering. Multiple methods can increase or decrease heat loss, including external and internal devices. Heat loss can trigger compensatory reflexes that increase stress and metabolic demand. Therefore, any active temperature management should include specific pharmacotherapy or other interventions to control thermogenesis, especially shivering. More research is required to determine whether individualized temperature management can improve outcomes.
Collapse
Affiliation(s)
- Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| |
Collapse
|
4
|
Annborn M, Ceric A, Borgquist O, During J, Moseby-Knappe M, Lybeck A. Hypothermia versus Normothermia after Out-of-Hospital Cardiac Arrest; The effect on post-intervention serum concentrations of sedatives and analgesics and time to awakening. Resuscitation 2023; 188:109831. [PMID: 37178902 DOI: 10.1016/j.resuscitation.2023.109831] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 04/19/2023] [Accepted: 05/07/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND This study investigated the association of two levels of targeted temperature management (TTM) after out-of-hospital cardiac arrest (OHCA) with administered doses of sedative and analgesic drugs, serum concentrations, and the effect on time to awakening. METHODS This substudy of the TTM2-trial was conducted at three centers in Sweden, with patients randomized to either hypothermia or normothermia. Deep sedation was mandatory during the 40-hour intervention. Blood samples were collected at the end of TTM and end of protocolized fever prevention (72 hours). Samples were analysed for concentrations of propofol, midazolam, clonidine, dexmedetomidine, morphine, oxycodone, ketamine and esketamine. Cumulative doses of administered sedative and analgesic drugs were recorded. RESULTS Seventy-one patients were alive at 40 hours and had received the TTM-intervention according to protocol. 33 patients were treated at hypothermia and 38 at normothermia. There were no differences between cumulative doses and concentration and of sedatives/analgesics between the intervention groups at any timepoint. Time until awakening was 53 hours in the hypothermia group compared to 46 hours in the normothermia group (p=0.09). CONCLUSION This study of OHCA patients treated at normothermia versus hypothermia found no significant differences in dosing or concentration of sedatives or analgesic drugs in blood samples drawn at the end of the TTM intervention, or at end of protocolized fever prevention, nor the time to awakening.
Collapse
Affiliation(s)
- Martin Annborn
- Anesthesia & Intensive Care, Department of Clinical Sciences Lund, Lund University, Helsingborg Hospital, Helsingborg, Sweden
| | - Ameldina Ceric
- Anesthesia & Intensive Care, Department of Clinical Sciences, Lund University, Skane University Hospital, Malmö, Sweden.
| | - Ola Borgquist
- Anesthesia & Intensive Care, Department of Clinical Sciences Lund, Lund University, Skane University Hospital, Lund, Sweden
| | - Joachim During
- Anesthesia & Intensive Care, Department of Clinical Sciences, Lund University, Skane University Hospital, Malmö, Sweden
| | - Marion Moseby-Knappe
- Neurology, Department of Clinical Sciences Lund, Lund University, Skane University Hospital, Lund, Sweden
| | - Anna Lybeck
- Anesthesia & Intensive Care, Department of Clinical Sciences Lund, Lund University, Skane University Hospital, Lund, Sweden
| |
Collapse
|
5
|
Kanji S, Williamson D, Hartwick M. Potential pharmacological confounders in the setting of death determined by neurologic criteria: a narrative review. Can J Anaesth 2023; 70:713-723. [PMID: 37131030 PMCID: PMC10202973 DOI: 10.1007/s12630-023-02415-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 10/11/2022] [Accepted: 10/18/2022] [Indexed: 05/04/2023] Open
Abstract
Guidelines for the determination of death by neurologic criteria (DNC) require an absence of confounding factors if clinical examination alone is to be used. Drugs that depress the central nervous system suppress neurologic responses and spontaneous breathing and must be excluded or reversed prior to proceeding. If these confounding factors cannot be eliminated, ancillary testing is required. These drugs may be present after being administered as part of the treatment of critically ill patients. While measurement of serum drug concentrations can help guide the timing of assessments for DNC, they are not always available or feasible. In this article, we review sedative and opioid drugs that may confound DNC, along with pharmacokinetic factors that govern the duration of drug action. Pharmacokinetic parameters including a context-sensitive half-life of sedatives and opioids are highly variable in critically ill patients because of the multitude of clinical variables and conditions that can affect drug distribution and clearance. Patient-, disease-, and treatment-related factors that influence the distribution and clearance of these drugs are discussed including end organ function, age, obesity, hyperdynamic states, augmented renal clearance, fluid balance, hypothermia, and the role of prolonged drug infusions in critically ill patients. In these contexts, it is often difficult to predict how long after drug discontinuation the confounding effects will take to dissipate. We propose a conservative framework for evaluating when or if DNC can be determined by clinical criteria alone. When pharmacologic confounders cannot be reversed, or doing so is not feasible, ancillary testing to confirm the absence of brain blood flow should be obtained.
Collapse
Affiliation(s)
- Salmaan Kanji
- Department of Pharmacy, The Ottawa Hospital, 501 Smyth Rd, Ottawa, ON, K1H 8L6, Canada.
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada.
| | - David Williamson
- Faculté de pharmacie, Université de Montréal, Montreal, QC, Canada
- Pharmacy Department, Hôpital du Sacré-Cœur de Montréal and CIUSSS-Nord-de-l'ile-de-Montreal Research Center, Montreal, QC, Canada
| | - Michael Hartwick
- Department of Pharmacy, The Ottawa Hospital, 501 Smyth Rd, Ottawa, ON, K1H 8L6, Canada
- Department of Critical Care, The Ottawa Hospital, Ottawa, Canada
| |
Collapse
|
6
|
Does One Size Fit All? External Validation of the rCAST Score to Predict the Hospital Outcomes of Post-Cardiac Arrest Patients Receiving Targeted Temperature Management. J Clin Med 2022; 12:jcm12010242. [PMID: 36615040 PMCID: PMC9821639 DOI: 10.3390/jcm12010242] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 12/19/2022] [Accepted: 12/26/2022] [Indexed: 12/31/2022] Open
Abstract
The revised post-Cardiac Arrest Syndrome for Therapeutic hypothermia (rCAST) score was proposed to predict neurologic outcomes and mortality among out-of-hospital cardiac arrest (OHCA) patients. However, it has rarely been validated outside Japan. Therefore, this study aimed to investigate this issue. All adult patients admitted to our medical intensive care unit for targeted temperature management (TTM) between July 2015 and July 2021 were enrolled. Their medical records were retrieved, and rCAST scores were calculated. A total of 108 post-cardiac arrest syndrome (PCAS) patients who received TTM were analyzed. According to the rCAST score, 49.1%, 50.0%, and 0.9% of the patients were classified as low, moderate, and high severity, respectively. The areas under the curves for the rCAST score were 0.806 (95% confidence interval [CI]: 0.719-0.876) and 0.794 (95% CI: 0.706-0.866) to predict poor neurologic outcomes and mortality at day 28, respectively. In contrast to the original report, only low-severity patients had favorable neurologic outcomes. The rCAST score showed moderate accuracy in our OHCA patients with PCAS who received TTM to predict poor neurologic outcomes and mortality at day 28.
Collapse
|
7
|
I Cardi A, Drohan CM, Elmer J, Callaway CW, X Guyette F, Doshi AA, Rittenberger JC. The association of brainstem and motor recovery with awakening after out-of-hospital cardiac arrest. Resusc Plus 2022; 12:100332. [DOI: 10.1016/j.resplu.2022.100332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 10/29/2022] [Accepted: 10/30/2022] [Indexed: 12/13/2022] Open
|
8
|
Jung KT, Bapat A, Kim YK, Hucker WJ, Lee K. Therapeutic hypothermia for acute myocardial infarction: a narrative review of evidence from animal and clinical studies. Korean J Anesthesiol 2022; 75:216-230. [PMID: 35350095 PMCID: PMC9171548 DOI: 10.4097/kja.22156] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 03/27/2022] [Accepted: 03/29/2022] [Indexed: 11/21/2022] Open
Abstract
Myocardial infarction (MI) is the leading cause of death from coronary heart disease and requires immediate reperfusion therapy with thrombolysis, primary percutaneous coronary intervention, or coronary artery bypass grafting. However, myocardial reperfusion therapy is often accompanied by cardiac ischemia/reperfusion (I/R) injury, which leads to myocardial injury with detrimental consequences. The causes of I/R injury are unclear, but are multifactorial, including free radicals, reactive oxygen species, calcium overload, mitochondria dysfunction, inflammation, and neutrophil-mediated vascular injury. Mild hypothermia has been introduced as one of the potential inhibitors of myocardial I/R injury. Although animal studies have demonstrated that mild hypothermia significantly reduces or delays I/R myocardium damage, human trials have not shown clinical benefits in acute MI (AMI). In addition, the practice of hypothermia treatment is increasing in various fields such as surgical anesthesia and intensive care units. Adequate sedation for anesthetic procedures and protection from body shivering has become essential during therapeutic hypothermia. Therefore, anesthesiologists should be aware of the effects of therapeutic hypothermia on the metabolism of anesthetic drugs. In this paper, we review the existing data on the use of therapeutic hypothermia for AMI in animal models and human clinical trials to better understand the discrepancy between perceived benefits in preclinical animal models and the absence thereof in clinical trials thus far.
Collapse
Affiliation(s)
- Ki Tae Jung
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Anesthesiology and Pain Medicine, College of Medicine and Medical School, Chosun University, Gwangju, Korea
| | - Aneesh Bapat
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, MA, USA
| | - Young-Kug Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - William J. Hucker
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, MA, USA
| | - Kichang Lee
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, MA, USA
| |
Collapse
|
9
|
Effect of Scalp Cooling on the Pharmacokinetics of Paclitaxel. Cancers (Basel) 2021; 13:cancers13153915. [PMID: 34359815 PMCID: PMC8345584 DOI: 10.3390/cancers13153915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 07/28/2021] [Accepted: 07/31/2021] [Indexed: 11/29/2022] Open
Abstract
Simple Summary This study investigated the correlation between scalp cooling used to prevent chemotherapy-induced alopecia and the pharmacokinetics of paclitaxel in female cancer patients with a solid tumor. In a prospective cohort study, 14 patients who were treated with weekly paclitaxel and scalp cooling were able to undergo pharmacokinetic sampling of paclitaxel during one cycle of treatment. In comparison to a control cohort of 24 patients treated with weekly paclitaxel without scalp cooling, our data showed that scalp cooling used concomitantly with one course of paclitaxel did not reduce or increase the clearance of paclitaxel. Therefore, it is unlikely that scalp cooling influences paclitaxel efficacy or toxicity. Finally, despite scalp cooling, half of the patients in our study developed a form of hair loss. Importantly, neither an association with difference in paclitaxel clearance nor change in hair loss was found. Abstract Chemotherapy-induced alopecia (CIA), a side effect with high impact, can be prevented by cooling the scalp during the administration of some cytotoxic drugs. However, the effects of this prolonged scalp cooling on the pharmacokinetics of chemotherapy have never been investigated. In this study, we compared the pharmacokinetics of the widely used chemotherapeutic agent paclitaxel (weekly dose of 80–100 mg/m2) in female patients with solid tumors using concomitant scalp cooling (n = 14) or not (n = 24). Blood samples were collected in all patients for pharmacokinetic analyses up to 6 h after one course of paclitaxel administration. The primary endpoint was the clearance (L/h) of paclitaxel. Paclitaxel clearance—expressed as relative difference in geometric means—was 6.8% (90% CI: −16.7% to 4.4%) lower when paclitaxel was administered with concomitant scalp cooling versus paclitaxel infusions without scalp cooling. Within the subgroup of patients using scalp cooling, paclitaxel clearance was not statistically significantly different between patients with CIA (alopecia grade 1 or 2) and those without CIA. Hence, scalp cooling did not negatively influence the clearance of paclitaxel treatment.
Collapse
|
10
|
Hawkins WA, Kim JY, Smith SE, Sikora Newsome A, Hall RG. Effects of Propofol on Hemodynamic Profile in Adults Receiving Targeted Temperature Management. Hosp Pharm 2021; 57:329-335. [DOI: 10.1177/00185787211032359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Propofol is a key component for the management of sedation and shivering during targeted temperature management (TTM) following cardiac arrest. The cardiac depressant effects of propofol have not been described during TTM and may be especially relevant given the stress to the myocardium following cardiac arrest. The purpose of this study is to describe hemodynamic changes associated with propofol administration during TTM. Methods: This single center, retrospective cohort study evaluated adult patients who received a propofol infusion for at least 30 minutes during TTM. The primary outcome was the change in cardiovascular Sequential Organ Failure Assessment (cvSOFA) score 30 minutes after propofol initiation. Secondary outcomes included change in systolic blood pressure (SBP), mean arterial pressure (MAP), heart rate (HR), and vasopressor requirements (VR) expressed as norepinephrine equivalents at 30, 60, 120, 180, and 240 minutes after propofol initiation. A multivariate regression was performed to assess the influence of propofol and body temperature on MAP, while controlling for vasopressor dose and cardiac arrest hospital prognosis (CAHP) score. Results: The cohort included 40 patients with a median CAHP score of 197. The goal temperature of 33°C was achieved for all patients. The median cvSOFA score was 1 at baseline and 0.5 at 30 minutes, with a non-significant change after propofol initiation ( P = .96). SBP and MAP reductions were the greatest at 60 minutes (17 and 8 mmHg; P < .05 for both). The median change in HR at 120 minutes was −9 beats/minute from baseline. This reduction was sustained through 240 minutes ( P < .05). No change in VR were seen at any time point. In multivariate regression, body temperature was the only characteristic independently associated with changes in MAP (coefficient 4.95, 95% CI 1.6-8.3). Conclusion: Administration of propofol during TTM did not affect cvSOFA score. The reductions in SBP, MAP, and HR did not have a corresponding change in vasopressor requirements and are likely not clinically meaningful. Propofol appears to be a safe choice for sedation in patients receiving targeted temperature management after cardiac arrest.
Collapse
Affiliation(s)
- W. Anthony Hawkins
- University of Georgia College of Pharmacy, Albany, GA, USA
- Medical College of Georgia at Augusta University, Augusta, GA, USA
| | | | - Susan E. Smith
- University of Georgia College of Pharmacy, Athens, GA, USA
| | - Andrea Sikora Newsome
- University of Georgia College of Pharmacy, Augusta, GA, USA
- Augusta University Medical Center, Augusta, GA, USA
| | - Ronald G. Hall
- Texas Tech University Health Sciences Center, Lubbock, TX, USA
- Dose Optimization and Outcomes Research Program, Dallas, TX, USA
| |
Collapse
|
11
|
Rittenberger JC, Weissman A, Flickinger KL, Guyette FX, Hopkins D, Repine MJ, Dezfulian C, Doshi AA, Elmer J, Sawyer KN, Callaway CW. Glycopyrrolate does not ameliorate hypothermia associated bradycardia in healthy individuals: A randomized crossover trial. Resuscitation 2021; 164:79-83. [PMID: 34087418 DOI: 10.1016/j.resuscitation.2021.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 05/14/2021] [Accepted: 05/23/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Hypothermia improves outcomes following ischemia-reperfusion injury. Shivering is common and can be mediated by agents such as dexmedetomidine. The combination of dexmedetomidine and hypothermia results in bradycardia. We hypothesized that glycopyrrolate would prevent bradycardia during dexmedetomidine-mediated hypothermia. METHODS We randomly assigned eight healthy subjects to premedication with a single 0.4 mg glycopyrrolate intravenous (IV) bolus, titrated glycopyrrolate (0.01 mg IV every 3 min as needed for heart rate <50), or no glycopyrrolate during three separate sessions of 3 h cooling. Following 1 mg/kg IV dexmedetomidine bolus, subjects received 20 ml/kg IV 4 °C saline and surface cooling (EM COOLS, Weinerdorf, Austria). We titrated dexmedetomidine infusion to suppress shivering but permit arousal to verbal stimuli. After 3 h of cooling, we allowed subjects to passively rewarm. We compared heart rate, core temperature, mean arterial blood pressure, perceived comfort and thermal sensation between groups using Kruskal-Wallis test and ANOVA. RESULTS Mean age was 27 (SD 6) years and most (N = 6, 75%) were male. Neither heart rate nor core temperature differed between the groups during maintenance of hypothermia (p > 0.05). Mean arterial blood pressure was higher in the glycopyrrolate bolus condition (p < 0.048). Thermal sensation was higher in the control condition than the glycopyrrolate bolus condition (p = 0.01). Bolus glycopyrrolate resulted in less discomfort than titrated glycopyrrolate (p = 0.04). CONCLUSIONS Glycopyrrolate did not prevent the bradycardic response to hypothermia and dexmedetomidine. Mean arterial blood pressure was higher in subjects receiving a bolus of glycopyrrolate before induction of hypothermia. Bolus glycopyrrolate was associated with less intense thermal sensation and less discomfort during cooling.
Collapse
Affiliation(s)
- Jon C Rittenberger
- Robert Packer Hospital Emergency Medicine Residency, Sayre, PA, United States; Geisinger Commonwealth School of Medicine, Scranton, PA, United States; University of Pittsburgh Department of Emergency Medicine, Pittsburgh, PA, United States.
| | - Alexandra Weissman
- University of Pittsburgh Department of Emergency Medicine, Pittsburgh, PA, United States
| | - Katharyn L Flickinger
- University of Pittsburgh Department of Emergency Medicine, Pittsburgh, PA, United States
| | - Francis X Guyette
- University of Pittsburgh Department of Emergency Medicine, Pittsburgh, PA, United States
| | - David Hopkins
- Geisinger Commonwealth School of Medicine, Scranton, PA, United States
| | - Melissa J Repine
- University of Pittsburgh Department of Emergency Medicine, Pittsburgh, PA, United States
| | - Cameron Dezfulian
- University of Pittsburgh Department of Critical Care Medicine, Pittsburgh, PA, United States
| | - Ankur A Doshi
- University of Pittsburgh Department of Emergency Medicine, Pittsburgh, PA, United States
| | - Jonathan Elmer
- University of Pittsburgh Department of Emergency Medicine, Pittsburgh, PA, United States; University of Pittsburgh Department of Critical Care Medicine, Pittsburgh, PA, United States
| | - Kelly N Sawyer
- University of Pittsburgh Department of Emergency Medicine, Pittsburgh, PA, United States
| | - Clifton W Callaway
- University of Pittsburgh Department of Emergency Medicine, Pittsburgh, PA, United States
| |
Collapse
|
12
|
Dezfulian C, Orkin AM, Maron BA, Elmer J, Girotra S, Gladwin MT, Merchant RM, Panchal AR, Perman SM, Starks MA, van Diepen S, Lavonas EJ. Opioid-Associated Out-of-Hospital Cardiac Arrest: Distinctive Clinical Features and Implications for Health Care and Public Responses: A Scientific Statement From the American Heart Association. Circulation 2021; 143:e836-e870. [PMID: 33682423 DOI: 10.1161/cir.0000000000000958] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Opioid overdose is the leading cause of death for Americans 25 to 64 years of age, and opioid use disorder affects >2 million Americans. The epidemiology of opioid-associated out-of-hospital cardiac arrest in the United States is changing rapidly, with exponential increases in death resulting from synthetic opioids and linear increases in heroin deaths more than offsetting modest reductions in deaths from prescription opioids. The pathophysiology of polysubstance toxidromes involving opioids, asphyxial death, and prolonged hypoxemia leading to global ischemia (cardiac arrest) differs from that of sudden cardiac arrest. People who use opioids may also develop bacteremia, central nervous system vasculitis and leukoencephalopathy, torsades de pointes, pulmonary vasculopathy, and pulmonary edema. Emergency management of opioid poisoning requires recognition by the lay public or emergency dispatchers, prompt emergency response, and effective ventilation coupled to compressions in the setting of opioid-associated out-of-hospital cardiac arrest. Effective ventilation is challenging to teach, whereas naloxone, an opioid antagonist, can be administered by emergency medical personnel, trained laypeople, and the general public with dispatcher instruction to prevent cardiac arrest. Opioid education and naloxone distributions programs have been developed to teach people who are likely to encounter a person with opioid poisoning how to administer naloxone, deliver high-quality compressions, and perform rescue breathing. Current American Heart Association recommendations call for laypeople and others who cannot reliably establish the presence of a pulse to initiate cardiopulmonary resuscitation in any individual who is unconscious and not breathing normally; if opioid overdose is suspected, naloxone should also be administered. Secondary prevention, including counseling, opioid overdose education with take-home naloxone, and medication for opioid use disorder, is important to prevent recurrent opioid overdose.
Collapse
|
13
|
Smits A, Annaert P, Van Cruchten S, Allegaert K. A Physiology-Based Pharmacokinetic Framework to Support Drug Development and Dose Precision During Therapeutic Hypothermia in Neonates. Front Pharmacol 2020; 11:587. [PMID: 32477113 PMCID: PMC7237643 DOI: 10.3389/fphar.2020.00587] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 04/16/2020] [Indexed: 12/21/2022] Open
Abstract
Therapeutic hypothermia (TH) is standard treatment for neonates (≥36 weeks) with perinatal asphyxia (PA) and hypoxic-ischemic encephalopathy. TH reduces mortality and neurodevelopmental disability due to reduced metabolic rate and decreased neuronal apoptosis. Since both hypothermia and PA influence physiology, they are expected to alter pharmacokinetics (PK). Tools for personalized dosing in this setting are lacking. A neonatal hypothermia physiology-based PK (PBPK) framework would enable precision dosing in the clinic. In this literature review, the stepwise approach, benefits and challenges to develop such a PBPK framework are covered. It hereby contributes to explore the impact of non-maturational PK covariates. First, the current evidence as well as knowledge gaps on the impact of PA and TH on drug absorption, distribution, metabolism and excretion in neonates is summarized. While reduced renal drug elimination is well-documented in neonates with PA undergoing hypothermia, knowledge of the impact on drug metabolism is limited. Second, a multidisciplinary approach to develop a neonatal hypothermia PBPK framework is presented. Insights on the effect of hypothermia on hepatic drug elimination can partly be generated from in vitro (human/animal) profiling of hepatic drug metabolizing enzymes and transporters. Also, endogenous biomarkers may be evaluated as surrogate for metabolic activity. To distinguish the impact of PA versus hypothermia on drug metabolism, in vivo neonatal animal data are needed. The conventional pig is a well-established model for PA and the neonatal Göttingen minipig should be further explored for PA under hypothermia conditions, as it is the most commonly used pig strain in nonclinical drug development. Finally, a strategy is proposed for establishing and fine-tuning compound-specific PBPK models for this application. Besides improvement of clinical exposure predictions of drugs used during hypothermia, the developed PBPK models can be applied in drug development. Add-on pharmacotherapies to further improve outcome in neonates undergoing hypothermia are under investigation, all in need for dosing guidance. Furthermore, the hypothermia PBPK framework can be used to develop temperature-driven PBPK models for other populations or indications. The applicability of the proposed workflow and the challenges in the development of the PBPK framework are illustrated for midazolam as model drug.
Collapse
Affiliation(s)
- Anne Smits
- Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Pieter Annaert
- Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Steven Van Cruchten
- Applied Veterinary Morphology, Department of Veterinary Sciences, University of Antwerp, Wilrijk, Belgium
| | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Department of Clinical Pharmacy, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| |
Collapse
|
14
|
Nee J, Schroeder T, Vornholt F, Schaeuble J, Leithner C, Stockmann M, Storm C. Dynamic determination of functional liver capacity with the LiMAx test in post-cardiac arrest patients undergoing targeted temperature management-A prospective trial. Acta Anaesthesiol Scand 2020; 64:501-507. [PMID: 31828754 DOI: 10.1111/aas.13523] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 11/27/2019] [Accepted: 11/28/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Transiently increased transaminases is a common finding after cardiac arrest but little is known about the functional liver capacity (LiMAx) during the post-cardiac arrest syndrome and treatment in the intensive care unit (ICU). The aim of this trial was to evaluate liver function capacity in post-cardiac arrest survivors undergoing targeted temperature management (TTM) in ICU. METHODS Thirty-two post-cardiac arrest survivors were prospectively included with all patients undergoing TTM at 33°C for 24 hours. Blood samples were collected, and LiMAx testing was performed at days 1, 2, 5, and 10 post-cardiac arrest. LiMAx is a non-invasive, in vivo, dynamic breath test determining cytochrome P450 1A2 (CYP1A2) capacity using intravenous (IV) 13 C-methacetin, thus reflecting maximum liver function capacity. Static liver parameters were determined and compared to LiMAx values. RESULTS A typical pattern of transiently, mildly increased transaminases was demonstrated without fulfilling the criteria for hypoxic hepatitis (HH). CYP1A2 activity was reduced with slow normalization over 10 days (lowest median 48 hours after cardiac arrest: 228.5 (25-75 percentile 105.2-301.7 μg/kg/h, P < .05). Parameters reflecting the liver synthetic function were not impaired, as assessed by, in standard laboratory testing. CONCLUSION Liver functional capacity is impaired in patients after cardiac arrest undergoing TTM at 33°C. More data are needed to determine if liver functional capacity may add relevant information, especially in the context of pharmacotherapy, to individualize post-cardiac arrest care.
Collapse
Affiliation(s)
- Jens Nee
- Department of Nephrology and Intensive Care Medicine Charité Universitätsmedizin Berlin Berlin Germany
| | - Tim Schroeder
- Department of Nephrology and Intensive Care Medicine Charité Universitätsmedizin Berlin Berlin Germany
| | - Florian Vornholt
- Department of Nephrology and Intensive Care Medicine Charité Universitätsmedizin Berlin Berlin Germany
| | - Julian Schaeuble
- Department of Nephrology and Intensive Care Medicine Charité Universitätsmedizin Berlin Berlin Germany
| | - Christoph Leithner
- Department of Neurology Charité Universitätsmedizin Berlin Berlin Germany
| | - Martin Stockmann
- Department of General, Visceral and Vascular Surgery Evangelisches Krankenhaus Paul Gerhard Stift Lutherstadt Wittenberg Germany
| | - Christian Storm
- Department of Nephrology and Intensive Care Medicine Charité Universitätsmedizin Berlin Berlin Germany
| |
Collapse
|
15
|
Sonnier M, Rittenberger JC. State-of-the-art considerations in post-arrest care. J Am Coll Emerg Physicians Open 2020; 1:107-116. [PMID: 33000021 PMCID: PMC7493544 DOI: 10.1002/emp2.12022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 01/14/2020] [Accepted: 01/16/2020] [Indexed: 11/10/2022] Open
Abstract
Cardiac arrest has a high rate of morbidity and mortality. Several advances in post-cardiac arrest management can improve outcome, but are time-dependent, placing the emergency physician in a critical role to both recognize the need for and initiate therapy. We present a novel perspective of both the workup and therapeutic interventions geared toward the emergency physician during the first few hours of care. We describe how the immediate care of a post-cardiac arrest patient is resource intensive and requires simultaneous evaluation for the underlying cause and intensive management to prevent further end organ damage, particularly of the central nervous system. The goal of the initial focused assessment is to rapidly determine if any reversible causes of cardiac arrest are present and to intervene when possible. Interventions performed in this acute period are aimed at preventing additional brain injury through optimizing hemodynamics, providing ventilatory support, and by using therapeutic hypothermia when indicated. After the initial phase of care, disposition is guided by available resources and the clinician's judgment. Transfer to a specialized cardiac arrest center is prudent in centers that do not have significant support or experience in the care of these patients.
Collapse
Affiliation(s)
| | - Jon C. Rittenberger
- Guthrie Robert Packer HospitalSayrePennsylvania
- Geisinger Commonwealth Medical CollegeScrantonPennsylvania
| |
Collapse
|
16
|
Abstract
PURPOSE OF REVIEW The present review aims to describe the clinical impact and assessment tools capable of identifying delirium in cardiac arrest survivors and providing strategies aimed at preventing and treating delirium. RECENT FINDINGS Patient factors leading to a cardiac arrest, initial resuscitation efforts, and postresuscitation management all influence the potential for recovery and the risk for development of delirium. Data suggest that delirium in cardiac arrest survivors is an independent risk factor for morbidity and mortality. Recognizing delirium in postcardiac arrest patients can be challenging; however, detection is not only achievable, but important as it may aid in predicting adverse outcomes. Serial neurologic examinations and delirium assessments, targeting light sedation when possible, limiting psychoactive medications, and initiating patient care bundles are important care aspects for not only allowing early identification of primary and secondary brain injury, but in improving patient morbidity and mortality. SUMMARY Developing delirium after cardiac arrest is associated with increased morbidity and mortality. The importance of addressing modifiable risk factors, recognizing symptoms early, and initiating coordinated treatment strategies can help to improve outcomes within this high risk population.
Collapse
|
17
|
Regan MD, Flynn-Evans EE, Griko YV, Kilduff TS, Rittenberger JC, Ruskin KJ, Buck CL. Shallow metabolic depression and human spaceflight: a feasible first step. J Appl Physiol (1985) 2020; 128:637-647. [PMID: 31999524 DOI: 10.1152/japplphysiol.00725.2019] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Synthetic torpor is an induced state of deep metabolic depression (MD) in an organism that does not naturally employ regulated and reversible MD. If applied to spaceflight crewmembers, this metabolic state may theoretically mitigate numerous biological and logistical challenges of human spaceflight. These benefits have been the focus of numerous recent articles where, invariably, they are discussed in the context of hypothetical deep MD states in which the metabolism of crewmembers is profoundly depressed relative to basal rates. However, inducing these deep MD states in humans, particularly humans aboard spacecraft, is currently impossible. Here, we discuss shallow MD as a feasible first step toward synthetic torpor during spaceflight and summarize perspectives following a recent NASA-hosted workshop. We discuss methods to safely induce shallow MD (e.g., sleep and slow wave enhancement via acoustic and photoperiod stimulation; moderate sedation via dexmedetomidine), which we define as an ~20% depression of metabolic rate relative to basal levels. We also discuss different modes of shallow MD application (e.g., habitual versus targeted, whereby shallow MD is induced routinely throughout a mission or only under certain circumstances, respectively) and different spaceflight scenarios that would benefit from its use. Finally, we propose a multistep development plan toward the application of synthetic torpor to human spaceflight, highlighting shallow MD's role. As space agencies develop missions to send humans further into space than ever before, shallow MD has the potential to confer health benefits for crewmembers, reduce demands on spacecraft capacities, and serve as a testbed for deeper MD technologies.
Collapse
Affiliation(s)
- Matthew D Regan
- Department of Comparative Biosciences, University of Wisconsin-Madison, Madison, Wisconsin
| | - Erin E Flynn-Evans
- Fatigue Countermeasures Laboratory, Human Systems Integration Division, NASA Ames Research Center, Moffett Field, California
| | - Yuri V Griko
- Countermeasure Development Laboratory, Space Biosciences Division, NASA Ames Research Center, Moffett Field, California
| | - Thomas S Kilduff
- Biosciences Division, Center for Neuroscience, SRI International, Menlo Park, California
| | - Jon C Rittenberger
- Guthrie Robert Packer Hospital Emergency Medicine Program, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania
| | - Keith J Ruskin
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois
| | - C Loren Buck
- Department of Biological Sciences, Northern Arizona University, Flagstaff, Arizona
| |
Collapse
|
18
|
May TL, Ruthazer R, Riker RR, Friberg H, Patel N, Soreide E, Hand R, Stammet P, Dupont A, Hirsch KG, Agarwal S, Wanscher MJ, Dankiewicz J, Nielsen N, Seder DB, Kent DM. Early withdrawal of life support after resuscitation from cardiac arrest is common and may result in additional deaths. Resuscitation 2019; 139:308-313. [PMID: 30836171 DOI: 10.1016/j.resuscitation.2019.02.031] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 02/16/2019] [Accepted: 02/22/2019] [Indexed: 11/26/2022]
Abstract
AIM "Early" withdrawal of life support therapies (eWLST) within the first 3 calendar days after resuscitation from cardiac arrest (CA) is discouraged. We evaluated a prospective multicenter registry of patients admitted to hospitals after resuscitation from CA to determine predictors of eWLST and estimate its impact on outcomes. METHODS CA survivors enrolled from 2012-2017 in the International Cardiac Arrest Registry (INTCAR) were included. We developed a propensity score for eWLST and matched a cohort with similar probabilities of eWLST who received ongoing care. The incidence of good outcome (Cerebral Performance Category of 1 or 2) was measured across deciles of eWLST in the matched cohort. RESULTS 2688 patients from 24 hospitals were included. Median ischemic time was 20 (IQR 11, 30) minutes, and 1148 (43%) had an initial shockable rhythm. Withdrawal of life support occurred in 1162 (43%) cases, with 459 (17%) classified as eWLST. Older age, initial non-shockable rhythm, increased ischemic time, shock on admission, out-of-hospital arrest, and admission in the United States were each independently associated with eWLST. All patients with eWLST died, while the matched cohort, good outcome occurred in 21% of patients. 19% of patients within the eWLST group were predicted to have a good outcome, had eWLST not occurred. CONCLUSIONS Early withdrawal of life support occurs frequently after cardiac arrest. Although the mortality of patients matched to those with eWLST was high, these data showed excess mortality with eWLST.
Collapse
Affiliation(s)
- Teresa L May
- Department of Critical Care Services, Maine Medical Center, 22 Bramhall St, Portland, ME, USA; Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies (ICRHPS), Tufts Medical Center, 800 Washington St. Boston, MA, USA.
| | - Robin Ruthazer
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies (ICRHPS), Tufts Medical Center, 800 Washington St. Boston, MA, USA
| | - Richard R Riker
- Department of Critical Care Services, Maine Medical Center, 22 Bramhall St, Portland, ME, USA
| | - Hans Friberg
- Skåne University Hospital, Lund University, Department of Cardiology, Cronquists gata 130, 214 28, Lund, Sweden
| | - Nainesh Patel
- Lehigh Valley Hospital and Health Network, Division of Cardiovascular Medicine, 1250 S Cedar Crest Blvd #305, Allentown, PA, USA
| | - Eldar Soreide
- Critical Care and Anesthesiology Research Group, Stavanger University Hospital, Stavanger, Norway; Department Clinical Medicine, University of Bergen, Norway
| | - Robert Hand
- Eastern Maine Medical Center, Department of Critical Care, Armauer Hansens vei 20, 4011, Stavanger, Norway
| | - Pascal Stammet
- National Fire and Rescue Services, Medical and Health Department, 1, rue Stumper L-2557 Luxembourg, Luxembourg
| | - Allison Dupont
- Eastern Georgia, Department of Cardiology, 200 S Enota Dr NE Ste 200, Gainesville GA, USA
| | - Karen G Hirsch
- Stanford University School of Medicine, Department of Neurology and Neurological Sciences, 213 Quarry Road, Palo Alto, CA, USA
| | - Sachin Agarwal
- Columbia-Presbyterian Medical Center, Department of Neurology. 710 West 168th Street, New York, NY, USA
| | - Michael J Wanscher
- Copenhagen University Hospital Rigshospitalet, Department of Cardiothoracic Anesthesia. 9 Blegdamsvej, Copenhagen, Denmark
| | - Josef Dankiewicz
- Skåne University Hospital, Lund University, Department of Cardiology, Cronquists gata 130, 214 28, Lund, Sweden
| | - Niklas Nielsen
- Lund University, Helsingborg Hospital, Department of Clinical Sciences, Anesthesia and Intensive care. Universitesplatsen 2, Helsingborg, Sweden
| | - David B Seder
- Department of Critical Care Services, Maine Medical Center, 22 Bramhall St, Portland, ME, USA
| | - David M Kent
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies (ICRHPS), Tufts Medical Center, 800 Washington St. Boston, MA, USA
| |
Collapse
|
19
|
Precision Medicine in Critical Care Requires an Understanding of Pharmacokinetic Variability. Pediatr Crit Care Med 2017; 18:728-729. [PMID: 28691967 DOI: 10.1097/pcc.0000000000001208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
20
|
Germovsek E, Barker CIS, Sharland M, Standing JF. Scaling clearance in paediatric pharmacokinetics: All models are wrong, which are useful? Br J Clin Pharmacol 2016; 83:777-790. [PMID: 27767204 PMCID: PMC5346879 DOI: 10.1111/bcp.13160] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 10/06/2016] [Accepted: 10/15/2016] [Indexed: 12/11/2022] Open
Abstract
Linked Articles This article is commented on in the editorial by Holford NHG and Anderson BJ. Why standards are useful for predicting doses. Br J Clin Pharmacol 2017; 83: 685–7. doi: 10.1111/bcp.13230 Aim When different models for weight and age are used in paediatric pharmacokinetic studies it is difficult to compare parameters between studies or perform model‐based meta‐analyses. This study aimed to compare published models with the proposed standard model (allometric weight0.75 and sigmoidal maturation function). Methods A systematic literature search was undertaken to identify published clearance (CL) reports for gentamicin and midazolam and all published models for scaling clearance in children. Each model was fitted to the CL values for gentamicin and midazolam, and the results compared with the standard model (allometric weight exponent of 0.75, along with a sigmoidal maturation function estimating the time in weeks of postmenstrual age to reach half the mature value and a shape parameter). For comparison, we also looked at allometric size models with no age effect, the influence of estimating the allometric exponent in the standard model and, for gentamicin, using a fixed allometric exponent of 0.632 as per a study on glomerular filtration rate maturation. Akaike information criteria (AIC) and visual predictive checks were used for evaluation. Results No model gave an improved AIC in all age groups, but one model for gentamicin and three models for midazolam gave slightly improved global AIC fits albeit using more parameters: AIC drop (number of parameters), –4.1 (5), –9.2 (4), –10.8 (5) and –10.1 (5), respectively. The 95% confidence interval of estimated CL for all top performing models overlapped. Conclusion No evidence to reject the standard model was found; given the benefits of standardised parameterisation, its use should therefore be recommended.
Collapse
Affiliation(s)
- Eva Germovsek
- Inflammation, Infection and Rheumatology Section, Great Ormond Street Institute of Child Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK
| | - Charlotte I S Barker
- Inflammation, Infection and Rheumatology Section, Great Ormond Street Institute of Child Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK.,Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, Cranmer Terrace, London, SW17 0RE, UK.,St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, UK
| | - Mike Sharland
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, Cranmer Terrace, London, SW17 0RE, UK.,St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, UK
| | - Joseph F Standing
- Inflammation, Infection and Rheumatology Section, Great Ormond Street Institute of Child Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK.,Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, Cranmer Terrace, London, SW17 0RE, UK
| |
Collapse
|
21
|
Bader MK, Brophy GM, Wavra T, Mathiesen C, Bader MK. Clinical Q & A: Translating Therapeutic Temperature Management from Theory to Practice. Ther Hypothermia Temp Manag 2016; 6:218-222. [PMID: 27809708 DOI: 10.1089/ther.2016.29018.mkb] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Gretchen M Brophy
- 2 Virginia Commonwealth University , Medical College of Virginia Campus, Richmond, Virginia
| | | | | | | |
Collapse
|
22
|
Seder DB, Lord C, Gagnon DJ. The Evolving Paradigm of Individualized Postresuscitation Care After Cardiac Arrest. Am J Crit Care 2016; 25:556-564. [PMID: 27802958 DOI: 10.4037/ajcc2016496] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
The postresuscitation period after a cardiac arrest is characterized by a wide range of physiological derangements. Variations between patients include preexisting medical problems, the underlying cause of the cardiac arrest, presence or absence of hemodynamic and circulatory instability, severity of the ischemia-reperfusion injury, and resuscitation-related injuries such as pulmonary aspiration and rib or sternal fractures. Although protocols can be applied to many elements of postresuscitation care, the widely disparate clinical condition of cardiac arrest survivors requires an individualized approach that stratifies patients according to their clinical profile and targets specific treatments to patients most likely to benefit. This article describes such an individualized approach, provides a practical framework for evaluation and triage at the bedside, and reviews concerns specific to all members of the interprofessional postresuscitation care team.
Collapse
Affiliation(s)
- David B. Seder
- David B. Seder is director of neurocritical care at Maine Medical Center, Portland, Maine, and an associate professor of medicine at Tufts University School of Medicine, Boston, Massachusetts. Christine Lord is a staff nurse and the unit-based educator for the cardiac intensive care unit at Maine Medical Center. David J. Gagnon is a critical care pharmacist at Maine Medical Center and a clinical assistant professor of medicine at Tufts University School of Medicine
| | - Christine Lord
- David B. Seder is director of neurocritical care at Maine Medical Center, Portland, Maine, and an associate professor of medicine at Tufts University School of Medicine, Boston, Massachusetts. Christine Lord is a staff nurse and the unit-based educator for the cardiac intensive care unit at Maine Medical Center. David J. Gagnon is a critical care pharmacist at Maine Medical Center and a clinical assistant professor of medicine at Tufts University School of Medicine
| | - David J. Gagnon
- David B. Seder is director of neurocritical care at Maine Medical Center, Portland, Maine, and an associate professor of medicine at Tufts University School of Medicine, Boston, Massachusetts. Christine Lord is a staff nurse and the unit-based educator for the cardiac intensive care unit at Maine Medical Center. David J. Gagnon is a critical care pharmacist at Maine Medical Center and a clinical assistant professor of medicine at Tufts University School of Medicine
| |
Collapse
|
23
|
Anderson KB, Poloyac SM, Kochanek PM, Empey PE. Effect of Hypothermia and Targeted Temperature Management on Drug Disposition and Response Following Cardiac Arrest: A Comprehensive Review of Preclinical and Clinical Investigations. Ther Hypothermia Temp Manag 2016; 6:169-179. [PMID: 27622966 DOI: 10.1089/ther.2016.0003] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Targeted temperature management (TTM) has been shown to reduce mortality and improve neurological outcomes in out-of-hospital cardiac arrest (CA) patients and in neonates with hypoxic-ischemic encephalopathy (HIE). TTM has also been associated with adverse drug events in the critically ill patient due to its effect on drug pharmacokinetics (PKs) and pharmacodynamics (PDs). We aim to evaluate the current literature on the effect of TTM on drug PKs and PDs following CA. MEDLINE/PubMed databases were searched for publications, which include the MeSH terms hypothermia, drug metabolism, drug transport, P450, critical care, cardiac arrest, hypoxic-ischemic encephalopathy, pharmacokinetics, and pharmacodynamics between July 2006 and October 2015. Twenty-three studies were included in this review. The studies demonstrate that hypothermia impacts PK parameters and increases concentrations of cytochrome-P450-metabolized drugs in the cooling and rewarming phase. Furthermore, the current data demonstrate a combined effect of CA and hypothermia on drug PK. Importantly, these effects can last greater than 4-5 days post-treatment. Limited evidence suggests hypothermia-mediated changes in the Phase II metabolism and the Phase III transport of drugs. Hypothermia also has been shown to potentially decrease the effect of specific drugs at the receptor level. Therapeutic hypothermia, as commonly deployed/applied during TTM, alters PK, and elevates concentrations of several commonly used medications. Hypothermia-mediated effects are an important factor when dosing and monitoring patients undergoing TTM treatment.
Collapse
Affiliation(s)
- Kacey B Anderson
- 1 Department of Pharmaceutical Sciences, Center for Clinical Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Samuel M Poloyac
- 1 Department of Pharmaceutical Sciences, Center for Clinical Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Patrick M Kochanek
- 2 Department of Critical Care Medicine, Safar Center for Resuscitation Research, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Philip E Empey
- 3 Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh , Pittsburgh, Pennsylvania
| |
Collapse
|
24
|
Coppler PJ, Sawyer KN, Youn CS, Choi SP, Park KN, Kim YM, Reynolds JC, Gaieski DF, Lee BK, Oh JS, Kim WY, Moon HJ, Abella BS, Elmer J, Callaway CW, Rittenberger JC. Variability of Post-Cardiac Arrest Care Practices Among Cardiac Arrest Centers: United States and South Korean Dual Network Survey of Emergency Physician Research Principal Investigators. Ther Hypothermia Temp Manag 2016; 7:30-35. [PMID: 27419613 DOI: 10.1089/ther.2016.0017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
There is little consensus regarding many post-cardiac arrest care parameters. Variability in such practices could confound the results and generalizability of post-arrest care research. We sought to characterize the variability in post-cardiac arrest care practice in Korea and the United States. A 54-question survey was sent to investigators participating in one of two research groups in South Korea (Korean Hypothermia Network [KORHN]) and the United States (National Post-Arrest Research Consortium [NPARC]). Single investigators from each site were surveyed (N = 40). Participants answered questions based on local institutional protocols and practice. We calculated descriptive statistics for all variables. Forty surveys were completed during the study period with 30 having greater than 50% of questions completed (75% response rate; 24 KORHN and 6 NPARC). Most centers target either 33°C (N = 16) or vary the target based on patient characteristics (N = 13). Both bolus and continuous infusion dosing of sedation are employed. No single indication was unanimous for cardiac catheterization. Only six investigators reported having an institutional protocol for withdrawal of life-sustaining therapy (WLST). US patients with poor neurological prognosis tended to have WLST with subsequent expiration (N = 5), whereas Korean patients are transferred to a secondary care facility (N = 19). Both electroencephalography modality and duration vary between institutions. Serum biomarkers are commonly employed by Korean, but not US centers. We found significant variability in post-cardiac arrest care practices among US and Korean medical centers. These practice variations must be taken into account in future studies of post-arrest care.
Collapse
Affiliation(s)
- Patrick J Coppler
- 1 Department of Emergency Medicine, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania.,2 Department of Physician Assistant Studies, University of the Sciences , Philadelphia, Pennsylvania
| | - Kelly N Sawyer
- 3 Department of Emergency Medicine, William Beaumont Hospital , Royal Oak, Michigan
| | - Chun Song Youn
- 4 Department of Emergency Medicine, The Catholic University of Korea , Seoul, South Korea
| | - Seung Pill Choi
- 4 Department of Emergency Medicine, The Catholic University of Korea , Seoul, South Korea
| | - Kyu Nam Park
- 4 Department of Emergency Medicine, The Catholic University of Korea , Seoul, South Korea
| | - Young-Min Kim
- 4 Department of Emergency Medicine, The Catholic University of Korea , Seoul, South Korea
| | - Joshua C Reynolds
- 5 Department of Emergency Medicine, Michigan State University College of Human Medicine , Grand Rapids, Michigan
| | - David F Gaieski
- 6 Department of Emergency Medicine, Sidney Kimmel Medical College at Thomas Jefferson University Hospital , Philadelphia, Pennsylvania
| | - Byung Kook Lee
- 7 Chonnam National University Hospital , Gwangju, South Korea
| | - Joo Suk Oh
- 4 Department of Emergency Medicine, The Catholic University of Korea , Seoul, South Korea
| | - Won Young Kim
- 8 Ulsan University College of Medicine , Asan Medical Center, Seoul, South Korea
| | - Hyung Jun Moon
- 9 Soonchunhyang University Cheonan Hospital , Cheonan, South Korea
| | - Benjamin S Abella
- 10 Department of Emergency Medicine, Pereleman School of Medicine at the University of Pennsylvania , Philadelphia, Pennsylvania
| | - Jonathan Elmer
- 1 Department of Emergency Medicine, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania.,11 Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Clifton W Callaway
- 1 Department of Emergency Medicine, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania
| | - Jon C Rittenberger
- 1 Department of Emergency Medicine, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania
| |
Collapse
|
25
|
Morbitzer KA, Jordan JD, Rhoney DH. Vancomycin pharmacokinetic parameters in patients with acute brain injury undergoing controlled normothermia, therapeutic hypothermia, or pentobarbital infusion. Neurocrit Care 2016; 22:258-64. [PMID: 25330755 DOI: 10.1007/s12028-014-0079-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Therapeutic strategies that cause an alteration in patient temperature, such as controlled normothermia (CN), therapeutic hypothermia (TH), and pentobarbital infusion (PI), are often used to manage complications caused by acute brain injury. The purpose of this study was to evaluate pharmacokinetic (PK) parameters of vancomycin in patients with acute brain injury undergoing temperature modulation. METHODS This was a retrospective cohort study of adult patients with acute brain injury admitted between May 2010 and March 2014 who underwent CN, TH, or PI and received vancomycin. Predicted PK parameters based on population data were compared with calculated PK parameters based on serum concentrations. RESULTS Seventeen CN patients and 10 TH/PI patients met inclusion criteria. Traumatic brain injury and aneurysmal subarachnoid hemorrhage accounted for the majority of admitting diagnoses. In the CN group, the median dose was 16.7 (15.5-18.4) mg/kg. The median calculated elimination rate constant [0.155 (0.108-0.17) vs. 0.103 (0.08-0.142) hr(-1); p = 0.04] was significantly higher than the predicted value. The median measured trough concentration [8.9 (7.7-11.1) vs. 17.1 (10.8-22.3) υg/mL; p = 0.004] was significantly lower than predicted. In the TH/PI group, the median dose was 15.4 (14.7-17.2) mg/kg. No significant differences were found between the median calculated and predicted elimination rate constant [0.107 (0.097-0.109) vs. 0.112 (0.102-0.127) hr(-1); p = 0.41] and median measured and predicted trough concentration [14.2 (12.7-17.1) vs. 13.1 (11-17.8) υg/mL; p = 0.71]. CONCLUSION Patients who underwent TH/PI did not exhibit PK alterations when compared to predicted PK parameters based on population data, while patients who underwent CN experienced PK alterations favoring an increased elimination of vancomycin.
Collapse
Affiliation(s)
- Kathryn A Morbitzer
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, 115 Beard Hall, Campus Box 7574, Chapel Hill, NC, 27599, USA
| | | | | |
Collapse
|
26
|
McSwain JR, Yared M, Doty JW, Wilson SH. Perioperative hypothermia: Causes, consequences and treatment. World J Anesthesiol 2015; 4:58-65. [DOI: 10.5313/wja.v4.i3.58] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 06/24/2015] [Accepted: 07/23/2015] [Indexed: 02/07/2023] Open
Abstract
Perioperative hypothermia, core temperature below 36.0 °C, transpires due to disruption of thermoregulation by anesthesia coupled with cold exposure to procedural surroundings and cleansing agents. Although most publications have focused on thermoregulation disruption with general anesthesia, neuraxial anesthesia may also cause significant hypothermia. The clinical consequences of perioperative hypothermia are multiple and include patient discomfort, shivering, platelet dysfunction, coagulopathy, and increased vasoconstriction associated with a higher risk of wound infection. Furthermore, postoperative cardiac events occur at a higher rate; although it is unclear whether this is due to increased oxygen consumption or norepinephrine levels. Hypothermia may also affect pharmacokinetics and prolong postoperative recovery times and hospital length of stay. In order to combat perioperative hypothermia, many prevention strategies have been examined. Active and passive cutaneous warming are likely the most common and aim to both warm and prevent heat loss; many consider active warming a standard of care for surgeries over one hour. Intravenous nutrients have also been examined to boost metabolic heat production. Additionally, pharmacologic agents that induce vasoconstriction have been studied with the goal of minimizing heat loss. Despite these multiple strategies for prevention and treatment, hypothermia continues to be a problem and a common consequence of the perioperative period. This literature review presents the most recent evidence on the disruption of temperature regulation by anesthesia and perioperative environment, the consequences of hypothermia, and the methods for hypothermia prevention and treatment.
Collapse
|
27
|
Callaway CW, Donnino MW, Fink EL, Geocadin RG, Golan E, Kern KB, Leary M, Meurer WJ, Peberdy MA, Thompson TM, Zimmerman JL. Part 8: Post-Cardiac Arrest Care: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015; 132:S465-82. [PMID: 26472996 PMCID: PMC4959439 DOI: 10.1161/cir.0000000000000262] [Citation(s) in RCA: 1018] [Impact Index Per Article: 113.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
|
28
|
Pharmacokinetic and Other Considerations for Drug Therapy During Targeted Temperature Management. Crit Care Med 2015; 43:2228-38. [DOI: 10.1097/ccm.0000000000001223] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
|
29
|
Jackson TC, Manole MD, Kotermanski SE, Jackson EK, Clark RSB, Kochanek PM. Cold stress protein RBM3 responds to temperature change in an ultra-sensitive manner in young neurons. Neuroscience 2015; 305:268-78. [PMID: 26265550 DOI: 10.1016/j.neuroscience.2015.08.012] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Revised: 08/02/2015] [Accepted: 08/05/2015] [Indexed: 12/21/2022]
Abstract
Extremely mild hypothermia to 36.0 °C is not thought to appreciably differ clinically from 37.0 °C. However, it is possible that 36.0 °C stimulates highly sensitive hypothermic signaling mechanism(s) and alters biochemistry. To the best of our knowledge, no such ultra-sensitive pathway/mechanisms have been described. Here we show that cold stress protein RNA binding motif 3 (RBM3) increases in neuron and astrocyte cultures maintained at 33 °C or 36 °C for 24 or 48 h, compared to 37 °C controls. Neurons cultured at 36 °C also had increased global protein synthesis (GPS). Finally, we found that melatonin or fibroblast growth factor 21 (FGF21) augmented RBM3 upregulation in young neurons cooled to 36 °C. Our results show that a 1 °C reduction in temperature can induce pleiotropic biochemical changes by upregulating GPS in neurons which may be mediated by RBM3 and that this process can be pharmacologically mimicked and enhanced with melatonin or FGF21.
Collapse
Affiliation(s)
- T C Jackson
- University of Pittsburgh School of Medicine, Safar Center for Resuscitation Research, 200 Hill Building, 3434 Fifth Avenue, Pittsburgh, PA 15260, United States; University of Pittsburgh School of Medicine, Department of Critical Care Medicine, 3550 Terrace Street, Pittsburgh, PA 15261, United States.
| | - M D Manole
- University of Pittsburgh School of Medicine, Safar Center for Resuscitation Research, 200 Hill Building, 3434 Fifth Avenue, Pittsburgh, PA 15260, United States; University of Pittsburgh School of Medicine, Department of Pediatrics, 4401 Penn Avenue, Pittsburgh, PA 15224, United States
| | - S E Kotermanski
- University of Pittsburgh School of Medicine, Department of Pharmacology and Chemical Biology, Bridgeside Point Building 1, 100 Technology Drive, Pittsburgh, PA 15219, United States
| | - E K Jackson
- University of Pittsburgh School of Medicine, Department of Pharmacology and Chemical Biology, Bridgeside Point Building 1, 100 Technology Drive, Pittsburgh, PA 15219, United States
| | - R S B Clark
- University of Pittsburgh School of Medicine, Safar Center for Resuscitation Research, 200 Hill Building, 3434 Fifth Avenue, Pittsburgh, PA 15260, United States; University of Pittsburgh School of Medicine, Department of Critical Care Medicine, 3550 Terrace Street, Pittsburgh, PA 15261, United States
| | - P M Kochanek
- University of Pittsburgh School of Medicine, Safar Center for Resuscitation Research, 200 Hill Building, 3434 Fifth Avenue, Pittsburgh, PA 15260, United States; University of Pittsburgh School of Medicine, Department of Critical Care Medicine, 3550 Terrace Street, Pittsburgh, PA 15261, United States
| |
Collapse
|
30
|
Callaway CW, Elmer J, Guyette FX, Molyneaux BJ, Anderson KB, Empey PE, Gerstel SJ, Holquist K, Repine MJ, Rittenberger JC. Dexmedetomidine Reduces Shivering during Mild Hypothermia in Waking Subjects. PLoS One 2015; 10:e0129709. [PMID: 26237219 PMCID: PMC4523180 DOI: 10.1371/journal.pone.0129709] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 05/12/2015] [Indexed: 12/20/2022] Open
Abstract
Background and Purpose Reducing body temperature can prolong tolerance to ischemic injury such as stroke or myocardial infarction, but is difficult and uncomfortable in awake patients because of shivering. We tested the efficacy and safety of the alpha-2-adrenergic agonist dexmedetomidine for suppressing shivering induced by a rapid infusion of cold intravenous fluids. Methods Ten subjects received a rapid intravenous infusion of two liters of cold (4°C) isotonic saline on two separate test days, and we measured their core body temperature, shivering, hemodynamics and sedation for two hours. On one test day, fluid infusion was preceded by placebo infusion. On the other test day, fluid infusion was preceded by 1.0 μg/kg bolus of dexmedetomidine over 10 minutes. Results All ten subjects experienced shivering on placebo days, with shivering beginning at a mean (SD) temperature of 36.6 (0.3)°C. The mean lowest temperature after placebo was 36.0 (0.3)°C (range 35.7-36.5°C). Only 3/10 subjects shivered on dexmedetomidine days, and the mean lowest temperature was 35.7 (0.4)°C (range 35.0-36.3°C). Temperature remained below 36°C for the full two hours in 6/10 subjects. After dexmedetomidine, subjects had moderate sedation and a mean 26 (13) mmHg reduction in blood pressure that resolved within 90 minutes. Heart rate declined a mean 23 (11) bpm after both placebo and dexmedetomidine. Dexmedetomidine produced no respiratory depression. Conclusion Dexmedetomidine decreases shivering in normal volunteers. This effect is associated with decreased systolic blood pressure and sedation, but no respiratory depression.
Collapse
Affiliation(s)
- Clifton W. Callaway
- Applied Physiology Laboratory, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Jonathan Elmer
- Applied Physiology Laboratory, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Francis X. Guyette
- Applied Physiology Laboratory, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Bradley J. Molyneaux
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Kacey B. Anderson
- School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Philip E. Empey
- School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Stacy J. Gerstel
- Applied Physiology Laboratory, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Kate Holquist
- Applied Physiology Laboratory, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Melissa J. Repine
- Applied Physiology Laboratory, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Jon C. Rittenberger
- Applied Physiology Laboratory, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
- * E-mail:
| |
Collapse
|
31
|
Miyamoto H, Matsueda S, Moritsuka A, Shimokawa K, Hirata H, Nakashima M, Sasaki H, Fumoto S, Nishida K. Evaluation of hypothermia on the in vitro metabolism and binding and in vivo disposition of midazolam in rats. Biopharm Drug Dispos 2015; 36:481-9. [PMID: 26037413 DOI: 10.1002/bdd.1960] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 05/10/2015] [Accepted: 05/20/2015] [Indexed: 01/16/2023]
Abstract
The effect of hypothermia on the in vivo pharmacokinetics of midazolam was evaluated, with a focus on altered metabolism in the liver and binding to serum proteins. Rat primary hepatocytes were incubated with midazolam (which is metabolized mainly by CYP3A2) at 37, 32 or 28 °C. The Michaelis-Menten constant (Km) and maximum velocity (Vmax) of midazolam were estimated using the Michaelis-Menten equation. The Km of CYP3A2 midazolam remained unchanged, but the Vmax decreased at 28 °C. In rats, whose temperature was maintained at 37, 32 or 28 °C by a heat lamp or ice pack, the plasma concentrations of midazolam were higher, whereas those in the brain and liver were unchanged at 28 °C. The tissue/plasma concentration ratios were, however, increased significantly. The unbound fraction of midazolam in serum at 28 °C was half that at 37 °C. These pharmacokinetic changes associated with hypothermic conditions were due to reductions in CYP3A2 activity and protein binding.
Collapse
Affiliation(s)
| | - Satoshi Matsueda
- Graduate School of Biomedical Sciences, Nagasaki University, Japan
| | - Akihiro Moritsuka
- Department of Hospital Pharmacy, Nagasaki University Hospital, Japan
| | - Kenta Shimokawa
- Graduate School of Biomedical Sciences, Nagasaki University, Japan
| | - Haruna Hirata
- Graduate School of Biomedical Sciences, Nagasaki University, Japan
| | - Mikiro Nakashima
- Graduate School of Biomedical Sciences, Nagasaki University, Japan
| | - Hitoshi Sasaki
- Department of Hospital Pharmacy, Nagasaki University Hospital, Japan
| | - Shintaro Fumoto
- Graduate School of Biomedical Sciences, Nagasaki University, Japan
| | - Koyo Nishida
- Graduate School of Biomedical Sciences, Nagasaki University, Japan
| |
Collapse
|
32
|
Abstract
Cardiac arrest afflicts more than 300,000 persons annually in North America alone. Advances in systematic, regimented postresuscitation care have lowered mortality and improved neurologic outcomes in select cohorts of patients over the last decade. Postcardiac arrest care now comprises its own link in the chain of survival. For most patients, high-quality postcardiac arrest care begins in the Emergency Department. This article reviews the evidence and offers treatment strategies for the key components of postcardiac arrest care.
Collapse
Affiliation(s)
- Jon C Rittenberger
- Department of Emergency Medicine, University of Pittsburgh, Suite 10028, Forbes Tower, Pittsburgh, PA 15260, USA
| | - Ankur A Doshi
- Department of Emergency Medicine, University of Pittsburgh, Suite 10028, Forbes Tower, Pittsburgh, PA 15260, USA
| | - Joshua C Reynolds
- Department of Emergency Medicine, Michigan State University College of Human Medicine, 15 Michigan Street Northeast, Suite 420, Grand Rapids, MI 49503, USA.
| | | |
Collapse
|
33
|
Kochanek PM, Jackson TC. It might be time to let cooler heads prevail after mild traumatic brain injury or concussion. Exp Neurol 2015; 267:13-7. [PMID: 25732932 DOI: 10.1016/j.expneurol.2015.02.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 02/09/2015] [Indexed: 01/10/2023]
Affiliation(s)
- Patrick M Kochanek
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Pittsburgh, PA 15261, USA; Safar Center for Resuscitation Research, 3434 Fifth Avenue, Pittsburgh, PA 15260, USA.
| | - Travis C Jackson
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Pittsburgh, PA 15261, USA; Safar Center for Resuscitation Research, 3434 Fifth Avenue, Pittsburgh, PA 15260, USA.
| |
Collapse
|
34
|
van den Broek MPH, van Straaten HLM, Huitema ADR, Egberts T, Toet MC, de Vries LS, Rademaker K, Groenendaal F. Anticonvulsant effectiveness and hemodynamic safety of midazolam in full-term infants treated with hypothermia. Neonatology 2015; 107:150-6. [PMID: 25572061 DOI: 10.1159/000368180] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Accepted: 09/03/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Midazolam is used as an anticonvulsant in neonatology, including newborns with perinatal asphyxia treated with hypothermia. Hypothermia may affect the safety and effectiveness of midazolam in these patients. OBJECTIVES The objective was to evaluate the anticonvulsant effectiveness and hemodynamic safety of midazolam in hypothermic newborns and to provide dosing guidance. METHODS Hypothermic newborns with perinatal asphyxia and treated with midazolam were included. Effectiveness was studied using continuous amplitude-integrated electroencephalography. Hemodynamic safety was assessed using pharmacokinetic-pharmacodynamic modeling with plasma samples and blood pressure recordings (mean arterial blood pressure) under hypothermia. RESULTS No effect of therapeutic hypothermia on pharmacokinetics could be identified. Add-on seizure control with midazolam was limited (23% seizure control). An inverse relationship between the midazolam plasma concentration and mean arterial blood pressure could be identified. At least one hypotensive episode was experienced in 64%. The concomitant use of inotropes decreased midazolam clearance by 33%. CONCLUSIONS Under therapeutic hypothermia, midazolam has limited add-on clinical anticonvulsant effectiveness after phenobarbital administration. Due to occurrence of hypotension requiring inotropic support, midazolam is less suitable as a second-line anticonvulsant drug under hypothermia.
Collapse
|
35
|
Hites M, Dell'Anna AM, Scolletta S, Taccone FS. The challenges of multiple organ dysfunction syndrome and extra-corporeal circuits for drug delivery in critically ill patients. Adv Drug Deliv Rev 2014; 77:12-21. [PMID: 24842474 DOI: 10.1016/j.addr.2014.05.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 04/01/2014] [Accepted: 05/07/2014] [Indexed: 12/25/2022]
Abstract
The multiple organ dysfunction syndrome (MODS) is characterized by more than one organ system failing, especially during critical illness. MODS is the leading cause of morbidity and mortality in current ICU practice; moreover, multiple organ dysfunction, especially liver and kidneys, may significantly affect the pharmacokinetics (PKs) of different drugs that are currently administered in critically ill patients. These PK alterations may either result in insufficient drug concentrations to achieve the desired effects or in blood and tissue accumulation, with the development of serious adverse events. The use of extra-corporeal circuits, such as extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT), may further contribute to PKs changes in this patients' population. In this review, we have described the main PK changes occurring in all these conditions and how drug concentrations may potentially be affected. The lack of prospective studies on large cohorts of patients makes impossible any specific recommendation on drug regimen adjustment in ICU patients. Nevertheless, the clinicians should be aware of these abnormalities in order to better understand some unexpected therapeutic issues occurring in such patients.
Collapse
Affiliation(s)
- Maya Hites
- Department of Infectious Diseases, Hopital Erasme - Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels Belgium
| | - Antonio Maria Dell'Anna
- Department of Intensive Care, Hopital Erasme - Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels Belgium
| | - Sabino Scolletta
- Department of Anesthesia and Intensive Care, University of Siena, Viale Bracci 1, 53100 Siena, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hopital Erasme - Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels Belgium.
| |
Collapse
|
36
|
Beseda R, Smith S, Veenstra A. Therapeutic hypothermia after cardiac arrest and return of spontaneous circulation: it's complicated. Crit Care Nurs Clin North Am 2014; 26:511-24. [PMID: 25438893 DOI: 10.1016/j.ccell.2014.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Providing evidence-based care to patients with return of spontaneous circulation after a cardiac arrest is a recent complex innovation. Once resuscitated patients must be assessed for appropriateness for therapeutic hypothermia, be cooled in a timely manner, maintained while hypothermic, rewarmed within a specified time frame, and then assessed for whether hypothermia was successful for the patient through neuroprognostication. Nurses caring for therapeutic hypothermia patients must be knowledgeable and prepared to provide care to the patient and family. This article provides an overview of the complexity of therapeutic hypothermia for patients with return of spontaneous circulation in the form of a case study.
Collapse
Affiliation(s)
- Ryan Beseda
- Department of Critical Care Services, Baylor University Medical Center at Dallas, 3500 Gaston Avenue, Dallas, TX 75246, USA
| | - Susan Smith
- Department of Critical Care Services, Baylor University Medical Center at Dallas, 3500 Gaston Avenue, Dallas, TX 75246, USA.
| | - Amy Veenstra
- Department of Nursing Administration, Baylor University Medical Center at Dallas, 3500 Gaston Avenue, Dallas, TX 75246, USA
| |
Collapse
|
37
|
Shein SL, Reynolds TQ, Gedela S, Kochanek PM, Bell MJ. Therapeutic hypothermia for refractory status epilepticus in a child with malignant migrating partial seizures of infancy and SCN1A mutation: a case report. Ther Hypothermia Temp Manag 2014; 2:144-9. [PMID: 23667778 DOI: 10.1089/ther.2012.0013] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Status epilepticus (SE) is a common indication for neurocritical care and can be refractory to standard measures. Refractory SE (RSE) is associated with high morbidity and mortality. Unconventional therapies may be utilized in certain cases, including therapeutic hypothermia (TH), bumetanide, and the ketogenic diet. However, the literature describing the use of such therapies in RSE is limited. Details of a case of TH for RSE in an infant with malignant migrating partial seizures of infancy were obtained from the medical record. A 4-month-old child developed SE that was refractory to treatment with concurrent midazolam, phenobarbital, fosphenytoin, topiramate, levetiracetam, folinic acid, and pyridoxal-5-phosphate. This led to progressive implementation of three unconventional therapies: TH, bumetanide, and the ketogentic diet. Electrographic seizures ceased for the entirety of a 43-hour period of TH with a target rectal temperature of 33.0°C–34.0°C. No adverse effects of hypothermia were noted other than a single episode of asymptomatic hypokalemia. Seizures recurred 10 hours after rewarming was begun and did not abate with reinstitution of hypothermia. No effect was seen with administration of bumetanide. Seizures were controlled long-term within 48 hours of institution of the ketogenic diet. TH and the ketogenic diet may be effective for treating RSE in children.
Collapse
|
38
|
BJELLAND TW, KLEPSTAD P, HAUGEN BO, NILSEN T, SALVESEN Ø, DALE O. Concentrations of remifentanil, propofol, fentanyl, and midazolam during rewarming from therapeutic hypothermia. Acta Anaesthesiol Scand 2014; 58:709-15. [PMID: 24611449 DOI: 10.1111/aas.12300] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND The clearance of sedatives and analgesics may be reduced by therapeutic hypothermia. However, little is known about the concentrations of such drugs during rewarming. The aim of this study was to describe the serum concentrations of sedatives and analgesics during rewarming from therapeutic hypothermia. METHODS Blood samples were collected for quantification of drug concentrations in 22 patients given analgesia/sedation with either remifentanil/propofol or fentanyl/midazolam during rewarming from therapeutic hypothermia (33-34°C) after cardiac arrest. Samples for were drawn before (-2 h) and during rewarming (0-8 h). Linear mixed effects models were used to describe serum concentrations and adjust for rates of infusion during rewarming from therapeutic hypothermia. RESULTS Subjects with samples analyzed were remifentanil (n = 8), propofol (n = 14), fentanyl (n = 8), and midazolam (n = 8). Age, body mass index, and simplified acute physiology score II [mean (standard deviation)] were 64 (14.2) years, 27.3 (3.7) kg/m(2), and 69 (13.2), respectively. While the concentration of fentanyl was not significantly affected by temperature, concentrations of remifentanil, propofol, and midazolam decreased with core temperature by 16%, 12%, and 11% (mean values) from 33°C to 37°C after adjusting for rates of infusion, respectively. CONCLUSION Concentrations of remifentanil, propofol, and midazolam decreased during rewarming from therapeutic hypothermia when adjusting for rates of infusion. No changes were demonstrated for fentanyl.
Collapse
Affiliation(s)
- T. W. BJELLAND
- Department of Circulation and Medical Imaging; Faculty of Medicine; Norwegian University of Science and Technology (NTNU); Trondheim Norway
| | - P. KLEPSTAD
- Department of Circulation and Medical Imaging; Faculty of Medicine; Norwegian University of Science and Technology (NTNU); Trondheim Norway
- Clinic of Anaesthesia and Intensive Care; St. Olav's University Hospital; Trondheim Norway
| | - B. O. HAUGEN
- Department of Circulation and Medical Imaging; Faculty of Medicine; Norwegian University of Science and Technology (NTNU); Trondheim Norway
- Clinic of Cardiology; St. Olav's University Hospital; Trondheim Norway
| | - T. NILSEN
- Department of Circulation and Medical Imaging; Faculty of Medicine; Norwegian University of Science and Technology (NTNU); Trondheim Norway
| | - Ø. SALVESEN
- Unit for Applied Clinical Research; Faculty of Medicine; Norwegian University of Science and Technology (NTNU); Trondheim Norway
| | - O. DALE
- Department of Circulation and Medical Imaging; Faculty of Medicine; Norwegian University of Science and Technology (NTNU); Trondheim Norway
- Clinic of Anaesthesia and Intensive Care; St. Olav's University Hospital; Trondheim Norway
| |
Collapse
|
39
|
Kochanek P, Puccio A, Diringer M, Kochanek P. Temperature management in neurological and neurosurgical intensive care units. Ther Hypothermia Temp Manag 2014; 3:41-5. [PMID: 24837796 DOI: 10.1089/ther.2013.1508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Patrick Kochanek
- 1 Department of Critical Care Medicine, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania
| | | | | | | |
Collapse
|
40
|
Bader EBMK. Clinical Q & A: Translating Therapeutic Temperature Management from Theory to Practice. Ther Hypothermia Temp Manag 2014. [DOI: 10.1089/ther.2014.1500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
|
41
|
Empey PE, Velez de Mendizabal N, Bell MJ, Bies RR, Anderson KB, Kochanek PM, Adelson PD, Poloyac SM. Therapeutic hypothermia decreases phenytoin elimination in children with traumatic brain injury. Crit Care Med 2013; 41:2379-87. [PMID: 23896831 PMCID: PMC3783553 DOI: 10.1097/ccm.0b013e318292316c] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Preclinical and clinical studies have suggested that therapeutic hypothermia, while decreasing neurologic injury, may also lead to drug toxicity that may limit its benefit. Cooling decreases cytochrome P450 (CYP)-mediated drug metabolism, and limited clinical data suggest that drug levels are elevated. Fosphenytoin is metabolized by cytochrome P450 2C, has a narrow therapeutic range, and is a commonly used antiepileptic medication. The objective of this study was to evaluate the impact of therapeutic hypothermia on phenytoin levels and pharmacokinetics in children with severe traumatic brain injury. DESIGN Pharmacokinetic analysis of subjects participating in a multicenter randomized phase III study of therapeutic hypothermia for severe traumatic brain injury. SETTING ICU at the Children's Hospital of Pittsburgh. PATIENTS Nineteen children with severe traumatic brain injury. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A sum of 121 total and 114 free phenytoin levels were evaluated retrospectively in 10 hypothermia-treated and nine normothermia-treated children who were randomized to 48 hours of cooling to 32-33°C followed by slow rewarming or controlled normothermia. Drug dosing, body temperatures, and demographics were collected during cooling, rewarming, and posttreatment periods (8 d). A trend toward elevated free phenytoin levels in the hypothermia group (p=0.051) to a median of 2.2 mg/L during rewarming was observed and was not explained by dosing differences. Nonlinear mixed-effects modeling incorporating both free and total levels demonstrated that therapeutic hypothermia specifically decreased the time-variant component of the maximum velocity of phenytoin metabolism (Vmax) 4.6-fold (11.6-2.53 mg/hr) and reduced the overall Vmax by ~50%. Simulations showed that the increased risk for drug toxicity extends many days beyond the end of the cooling period. CONCLUSIONS Therapeutic hypothermia significantly reduces phenytoin elimination in children with severe traumatic brain injury leading to increased drug levels for an extended period of time after cooling. Pharmacokinetic interactions between hypothermia and medications should be considered when caring for children receiving this therapy.
Collapse
Affiliation(s)
- Philip E Empey
- 1Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA. 2Division of Clinical Pharmacology, School of Medicine and Indiana Clinical and Translational Sciences Institute, Indiana University, Indianapolis, IN. 3Department of Critical Care Medicine, School of Medicine, and the Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA. 4Department of Neurological Surgery, School of Medicine, and the Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA. 5Department of Pharmaceutical Sciences, Center for Clinical Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA. 6Division of Neurosurgery/Children's Neuroscience, Department of Child Health, Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ
| | | | | | | | | | | | | | | |
Collapse
|
42
|
Miyamoto H, Matsueda S, Komori K, Fumoto S, Nakashima M, Yoshikawa N, Hirata H, Shimokawa K, Ohwaki Y, Nishida K. Evaluation for effect of hypothermia on the disposition of 4-nitrophenol in rats by in-vitro metabolism study and rat liver perfusion system. J Pharm Pharmacol 2013; 65:1536-40. [DOI: 10.1111/jphp.12130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2013] [Accepted: 07/23/2013] [Indexed: 11/26/2022]
Abstract
Abstract
Objectives
The aim of this study was to evaluate the effect of hypothermia on the in-vivo pharmacokinetics of 4-nitrophenol (4NP) using rat liver homogenate and rat liver perfusion system.
Methods
Rat liver homogenate was incubated with 4NP, which is mainly metabolized by cytochrome P450 2E1, at 37, 34, 32 or 28°C. The Michaelis constant (Km) and maximum elimination velocity (Vmax) of 4NP were calculated by a Hanes–Woolf plot. The hepatic extraction ratio (Eh) of 4NP was evaluated in a rat liver perfusion study at 37, 34, 32 or 28°C. Moreover, the plasma concentration profiles of 4NP after its intravenous (i.v.) administration to rats were analysed by the moment theory and were compared with in-vitro parameters.
Key findings
While the Km of 4NP was not changed, the Vmax and Eh were reduced at low temperatures. The plasma concentrations of 4NP after its i.v. administration to rats were significantly increased at 28°C.
Conclusion
Changes in the pharmacokinetics of 4NP under hypothermic conditions were caused by alterations in Vmax and Eh. We may be able to predict the disposition of a drug by in-vitro studies.
Collapse
Affiliation(s)
- Hirotaka Miyamoto
- Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Satoshi Matsueda
- Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Kotaro Komori
- Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Shintaro Fumoto
- Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Mikiro Nakashima
- Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Naoki Yoshikawa
- Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Haruna Hirata
- Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Kenta Shimokawa
- Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Yuichi Ohwaki
- Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Koyo Nishida
- Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| |
Collapse
|
43
|
Roberts DJ, Hall RI. Drug absorption, distribution, metabolism and excretion considerations in critically ill adults. Expert Opin Drug Metab Toxicol 2013; 9:1067-84. [PMID: 23682923 DOI: 10.1517/17425255.2013.799137] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION All critically ill patients require medication to treat organ dysfunction. However, the pharmacokinetics of drugs used to treat these patients is complex due to frequent alterations in drug absorption, distribution, metabolism, and excretion (ADME). AREAS COVERED This review examines pharmacokinetic aspects of drug administration for adult intensive care unit (ICU) patients. Specifically, the authors examine the ADME changes that occur and which should be considered by clinicians when delivering drug therapy to critically ill patients. EXPERT OPINION Dosage pharmacokinetics determined from single-dose or limited-duration administration studies in healthy volunteers may not apply to critically ill patients. Organ dysfunction among these patients may be due to pre-existing disease or the effects of a systemic or locoregional inflammatory response precipitated by their illness. Alterations in pharmacokinetics observed among the critically ill include altered bioavailability after enteral administration, increased volume of distribution and blood-brain barrier permeability and changes in P-glycoprotein and cytochrome P450 enzyme function. However, the effect of these changes on clinically important outcomes remains uncertain and poorly studied. Future investigations should examine not only pharmacokinetic changes among the critically ill, but also whether recognition of these changes and alterations in drug therapy directed as a consequence of their observation alters patient outcomes.
Collapse
Affiliation(s)
- Derek J Roberts
- University of Calgary, Departments of Surgery and Community Health Sciences, Calgary, Alberta T2N 5A1, Canada
| | | |
Collapse
|
44
|
Poloyac SM, Empey PE. Drug dosing during hypothermia: to adjust, or not to adjust, that is the question. Pediatr Crit Care Med 2013; 14:228-9. [PMID: 23388572 PMCID: PMC3728377 DOI: 10.1097/pcc.0b013e31826775cd] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
|
45
|
Effect of hypothermia and extracorporeal life support on drug disposition in neonates. Semin Fetal Neonatal Med 2013; 18:23-7. [PMID: 23158109 DOI: 10.1016/j.siny.2012.10.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a valuable treatment modality in neonates with reversible cardiopulmonary failure in therapy-resistant pulmonary hypertension after perinatal asphyxia, septic shock or ECMO cardiopulmonary resuscitation. Neonates with severe perinatal asphyxia are currently treated with therapeutic hypothermia to improve neurological outcome. Consequently, therapeutic hypothermia may be indicated in the neonatal ECMO population. Both ECMO and hypothermia have been associated with changes in drug disposition. However, little is known about the combined effects of these treatment modalities. This review will explore the available literature, identify possible changes in pharmacokinetics and make suggestions for future research directions.
Collapse
|
46
|
Sappenfield JW, Hong CM, Galvagno SM. Perioperative temperature measurement and management: moving beyond the Surgical Care Improvement Project. ACTA ACUST UNITED AC 2013. [DOI: 10.7243/2049-9752-2-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
47
|
Pharmacokinetics of midazolam in resuscitated patients treated with moderate hypothermia. Int J Clin Pharm 2012. [DOI: 10.1007/s11096-012-9725-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
48
|
Bjelland TW, Klepstad P, Haugen BO, Nilsen T, Dale O. Effects of Hypothermia on the Disposition of Morphine, Midazolam, Fentanyl, and Propofol in Intensive Care Unit Patients. Drug Metab Dispos 2012; 41:214-23. [DOI: 10.1124/dmd.112.045567] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
|
49
|
Wildschut ED, van Saet A, Pokorna P, Ahsman MJ, Van den Anker JN, Tibboel D. The impact of extracorporeal life support and hypothermia on drug disposition in critically ill infants and children. Pediatr Clin North Am 2012; 59:1183-204. [PMID: 23036251 PMCID: PMC4709257 DOI: 10.1016/j.pcl.2012.07.013] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) support is an established lifesaving therapy for potentially reversible respiratory or cardiac failure. In 10% of all pediatric patients receiving ECMO, ECMO therapy is initiated during or after cardiopulmonary resuscitation. Therapeutic hypothermia is frequently used in children after cardiac arrest, despite the lack of randomized controlled trials that show its efficacy. Hypothermia is frequently used in children and neonates during cardiopulmonary bypass (CPB). By combining data from pharmacokinetic studies in children on ECMO and CPB and during hypothermia, this review elucidates the possible effects of hypothermia during ECMO on drug disposition.
Collapse
Affiliation(s)
- Enno D. Wildschut
- Department of Pediatric Surgery, Intensive Care, Erasmus MC-Sophia Children’s Hospital, Dr. Molewaterplein 60, 3015 GJ Rotterdam, The Netherlands,Corresponding author. Department of Pediatric Surgery, Intensive Care, Erasmus MC-Sophia Children’s Hospital, Dr Molewaterplein 60, 3015 GJ Rotterdam, The Netherlands.
| | - Annewil van Saet
- Department of Pediatric Surgery, Intensive Care, Erasmus MC-Sophia Children’s Hospital, Dr. Molewaterplein 60, 3015 GJ Rotterdam, The Netherlands,Department of Cardio-Thoracic Anesthesiology, Erasmus MC, Dr. Molewaterplein 60, 3015 GJ Rotterdam, The Netherlands
| | - Pavla Pokorna
- Department of Pediatric Surgery, Intensive Care, Erasmus MC-Sophia Children’s Hospital, Dr. Molewaterplein 60, 3015 GJ Rotterdam, The Netherlands,Faculty of Medicine, Department of Pediatrics, PICU/NICU, Charles University, ke Karlovu 2, Praha 2, 121 00 Prague, Czech Republic
| | - Maurice J. Ahsman
- LAP&P Consultants BV, Archimedesweg 31, 2333 CM, Leiden, The Netherlands
| | - John N. Van den Anker
- Department of Pediatric Surgery, Intensive Care, Erasmus MC-Sophia Children’s Hospital, Dr. Molewaterplein 60, 3015 GJ Rotterdam, The Netherlands,Division of Pediatric Clinical Pharmacology, Children’s National Medical Center, Sheikh Zayed Campus for Advanced Children’s Medicine, 111 Michigan Avenue, NW, Washington, DC 20010, USA,Department of Pediatrics, School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA,Department of Pharmacology & Physiology, School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA
| | - Dick Tibboel
- Department of Pediatric Surgery, Intensive Care, Erasmus MC-Sophia Children’s Hospital, Dr. Molewaterplein 60, 3015 GJ Rotterdam, The Netherlands
| |
Collapse
|
50
|
|