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Wimmer H, Stensønes SH, Benth JŠ, Lundqvist C, Andersen GØ, Draegni T, Sunde K, Nakstad ER. Outcome prediction in comatose cardiac arrest patients with initial shockable and non-shockable rhythms. Acta Anaesthesiol Scand 2024; 68:263-273. [PMID: 37876138 DOI: 10.1111/aas.14337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 09/16/2023] [Accepted: 09/19/2023] [Indexed: 10/26/2023]
Abstract
BACKGROUND Prognosis after out-of-hospital cardiac arrest (OHCA) is presumed poorer in patients with non-shockable than shockable rhythms, frequently leading to treatment withdrawal. Multimodal outcome prediction is recommended 72 h post-arrest in still comatose patients, not considering initial rhythms. We investigated accuracy of outcome predictors in all comatose OHCA survivors, with a particular focus on shockable vs. non-shockable rhythms. METHODS In this observational NORCAST sub-study, patients still comatose 72 h post-arrest were stratified by shockable vs. non-shockable rhythms for outcome prediction analyzes. Good outcome was defined as cerebral performance category 1-2 within 6 months. False positive rate (FPR) was used for poor and sensitivity for good outcome prediction accuracy. RESULTS Overall, 72/128 (56%) patients with shockable and 12/50 (24%) with non-shockable rhythms had good outcome (p < .001). For poor outcome prediction, absent pupillary light reflexes (PLR) and corneal reflexes (clinical predictors) 72 h after sedation withdrawal, PLR 96 h post-arrest, and somatosensory evoked potentials (SSEP), all had FPR <0.1% in both groups. Unreactive EEG and neuron-specific enolase (NSE) >60 μg/L 24-72 h post-arrest had better precision in shockable patients. For good outcome, the clinical predictors, SSEP and CT, had 86%-100% sensitivity in both groups. For NSE, sensitivity varied from 22% to 69% 24-72 h post-arrest. The outcome predictors indicated severe brain injury proportionally more often in patients with non-shockable than with shockable rhythms. For all patients, clinical predictors, CT, and SSEP, predicted poor and good outcome with high accuracy. CONCLUSION Outcome prediction accuracy was comparable for shockable and non-shockable rhythms. PLR and corneal reflexes had best precision 72 h after sedation withdrawal and 96 h post-arrest.
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Affiliation(s)
- Henning Wimmer
- Department of Acute Medicine, Oslo University Hospital, Ullevål, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Jūratė Šaltytė Benth
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Health Services Research Unit, Akershus University Hospital, Nordbyhagen, Norway
| | - Christofer Lundqvist
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Health Services Research Unit, Akershus University Hospital, Nordbyhagen, Norway
- Department of Neurology, Akershus University Hospital, Nordbyhagen, Norway
| | - Geir Ø Andersen
- Department of Cardiology, Oslo University Hospital, Ullevål, Norway
| | - Tomas Draegni
- Department of Research and Development, Oslo University Hospital, Ullevål, Norway
| | - Kjetil Sunde
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Anaesthesia and Intensive Care, Oslo University Hospital, Ullevål, Norway
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Holzer M, Poole JE, Lascarrou JB, Fujise K, Nichol G. A Commentary on the Effect of Targeted Temperature Management in Patients Resuscitated from Cardiac Arrest. Ther Hypothermia Temp Manag 2023; 13:102-111. [PMID: 36378270 PMCID: PMC10625468 DOI: 10.1089/ther.2022.0041] [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] [Indexed: 11/16/2022] Open
Abstract
The members of the International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support Task Force have written a comprehensive summary of trials of the effectiveness of induced hypothermia (IH) or targeted temperature management (TTM) in comatose patients after cardiac arrest (CA). However, in-depth analysis of these studies is incomplete, especially since there was no significant difference in primary outcome between hypothermia versus normothermia in the recently reported TTM2 trial. We critically appraise trials of IH/TTM versus normothermia to characterize reasons for the lack of treatment effect, based on a previously published framework for what to consider when the primary outcome fails. We found a strong biologic rationale and external clinical evidence that IH treatment is beneficial. Recent TTM trials mainly included unselected patients with a high rate of bystander cardiopulmonary resuscitation. The treatment was not applied as intended, which led to a large delay in achievement of target temperature. While receiving intensive care, sedative drugs were likely used that might have led to increased neurologic damage as were antiplatelet drugs that could be associated with increased acute stent thrombosis in hypothermic patients. It is reasonable to still use or evaluate IH treatment in patients who are comatose after CA as there are multiple plausible reasons why IH compared to normothermia did not significantly improve neurologic outcome in the TTM trials.
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Affiliation(s)
- Michael Holzer
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Jeanne E. Poole
- Division of Cardiology, University of Washington, Seattle, Washington, USA
| | | | - Ken Fujise
- Harborview Medical Center, Heart Institute, University of Washington, Seattle, Washington, USA
| | - Graham Nichol
- Departments of Medicine and Emergency Medicine, University of Washington-Harborview Center for Prehospital Emergency Care, University of Washington, Seattle, Washington, USA
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Geller BJ, Maciel CB, May TL, Jentzer JC. Sedation and shivering management after cardiac arrest. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:518-524. [PMID: 37479475 DOI: 10.1093/ehjacc/zuad087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/17/2023] [Accepted: 07/19/2023] [Indexed: 07/23/2023]
Abstract
Management of sedation and shivering during targeted temperature management (TTM) after cardiac arrest is limited by a dearth of high-quality evidence to guide clinicians. Data from general intensive care unit (ICU) populations can likely be extrapolated to post-cardiac arrest patients, but clinicians should be mindful of key differences that exist between these populations. Most importantly, the goals of sedation after cardiac arrest are distinct from other ICU patients and may also involve suppression of shivering during TTM. Drug metabolism and clearance are altered considerably during TTM when a low goal temperature is used, which can delay accurate neuroprognostication. When neuromuscular blockade is used to prevent shivering, sedation should be deep enough to prevent awareness and providers should be aware that this can mask clinical manifestations of seizures. However, excessively deep or prolonged sedation is associated with complications including delirium, infections, increased duration of ventilatory support, prolonged ICU length of stay, and delays in neuroprognostication. In this manuscript, we review sedation and shivering management best practices in the post-cardiac arrest patient population.
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Affiliation(s)
- Bram J Geller
- Department of Cardiovascular Medicine and Cardiovascular Critical Care Services, Maine Medical Center, Portland, ME, USA
| | - Carolina B Maciel
- Department of Neurology and Neurosurgery and Neurocritical Care, University of Florida, Gainesville, FL, USA
| | - Teresa L May
- Department of Critical Care Medicine, Maine Medical Center, Portland, ME, USA
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
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Chalkias A, Adamos G, Mentzelopoulos SD. General Critical Care, Temperature Control, and End-of-Life Decision Making in Patients Resuscitated from Cardiac Arrest. J Clin Med 2023; 12:4118. [PMID: 37373812 DOI: 10.3390/jcm12124118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 06/02/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
Cardiac arrest affects millions of people per year worldwide. Although advances in cardiopulmonary resuscitation and intensive care have improved outcomes over time, neurologic impairment and multiple organ dysfunction continue to be associated with a high mortality rate. The pathophysiologic mechanisms underlying the post-resuscitation disease are complex, and a coordinated, evidence-based approach to post-resuscitation care has significant potential to improve survival. Critical care management of patients resuscitated from cardiac arrest focuses on the identification and treatment of the underlying cause(s), hemodynamic and respiratory support, organ protection, and active temperature control. This review provides a state-of-the-art appraisal of critical care management of the post-cardiac arrest patient.
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Affiliation(s)
- Athanasios Chalkias
- Department of Anesthesiology, Faculty of Medicine, University of Thessaly, 41500 Larisa, Greece
- Outcomes Research Consortium, Cleveland, OH 44195, USA
| | - Georgios Adamos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, 10675 Athens, Greece
| | - Spyros D Mentzelopoulos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, 10675 Athens, Greece
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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: 0] [Impact Index Per Article: 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.
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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
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Ceric A, May TL, Lybeck A, Cronberg T, Seder DB, Riker RR, Hassager C, Kjaergaard J, Haxhija Z, Friberg H, Dankiewicz J, Nielsen N. Cardiac Arrest Treatment Center Differences in Sedation and Analgesia Dosing During Targeted Temperature Management. Neurocrit Care 2023; 38:16-25. [PMID: 35896768 PMCID: PMC9935704 DOI: 10.1007/s12028-022-01564-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 06/20/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Sedation and analgesia are recommended during targeted temperature management (TTM) after cardiac arrest, but there are few data to provide guidance on dosing to bedside clinicians. We evaluated differences in patient-level sedation and analgesia dosing in an international multicenter TTM trial to better characterize current practice and clinically important outcomes. METHODS A total 950 patients in the international TTM trial were randomly assigned to a TTM of 33 °C or 36 °C after resuscitation from cardiac arrest in 36 intensive care units. We recorded cumulative doses of sedative and analgesic drugs at 12, 24, and 48 h and normalized to midazolam and fentanyl equivalents. We compared number of medications used, dosing, and titration among centers by using multivariable models, including common severity of illness factors. We also compared dosing with time to awakening, incidence of clinical seizures, and survival. RESULTS A total of 614 patients at 18 centers were analyzed. Propofol (70%) and fentanyl (51%) were most frequently used. The average dosages of midazolam and fentanyl equivalents were 0.13 (0.07, 0.22) mg/kg/h and 1.16 (0.49, 1.81) µg/kg/h, respectively. There were significant differences in number of medications (p < 0.001), average dosages (p < 0.001), and titration at all time points between centers (p < 0.001), and the outcomes of patients in these centers were associated with all parameters described in the multivariate analysis, except for a difference in the titration of sedatives between 12 and 24 h (p = 0.40). There were associations between higher dosing at 48 h (p = 0.003, odds ratio [OR] 1.75) and increased titration of analgesics between 24 and 48 h (p = 0.005, OR 4.89) with awakening after 5 days, increased titration of sedatives between 24 and 48 h with awakening after 5 days (p < 0.001, OR > 100), and increased titration of sedatives between 24 and 48 h with a higher incidence of clinical seizures in the multivariate analysis (p = 0.04, OR 240). There were also significant associations between decreased titration of analgesics and survival at 6 months in the multivariate analysis (p = 0.048). CONCLUSIONS There is significant variation in choice of drug, dosing, and titration when providing sedation and analgesics between centers. Sedation and analgesia dosing and titration were associated with delayed awakening, incidence of clinical seizures, and survival, but the causal relation of these findings cannot be proven.
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Affiliation(s)
- Ameldina Ceric
- Division of Anesthesia and Intensive Care, Department of Clinical Sciences Lund, Helsingborg Hospital, Lund University, Svartbrödragränden 3, 251 87, Helsingborg, Sweden.
| | - Teresa L May
- Department of Critical Care, Maine Medical Center, Portland, ME, USA
| | - Anna Lybeck
- Division of Anesthesia and Intensive Care, Department of Clinical Sciences Lund, Skane University Hospital, Lund University, Lund, Sweden
| | - Tobias Cronberg
- Division of Neurology, Department of Clinical Sciences, Skane University Hospital, Lund University, Lund, Sweden
| | - David B Seder
- Department of Critical Care, Maine Medical Center, Portland, ME, USA
| | - Richard R Riker
- Department of Critical Care, Maine Medical Center, Portland, ME, USA
| | - Christian Hassager
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jesper Kjaergaard
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Zana Haxhija
- Division of Anesthesia and Intensive Care, Department of Clinical Sciences Lund, Helsingborg Hospital, Lund University, Svartbrödragränden 3, 251 87, Helsingborg, Sweden
| | - Hans Friberg
- Division of Anesthesia and Intensive Care, Department of Clinical Sciences Lund, Skane University Hospital, Lund University, Malmö, Sweden
| | - Josef Dankiewicz
- Division of Cardiology, Department of Clinical Sciences Lund, Skane University Hospital, Lund University, Lund, Sweden
| | - Niklas Nielsen
- Division of Anesthesia and Intensive Care, Department of Clinical Sciences Lund, Helsingborg Hospital, Lund University, Svartbrödragränden 3, 251 87, Helsingborg, Sweden
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Bäcke P, Bruschettini M, Blomqvist YT, Sibrecht G, Olsson E. Interventions for the Management of Pain and Sedation in Newborns Undergoing Therapeutic Hypothermia for Hypoxic-Ischemic Encephalopathy: A Systematic Review. Paediatr Drugs 2023; 25:27-41. [PMID: 36481984 PMCID: PMC9810674 DOI: 10.1007/s40272-022-00546-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/06/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Newborn infants undergoing therapeutic hypothermia (TH) are exposed to multiple painful and stressful procedures. The aim of this systematic review was to assess benefits and harms of pharmacological and non-pharmacological interventions for the management of pain and sedation in newborn infants undergoing TH for hypoxic-ischemic encephalopathy. METHODS We included randomized and observational studies reporting any intervention (either drugs or non-pharmacological interventions) to manage pain and sedation in newborn infants (> 33 weeks' gestational age) undergoing TH. We included any dose, duration and route of administration. We also included any type and duration of non-pharmacological interventions. Our prespecified primary outcomes were analgesia and sedation assessed using validated pain scales in the neonatal population; circulatory instability; mortality to discharge; and neurodevelopmental disability. A systematic literature search was conducted in the PubMed, Embase, CINAHL, Cochrane CENTRAL, Scopus, and Web of Science databases, with no language restrictions. Included studies underwent risk-of-bias assessment (Cochrane risk-of-bias tool and ROBINS-I) and data extraction performed by two authors independently. The plan had been to use effect measures such as mean difference for continuous outcomes and risk ratio for dichotomous outcomes, however the included studies are presented in a narrative synthesis due to their paucity and heterogeneity. RESULTS Ten studies involving 3551 infants were included-one trial and nine observational studies. Most studies examined the use of phenobarbital or other antiepileptic drugs with primary outcomes related to seizure activity. The single trial that was included compared pentoxifylline with placebo. Among the primary outcomes, six studies reported circulatory instability and five reported mortality to discharge without relevant differences; two studies reported on neurodevelopmental disability and one study reported on pain scale. Three studies were ongoing. CONCLUSIONS We found limited evidence to establish the benefits and harms of the interventions for the management of pain and sedation in newborn infants undergoing TH. Long-term outcomes were not reported. Given the very low certainty of evidence-due to imprecision of the estimates, inconsistency and limitations in study design (all nine observational studies with overall serious risk of bias)-for all outcomes, clinical trials are required to determine the most effective interventions in this population. SYSTEMATIC REVIEW REGISTRATION PROSPERO registration number: CRD42020205755.
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Affiliation(s)
- Pyrola Bäcke
- Neonatal Intensive Care Unit, University Hospital, Uppsala, Sweden ,Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
| | - Matteo Bruschettini
- Department of Pediatrics, Lund University, Lund, Sweden ,Cochrane Sweden; Research and Education, Skåne University Hospital, Lund, Sweden
| | - Ylva Thernström Blomqvist
- Neonatal Intensive Care Unit, University Hospital, Uppsala, Sweden ,Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
| | - Greta Sibrecht
- Newborns’ Infectious Diseases Department, Poznan University of Medical Sciences, Poznan, Poland
| | - Emma Olsson
- Department of Pediatrics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden. .,Faculty of Medicine and Health, School of Health Sciences, Örebro University, S-701 82, Örebro, Sweden.
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The Impact of Low Cardiac Output on Propofol Pharmacokinetics across Age Groups-An Investigation Using Physiologically Based Pharmacokinetic Modelling. Pharmaceutics 2022; 14:pharmaceutics14091957. [PMID: 36145705 PMCID: PMC9502676 DOI: 10.3390/pharmaceutics14091957] [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: 08/05/2022] [Revised: 09/09/2022] [Accepted: 09/13/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND pathophysiological changes such as low cardiac output (LCO) impact pharmacokinetics, but its extent may be different throughout pediatrics compared to adults. Physiologically based pharmacokinetic (PBPK) modelling enables further exploration. METHODS A validated propofol model was used to simulate the impact of LCO on propofol clearance across age groups using the PBPK platform, Simcyp® (version 19). The hepatic and renal extraction ratio of propofol was then determined in all age groups. Subsequently, manual infusion dose explorations were conducted under LCO conditions, targeting a 3 µg/mL (80-125%) propofol concentration range. RESULTS Both hepatic and renal extraction ratios increased from neonates, infants, children to adolescents and adults. The relative change in clearance following CO reductions increased with age, with the least impact of LCO in neonates. The predicted concentration remained within the 3 µg/mL (80-125%) range under normal CO and LCO (up to 30%) conditions in all age groups. When CO was reduced by 40-50%, a dose reduction of 15% is warranted in neonates, infants and children, and 25% in adolescents and adults. CONCLUSIONS PBPK-driven, the impact of reduced CO on propofol clearance is predicted to be age-dependent, and proportionally greater in adults. Consequently, age group-specific dose reductions for propofol are required in LCO conditions.
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Ceric A, Holgersson J, May T, Skrifvars MB, Hästbacka J, Saxena M, Aneman A, Delaney A, Reade MC, Delcourt C, Jakobsen J, Nielsen N. Level of sedation in critically ill adult patients: a protocol for a systematic review with meta-analysis and trial sequential analysis. BMJ Open 2022; 12:e061806. [PMID: 36691212 PMCID: PMC9462111 DOI: 10.1136/bmjopen-2022-061806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 08/10/2022] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION It is standard of care to provide sedation to critically ill patients to reduce anxiety, discomfort and promote tolerance of mechanical ventilation. Given that sedatives can have differing effects based on a variety of patient and pharmacological characteristics, treatment approaches are largely based on targeting the level of sedation. The benefits of differing levels of sedation must be balanced against potential adverse effects including haemodynamic instability, causing delirium, delaying awakening and prolonging the time of mechanical ventilation and intensive care stay. This systematic review with meta-analysis aims to investigate the current evidence and compare the effects of differing sedation levels in adult critically ill patients. METHODS AND ANALYSES We will conduct a systematic review based on searches of preidentified major medical databases (eg, MEDLINE, EMBASE, CENTRAL) and clinical trial registries from their inception onwards to identify trials meeting inclusion criteria. We will include randomised clinical trials comparing any degree of sedation with no sedation and lighter sedation with deeper sedation for critically ill patients admitted to the intensive care unit. We will include aggregate data meta-analyses and trial sequential analyses. Risk of bias will be assessed with domains based on the Cochrane risk of bias tool. An eight-step procedure will be used to assess if the thresholds for clinical significance are crossed, and the certainty of the evidence will be assessed using Grades of Recommendations, Assessment, Development and Evaluation. ETHICS AND DISSEMINATION No formal approval or review of ethics is required as individual patient data will not be included. This systematic review has the potential to highlight (1) whether one should believe sedation to be beneficial, harmful or neither in critically ill adults; (2) the existing knowledge gaps and (3) whether the recommendations from guidelines and daily clinical practice are supported by current evidence. These results will be disseminated through publication in a peer-reviewed journal.
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Affiliation(s)
- Ameldina Ceric
- Department of Clinical Sciences Lund, Anesthesia and Intensive Care, Lund University, Helsingborg Hospital, Helsingborg, Sweden
| | - Johan Holgersson
- Department of Clinical Sciences Lund, Anesthesia and Intensive Care, Lund University, Helsingborg Hospital, Helsingborg, Sweden
| | - Teresa May
- Department of Critical Care, Maine Medical Center, Portland, Maine, USA
| | - Markus B Skrifvars
- Department of Emergency Care and Services, Helsinki University, Helsinki University Hospital, Helsinki, Finland
| | - Johanna Hästbacka
- Department of Anesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Manoj Saxena
- Senior Lecturer, Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Anders Aneman
- Intensive Care Unit, South Western Sydney Local Health District, Liverpool Hospital, South Western Sydney Local Health District, South Western Sydney Clinical School, University of New South Wales, and Faculty of Medicine, Health and Human Sciences, Macquarie University, Liverpool, New South Wales, Australia
| | - Anthony Delaney
- The George Institute for Global Health and the University of New South Wales, Sydney, New South Wales, Australia
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Michael C Reade
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Denmark, Denmark
| | - Candice Delcourt
- Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Janus Jakobsen
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Denmark, Denmark
| | - Niklas Nielsen
- Department of Clinical Sciences Lund, Anesthesia and Intensive Care, Lund University, Helsingborg Hospital, Helsingborg, Sweden
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Poppe M, Clodi C, Schriefl C, Mueller M, Sunder-Plaßmann R, Reiter B, Rechenmacher M, van Os W, van Hasselt JGC, Holzer M, Herkner H, Schwameis M, Jilma B, Schoergenhofer C, Weiser C. Targeted temperature management after cardiac arrest is associated with reduced metabolism of pantoprazole - A probe drug of CYP2C19 metabolism. Biomed Pharmacother 2021; 146:112573. [PMID: 34959115 DOI: 10.1016/j.biopha.2021.112573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 12/16/2021] [Accepted: 12/19/2021] [Indexed: 11/02/2022] Open
Abstract
OBJECTIVE Targeted temperature management (TTM) is part of standard post-resuscitation care. TTM may downregulate cytochrome enzyme activity and thus impact drug metabolism. This study compared the pharmacokinetics (PK) of pantoprazole, a probe drug of CYP2C19-dependent metabolism, at different stages of TTM following cardiac arrest. METHODS This prospective controlled study was performed at the Medical University of Vienna and enrolled 16 patients following cardiac arrest. The patients completed up to three study periods (each lasting 24 h) in which plasma concentrations of pantoprazole were quantified: (P1) hypothermia (33 °C) after admission, (P2) normothermia after rewarming (36 °C, intensive care), and (P3) normothermia during recovery (normal ward, control group). PK was analysed using non-compartmental analysis and nonlinear mixed-effects modelling. RESULTS 16 patients completed periods P1 and P2; ten completed P3. The median half-life of pantoprazole was 2.4 h (quartiles: 1.8-4.8 h) in P1, 2.8 h (2.1-6.8 h, p = 0.046 vs. P1, p = 0.005 vs. P3) in P2 and 1.2 h (0.9 - 2.3 h, p = 0.007 vs. P1) in P3. A two-compartment model described the PK data best. Typical values for clearance were estimated separately for each study period, indicating 40% and 29% reductions during P1 and P2, respectively, compared to P3. The central volume of distribution was estimated separately for P2, indicating a 64% increase compared to P1 and P3. CONCLUSION CYP2C19-dependent drug metabolism is downregulated during TTM following cardiac arrest. These results may influence drug choice and dosing of similarly metabolized drugs and may be helpful for designing studies in similar clinical situations.
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Affiliation(s)
- Michael Poppe
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Christian Clodi
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | | | - Matthias Mueller
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Raute Sunder-Plaßmann
- Clinical Institute of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Birgit Reiter
- Clinical Institute of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | | | - Wisse van Os
- Department of Clinical Pharmacology, Medical University of Vienna, Austria
| | | | - Michael Holzer
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Harald Herkner
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Michael Schwameis
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Austria
| | | | - Christoph Weiser
- Department of Emergency Medicine, Medical University of Vienna, Austria
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Bienert A, Sobczyński P, Młodawska K, Hartmann-Sobczyńska R, Grześkowiak E, Wiczling P. The influence of cardiac output on propofol and fentanyl pharmacokinetics and pharmacodynamics in patients undergoing abdominal aortic surgery. J Pharmacokinet Pharmacodyn 2020; 47:583-596. [PMID: 32840723 PMCID: PMC7652808 DOI: 10.1007/s10928-020-09712-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 08/13/2020] [Indexed: 12/27/2022]
Abstract
Cardiac output (CO) is expected to affect elimination and distribution of highly extracted and perfusion rate-limited drugs. This work was undertaken to quantify the effect of CO measured by the pulse pressure method on pharmacokinetics and pharmacodynamics of propofol and fentanyl administrated during total intravenous anesthesia (TIVA). The data were obtained from 22 ASA III patients undergoing abdominal aortic surgery. Propofol was administered via target-controlled infusion system (Diprifusor) and fentanyl was administered at a dose of 2-3 µg/kg each time analgesia appeared to be inadequate. Hemodynamic measurements as well as bispectral index were monitored and recorded throughout the surgery. Data analysis was performed by using a non-linear mixed-effect population modeling (NONMEM 7.4 software). Three compartment models that incorporated blood flows as parameters were used to describe propofol and fentanyl pharmacokinetics. The delay of the anesthetic effect, with respect to plasma concentrations, was described using a biophase (effect) compartment. The bispectral index was linked to the propofol and fentanyl effect site concentrations through a synergistic Emax model. An empirical linear model was used to describe CO changes observed during the surgery. Cardiac output was identified as an important predictor of propofol and fentanyl pharmacokinetics. Consequently, it affected the depth of anesthesia and the recovery time after propofol-fentanyl TIVA infusion cessation. The model predicted (not observed) CO values correlated best with measured responses. Patients' age was identified as a covariate affecting the rate of CO changes during the anesthesia leading to age-related difference in individual patient's responses to both drugs.
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Affiliation(s)
- Agnieszka Bienert
- Department of Clinical Pharmacy and Biopharmacy, Poznan University of Medical Sciences, Sw. Marii Magdaleny 14 Street, 61-861, Poznan, Poland.
| | - Paweł Sobczyński
- Department of Anesthesiology and Intensive Therapy, Poznan University of Medical Sciences, 1/2 Długa Str., 61-848, Poznań, Poland
| | - Katarzyna Młodawska
- Department of Clinical Pharmacy and Biopharmacy, Poznan University of Medical Sciences, Sw. Marii Magdaleny 14 Street, 61-861, Poznan, Poland
| | - Roma Hartmann-Sobczyńska
- Department of Experimental Anaesthesiology, Poznan University of Medical Sciences, Sw. Marii Magdaleny 14 Street, 61-861, Poznan, Poland
| | - Edmund Grześkowiak
- Department of Clinical Pharmacy and Biopharmacy, Poznan University of Medical Sciences, Sw. Marii Magdaleny 14 Street, 61-861, Poznan, Poland
| | - Paweł Wiczling
- Department of Biopharmacy and Pharmacodynamics, Medical University of Gdansk, Hallera 107 Street, 80-416, Gdansk, Poland
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12
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Jutras M, Williamson D, Chassé M, Leclair G. Development and validation of a liquid chromatography coupled to tandem mass spectrometry method for the simultaneous quantification of five analgesics and sedatives, and six of their active metabolites in human plasma: Application to a clinical study on the determination of neurological death in the intensive care unit. J Pharm Biomed Anal 2020; 190:113521. [PMID: 32861167 DOI: 10.1016/j.jpba.2020.113521] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 07/13/2020] [Accepted: 07/28/2020] [Indexed: 11/29/2022]
Abstract
A sensitive and selective high-performance liquid chromatographic method coupled to tandem mass spectrometry was developed and validated for the quantification of morphine, hydromorphone, fentanyl, midazolam and propofol and their metabolites morphine-3-β-d-glucuronide, morphine-6-β-d-glucuronide, hydromorphone-3-β-d-glucuronide, 1'-hydroxymidazolam-β-d-glucuronide, α-hydroxymidazolam and 4-hydroxymidazolam in human plasma using potassium oxalate/sodium fluoride mixture as anticoagulant. Human plasma samples (0.4 mL) to which were added a mixture of eleven deuterated internal standards were subjected to solid phase extraction using a mixed-mode polymeric Oasis PRiME MCX in 96-well format. Propofol was selectively eluted and further derivatized using 2-Fluoro-1-methylpyridinium p-toluenesulfonate, whereas the remaining 10 analytes were eluted separately and further concentrated. The derivatized propofol was analyzed separately in a second injection. The analytes were chromatographically separated on a Kinetex phenyl-hexyl analytical column in gradient elution mode, using a mobile phase consisting of aqueous ammonium formate/formic acid buffer and methanol. The overall run time was 8 min. Detection was performed using an AB/SCIEX 4000 QTRAP instrument with positive electrospray ionization employing scheduled multiple reaction monitoring mode. The lower limits of quantification ranged from 0.02 to 5 ng/mL depending on the analyte. Calibration curves covered a concentration range of 1000× in all cases but 1'-hydroxymidazolam-β-d-glucuronide where it covered a range of 500 × . The validated method was accurate and precise, the intra-day accuracy and precision of quality control samples (4 concentration levels, n = 6 each) being within 91.5-112 % and 1.3-13.2 % (coefficient of variation), respectively, and inter-day (n = 24; 4 days) accuracy and precision of quality control samples (3 concentration levels) being within 94.8-103.5 % and 3.2-11.2 % (coefficient of variation). Mean absolute extraction recoveries were above 60 % for all compounds, except for hydromorphone-3-β-d-glucuronide (44 %) and for 1'-hydroxymidazolam-β-d-glucuronide (33 %). Internal standard corrected matrix effect ranged from -4.8 to 3.8 % in normal plasma and in plasma containing 1 % hemolyzed blood. Analytes were stable (above 90 %) in plasma and blood for 19 h at 22 °C, in blood for 90 h at 5 °C, in plasma for 60 days at -20 °C, for 4 months at -70 °C and after three freeze-thaw cycles, and in the injection solvent for at least 3 days in the autosampler. The present method is successfully being applied in a multicenter clinical study for the analysis of plasma samples from patients in intensive care units from a number of Canadian hospitals.
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Affiliation(s)
- Martin Jutras
- Platform of Biopharmacy, Faculty of Pharmacy, Université de Montréal, H3T 1J4, Canada.
| | - David Williamson
- Platform of Biopharmacy, Faculty of Pharmacy, Université de Montréal, H3T 1J4, Canada; Research Center and Pharmacy Department, Hôpital du Sacré-Coeur de Montréal, H4J 1C5, Canada.
| | - Michaël Chassé
- Faculty of Medecine, Université de Montréal, H3T 1J4, Canada; Research Center and Department of Medicine (Critical Care), Centre Hospitalier de l'Université de Montréal, H2X 0A9, Canada.
| | - Grégoire Leclair
- Platform of Biopharmacy, Faculty of Pharmacy, Université de Montréal, H3T 1J4, Canada.
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Late awakening, prognostic factors and long-term outcome in out-of-hospital cardiac arrest – results of the prospective Norwegian Cardio-Respiratory Arrest Study (NORCAST). Resuscitation 2020; 149:170-179. [DOI: 10.1016/j.resuscitation.2019.12.031] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 11/24/2019] [Accepted: 12/04/2019] [Indexed: 02/02/2023]
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14
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Baldwin F, Gray R, Boyd O, Waxman D, Patel B, Allen M, Scutt G. Safe prognostication following cardiac arrest: The role of the pharmacokinetics of fentanyl in patients treated with targeted temperature management. Resuscitation 2020; 149:10-16. [DOI: 10.1016/j.resuscitation.2020.01.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 01/23/2020] [Accepted: 01/26/2020] [Indexed: 11/25/2022]
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16
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Thomas I, Manara A. Pitfalls in the diagnosis of death using neurological criteria. BJA Educ 2020; 20:2-4. [DOI: 10.1016/j.bjae.2019.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2019] [Indexed: 12/01/2022] Open
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Üner IL, Johansen T, Dahle J, Persson M, Stiris T, Andresen JH. Therapeutic hypothermia and N-PASS; results from implementation in a level 3 NICU. Early Hum Dev 2019; 137:104828. [PMID: 31357084 DOI: 10.1016/j.earlhumdev.2019.104828] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 07/22/2019] [Accepted: 07/23/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Neonates that have been subjected to perinatal asphyxia and fulfill criteria for therapeutic hypothermia are cooled to 33.5 °C for 72 h. There is no consensus regarding sedation and analgesic use during hypothermia, but there is evidence supporting the importance of pain relief and adequate sedation. There is a need for assessment of the neonates need for pain relief and sedation, and for adjustments of medication to ensure adequate treatment. There are many different scoring tools available. We found the N-PASS (Neonatal Pain, Agitation and Sedation Scale) scoring tool to be the most suitable for this patient group as it assesses both pain and sedation. METHODS We translated the scoring tool according to guidelines published by Wilder et al., and scored neonates treated with therapeutic hypothermia. Sedation and analgesia were adjusted according to scoring results. At the end of the study a questionnaire was filled out by the nurses in charge of this group of patients. RESULTS Both pain and sedation scores did not reach the desired levels until day 3. The nurses reported a high level of satisfaction (79.7% were extremely of very satisfied), and 96.7% of the nurses found the neonates to be better pain relieved after the initiation of the study. CONCLUSION The implementation of the N-PASS scoring tool in our unit has been successful, and has led to better pain relief and sedation than before the implementation.
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Affiliation(s)
| | - Tove Johansen
- Department of Neonatology, Oslo University Hospital, Norway.
| | - Julie Dahle
- Department of Neonatology, Oslo University Hospital, Norway.
| | - Mette Persson
- Department of Neonatology, Oslo University Hospital, Norway.
| | - Tom Stiris
- Department of Neonatology, Oslo University Hospital, Norway; Faculty of Medicine, University of Oslo, Norway.
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Variation in Sedation and Neuromuscular Blockade Regimens on Outcome After Cardiac Arrest. Crit Care Med 2019; 46:e975-e980. [PMID: 29979225 PMCID: PMC6138551 DOI: 10.1097/ccm.0000000000003301] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Sedation and neuromuscular blockade protocols in patients undergoing targeted temperature management after cardiac arrest address patient discomfort and manage shivering. These protocols vary widely between centers and may affect outcomes. DESIGN Consecutive patients admitted to 20 centers after resuscitation from cardiac arrest were prospectively entered into the International Cardiac Arrest Registry between 2006 and 2016. Additional data about each center's sedation and shivering management practice were obtained via survey. Sedation and shivering practices were categorized as escalating doses of sedation and minimal or no neuromuscular blockade (sedation and shivering practice 1), sedation with continuous or scheduled neuromuscular blockade (sedation and shivering practice 2), or sedation with as-needed neuromuscular blockade (sedation and shivering practice 3). Good outcome was defined as Cerebral Performance Category score of 1 or 2. A logistic regression hierarchical model was created with two levels (patient-level data with standard confounders at level 1 and hospitals at level 2) and sedation and shivering practices as a fixed effect at the hospital level. The primary outcome was dichotomized Cerebral Performance Category at 6 months. SETTING Cardiac arrest receiving centers in Europe and the United states from 2006 to 2016 PATIENTS:: Four-thousand two-hundred sixty-seven cardiac arrest patients 18 years old or older enrolled in the International Cardiac Arrest Registry. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The mean age was 62 ± 15 years, 36% were female, 77% out-of-hospital arrests, and mean ischemic time was 24 (± 18) minutes. Adjusted odds ratio (for age, return of spontaneous circulation, location of arrest, witnessed, initial rhythm, bystander cardiopulmonary resuscitation, defibrillation, medical history, country, and size of hospital) was 1.13 (0.74-1.73; p = 0.56) and 1.45 (1.00-2.13; p = 0.046) for sedation and shivering practice 2 and sedation and shivering practice 3, respectively, referenced to sedation and shivering practice 1. CONCLUSION Cardiac arrest patients treated at centers using as-needed neuromuscular blockade had increased odds of good outcomes compared with centers using escalating sedation doses and avoidance of neuromuscular blockade, after adjusting for potential confounders. These findings should be further investigated in prospective studies.
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19
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Eyileten C, Soplinska A, Pordzik J, Siller‐Matula JM, Postuła M. Effectiveness of Antiplatelet Drugs Under Therapeutic Hypothermia: A Comprehensive Review. Clin Pharmacol Ther 2019; 106:993-1005. [DOI: 10.1002/cpt.1492] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 04/12/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Ceren Eyileten
- Department of Experimental and Clinical PharmacologyCenter for Preclinical Research and Technology CEPTMedical University of Warsaw Warsaw Poland
| | - Aleksandra Soplinska
- Department of Experimental and Clinical PharmacologyCenter for Preclinical Research and Technology CEPTMedical University of Warsaw Warsaw Poland
| | - Justyna Pordzik
- Department of Experimental and Clinical PharmacologyCenter for Preclinical Research and Technology CEPTMedical University of Warsaw Warsaw Poland
| | | | - Marek Postuła
- Department of Experimental and Clinical PharmacologyCenter for Preclinical Research and Technology CEPTMedical University of Warsaw Warsaw Poland
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Circulating Levels of miR-574-5p Are Associated with Neurological Outcome after Cardiac Arrest in Women: A Target Temperature Management (TTM) Trial Substudy. DISEASE MARKERS 2019; 2019:1802879. [PMID: 31275442 PMCID: PMC6589199 DOI: 10.1155/2019/1802879] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 03/18/2019] [Accepted: 03/26/2019] [Indexed: 01/10/2023]
Abstract
Purpose Postresuscitation neuroprognostication is guided by neurophysiological tests, biomarker measurement, and clinical examination. Recent investigations suggest that circulating microRNAs (miRNA) may help in outcome prediction after cardiac arrest. We assessed the ability of miR-574-5p to predict neurological outcome after cardiac arrest, in a sex-specific manner. Methods In this substudy of the Target Temperature Management (TTM) Trial, we enrolled 590 cardiac arrest patients for which blood samples were available. Expression levels of miR-574-5p were measured by quantitative PCR in plasma samples collected 48 h after cardiac arrest. The endpoint of the study was poor neurological outcome at 6 months (cerebral performance category scores 3 to 5). Results Eighty-one percent of patients were men, and 49% had a poor neurological outcome. Circulating levels of miR-574-5p at 48 h were higher in patients with a poor neurological outcome at 6 months (p < 0.001), both in women and in men. Circulating levels of miR-574-5p were univariate predictors of neurological outcome (odds ratio (OR) [95% confidence interval (CI)]: 1.5 [1.26-1.78]). After adjustment with clinical variables and NSE, circulating levels of miR-574-5p predicted neurological outcome in women (OR [95% CI]: 1.9 [1.09-3.45]), but not in men (OR [95% CI]: 1.0 [0.74-1.28]). Conclusion miR-574-5p is associated with neurological outcome after cardiac arrest in women.
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21
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Zaporowska-Stachowiak I, Szymański K, Oduah MT, Stachowiak-Szymczak K, Łuczak J, Sopata M. Midazolam: Safety of use in palliative care: A systematic critical review. Biomed Pharmacother 2019; 114:108838. [PMID: 30981104 DOI: 10.1016/j.biopha.2019.108838] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 03/29/2019] [Accepted: 03/31/2019] [Indexed: 10/27/2022] Open
Abstract
PURPOSE The undesired effects of midazolam can be life-threatening. This paper delineates the findings related to the pharmacokinetics, adverse effects and drug-drug interactions as well as associated therapeutic implications for safe midazolam use. METHODS A systematic review of literature was conducted. RESULTS The pharmacokinetics of midazolam depends on hepatic and renal functions, fat tissue mass, route and duration of administration, as well as potential drug-drug interactions. Palliative care patients constitute a high-risk group prone to side effects of drugs, due to polytherapy and multi-organ failure. CONCLUSION Midazolam is one of three most frequently administered drugs in palliative care. The indications for its use include anxiety, dyspnea, seizures, vomiting refractory to treatment, agitation, myoclonus, status epilepticus, restlessness, delirium, pruritus, hiccups, insomnia, analgosedation, palliative sedation and preventing or counteracting undesired effects of ketamine.
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Affiliation(s)
- Iwona Zaporowska-Stachowiak
- Chair and Department of Pharmacology, Poznan University of Medical Sciences, Poland; Palliative Medicine In-Patient Unit, University Hospital of Lord's Transfiguration, Poznan University of Medical Sciences, Poland.
| | - Krzysztof Szymański
- Students' Scientific Society, Poznan University of Medical Sciences, Poznań, Poland
| | - Mary-Tiffany Oduah
- English Students' Research Association, Poznan University of Medical Sciences, Poland
| | - Katarzyna Stachowiak-Szymczak
- Department of Interpreting Studies and Audiovisual Translation, Institute of Applied Linguistics, University of Warsaw, Poland
| | - Jacek Łuczak
- Department of Palliative Medicine, Poznan University of Medical Sciences, Poland
| | - Maciej Sopata
- Department of Palliative Medicine, Poznan University of Medical Sciences, Poland
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Andrews PJ, Sinclair HL, Rodríguez A, Harris B, Rhodes J, Watson H, Murray G. Therapeutic hypothermia to reduce intracranial pressure after traumatic brain injury: the Eurotherm3235 RCT. Health Technol Assess 2019; 22:1-134. [PMID: 30168413 DOI: 10.3310/hta22450] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Traumatic brain injury (TBI) is a major cause of disability and death in young adults worldwide. It results in around 1 million hospital admissions annually in the European Union (EU), causes a majority of the 50,000 deaths from road traffic accidents and leaves a further ≈10,000 people severely disabled. OBJECTIVE The Eurotherm3235 Trial was a pragmatic trial examining the effectiveness of hypothermia (32-35 °C) to reduce raised intracranial pressure (ICP) following severe TBI and reduce morbidity and mortality 6 months after TBI. DESIGN An international, multicentre, randomised controlled trial. SETTING Specialist neurological critical care units. PARTICIPANTS We included adult participants following TBI. Eligible patients had ICP monitoring in place with an ICP of > 20 mmHg despite first-line treatments. Participants were randomised to receive standard care with the addition of hypothermia (32-35 °C) or standard care alone. Online randomisation and the use of an electronic case report form (CRF) ensured concealment of random treatment allocation. It was not possible to blind local investigators to allocation as it was obvious which participants were receiving hypothermia. We collected information on how well the participant had recovered 6 months after injury. This information was provided either by the participant themself (if they were able) and/or a person close to them by completing the Glasgow Outcome Scale - Extended (GOSE) questionnaire. Telephone follow-up was carried out by a blinded independent clinician. INTERVENTIONS The primary intervention to reduce ICP in the hypothermia group after randomisation was induction of hypothermia. Core temperature was initially reduced to 35 °C and decreased incrementally to a lower limit of 32 °C if necessary to maintain ICP at < 20 mmHg. Rewarming began after 48 hours if ICP remained controlled. Participants in the standard-care group received usual care at that centre, but without hypothermia. MAIN OUTCOME MEASURES The primary outcome measure was the GOSE [range 1 (dead) to 8 (upper good recovery)] at 6 months after the injury as assessed by an independent collaborator, blind to the intervention. A priori subgroup analysis tested the relationship between minimisation factors including being aged < 45 years, having a post-resuscitation Glasgow Coma Scale (GCS) motor score of < 2 on admission, having a time from injury of < 12 hours and patient outcome. RESULTS We enrolled 387 patients from 47 centres in 18 countries. The trial was closed to recruitment following concerns raised by the Data and Safety Monitoring Committee in October 2014. On an intention-to-treat basis, 195 participants were randomised to hypothermia treatment and 192 to standard care. Regarding participant outcome, there was a higher mortality rate and poorer functional recovery at 6 months in the hypothermia group. The adjusted common odds ratio (OR) for the primary statistical analysis of the GOSE was 1.54 [95% confidence interval (CI) 1.03 to 2.31]; when the GOSE was dichotomised the OR was 1.74 (95% CI 1.09 to 2.77). Both results favoured standard care alone. In this pragmatic study, we did not collect data on adverse events. Data on serious adverse events (SAEs) were collected but were subject to reporting bias, with most SAEs being reported in the hypothermia group. CONCLUSIONS In participants following TBI and with an ICP of > 20 mmHg, titrated therapeutic hypothermia successfully reduced ICP but led to a higher mortality rate and worse functional outcome. LIMITATIONS Inability to blind treatment allocation as it was obvious which participants were randomised to the hypothermia group; there was biased recording of SAEs in the hypothermia group. We now believe that more adequately powered clinical trials of common therapies used to reduce ICP, such as hypertonic therapy, barbiturates and hyperventilation, are required to assess their potential benefits and risks to patients. TRIAL REGISTRATION Current Controlled Trials ISRCTN34555414. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 45. See the NIHR Journals Library website for further project information. The European Society of Intensive Care Medicine supported the pilot phase of this trial.
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Affiliation(s)
- Peter Jd Andrews
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - H Louise Sinclair
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Aryelly Rodríguez
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Bridget Harris
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | | | | | - Gordon Murray
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
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23
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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.
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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
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Khan S, Meyers CM, Bentley S, Manini AF. Impact of Targeted Temperature Management on ED Patients with Drug Overdose-Related Cardiac Arrest. J Med Toxicol 2018; 15:22-29. [PMID: 30411236 DOI: 10.1007/s13181-018-0686-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 10/17/2018] [Accepted: 10/19/2018] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION Drug overdose is the leading cause of non-traumatic out-of-hospital cardiac arrest (OHCA) among young adults. This study investigates whether targeted temperature management (TTM) improves hospital survival from presumed overdose-related cardiac arrest. METHODS Retrospective chart review of consecutive cardiac arrests presenting to an urban tertiary care hospital ED from 2011 to 2015. ED patients with cardiac arrest were included if < 50 years old, and excluded if there was a non-overdose etiology (e.g., trauma, ST-elevation myocardial infarction, subarachnoid hemorrhage). The main intervention was TTM, carried out with a combination of the Arctic Sun device and refrigerated crystalloid/antipyretics (goal temperature 33-36 °C). The primary outcome was survival to hospital discharge; neurologically intact survival was the secondary outcome. RESULTS Of 923 patients with cardiac arrest, 802 (86.9%) met exclusion criteria, leaving 121 patients for final analysis. There were 29 patients in the TTM group (24.0%) vs 92 patients in the non-TTM group (76.0%). Eleven patients (9.1%) survived to hospital discharge. TTM was associated with increased odds of survival to hospital discharge (OR 11.3, 95% CI 2.8-46.3, p < 0.001), which increased substantially when palliative outcomes were excluded from the cohort (OR 117.3, 95% CI 17.0-808.4, p < 0.001). Despite achieving statistical significance (OR 1.1, 95% CI 1.0-1.3), TTM had no clinically significant effect on neurologically intact survival. CONCLUSIONS TTM was associated with improved survival in ED patients with presumed drug overdose-related cardiac arrest. The impact of TTM on neurologically intact survival among these patients requires further study.
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Affiliation(s)
- Sharaf Khan
- Department of Emergency Medicine, The Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Chad M Meyers
- Department of Emergency Medicine, The Icahn School of Medicine at Mount Sinai, Elmhurst Hospital Center, New York, NY, USA
| | - Suzanne Bentley
- Department of Emergency Medicine, The Icahn School of Medicine at Mount Sinai, Elmhurst Hospital Center, New York, NY, USA
| | - Alex F Manini
- Division of Medical Toxicology, The Icahn School of Medicine at Mount Sinai, Elmhurst Hospital Center, New York, NY, USA
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Brinkman D, Wang JH, Redmond HP. Morphine as a treatment of cancer-induced pain-is it safe? A review of in vivo studies and mechanisms. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2018; 391:1169-1178. [PMID: 30232510 DOI: 10.1007/s00210-018-1565-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 09/11/2018] [Indexed: 11/26/2022]
Abstract
Morphine has been used in the treatment of pain for centuries. It is commonly used by oncology in terminal cancer cases and by surgery perioperatively for oncology surgery. Its extra-analgesic effects on cancer have been described extensively but conflicting results abound. It has been shown to have varying effects on tumour progression, cell proliferation, tumour invasion, angiogenesis, immune function, and metastatic potential. In vivo studies on the effects of morphine and the mu-opioid receptor on tumours are discussed below. Mechanisms involved are also discussed, drawn from a combination of both in vivo and in vitro methods. At present, no consensus can be drawn from data collected, and further studies are necessary to elicit the safest method and agent for analgesia in oncology patients.
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Affiliation(s)
- David Brinkman
- Department of Academic Surgery, Cork University Hospital, Wilton, Cork, Ireland.
- University College Cork, College Road, Cork, Ireland.
| | - Jiang H Wang
- Department of Academic Surgery, Cork University Hospital, Wilton, Cork, Ireland
- University College Cork, College Road, Cork, Ireland
| | - Henry P Redmond
- Department of Academic Surgery, Cork University Hospital, Wilton, Cork, Ireland
- University College Cork, College Road, Cork, Ireland
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Huang W, Isoherranen N. Development of a Dynamic Physiologically Based Mechanistic Kidney Model to Predict Renal Clearance. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2018; 7:593-602. [PMID: 30043446 PMCID: PMC6157663 DOI: 10.1002/psp4.12321] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 05/31/2018] [Indexed: 11/10/2022]
Abstract
Renal clearance is usually predicted via empirical approaches including quantitative structure activity relationship and allometric scaling. Recently, mechanistic prediction approaches using in silico kidney models have been proposed. However, empirical scaling factors are typically used to adjust for either passive diffusion or active secretion, to acceptably predict renal clearances. The goal of this study was to establish a renal clearance simulation tool that allows prediction of renal clearance (filtration and pH-dependent passive reabsorption) from in vitro permeability data. A 35-compartment physiologically based mechanistic kidney model was developed based on human physiology. The model was verified using 46 test compounds, including neutrals, acids, bases, and zwitterions. The feasibility of incorporating active secretion and pH-dependent bidirectional passive diffusion into the model was demonstrated using para-aminohippuric acid (PAH), cimetidine, memantine, and salicylic acid. The developed model enables simulation of renal clearance from in vitro permeability data, with predicted renal clearance within twofold of observed for 87% of the test drugs.
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Affiliation(s)
- Weize Huang
- Department of Pharmaceutics, School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - Nina Isoherranen
- Department of Pharmaceutics, School of Pharmacy, University of Washington, Seattle, Washington, USA
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Madden LK, Hill M, May TL, Human T, Guanci MM, Jacobi J, Moreda MV, Badjatia N. The Implementation of Targeted Temperature Management: An Evidence-Based Guideline from the Neurocritical Care Society. Neurocrit Care 2017; 27:468-487. [DOI: 10.1007/s12028-017-0469-5] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Crombez T, Hachimi-Idrissi S. The influence of targeted temperature management on the pharmacokinetics of drugs administered during and after cardiac arrest: a systematic review. Acta Clin Belg 2017; 72:116-122. [PMID: 28220713 DOI: 10.1080/17843286.2017.1291782] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Pharmacokinetic parameters of drugs are widely investigated under normothermic conditions and normal hemodynamic parameters. The European Resuscitation Council recommends the use of targeted temperature management (TTM) with a target temperature of 34 °C in cardiac arrest (CA) patients. The aim of this literature review is to investigate the influence of CA combined with TTM on the pharmacokinetics of drugs. Results of preclinical and clinical studies are compared with each other. Only the most important drugs, administered during CA in emergency setting, were studied. METHODS A literature search was conducted within PubMed and Google Scholar. The search terms included 'therapeutic hypothermia', 'TTM', 'drug metabolism', 'pharmacokinetics during hypothermia', 'cardiac arrest/etiology'. In Pubmed, MeSH-terms were also included: 'myocardial infarction/therapy', 'heart arrest/complications' and 'hypothermia'. To search for preclinical studies: the search terms 'pigs' and 'swine' were used. After the primary shift of relevant findings, further articles were found through references of these (snowballing method), as well as through related articles as suggested by the databases. RESULTS Due to the reduced cardiac output during TTM, most of the distribution volume ([Formula: see text]) of drugs included in this literature study is decreased. Only the [Formula: see text] of chlorzoxazone in CA rats and midazolam in non-CA patients are significantly increased during respectively deep and mild hypothermia. The renal, hepatic and biliary clearance of drugs administered during CA/TTM/hypothermia are decreased. DISCUSSION The combination of a decreased [Formula: see text] and a decrease in the metabolization/excretion of drugs during CA/TTM result in higher plasma concentrations compared to the plasma concentrations during CA without TTM.
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Affiliation(s)
- Tessa Crombez
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Said Hachimi-Idrissi
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Department of Emergency Medicine, Ghent University Hospital, Ghent, Belgium
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Bornkamp JL, Robertson S, Isaza NM, Harrison K, DiGangi BA, Pablo L. Effects of anesthetic induction with a benzodiazepine plus ketamine hydrochloride or propofol on hypothermia in dogs undergoing ovariohysterectomy. Am J Vet Res 2016; 77:351-7. [PMID: 27027833 DOI: 10.2460/ajvr.77.4.351] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To assess the effect of anesthetic induction with a benzodiazepine plus ketamine or propofol on hypothermia in dogs undergoing ovariohysterectomy without heat support. ANIMALS 23 adult sexually intact female dogs undergoing ovariohysterectomy. PROCEDURES Baseline rectal temperature, heart rate, and respiratory rate were recorded prior to premedication with buprenorphine (0.02 mg/kg, IM) and acepromazine (0.05 mg/kg, IM). Anesthesia was induced with midazolam or diazepam (0.25 mg/kg, IV) plus ketamine (5 mg/kg, IV; n = 11) or propofol (4 mg/kg, IV; 12) and maintained with isoflurane in oxygen. Rectal temperature was measured at hospital intake, prior to premedication, immediately after anesthetic induction, and every 5 minutes after anesthetic induction. Esophageal temperature was measured every 5 minutes during anesthesia, beginning 30 minutes after anesthetic induction. After anesthesia, dogs were covered with a warm-air blanket and rectal temperature was measured every 10 minutes until normothermia (37°C) was achieved. RESULTS Dogs in both treatment groups had lower rectal temperatures within 5 minutes after anesthetic induction and throughout anesthesia. Compared with dogs that received a benzodiazepine plus ketamine, dogs that received a benzodiazepine plus propofol had significantly lower rectal temperatures and the interval from discontinuation of anesthesia to achievement of normothermia was significantly longer. CONCLUSIONS AND CLINICAL RELEVANCE Dogs in which anesthesia was induced with a benzodiazepine plus propofol or ketamine became hypothermic; the extent of hypothermia was more profound for the propofol combination. Dogs should be provided with adequate heat support after induction of anesthesia, particularly when a propofol-benzodiazepine combination is administered.
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Witcher R, Dzierba AL, Kim C, Smithburger PL, Kane-Gill SL. Adverse drug reactions in therapeutic hypothermia after cardiac arrest. Ther Adv Drug Saf 2016; 8:101-111. [PMID: 28382198 DOI: 10.1177/2042098616679813] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Therapeutic hypothermia (TH) improves survival and neurologic function in comatose survivors of cardiac arrest. Many medications used to support TH have altered pharmacokinetics and pharmacodynamics during this treatment. It is unknown if or at what frequency the medications used during TH cause adverse drug reactions (ADRs). METHODS A retrospective chart review was conducted for patients admitted to an intensive care unit (ICU) after cardiac arrest and treated with TH from January 2009 to June 2012 at two urban, university-affiliated, tertiary-care medical centres. Medications commonly used during TH were screened for association with significant ADRs (grade 3 or greater per Common Terminology Criteria for Adverse Events) using three published ADR detection instruments. RESULTS A total of 229 patients were included, the majority being males with median age of 62 presenting with an out-of-hospital cardiac arrest in pulseless electrical activity or asystole. The most common comorbidities were hypertension, coronary artery disease, and diabetes mellitus. There were 670 possible ADRs and 69 probable ADRs identified. Of the 670 possible ADRs, propofol, fentanyl, and acetaminophen were the most common drugs associated with ADRs. Whereas fentanyl, insulin, and propofol were the most common drugs associated with a probable ADR. Patients were managed with TH for a median of 22 hours, with 38% of patients surviving to hospital discharge. CONCLUSIONS Patients undergoing TH after cardiac arrest frequently experience possible adverse reactions associated with medications and the corresponding laboratory abnormalities are significant. There is a need for judicious use and close monitoring of drugs in the setting of TH until recommendations for dose adjustments are available to help prevent ADRs.
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Affiliation(s)
- Robert Witcher
- New York University Langone Medical Centre, New York, NY, USA
| | | | - Catherine Kim
- University of Pittsburgh, School of Pharmacy, Pittsburgh, PA, USA Department of Pharmacy, University of Pittsburgh Medical Centre, Pittsburgh, PA, USA
| | - Pamela L Smithburger
- University of Pittsburgh, School of Pharmacy, Pittsburgh, PA, USA Department of Pharmacy, University of Pittsburgh Medical Centre, Pittsburgh, PA, USA
| | - Sandra L Kane-Gill
- School of Pharmacy, University of Pittsburgh, 918 Salk Hall, 3501 Terrace Street, Pittsburgh, PA 15261, USA
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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: 1] [Impact Index Per Article: 0.1] [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.
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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
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Yamanaka D, Kawano T, Nishigaki A, Aoyama B, Tateiwa H, Shigematsu-Locatelli M, Locatelli FM, Yokoyama M. Preventive effects of dexmedetomidine on the development of cognitive dysfunction following systemic inflammation in aged rats. J Anesth 2016; 31:25-35. [DOI: 10.1007/s00540-016-2264-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 10/02/2016] [Indexed: 01/14/2023]
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Analgesia, sedation, and neuromuscular blockade during targeted temperature management after cardiac arrest. Best Pract Res Clin Anaesthesiol 2016; 29:435-50. [PMID: 26670815 DOI: 10.1016/j.bpa.2015.09.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 09/22/2015] [Indexed: 12/16/2022]
Abstract
The approach to sedation, analgesia, and neuromuscular blockade during targeted temperature management (TTM) remains largely unstudied, forcing clinicians to adapt previous research from other patient environments. During TTM, very little data guide drug selection, doses, and specific therapeutic goals. Sedation should be deep enough to prevent awareness during neuromuscular blockade, but titration is complex as metabolism and clearance are delayed for almost all drugs during hypothermia. Deeper sedation is associated with prolonged intensive care unit (ICU) and ventilator therapy, increased delirium and infection, and delayed wakening which can confound early critical neurological assessments, potentially resulting in erroneous prognostication and inappropriate withdrawal of life support. We review the potential therapeutic goals for sedation, analgesia, and neuromuscular blockade during TTM; the adverse events associated with that treatment; data suggesting that TTM and organ dysfunction impair drug metabolism; and controversies and potential benefits of specific monitoring. We also highlight the areas needing better research to guide our therapy.
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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.
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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
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El-Baraky IA, Abbassi MM, Marei TA, Sabry NA. Obesity Does Not Affect Propofol Pharmacokinetics During Hypothermic Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2016; 30:876-83. [DOI: 10.1053/j.jvca.2016.02.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Indexed: 01/21/2023]
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Hong CC, Lin CC, Hong CL, Lin ZX, Chung MH, Hsieh PW. Handheld analyzer with on-chip molecularly-imprinted biosensors for electrical detection of propofol in plasma samples. Biosens Bioelectron 2016; 86:623-629. [PMID: 27471152 DOI: 10.1016/j.bios.2016.07.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 06/29/2016] [Accepted: 07/09/2016] [Indexed: 10/21/2022]
Abstract
This paper proposes a novel handheld analyzer with disposable lab-on-a-chip technology for the electrical detection of the anesthetic propofol in human plasma samples for clinical diagnoses. The developed on-chip biosensors are based on the conduction of molecularly imprinted polymers (MIPs) that employ label-free electrical detection techniques. Propofol in total intravenous anesthesia is widely used with a target-controlled infusion system. At present, the methods employed for detecting blood propofol concentrations in hospitals comprise high-performance liquid chromatography and ion mobility spectrometry. These conventional instruments are bulky, expensive, and difficult to access. In this study, we developed a novel plastic microfluidic biochip with an on-chip anesthetic biosensor that was characterized for the rapid detection of propofol concentrations. The experimental results revealed that the response time of the developed propofol biosensors was 25s. The specific binding of an MIP to a nonimprinted polymer (NIP) reached up to 560%. Moreover, the detection limit of the biosensors was 0.1μg/mL, with a linear detection range of 0.1-30μg/mL. The proposed disposable microfluidic biochip with an on-chip anesthetic biosensor using MIPs exhibited excellent performance in the separation and sensing of propofol molecules in the human plasma samples. Compared with large-scale conventional instruments, the developed microfluidic biochips with on-chip MIP biosensors present the advantages of a compact size, high selectivity, low cost, rapid response, and single-step detection.
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Affiliation(s)
- Chien-Chong Hong
- BioMEMS and Nanobiosystems Laboratory, Department of Power Mechanical Engineering, National Tsing Hua University, Hsinchu, Taiwan.
| | - Chih-Chung Lin
- Department of Anesthesiology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chian-Lang Hong
- Department of Anesthesiology, Chang Gung Memorial Hospital, Chiayi, Taiwan; Chang Gung University of Science and Technology, Chiayi, Taiwan.
| | - Zi-Xiang Lin
- BioMEMS and Nanobiosystems Laboratory, Department of Power Mechanical Engineering, National Tsing Hua University, Hsinchu, Taiwan
| | - Meng-Hua Chung
- BioMEMS and Nanobiosystems Laboratory, Department of Power Mechanical Engineering, National Tsing Hua University, Hsinchu, Taiwan
| | - Pei-Wen Hsieh
- Department of Anesthesiology, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Graduate Institute of Natural Products, School of Traditional Chinese Medicine, and Graduate Institute of Biomedical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
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Madathil RJ, Hira RS, Stoeckl M, Sterz F, Elrod JB, Nichol G. Ischemia reperfusion injury as a modifiable therapeutic target for cardioprotection or neuroprotection in patients undergoing cardiopulmonary resuscitation. Resuscitation 2016; 105:85-91. [PMID: 27131843 DOI: 10.1016/j.resuscitation.2016.04.009] [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] [Received: 01/25/2016] [Revised: 04/07/2016] [Accepted: 04/13/2016] [Indexed: 12/13/2022]
Abstract
AIMS We sought to review cellular changes that occur with reperfusion to try to understand whether ischemia-reperfusion injury (RI) is a potentially modifiable therapeutic target for cardioprotection or neuroprotection in patients undergoing cardiopulmonary resuscitation. DATA SOURCES Articles written in English and published in PubMed. RESULTS Remote ischemic conditioning (RIC) involves brief episodes of non-lethal ischemia and reperfusion applied to an organ or limb distal to the heart and brain. Induction of hypothermia involves cooling an ischemic organ or body. Both have pluripotent effects that reduce the potential harm associated with RI in the heart and brain by reduced opening of the mitochondrial permeability transition pore. Recent trials of RIC and induced hypothermia did not demonstrate these treatments to be effective. Assessment of the effect of these interventions in humans to date may have been modified by use of concurrent medications including propofol. CONCLUSIONS Ongoing research is necessary to assess whether reduction of RI improves patient outcomes.
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Affiliation(s)
| | - Ravi S Hira
- University of Washington, Seattle, WA, United States
| | | | - Fritz Sterz
- Medical University of Vienna, Vienna, Austria
| | | | - Graham Nichol
- University of Washington, Seattle, WA, United States.
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Paul M, Bougouin W, Geri G, Dumas F, Champigneulle B, Legriel S, Charpentier J, Mira JP, Sandroni C, Cariou A. Delayed awakening after cardiac arrest: prevalence and risk factors in the Parisian registry. Intensive Care Med 2016; 42:1128-36. [DOI: 10.1007/s00134-016-4349-9] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 04/03/2016] [Indexed: 10/21/2022]
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May TL, Seder DB, Fraser GL, Stone P, McCrum B, Riker RR. Moderate-dose sedation and analgesia during targeted temperature management after cardiac arrest. Neurocrit Care 2016; 22:105-11. [PMID: 24962894 DOI: 10.1007/s12028-014-9998-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Sedation and analgesia regimens during targeted temperature management (TTM), after cardiac arrest varies widely, are poorly described in the literature and may have a negative impact on outcome. Since implementing TTM in 2005, we have used moderate-dose sedation and describe our experience with this approach. METHODS In this retrospective review, we included patients treated with TTM for cardiac arrest at our institution for 2008-2012. Patients received TTM if they did not follow verbal commands following cardiac arrest, regardless of place of arrest or rhythm. Utstein-compatible data were prospectively entered into the International Cardiac Arrest Registry, supplemented by review of nursing, pharmacy, and physical therapy records. We report analgesic and sedative medications and doses during the 24 h of active TTM at 33 °C, resource utilization, and important clinical events. RESULTS 166 patients treated with TTM after in- and out-of-hospital cardiac arrest with complete data were included. Overall survival was 42 %, median time to following commands was 3 h after rewarming (-6, 14), time to spontaneous breathing trial was 19 h (5-35), time to extubation was 28 h (9-60), and 59 % of survivors were discharged directly home at 13 (10-20) days. The incidence of seizure was 6 %, septic shock 4 %, and pneumonia 32 %. Four survivors required tracheostomy at 8, 8, 12, and 16 days. CONCLUSIONS A moderate-dose sedation and analgesia regimen was well tolerated and effective during therapeutic hypothermia after cardiac arrest and is an effective alternative to very deep sedation. We recommend more complete description of sedation and analgesia protocols in future studies, including expanded outcome reporting to include variables affected by sedation therapy. Further study is required to define which sedation approach for TTM may be best.
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Affiliation(s)
- Teresa L May
- Division of Pulmonary and Critical Care Medicine, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA,
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Giménez-Milà M, Videla S, Jenkins D, Klein AA, Gerrard C, Nalpon J, Valchanov K. Acute Pain and Analgesic Requirements After Pulmonary Endarterectomy With Deep Hypothermic Circulatory Arrest. J Cardiothorac Vasc Anesth 2015; 30:993-6. [PMID: 26948465 DOI: 10.1053/j.jvca.2015.11.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To assess postoperative pain intensity and the analgesic requirements in the postoperative period in patients undergoing sternotomy for pulmonary endarterectomy involving deep hypothermic circulatory arrest. DESIGN Retrospective cohort study. SETTING Single-center hospital study. PARTICIPANTS Patients 18 years and older undergoing sternotomy for cardiac surgery between August 2012 and August 2014. INTERVENTIONS No modification to usual clinical practice. MEASUREMENTS AND MAIN RESULTS Intraoperative opioid and steroid administration, referral to the chronic pain unit, intensive care unit pain scores, and analgesic administration in the first 48 hours after the admission to the intensive care unit were recorded. Postoperative pain was evaluated by means of a categoric verbal scale from no pain (0) to severe pain (3); this is the routine analgesic scale used in the authors' intensive care unit. A total of 200 consecutive patients undergoing pulmonary endarterectomy (PEA group) were included in the study. No patient in the PEA group received morphine during surgery. The mean (standard deviation) postoperative pain intensity score at 24 hours was 0.30 (0.54) in the PEA group. Postoperative morphine was administered in 39% of patients. No PEA patient was referred to the chronic pain unit after hospital discharge. CONCLUSION The total analgesic requirements and pain score of patients undergoing sternotomy for pulmonary endarterectomy with deep hypothermic circulatory arrest seemed to be low.
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Affiliation(s)
- Marc Giménez-Milà
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, United Kingdom;.
| | - Sebastian Videla
- Department of Experimental and Health Sciences, Universitat Pompeu Fabra, Barcelona, Catalonia, Spain
| | - David Jenkins
- Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, United Kingdom
| | - Andrew A Klein
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, United Kingdom
| | - Caroline Gerrard
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, United Kingdom
| | - Jacinta Nalpon
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, United Kingdom
| | - Kamen Valchanov
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, United Kingdom
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41
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Howes D, Gray SH, Brooks SC, Boyd JG, Djogovic D, Golan E, Green RS, Jacka MJ, Sinuff T, Chaplin T, Smith OM, Owen J, Szulewski A, Murphy L, Irvine S, Jichici D, Muscedere J. Canadian Guidelines for the use of targeted temperature management (therapeutic hypothermia) after cardiac arrest: A joint statement from The Canadian Critical Care Society (CCCS), Canadian Neurocritical Care Society (CNCCS), and the Canadian Critical Care Trials Group (CCCTG). Resuscitation 2015; 98:48-63. [PMID: 26417702 DOI: 10.1016/j.resuscitation.2015.07.052] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 07/25/2015] [Accepted: 07/30/2015] [Indexed: 11/19/2022]
Affiliation(s)
- Daniel Howes
- Department of Emergency Medicine Queen's University, Kingston, ON, Canada; Queen's University, Kingston, ON, Canada.
| | - Sara H Gray
- Division of Emergency Medicine, Department of Medicine, and the Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada
| | - Steven C Brooks
- Department of Emergency Medicine Queen's University, Kingston, ON, Canada; Rescu, Li Ka Shing Knowledge Institute, St. Michael's, Toronto, ON, Canada
| | - J Gordon Boyd
- Queen's University, Kingston, ON, Canada; Division of Neurology Department of Medicine Queen's University, Kingston, ON, Canada
| | - Dennis Djogovic
- Division of Critical Care Medicine and Department of Emergency Medicine, University of Alberta, Edmonton, AB, Canada
| | - Eyal Golan
- Interdepartmental Division of Critical Care and Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Robert S Green
- Department of Emergency Medicine, Department of Critical Care Medicine, Dalhousie University, Halifax, NS, Canada
| | - Michael J Jacka
- Departments of Anesthesiology and Critical Care, University of Alberta Hospital, Edmonton, AB, Canada
| | - Tasnim Sinuff
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Critical Care Medicine and Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Timothy Chaplin
- Department of Emergency Medicine Queen's University, Kingston, ON, Canada
| | - Orla M Smith
- Critical Care Department, Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michaels Hospital, Toronto, ON, Canada
| | - Julian Owen
- McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Adam Szulewski
- Department of Emergency Medicine Queen's University, Kingston, ON, Canada
| | - Laurel Murphy
- Department of Emergency Medicine, Department of Critical Care Medicine, Dalhousie University, Halifax, NS, Canada
| | | | - Draga Jichici
- Department of Neurology and Critical Care Medicine, McMaster University, Hamilton, ON, Canada
| | - John Muscedere
- Queen's University, Kingston, ON, Canada; Department of Medicine Queen's University, Kingston, ON, Canada
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42
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Dengler B, Garvin R, Seifi A. Can therapeutic hypothermia trigger propofol-related infusion syndrome? J Crit Care 2015; 30:823-4. [PMID: 25922173 DOI: 10.1016/j.jcrc.2015.03.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Accepted: 03/30/2015] [Indexed: 12/29/2022]
Affiliation(s)
- Bradley Dengler
- Department of Neurosurgery, Division of Neuro Critical Care, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Rachel Garvin
- Department of Neurosurgery, Division of Neuro Critical Care, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Ali Seifi
- Department of Neurosurgery, Division of Neuro Critical Care, University of Texas Health Science Center at San Antonio, San Antonio, TX.
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43
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Hemodynamics and Vasopressor Support During Targeted Temperature Management at 33°C Versus 36°C After Out-of-Hospital Cardiac Arrest. Crit Care Med 2015; 43:318-27. [DOI: 10.1097/ccm.0000000000000691] [Citation(s) in RCA: 114] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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44
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Kim F, Bravo PE, Nichol G. What is the use of hypothermia for neuroprotection after out-of-hospital cardiac arrest? Stroke 2015; 46:592-7. [PMID: 25563645 DOI: 10.1161/strokeaha.114.006975] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Francis Kim
- From the Department of Medicine, Harborview Medical Center, University of Washington, Seattle
| | - Paco E Bravo
- From the Department of Medicine, Harborview Medical Center, University of Washington, Seattle
| | - Graham Nichol
- From the Department of Medicine, Harborview Medical Center, University of Washington, Seattle.
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45
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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.
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46
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Abstract
This paper is the thirty-sixth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2013 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia; stress and social status; tolerance and dependence; learning and memory; eating and drinking; alcohol and drugs of abuse; sexual activity and hormones, pregnancy, development and endocrinology; mental illness and mood; seizures and neurologic disorders; electrical-related activity and neurophysiology; general activity and locomotion; gastrointestinal, renal and hepatic functions; cardiovascular responses; respiration and thermoregulation; and immunological responses.
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, Flushing, NY 11367, United States.
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47
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Annborn M, Bro-Jeppesen J, Nielsen N, Ullén S, Kjaergaard J, Hassager C, Wanscher M, Hovdenes J, Pellis T, Pelosi P, Wise MP, Cronberg T, Erlinge D, Friberg H. The association of targeted temperature management at 33 and 36 °C with outcome in patients with moderate shock on admission after out-of-hospital cardiac arrest: a post hoc analysis of the Target Temperature Management trial. Intensive Care Med 2014; 40:1210-9. [DOI: 10.1007/s00134-014-3375-8] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 06/10/2014] [Indexed: 12/22/2022]
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48
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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.
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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
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49
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Holzer M. Therapeutic hypothermia following cardiac arrest. Best Pract Res Clin Anaesthesiol 2014; 27:335-46. [PMID: 24054512 DOI: 10.1016/j.bpa.2013.07.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Accepted: 07/23/2013] [Indexed: 11/19/2022]
Abstract
More than 10 years ago, the randomised studies of therapeutic hypothermia after cardiac arrest showed significant improvement of neurological outcome and survival. Since then, it has become clear that most of the possible adverse events of therapeutic hypothermia are mild and can easily be controlled by proper administration of intensive care. Although implementation of this effective therapy is quite successful, many questions of the exact treatment protocol still remain unanswered. Therapeutic hypothermia treatment therefore must be tailored to the specific patient's needs. Hence, the exact level of target temperature, duration of cooling, rewarming, timing of the therapy and concomitant medication to facilitate therapeutic hypothermia will be important in the future. Additionally, the use of a post-resuscitation treatment bundle (specialised cardiac-arrest centres including intensive post-resuscitation care, appropriate haemodynamic and respiratory management, therapeutic hypothermia and percutaneous coronary intervention) could further improve treatment of cardiac arrest.
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Affiliation(s)
- Michael Holzer
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria.
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50
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Grossestreuer AV, Perman SM, Gaieski DF. Reply to Letter: Uneventful neurological outcome in case of late awakening after cardiac arrest treated with hypothermia. Resuscitation 2014; 85:e41-2. [DOI: 10.1016/j.resuscitation.2013.12.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 12/20/2013] [Indexed: 11/26/2022]
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